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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bright red blood per rectum major surgical or invasive procedure: colonoscopy with cauterization of active bleeding history of present illness: an otherwise 50 year old lady s/p screening colonoscopy yesterday with 3 polyps removed at presents after ~ 8 bloody bowel movements over night into this morning with worsening lightheadedness and ? syncope between re-presentation to this morning and transfer to the ed today. . in the ed, initial vs were: 98.4 84 130/92 20 100. patient was given 2 ivs in the ed, type & screen seen. patient was seen by gi who recommended icu admission for serial hematocrits and possible colonoscopy. transfer vs: hr 78 121/75 12 100% ra. . on the floor, the patient is resting comfortably complaining only of stomach growling and flatulence. she has not had bowel movements or bleeding since presentation. she denies and dyspnea or chest pain and has not stood up to know if she is still weak or lightheaded. . 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. denies nausea, vomiting, constipation. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: anxiety insomnia sciatica/spinal stenosis s/p sacral laminectomy 4-5 years ago s/p appendectomy s/p salpingolysis breast atypical hyperplasia s/p breast implant social history: tobacco: currently smokes ~ 8 cigarettes a day, 1/2-1 pack per day history for ~ 20 years, attempting to quit alcohol: 1 drink/weekly denies illicit drug use family history: father: copd mother: cad, breast ca physical exam: vitals: t: 98.4 bp: 130/92 p: 84 r: 20 18 o2: 100% ra general: well appearing, no acute distress heent: conjunctiva not pale, mm dry neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly rectal: small dried blood on skin, no output to bed gu: no foley ext: warm, well perfused, 2+ pulses, no edema pertinent results: endoscopy report from : 12mm sessile polyp in the hepatic flexure. polypectomy performed with saline injection/snare cautery. 3-5mm polyp in sigmoid colon. snared/retrieved 7mm polyp in rectum- snare cautery. admission labs: 10:45pm hct-28.0* 03:59pm wbc-10.7 rbc-2.60* hgb-8.0* hct-24.2* mcv-93 mch-30.6 mchc-32.9 rdw-13.4 03:59pm plt count-318 09:20am glucose-105* urea n-13 creat-0.7 sodium-137 potassium-3.9 chloride-105 total co2-23 anion gap-13 09:20am estgfr-using this 09:20am wbc-14.5* rbc-3.34* hgb-10.2* hct-30.6* mcv-92 mch-30.5 mchc-33.3 rdw-13.5 09:20am neuts-75.4* lymphs-21.1 monos-2.3 eos-1.0 basos-0.2 09:20am plt count-365 09:20am pt-13.2 ptt-25.8 inr(pt)-1.1 . hct trend: 09:20am hct-30.6* 03:59pm hct-24.2* 10:45pm hct-28.0* 03:38am hct-26.9* 12:03pm hct-30.3* 05:40pm hct-29.2* 06:35am hct-31.4* . coags: 03:38am blood pt-13.5* ptt-29.6 inr(pt)-1.2* . discharge labs: 06:35am blood wbc-11.0 rbc-3.54* hgb-10.6* hct-31.4* mcv-89 mch-30.1 mchc-33.9 rdw-16.8* plt ct-309 06:35am blood glucose-88 urean-4* creat-0.6 na-139 k-3.9 cl-107 hco3-25 angap-11 06:35am blood calcium-8.6 phos-3.5 mg-1.8 brief hospital course: 50yo woman who presented with brbpr and was initially admitted to the icu with a post-polypectomy lgib. 1) hematochezia: the patient was admitted to the icu with post-polypectomy bleed. her hct continued to trend down. she had more bloody bowel movements and received 3 units prbcs, with subsequent stabilization of her hct. she underwent a colonoscopy by gi the morning after admission. polypectomy site with stigmata of recent bleeding was visualized during the procedure and cauterized with good effect. hct and vs remained stable after the procedure and transfusion. she had no further episodes of bleeding and did not require any additional transfusions. coags were normal. she was transferred from the icu to the general medicine floor on for one additional night of observation. her hct and vs were again stable overnight, and she was discharged to home in good condition. 2) back pain: not an active issue at time of discharge. she was ordered for tylenol prn pain. 3) anxiety: she was ordered for ativan prn anxiety. 4) smoking cessation: she was counseled about quitting smoking, and offered a nicotine patch during the admission, which she declined. medications on admission: nicotine inhaled ativan 1-2mg po prn ~ weekly tylenol prn back pain ~ 1-2x weekly tramadol 50mg po prn back pain ~ 1 weekly discharge medications: 1. lorazepam 1 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for insomnia/anxiety. 2. tramadol 50 mg tablet sig: one (1) tablet po once a day as needed for pain. discharge disposition: home discharge diagnosis: primary diagnosis:post polypectomy lower gi bleed secondary diagnosis: anxiety discharge condition: aaox3, hemodynamically stable, no further bleeding discharge instructions: you were admitted to the hospital with bleeding after your colonoscopy. your blood counts were low so you were transfused 3 units of blood. the site of bleeding in your colon was seen on a repeat colonoscopy and treated. we did not make any changes to your medications and counseled you about quitting smoking. followup instructions: please follow up with your primary care doctor in the next weeks. call to make an appointment. Procedure: Endoscopic destruction of other lesion or tissue of large intestine Diagnoses: Tobacco use disorder Hemorrhage complicating a procedure Anxiety state, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Benign neoplasm of colon Insomnia, unspecified Volume depletion, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: unresponsiveness major surgical or invasive procedure: intraosseous access removal hd line placement cvvh history of present illness: mr. is a 79 yo m w/hx of cad s/p mi x 2, dm, chf ef 35-40%, afib, stage iv diabetic nephropathy (cr 3.0) who presented to the ed after a witness unresponsive episode. per the family, he was walking down the street and had a wittness loss of consciousness. ems was called and he was taken to hospital. on arrival (11:20am) he was in asystole. he was given epi x 3 and atropine x 1. he then went into vfib and shocked (200 joules). he then went into afib and became bradycardic. dopamine was started. he regained a perfusing rhythm at 11:35am. he was given calcium chloride, magnesium, amiodarone 300mg iv x 1 and bicarb during the resuscitation at . he later had another episode of vt at 12:40 and an amiodarone gtt was started. he was transferred to the ed. . per ed report, he had presented to hospital in vfib, then became asystolic. after the initial resuscitation he had 2 additional asystolic arrests in the er. . in the ed, initial vitals were t98.2 hr75, bp149/106, rr32 100% on the vent. the post-arrest consult team was called and recommended cooling him to 33-34 degrees and weaning his propofol to fentanyl/versed. a r femoral line was placed, he was given 1l ivf and had a head, chest, abdomen ct done without contrast. he was kept on dopamine, propofol and amiodarone. he was given 1mg atropine for bradycardia to 35during transfer to the floor, he became bradycardic. external pacer pad were placed and his dopamine was increased from 15mcg/kg to 20mcg/kg. he was briefly externally paced and given additional an additional 1mg of atropine. on arrival to the ccu he was not being paced and his dopamine was back down to 15mcg/min. ct scan showed a sternal fracture and mediastinal hematoma. . ros unable to be obtained as the patient is intubated and sedated. past medical history: 1. coronary artery disease, -s/p mi , cath showing occluded om1 -s/p ami with stent to proximal lad 80% lesion, 70% d1, 70% om1 with circ occluded after om1 2. systolic left ventricular heart failure, ef 35-40% (echo ) 3. hypertension 4. diabetes mellitus type 2 5. diabetic nephropathy - chronic kidney disease stage iv, baseline creatinine 3.0 6. atrial fibrillation - on coumadin 7. gout 8. prostate cancer - t1c, nx, score 5+5, s/p xrt social history: unable to obtain as patient is intubated and sedated. per omr, no tobacco, alcohol or drug use. confirmed with family. family history: unable to obtain. per omr, there is no family history of premature coronary artery disease or sudden death. physical exam: vs: t=36.4 bp 134/83 hr 90 rr 20 99% on ac 550x20 100% fio2, peep 5 general: intubated and sedated. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple, jvp unable to be assessed due to cervical collar. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. extremities: 2+ peripheral edema. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral dopplerable dp dopplerable left: carotid 2+ femoral dopplerable popliteal dopplerable pertinent results: admission labs: 03:40pm blood wbc-13.3* rbc-5.40 hgb-15.7 hct-49.7 mcv-92 mch-29.0 mchc-31.6 rdw-16.8* plt ct-216 03:40pm blood neuts-86.1* lymphs-5.9* monos-7.8 eos-0.1 baso-0.2 03:40pm blood pt-30.1* ptt-44.2* inr(pt)-3.0* 09:35pm blood glucose-276* urean-69* creat-3.3* na-134 k-4.6 cl-104 hco3-21* angap-14 03:40pm blood alt-465* ast-572* ck(cpk)-881* alkphos-141* totbili-1.4 09:35pm blood alt-385* ast-493* ck(cpk)-1141* alkphos-123 totbili-1.9* 03:29am blood alt-317* ast-304* ck(cpk)-870* alkphos-106 totbili-1.2 01:41pm blood ck(cpk)-936* 03:40pm blood ctropnt-0.64* 03:40pm blood ck-mb-35* mb indx-4.0 09:35pm blood ck-mb-45* mb indx-3.9 ctropnt-1.34* 03:29am blood ck-mb-41* mb indx-4.7 ctropnt-1.19* 01:41pm blood ck-mb-38* mb indx-4.1 ctropnt-1.25* 03:40pm blood albumin-3.5 calcium-9.0 phos-5.5* mg-3.0* 03:29am blood triglyc-103 hdl-21 chol/hd-3.1 ldlcalc-24 microbiology: . respiratory culture ( and ) moraxella catarrhalis. 5:14 pm blood culture source: line-aline. staphylococcus, coagulase negative | erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ 2 s . 11:25 pm blood culture source: line-mlc. staphylococcus, coagulase negative | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- 0.25 s oxacillin-------------<=0.25 s tetracycline---------- <=1 s vancomycin------------ 2 s studies: . cxr (): cardiomegaly with mild congestive heart failure. endotracheal tube and nasogastric tube in standard positions. . ct spine (): 1. no acute fracture or malalignment of the cervical spine. 2. pulmonary edema and right pleural effusion, partially imaged. 3. multilevel degenerative changes, worst at c4-c5, which predisposes the patient to cord injury. consider mri for further evaluation if clinically indicated. . non-contrast head ct (): non-contrast head ct: there is no intracranial hemorrhage, mass effect, or -white matter differentiation abnormality. the ventricles and extra-axial spaces are appropriate for age. intracranial carotid artery atherosclerotic calcifications are moderate-to-severe. mucosal secretions within the nasal passages, nasopharynx, and opacification of the ethmoid sinus air cells are noted, at least partially related to recent intubation. there is mucosal thickening in bilateral maxillary, frontal, and sphenoid sinuses, mild in degree. imaged mastoid air cells are clear. there is no fracture. mild prominence of the ventricles and cerebral sulci is likely related to age-appropriate atrophy. impression: no acute intracranial abnormality. sinus disease, as noted above. . ct chest, abdomen, pelvis (): impression: 1. mildly displaced transversefracture of the mid sternum likely involves the medial aspect of the anterior left third rib with associated substernal anterior mediastinal hematoma. 2. mild pulmonary edema with bilateral small pleural effusions with associated atelectasis. 3. 1.9 cm right renal hypodense lesion, likely a complex cyst. a renal ultrasound is recommended further evaluation. 4. gallbladder wall edema and trace perihepatic ascites, likely related to heart failure. . echo the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the inferior and inferolateral walls, distal anterior wall and distal lateral wall. there is an apical left ventricular aneurysm. the remaining walls contract well (lvef 30-35%). no masses or thrombi are seen in the left ventricle. the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. significant pulmonic regurgitation is seen. the pulmonary artery systolic pressure could not be quantified (but pulmonary artery systolic hypertension is suggested). there is a trivial/physiologic pericardial effusion. impression: suboptimal image quality. moderate regional left ventricular systolic dysfunction consistent with multivessel cad. right ventricular cavity enlargement with free wall hypokinesis. mild mitral regurgitation. compared with the findings of the prior study (images reviewed) of , left ventricular function has further deteriorated and the right ventricular cavity is more dilated with new free wall hypokinesis. is there a history to suggest a primary pulmonary process (e.g., pulmonary embolism, bronchospasm, etc. brief hospital course: 79yo m w/hx of cad s/p mi x 2, chf, dm, stage iv ckd who presents s/p cardiac arrest. . # cardiac arrest: there was little information about the events of the hours that preceded his admission. we know that he had a witnessed syncopal episode; he may have been in asystole at an osh. the etiology of the cardiac arrest was likely hyperkalemia. he underwent artic sun cooling protocol at , which was complicated by persistent bradycardia to the 20's. therefore, arctic sun was terminated after 6 hours. he was placed on epinephrine, isoproteronol & dopamine and his hr eventually rebounded. his pressors were slowly weaned. neurology was consulted regarding his neurological prognosis. based on his eeg result, non-arousal, and lack of brainstem reflexes except for overbreathing on the ventilator, neurology suggested that meaningful recovery from the neurological standpoint is very unlikely. serial family meetings were held, and the family decided to withdraw care on at 10am. following extubation, patient expired 40 minutes later at 10:40am on . . # anoxic brain injury: neurology was consulted on admission and patient was placed on a 48 hour eeg per protocol. p er examination, the patient demonstrated no brainstem function, save for a respiratory rate that exceeded the ventilator settings. over the next few days, he did demonstrate the presence of a gag reflex as well as a questionable r-sided pupillary constriction and corneal reflex, but despite being off pressors and sedation, he did not exhibit further cortical function. eeg's demonstrated some e/o encephalopathy. serial family meetings were held, and the family decided to withdraw care on at 10am. following extubation, patient expired 40 minutes later at 10:40am on . . # respiratory failure: patient was placed on a ventilator s/p cardiac arrest. his chest ct demonstrated mild pulmonary edema. sputum culture from and grew out moraxella for which he was covered with ceftriaxone. he remained intubated with stepwise decrements in his degree of pressure support. following extubation, patient expired 40 minutes later at 10:40am on . . # anuric renal failure: patient with known ckd, baseline cr 3.0. on admission, patient was anuric, likely due to atn s/p shock and poor perfusion despite receiving several liters of ivf's at the osh and in the ed. his electrolytes and acid/base status was stabilized after he was placed on cvvh. his cvvh filter was clotted off on . given that his his uop improved and his electrolytes were stable off cvvh, and because of his poor prognosis, cvvh was discontinued. his electrolytes were stable during the rest of the hospitalization. . # congestive heart failure: ef of 35-40% in , down to 30-35% on repeat tte on , likely further impaired by the cardiac arrest. patient with mild pulmonary edema on chest ct, but intubated since admission. his ace was held given renal insufficiency and his fluid status was managed as above. . # leukocytosis: patient presented with leukocytosis & grossly positive u/a, but elevated wbc may also be due to stress response to cardiac arrest. he was started on ceftriaxone 1g iv q24h on . sputum cx was positive for moraxella & blood cultures demonstrated coag negative staph. vancomycin was added on . . # dmii: patient was continued on lantus with regular insulin sliding scale. medications on admission: allopurinol 300 mg tablet atorvastatin 80 mg tablet calcitriol 0.25mg po qday carvedilol 12.5mg po bid lasix 80mg po bid humalog dose unknown hydralazine 10mg po bid lantus 33 units in the am imdur 30mg po q24h warfarin 2mg daily except wednesday, 1 mg on wednesday aspirin 81mg po qday colace 100mg po qday prn constipation mvi senna 2 tabs daily prn constipation discharge medications: expired discharge disposition: expired discharge diagnosis: cardiac arrest discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Hemodialysis Diagnoses: Hyperpotassemia Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Closed fracture of sternum Cardiac arrest Anoxic brain damage Old myocardial infarction Chronic systolic heart failure Long-term (current) use of anticoagulants Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Polycythemia vera |
allergies: toprol xl attending: chief complaint: fevers, tachycardia major surgical or invasive procedure: lithotripsy right ureteral stent placement x 2 history of present illness: mr. is an 83 year old man with stage v ckd, h/o multiple malignancies including bladder cancer s/p resection, bilateral nephrolithiasis, and non-ischemic cardiomyopathy (ef 25-30%) here with fevers, rigors, hypotension, and tachycardia after right ureteral stent placement today for chronic kidney stones. the patient underwent lithotripsy with right ureteral stent placement x 2 today with dr. , but approximately 90 minutes after the procedure, while recovering in the pacu, he began experiencing rigors and a temperature at that time was 101. he then became hypotensive to the 90's systolic and tachycardic to 116, so he was given vancomycin & ceftriaxone x 1 and transferred to the icu for further monitoring. in the , initial vs were: t100.9 p114 bp127/48 r15 o2 sat 94% 3l. patient denied any subjective fevers, chills, abdominal/flank pain. he further denied any nausea, vomiting, or shortness of breath. he did endorse several weeks of solid food dysphagia and a 25 pound weight loss over the past year, including approximately 15 pounds in the last 2 weeks. past medical history: - htn - non-ischemic cardiomyopathy (ef 25-30%) - chronic renal insufficiency (baesline 5.5-6. positive. possibly secondary to tubular interstitial disease.) - nephrolithiasis (first kidney stone at the age of 25 which he passed with a lot of pain. asymptomatic since then. back ct revealed bilateral renal stones that were quite large (>1.0 cm). the patient had laser lithotripsy in on the right side and in on the left side by dr. . this was repeated on last admission in .) - chronic back pain since secondary to ankylosing spondylitis, ddd and facet degeneration (mri l spine on : mild l45 central, mod/sev r and mild l foraminal stenosis, moderate l34 central and mod l l3 foraminal stenosis. spine survey on at nebh: ossification of pll c/w ankylosing spondylitis. ct l spine on : l34 and l45 advanced degenerative disc disease. on tens for mobility.) - memory difficulties - nhl (initially thought to have crohn disease, went for surgery that revealed lymphoma, involving bladder. he was further treated with 9 cycles chemotherapy, radiation and bowel resection. no recurrence.) - short gut syndrome after bowel surgery. takes monthly b12 injections. () - urinary frequency - papillary urothelial carcinoma of the bladder s/p partial bladder resection - scc l ear () - bcc l nose () - femoral neck fracture s/p internal stabilization - left partial lateral knee meniscectomy () - secondary hyperparathyroidism - anemia esrd & b12 deficiency social history: social history: professor and is teaching history. he has insignificant history of smoking when he was much younger and experimented with tobacco but nothing really significant. he has no history of alcohol abuse or illicit drug use. he lives with his wife, . family history: family history: his father died of mi age 57. his brother died of multiple sclerosis at the age of 40. his sister is 86 and in very good health. his mother died after falling down the stairs but his maternal aunts lived over the age of 100. otherwise non-contributory. pertinent results: 08:50am blood calcium-7.5* phos-4.5# mg-2.1 08:50am blood wbc-11.4* rbc-3.12* hgb-9.7* hct-30.9* mcv-99* mch-31.1 mchc-31.4 rdw-13.1 plt ct-353 brief hospital course: 83 year old man with ckd (cr 5.5-6 baseline), h/o multiple malignancies including bladder cancer s/p resection, bilateral nephrolithiasis, and non-ischemic cardiomyopathy (ef 45%) transferred to s/p bilateral ureteral stent placement for fevers, rigors, hypotension, and tachycardia with concern for sepsis. stabalized in with fluid resusitation, broad spectrum empiric antibiotics started. patient transferred to floor when stable. cultures followed and antibiotic narrowed to ampicillin. foley was removed pod3 and patient passed a voiding trial. creatinine returned to baseline, wbc returned to range. renal was informed of his admission, specifically dr. who visited the patient in house on the day of discharge. he was discharged home in stable condition, on pod4, voiding without difficulty, ambulating without assistance, tolerating a regular diet. he was given a 7 day course of ampicillin, and istructed to contact dr. arrange/confirm follow up. he is also advised to contact dr. and his pcp upon discharge to arrange follow up. medications on admission: amlodipine 5 mg po daily calcitriol 0.25 mcg qod cyanocobalamin 1,000 mcg/ml qmonth testosterone cypionate 200 mg q3 weeks tramadol 50mg po bid acetaminophen 650mg po daily ergocalciferol 400 unit po daily mvi daily discharge medications: 1. multivitamin tablet sig: one (1) tablet po daily (daily). 2. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day (every other day). 3. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). 4. amoxicillin 250 mg capsule sig: two (2) capsule po q12h (every 12 hours) for 7 days. disp:*28 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: sepsis following bilateral ureteral stent placement discharge condition: stable discharge instructions: -you may shower and bathe normally. -tylenol should be used for pain -resume all of your home medications at their usual dose, please follow up with your pcp and renal specialist to inform them of your recent hospital stay. - if you develop fevers > 101.5 f, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. general instructions and information for the patient post procedure definitions: ureter: the duct that transports urine from the kidney to the bladder: stent: a plastic hollow tube that is placed into the ureter, from the kidney to the bladder to prevent the ureter from swelling shut. despite the fact that no skin incisions were used, the area around the ureter and bladder is irritated. the stent is required in order keep the ureter open and urine flowing from the kidney to the bladder. because one end of the ureter is in the bladder, it can cause irritation to the bladder. therefore, it is normal to feel that you need the urge to urinate frequently when the stent is in place. although the stent can be uncomfortable, it is important to have the stent to avoid damaging the kidney and ureter after your procedure. you may see some blood in your urine while the stent is in place and a few days afterward. drink lots of fluid - this will help clear up your urine.

 diet: you may return to your normal diet immediately. because of the raw surface of your bladder, alcohol, spicy foods, acidy foods and drinks with caffeine may cause irritation or frequency and should be used in moderation. to keep your urine flowing freely and to avoid constipation, drink plenty of fluids during the day (8 - 10 glasses) activity: your physical activity doesn't need to be restricted. however, if you are very active, you may see some blood in the urine. we would suggest to cut down your activity under these circumstances until the bleeding has stopped bowels-it is important to keep your bowels regular during the postoperative period. straining with bowel movements can cause bleeding. a bowel movement every other day is reasonable. use a mild laxative if needed, such as milk of magnesia tablespoons, or 2 dulcolax tablets. call if you continue to have problems. if you had been taking narcotics for pain, before, during or after your surgery, you may be constipated. take a laxative if necessary medication-you should resume your pre-surgery medications unless told not to. in addition you will often be given an antibiotic to prevent infection. these should be taken as prescribed until the bottles are finished unless you are having an unusual reaction to one of the drugs. problems should report to urology service a. fevers over 100.5 fahrenheit b. heavy bleeding, or clots (see notes above about blood in urine). c. inability to urinate. d. drug reactions (hives, rash, nausea, vomiting, diarrhea). e. severe burning or pain with urination that is not improving. f. you have and internal stent and it is important to have a follow-up appointment to remove your stent. call your doctor for this appointment when you get home followup instructions: 1. please contact dr. office to arrange/confirm follow up appointment. 2. please contact your pcp to inform him/her of your recent hospital stay Procedure: Other cystoscopy Retrograde pyelogram Transurethral removal of obstruction from ureter and renal pelvis Ureteroscopy Replacement of ureterostomy tube Diagnoses: Chronic kidney disease, Stage V Other primary cardiomyopathies Acidosis Anemia in chronic kidney disease Other postoperative infection Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Other B-complex deficiencies Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Calculus of ureter Degeneration of intervertebral disc, site unspecified Ankylosing spondylitis |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever major surgical or invasive procedure: tagged wbc scan history of present illness: mr is a 83 m w/esrd on hd, chf, ankylosing spondylitis and remote hx nhl w/bowel resection & papillary bladder ca, presenting with hypotension and fever to 101.8 during hd. he undergoes home hd 5x weekly. today, at the onset of dialysis he complained of shaking and chills; his temperature was noted to drop from 97.9-->94.9 and then increase to 101.8 at the end of hd. he was negative 800 cc today. he had otherwise been in his usual state of health besides some overnight dizziness which was attributed by the patient and his wife to newly prescribed gapapentin. his hd graft includes plastic hardware and was placed in 5-. he was discharged in for proctitis and painful stooling with a 14-day course of abx; his pain with defecation recurred recently but has been better in last week with anal care. his chronic diarrhea (he is s/p bowel resection) has been worse in last week. he denies cp, sob, abp, n/v, cough. he makes only small ammounts of urine; he denies tenderness over av fistula in the ed vitals were 101.7, 87/47, 18. he was given 2l ivf, was persistently hypotensive, received further 2l ivf and was started on pressors. he had a tachycardic response to levophed and was transitioned to neosynephrine. his mental status remained intact throughout. a ua was suggestive of uti, a cxr and a ct pelvis was performed. peripheral blood cultures were drawn. he was admitted to the micu. past medical history: - htn - non-ischemic cardiomyopathy (ef 25-30%) - chronic renal insufficiency (baesline 5.5-6. positive. possibly secondary to tubular interstitial disease.) - nephrolithiasis (first kidney stone at the age of 25 which he passed with a lot of pain. asymptomatic since then. back ct revealed bilateral renal stones that were quite large (>1.0 cm). the patient had laser lithotripsy in on the right side and in on the left side by dr. . this was repeated on last admission in .) - chronic back pain since secondary to ankylosing spondylitis, ddd and facet degeneration (mri l spine on : mild l45 central, mod/sev r and mild l foraminal stenosis, moderate l34 central and mod l l3 foraminal stenosis. spine survey on at nebh: ossification of pll c/w ankylosing spondylitis. ct l spine on : l34 and l45 advanced degenerative disc disease. on tens for mobility.) - memory difficulties - nhl (initially thought to have crohn disease, went for surgery that revealed lymphoma, involving bladder. he was further treated with 9 cycles chemotherapy, radiation and bowel resection. no recurrence.) - short gut syndrome after bowel surgery. takes monthly b12 injections. () - urinary frequency - papillary urothelial carcinoma of the bladder s/p partial bladder resection - scc l ear () - bcc l nose () - femoral neck fracture s/p internal stabilization - left partial lateral knee meniscectomy () - secondary hyperparathyroidism - anemia esrd & b12 deficiency social history: professor and is teaching european history. he has insignificant history of smoking when he was much younger and experimented with tobacco but nothing really significant. he has no history of alcohol abuse or illicit drug use. he lives with his wife, , who runs his hemodialysis machine at home and manages all of his chronic medications and treatments. family history: family history: his father died of mi age 57. his brother died of multiple sclerosis at the age of 40. his sister is 86 and in very good health. his mother died after falling down the stairs but his maternal aunts lived over the age of 100. otherwise non-contributory. physical exam: on admission to micu: general: tall man lying in bed shivering. alert, oriented, names date of invasion of poland () without delay, in no acute distress heent: sclera anicteric, conjunctiva pale, mmm, oropharynx clear. neck: supple, neck veins distended to past ear lungs: clear to auscultation bilaterally with good inspiration, no wheezes, rales, ronchi cv: regular rate and rhythm. at rusb: ii-iii/vi murmur loudest at rusb with diminished s1, s2. otherwise no m/r/g, normal s1, s2. abdomen: soft, non-tender, non-distended, bowel sounds present ext: warm, well perfused, 2+ radial pulses, dp pulses 1+, no clubbing, cyanosis or edema. 3rd digit on lle with brackish plaque on distal toe. pertinent results: admission labs: . 07:55pm pt-14.4* ptt-23.1 inr(pt)-1.2* 07:55pm plt count-136* 07:55pm wbc-14.5* rbc-3.03*# hgb-10.1*# hct-30.2*# mcv-100* mch-33.5* mchc-33.6 rdw-16.1* 07:55pm calcium-7.8* phosphate-4.0# magnesium-1.7 08:20pm urine color-yellow appear-cloudy sp -1.017 . .ekg: . : sinus tachycardia. a-v conduction delay. left axis deviation. left anterior fascicular block. left ventricular hypertrophy. diffuse non-specific st-t wave changes. compared to the previous tracing of left anterior fascicular block is present and the rhythm is now sinus tachycardia. . . upper extremity ultrasound: appearance most suggestive of a 2-cm partially thrombosed pseudoaneurysm at the arterial anastomosis of the av graft in the antecubital fossa. . echo:the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild to moderate regional left ventricular systolic dysfunction with inferior/ inferolateral hypokinesis/akinesis. left ventricular ejection fraction estimated ?40%.. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). there is probably at least mild aortic stenosis but adequate aortic valve gradient was not obtained due to suboptimal acoustic windows.. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the tricuspid valve leaflets are mildly thickened. there is no pericardial effusion. . cxr: : interval placement of right ij central venous catheter with tip in good position. . ct pelvis:. no evidence of perirectal abscess formation or deep space infection. 2. previously seen proctitis has significantly improved/resolved. . tagged wbc scan: mildly increased asymmetric tracer uptake corresponding to the right proximal femur seen on the whole body posterior images. if there is clinical concern for persistant infection, a sulfur colloid scan may be obtained for further evaluation. brief hospital course: mr. is a pleasant 83 year old male with a history of esrd on in-home hd who presented s/p hd with fevers and hypotension requiring icu admission: . 1. suspected sepsis -- mr presented to the ed with a wbc of 14.5 and lactate of 2.1 in the setting of fever and hypotension. cardiac causes of hypotension were excluded with ekg and history, and he received 4l fluids in the ed. a uti was considered; his ua was suggestive but he is anuric and a urine culture was negative. given his hx of proctitis, a pelvic ct was performed which did not suggest a source. as his chronic diarrhea had increased slightly in the last week, c diff toxin screening was performed and was negative. given the history of symptoms beginning during dialysis and the recent surgical manipulation of his av graft site (recent fistulogram and dilation of stenosis 1 week pta) a graft infection was also considered. an ultrasound performed on the second hospital day demonstrated a 2cm pseudoaneurysm of the graft site with a 90% occlusive thrombus. he received coverage with vancomycin and zosyn while in the icu, which was revised to vanco monotherapy upon callout to the floor. he was initially maintained on neosynephrine for hypotension for the first 24 hours of his icu stay. importantly, his pulse pressure is normally wide with his av graft and pseudoaneurysm, and his sbps run in the 90s-100s pre-hd and in the 80s post-hd- his pressor was subsequently weaned rapidly, which was well tolerated. he had no further episodes of hypotension while in the hospital. infectious disease was consulted. they felt that he developed a transient bacteremia in the context of hd. culture data remained negative throughout the admission. his wife sent a sample of his home dialysate fluid taken from the session prior to admission to his hd laboratory. these were negative at 24 and 48hrs. no vegetations were seen on echo. per id recommendation, he underwent a tagged wbc scan on , and was reimaged on . while it demonstrated a possible abnormality of the right femur, he had been clinically improving with resolving leukocytosis and fevers, so further imaging with the recommended sulfer colloid scan was not pursued. he finished a 7 day course of vancomycin on the day prior to discharge. he was not sent out on antibiotics. he was given strict instructions to call his physician in the event of fevers, chills, or rigors. . 2. atrial fibrillation: upon transfer to the floor, mr. developed new onset atrial fibrillation with rates to 100-110. this occurred following hd, and was transient. he was started on 12.5mg metoprolol . his echo was not demonstrative of structural etiology, and his tsh was normal. he reverted back into sinus rhythm by the following morning. he had one other episode of afib with rate 80-100 following hd the next day. his metoprolol was discontinued due to borderline bp in the 90s and due to the fact that his rates were generally low while in atrial fibrillation. due to his paroxysmal afib and chads2 score of 3, he met requirement for warfarin, and was subsequently heparinized and started on warfarin. he received 5mg x2 days with achievement of therapeutic inr of 2.9. he will follow up with his pcp to have his inr checked. 3. diarrhea -- chronic, bowel resection in past. rate had increased in last week and he was ruled out for c diff with a stool toxin assay x1. 4. esrd -- he continued to receive dialysis through his graft throughout the hospitalization which was well tolerated. 5. anemia -- mr. has chronic anemia esrd, and is on aranesp. he presented with hb/hct 10.1/30.2; his hct dropped to 26 after fluid resuscitation was was judged to be dilutional. his stool was guaiac positive but he has known hemorrhoids; it was not grossly bloodly. his hct remained stable afterward. 6. chest pain -- mr. had a brief episode of central sharp chest pain after straining on hd#2. an ekg was unchanged and the pain resolved without treatment. medications on admission: gabapentin 100mg caps 1-2 tabs qhs prn pain omeprazole 20mg renvela 800mg 3-5tabs po daily with meals epogen unit qmonday subcut ergocalciferol 400 units once daily calcitriol 0.25mg once every other day renal caps calcium 500mg nepro supplement two bottles daily hydrocortisone 1mg cream prn anal irritation hydrocortisone suppository oxycodone/acetaminophen 2.5-325mg prn pain cyanocobalamin 1000mg subcut monthly testosterone 200mg im q 3 weeks prednisone prn gout attack dosed as 30-20-10mg 3-day taper loperamide 2mg prn diarrhea 2caps 4 times daily heparin 3000 unit prior to each dialysis lidocaine cream (for dialysis site)prior meds: amlodipine, metoprolol, calcium, mvi, tramadol discharge medications: 1. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals): 3-5 times daily with meals. 2. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day (every other day). 3. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 4. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po twice a day. 5. loperamide 2 mg capsule sig: two (2) capsule po qid (4 times a day) as needed for diarrhea. 6. hydrocortisone acetate 25 mg suppository sig: one (1) suppository rectal daily (daily). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 8. lidocaine-prilocaine 2.5-2.5 % cream sig: one (1) appl topical prior to dialysis (). 9. gabapentin 100 mg capsule sig: capsules po at bedtime as needed for pain. 10. epogen injection 11. ergocalciferol (vitamin d2) 400 unit tablet sig: one (1) tablet po once a day. 12. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day. 13. hydrocortisone topical 14. cyanocobalamin (vitamin b-12) 1,000 mcg/ml solution sig: one (1) injection injection once a month. 15. testosterone cypionate 200 mg/ml oil sig: one (1) injection intramuscular every 3 weeks. 16. heparin flush intravenous 17. prednisone oral 18. percocet 2.5-325 mg tablet sig: 1-2 tablets po twice a day as needed for pain. 19. nephrocaps oral 20. warfarin 2.5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 21. nepro 0.08-1.80 gram-kcal/ml liquid sig: two (2) bottles po once a day. discharge disposition: home discharge diagnosis: primary diagnoses: 1. sepsis from transient bacteremia during hd 2. atrial fibrillation secondary diagnoses: 1. end stage renal disease 2. chf 3. htn discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. bunion, you were admitted to because of fevers and low blood pressure during home hemodialysis. you were admitted to the icu on medications to maintain your blood pressure, and you were started on iv antibiotics. you remained without fevers during your hospital stay. infectious disease doctors recommended a special study to look for a source of the infection which was initially normal, though the radiologists recommended repeating this test again to be sure. this scan did not reveal any overt signs of infection. the source of your infection is not immediately clear- it may be related to your hemodialysis or your graft. we did an ultrasound of your graft, which did not reveal any infections. we finished your antibiotics course in the hospital. it is important that you call your doctor if you develop any fevers or chills concerning for infection. you developed an abnormal heart rhythm called atrial fibrillation during your hospital stay. it's source is unclear, but it seems to occur following hemodialysis. because of an increased risk of stroke, you will be starting a blood thinning medication called coumadin. please make the following changes to your medications: start warfarin, 2.5mg daily until you have your blood checked by your primary care doctor , who will manage your dose. while taking coumadin, it is important to eat a constant diet, particularly with regards to fruits, vegetables (particularly green leafy vegetables), and other foods in vitamin k. followup instructions: have an appointment to follow up with dr. on to go over your hospital course and monitor your blood inr (a measure of how thin it is) department: when: at 1:20 pm with: , md building: (, ma) campus: off campus best parking: on street parking department: cardiac services when: at 4:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: advanced vasc. care cnt when: tuesday at 9:00 am with: , md building: (, ma) campus: off campus best parking: free parking on site Procedure: Venous catheterization, not elsewhere classified Hemodialysis Diagnoses: Other primary cardiomyopathies Anemia in chronic kidney disease End stage renal disease Renal dialysis status Unspecified septicemia Atrial fibrillation Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Personal history of other lymphatic and hematopoietic neoplasms Personal history of other malignant neoplasm of skin Personal history of malignant neoplasm of bladder Secondary hyperparathyroidism (of renal origin) Diarrhea Other and unspecified postsurgical nonabsorption Ankylosing spondylitis |
allergies: no known allergies / adverse drug reactions attending: chief complaint: thrombosed avg, weakness major surgical or invasive procedure: r ue avg thrombectomy w/ jump graft history of present illness: 84yom with h/o esrd on home hd s/p rue forearm avg on (not-functioning due to thrombus), recent hospitalization for mrsa pneumonia from to , recent c.diff infection on , afib on coumadin, htn, non-ischemic cardiomyopathy (ef 25-30%), shortgut syndrome presents to ed because avg is not working, also complains of weakness. the patient reports that since , when he was discharged from after treatment for pneumonia, he has felt more weak. he is now nearly unable to stand on his own. the reason he came to the ed this morning was because he contact his hd nursing company to explain that his avg was not-functioning (his wife is trained to perform hd at home) and he was referred to the ed. . in the ed, initial vs were 98.0 91 102/55 18 97% on 3l. labs showed k 5.9, cr 11.9, hct at baseline 38.3, inr 2.5 and troponin at 'baseline' of 0.05. cxr was negative for acute process. ekg showed afib with lad, twi in lateral leads and 1-mm st depressions in v4 to v6, also with 2mm isolated ste in v2. patient was administered aspirin 325 mg, ceftriaxone 1g, kayexelate, azithromycin 500 mg, vancomycin 1g for presumed pneumonia and hyperkalemia. he was also seen in the ed by transplant surgery for a thrombus in his new rue avg - transplant surgery plans to perform thrombectomy on . . on the floor, vs 98.6 100/82 75 16 95% on ra. the patient appears well. he denies cp, sob, productive cough, abdominal pain, fevers. he endorses diarrhea (has shortgut at baseline) but thinks stools are more frequent than normal. did have a dark bm this morning. his wife is very involved in his care. they state his graft was working , wed, thurs of last week but could not be accessed and had no thrill on friday. . of note, the patient was recently hospitalized twice. first on the transplant surgery service after his rue avg from to for proctitis - c.diff + during that admission (po flagyl and vancomycin have been continued since - due to finish on ). he was again hospitalized from to on the medicine service for fever. he was treated for mrsa pneumonia with iv vancomycin and was discharged to complete 8-days of linezolid and an additional course of flagyl and vanco for c.diff. . ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: medical & surgical history (per omr): -hypertension -atrial fibrillation on coumadin -non-ischemic cardiomyopathy (ef 25-30%) -esrd on hd at home qmon/tue/wed/fri/sat -kidney stones -ankylosing spondylitis -memory difficulties -nhl (chemo, xrt - ), s/p colon and small bowel resection -shortgut -secondary hyperparathyroidism -anemia . past surgical hx (per omr): -rue forearm avg () -lue av graft failed thrombectomy () -debridement left 3rd toe () -lue av graft angioplasty () -lue av graft () -lithotripsy ( and ) -papillary urothelial carcinoma of the bladder s/p partial bladder resection -scc l ear () -bcc l nose () -femoral neck fracture s/p internal stabilization -l partial lateral knee meniscectomy () social history: part time professor , insignificant history of smoking when he was much younger and experimented with tobacco. he has no history of alcohol abuse or illicit drug use. he lives with his wife, , who runs his hemodialysis machine at home and manages all of his chronic medications and treatments. family history: father died of mi age 57. brother died of multiple sclerosis at the age of 40. sister is 86 and in very good health. mother died after falling down the stairs maternal aunts lived over the age of 100. physical exam: on admission: vs - 98.6 100/82 75 16 95% on ra general - elderly man in nad, comfortable, appropriate heent - nc/at, perrl, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - cta bilat, resp unlabored, no rales heart - irregularly irregular rhythm, no mrg, nl s1-s2, av fistula heard abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, l middle toe with tip amputated, diminished peripheral pulses but dps are palpable skin - no rashes or lesions neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughou . on discharge: pertinent results: on admission: . 12:00pm blood wbc-10.6 rbc-3.96* hgb-12.7* hct-38.1* mcv-96 mch-32.0 mchc-33.2 rdw-15.9* plt ct-205 01:00pm blood pt-26.1* inr(pt)-2.5* 01:00pm blood glucose-187* urean-58* creat-11.9*# na-139 k-6.1* cl-101 hco3-25 angap-19 01:00pm blood albumin-3.5 calcium-7.9* phos-4.2 mg-1.8 . blood and urine cultures: negative . cxr: no acute intrathoracic process repeat cxr read as rll pneumonia but appears largely unchanged from prior xrays brief hospital course: 84 year old man with h/o esrd on home hd, recent hospitalization for mrsa pneumonia (), recent c.diff infection ( ), afib on coumadin, htn, non-ischemic cardiomyopathy (ef 25-30%), shortgut syndrome, who presented with persistent cough and weakness. his respiratory status declined throughout this admission, prompting frequent hemodialysis and ultrafiltration to improve pulmonary edema in addition to a 10 day course of antibiotics for hospital acquired pneumonia. despite this, his respiratory failure worsened and he continued to require 4l of oxygen. pulmonary edema worsened and required nearly daily hemodialysis or ultrafiltration. the decision was made with the patient and his family to transition to home hospice. he passed away with his wife at the bedside on at 12:00pm. medications on admission: 1. linezolid (completed) 2. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 19 days: please take medication from until . (please take this medication until two weeks after finishing your linezolid course.). disp:*57 tablet(s)* refills:*0* 3. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 19 days: please take medication from until . (please take this medication until two weeks after finishing your linezolid course.) . disp:*76 capsule(s)* refills:*0* 4. testosterone cypionate 200 mg/ml oil sig: one (1) cc intramuscular every three weeks. 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 6. cyanocobalamin (vitamin b-12) 1,000 mcg/ml solution sig: one (1) cc injection once a month. 7. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 8. warfarin 1 mg tablet sig: one (1) tablet po once a day: please adjust dose based on coumadin level. . 9. anusol-hc 25 mg suppository sig: two (2) suppositories rectal once a day as needed for for excruciating anal pain. 10. hydromorphone 2 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 11. gabapentin 100 mg capsule sig: two (2) capsule po hs (at bedtime) as needed for pain. 12. lidocaine-prilocaine 2.5-2.5 % cream sig: one (1) application topical prior to dialysis. 13. heparin (porcine) 1,000 unit/ml solution sig: 2.5 cc through arterial access and 2.6 cc via venous access s/p dialysis injection see above. 14. heparin (porcine) 1,000 unit/ml solution sig: given through venous access before dialysis injection see above. 15. epogen 2,000 unit/ml solution sig: one (1) solution subcutanesouly injection once a week: on tuesday. 16. nepro 0.08-1.80 gram-kcal/ml liquid sig: 1-2 bottles po once a day. 17. sensipar 30 mg tablet sig: one (1) tablet po once a day. 18. calcium 500 500 mg (1,250 mg) tablet sig: two (2) tablet po once a day. 19. renal caps 1 mg capsule sig: one (1) capsule po once a day. 20. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 21. ergocalciferol (vitamin d2) 400 unit tablet sig: one (1) tablet po once a day. 22. codeine-guaifenesin 10-100 mg/5 ml liquid sig: 5-10 mls po q4h (every 4 hours) as needed for cough for 7 days. disp:*1 bottle* refills:*0* 23. renvela 800 mg tablet sig: one (1) tablet po three times a day: with meals. 24. hydrocortisone 1 % ointment sig: 1 application to anal area topical once a day as needed for irritation. discharge medications: patient is deceased discharge disposition: expired discharge diagnosis: primary: weakness a-v graft thrombus esrd on hemodialysis . secondary: atrial fibrillation hypertension non-ischemic cardiomyopathy discharge condition: patient is deceased. discharge instructions: patient is deceased followup instructions: patient is deceased Procedure: Venous catheterization, not elsewhere classified Hemodialysis Revision of arteriovenous shunt for renal dialysis Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Hyperpotassemia End stage renal disease Renal dialysis status Congestive heart failure, unspecified Atrial fibrillation Depressive disorder, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Personal history of other lymphatic and hematopoietic neoplasms Personal history of other malignant neoplasm of skin 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 Personal history of malignant neoplasm of bladder Diarrhea Encounter for palliative care Other and unspecified postsurgical nonabsorption Other malaise and fatigue Other complications due to renal dialysis device, implant, and graft Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Other specified hypotension Personal history of Methicillin resistant Staphylococcus aureus Chronic combined systolic and diastolic heart failure Ankylosing spondylitis |
allergies: no known allergies / adverse drug reactions attending: chief complaint: respiratory distress. major surgical or invasive procedure: thoracentesis . bronchoscopy with stent placement . bronchoscopy with stent removal . thoracentesis with pigtail drain placement . removal of pigtail picc line placement history of present illness: 77 year old man with h/o stage ib (pt2an0mx) squamous nsclc s/p right lower wedge resection (), presenting with lung/pleural and rib mets with extrinsic and intrinsic compression. he presented for rigid and flexible bronchoscopy, initially planned as a day/ambulatory procedure. flexible bronchoscope showed patent distal airways. a stent was placed at the . balloon dilatation perfomed with-in the stent. patency of distal airways confirmed. estimated blood loss was minimal. . in , pt was hypoxemic after extubation to 88-91% on room air (does not use oxygen at home). blood pressure 89/70. he remained well-appearing and mentating post-operatively and ambulating with the rn around the . planned thoracentesis was performed at bedside, with 2.2l drained from the right pleural space with subjective improvement in symptoms. post-procedure cxr without pneumothorax. given his vital signs, the patient was planned for admission overnight with telemetry and continuous pulse oximetry observation. he was placed on 10l non-rebreather initially for desaturations into the low 80s and then transitioned to 4l shovel mask, gradually to 4l nasal cannula with neb treatments and mucinex. . pt received ivf without improvement in his blood pressures. his blood pressures improved with attempted a-line, peripheral placements to peak sbp100. while awaiting micu bed, the patient had labs drawn (within normal limits, wbc 6.7 --> 10), blood cultures sent, received vancomycin/cefepime. in discussions with ip, second cxr while in suggestive of rml/rll collapse after procedures with planned flex bronch by ip in the morning. . he was admitted from the to the micu due to concerns about his respiratory status. he was taken back to the or for another rigid/flex bronch. attempt was made to reposition the stent more proximally, which did not improve rml/rll aeration and obstructed the rul, so stent was removed. lma removal/extubation occurred right away, but bipap was initially required upon transfer to icu after this procedure. a pigtail was also placed for continued drainage of r sided effusion. oxygen has been weaned down to nasal cannula, bp remained stable and t transferred to th eoncology floor on .on th eoncology floor pt reports he feels quite well, feels breathing significantly improved. no chest pain, nausea/abdominal pain. has had occasional cough with yellow sputum, no blood. stable weight, no edema, no orthopnea. all other ten point ros was negative. past medical history: obesity, hypertension, cad s/p cabg, hyperlipidemia, anemia, polyclonal gammopathy, osteoarthritis, hypogonadism, renal insufficiency, bph, allergic rhinitis, skin cancer, and ischemic optic neuropathy, l orbital pseudotumor s/p biopsy. s/p wedge resection of rll as above. . oncologic history: -- in , he was seen in the ophthalmology clinic for worsening right eye blindness and headache. -- in cta revealed complete occlusion of the right ica and patent acom, and moderate stenosis of the right vertebral artery. -- in early , he was reevaluated for persistent headaches and progressive visual loss. imaging revealed a retroorbital lesion. on mri and mra imaging studies nsmc: an ill-defined mass in the right posterior orbit encasing the optic nerve extending into the right cavernous sinus with thrombosis of the rca inside the cavernous sinus. -- on , he was seen by neurosurgery for evaluation. -- on , given the concern for lymphoma, a ct of chest, abdomen, and pelvis was performed to assess for other lesions. this revealed a 1 cm right lower pulmonary nodule with irregular margin concerning for primary lung cancer or metastatic disease. otherwise, on imaging was found no evidence of lymphoma, a 6-mm bladder diverticulum. -- on , pet ct scan revealed 24 x 22 mm right retroorbital soft tissue mass which is fdg avid (suv maximum 5) with fdg avid retrobulbar fat. in the right lower , fdg avid 14-mm solitary nodule (suv maximum 7.1) otherwise no evidence of distant fdg avid disease. -- on , biopsy of the orbital apex lesion showed a mixed inflammatory picture, it was not diagnostic lymphoma. -- on , pet ct noted a 2.2 cm right lower nodule with a suv maximum 8.24 with no fdg avid mediastinal, hilar, or axillary lymphadenopathy. again noted was the fdg avid right retroorbital soft tissue density. -- on , he underwent a right lower wedge resection, which revealed squamous cell carcinoma (2.5 x 2 x 1.5 cm) grade 2 moderately differentiated t2a n0 mx tumor which was invading the visceral pleura and had lymphovascular invasion. level 7 and 9 lymph nodes were negative for malignancy. a few days prior to his six-month followup visit, he noticed being increasingly short of breath. -- on , ct of the chest revealed new right-sided effusions and new 3-mm nodules in the left upper and lower lobes, suspicious. -- on , 2 liters of pleural fluid were drained from his right lung, which was negative for malignant cells. -- on , pet ct revealed stable retroorbital soft tissue fullness. a 3.4 cm right lower fdg avid nodule (maximum suv is 30), fdg avid lymph nodes in the right perihilar region measuring largest 2.5 x 1.4 x 5 cm maximum suv 30 associated with marked narrowing of the bronchus intermedius, obstruction of the lower bronchus with distal patency, and marked narrowing of the origin of the middle bronchus. there were 2 fdg avid pleural soft tissue masses on the right measuring 2.8 x 3.2 cm (maximum suv 36) and another nodule measuring 3.9 x 4.2 cm (maximum suv 19) along with pleural posterior to the right costophrenic angle highly suspicious for metastatic deposits. in addition to right pleural effusion, there is bronchovascular thickening in the right lower suspicious for lymphangitic spread of disease. the three nodules which are seen in the previous study remain unchanged. there are postoperative changes consistent with right lung wedge resection. there are two fdg avid rib metastases, anterior fourth rib (maximum suv 37) and posterior eighth rib (maximum suv 17) and a right sacral metastasis (maximum suv 26). -- on , dr. performed bronchoscopy. fine needle aspirate of the right upper lope endobronchial mass and right bronchus intermediate mass both revealed squamous cell carcinoma, non-small-cell carcinoma. social history: previously with relatively active lifestyle. he enjoys fishing, boating, gardening, and walks with his wife. 60 pack year smoking history, quit 20 years ago. family history: positive for hypertension, renal failure, and possibly cad in his mother. family history of diabetes or malignancies. physical exam: on transfer from micu to oncology: t97.3, 130/56, hr 73, r20, 92% on 4l nc alert, appropriate, breathing comfortably, no distress. heent: small healing lac on lower lip on r. perrl and anicteric. slight r eyelid droop. op clear. neck: obese, supple, no jvd elevation appreciated, no adenopathy. heart: regular, slightly distant, no m/r/g. chest: symmetric expansion. r side diminished throughout particularly at post base, with expiratory rhonchi. l side clear. abdomen: +bs, soft, nt/nd. extrem: warm, picc site lue benign. 1+ pitting le edema. no clubbing. neuro: alert. ue/le strength bilat. pertinent results: on admission: 06:46pm blood wbc-10.7# rbc-3.74* hgb-11.1* hct-33.5* mcv-90 mch-29.7 mchc-33.1 rdw-14.4 plt ct-358 06:46pm blood glucose-102* urean-21* creat-1.1 na-139 k-4.5 cl-105 hco3-25 angap-14 06:46pm blood calcium-8.4 phos-4.3 mg-1.9 06:40pm blood type-art po2-62* pco2-64* ph-7.20* caltco2-26 base xs--3 05:34am blood lactate-1.2 . lactate trend: 05:34am blood lactate-1.2 06:40pm blood lactate-0.7 08:54pm blood lactate-0.7 10:25pm blood lactate-0.6 11:50am blood lactate-0.6 05:33pm blood lactate-0.7 . labs at transfer from micu to floor: 03:15am wbc-8.3 rbc-3.17* hgb-9.4* hct-28.2* mcv-89 mch-29.5 mchc-33.2 rdw-14.2 plt ct-275 glucose-96 urean-13 creat-0.9 na-138 k-4.4 cl-104 hco3-26 angap-12 calcium-8.7 phos-2.6* mg-2.1 o2 flow-4 po2-71* pco2-49* ph-7.38 caltco2-30 base xs-2 . reports: ct chest: impression: 1. new collapse of the entire right lung is explained by tumor impinging on the right upper bronchus and occlusion of the bronchus intermedius stent by secretions, partially bloody. 2. moderate right pleural effusion, stable volume since , despite large, interval thoracentesis, may contain minimal bleeding. 3. right pleural metastasis, increased since . 4. new moderate left basilar atelectasis and a small left pleural effusion. . cxr: impression: 1. left approach picc terminating within the right atrium. 2. only mild improvement in dense opacification of the right hemithorax with aeration of only the right upper . there is still a large right pleural effusion demonstrating loculated components. no evidence of pneumothorax. . : lue u/s:non-occlusive thrombosis of the left basilic vein (superficial vein). . brief hospital course: 77yo man with stage iv squamous cell ca of the lung and cad admitted for dyspnea, respiratory distress, and a obstructive right lung collapse. bronchial stent was attempted by interventional pulmonary, but the stent became occluded and was not able to be reopened. so it was removed . pus from the obstructed bronchus was noted. thoracentesis drained ~2.2 lit. he was transferred out of the icu 0n . . # hypoxia: due to obstructive right lung collapse, progressive nsclc, and post-obstructive bacterial pneumonia. stent placed , removed . right-sided pig-tail placed, continues to drain. radiation oncology consulted for xrt to relieve bronchial obstruction. pt completed antibiotics (ceftriaxone/azithromycin) for post-obstructive pneumonia and also received prn nebs. on d/c sats in high 90's on 4 lit nc and able to amnbualte with assistance comfortably.. . # nsclc: pt started xrt to relieve bronchial obstruction on and plan for 10 day treatemnt total dose 3000cgy. he is scheduled to see dr , his medical oncologist, after completion of radiation treatment or earlier as needed. . # hypotension: pt became hypotensive after the treatment. he did require pressors in the icu. on th efloor he did have a few brief episodes of asymptomatic hypotension ( systolic to 80's). am cortisol level was 12.2 and a cosyntropin test was negative for adrenal insufficiency.ecg was unremarkable and pt was also monitored on telemetry, which was uneventful. blood cutures were obtained and remained sterile. orthostatics also negative. 48 hrs prior to discharge blood pressure remained stable. # non-occlusive thrombosis of left basilic vein: pt developed lue pain and swelling . u/s of lue revealed a non-occlusive thrombosis of left basilic vein, which was the site of teh picc line. the pain and swelling resolevd spontaneously adn the picc line was removed. . # anemia: anemia panel c/w anemia of inflammation.pt did receive 1 unit of prbcs during hospital stay with appropriate response. . # urinary retention: pt had a foley cath placed prioir to transferto teh oncology floor. initiail voiding trial unsuccessful and foley was replaced . 1 dose of tamsulosin was given but not tolerated due to low blood pressures. after d/w urology a second trial was attempted and successful. . # cad: aspirin held for procedures and restarted a t a dose of 81 mg. . # hyperlipidemia: continued outpatient statin. . # pain: pain was well controlled with acetaminophen as needed. . # fen: regular diet. . # gi ppx: started a ppi and bowel regimen. . # dvt ppx: heparin sc. . # precautions: none. . # code: full. medications on admission: 1. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet sl prn cp. 4. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 5. miconazole nitrate 2 % powder sig: one (1) appl topical prn candidiasis. 6. acetaminophen 325 mg tablet sig: two (2) tablet po q6h as needed for pain. . medications on transfer from icu to oncology: - hsq 5000 units tid - atorvastatin 20 mg daily - mucinex 600 mg - atrovent neb q6h - albuterol neb q6h prn - nitro sl prn - apap prn discharge medications: 1. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 2. guaifenesin 600 mg tablet extended release sig: one (1) tablet extended release po bid (2 times a day) for 5 days. 3. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for dyspnea or wheeze. 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every six (6) hours as needed for sob/wheezing. 5. petrolatum ointment sig: one (1) appl topical tid (3 times a day) as needed for to lip abrasion. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for loose stools. discharge disposition: extended care facility: discharge diagnosis: 1. shortness of breath. 2. pleural effusion (fluid in the lung space). 3. collapsed right lung. 4. post-obstructive pneumonia (lung infection due to a blocking tumor). 5.hypoxia (low oxygen levels). 6.hypotension 7.urinary retension 8.anemia 9.basilic vein non-occlusive thrombosis ( superficial clot) discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital for shortness of breath. this was due to a collapsed right lung from a blocking tumor. the pulmonary physicians attempted to open up the lung by inserting a stent into the airway. unfortunately, after multiple attempts, this did not work, so the stent was removed. fluid from the right lung was removed and a drain was left in place. after the procedure you became hypotensive and you were transferred to the intensive care unit. you were placed on antibiotics for pneumonia (lung infection) and continued to need oxygen.you were transferred to the oncology floor when stabilized. antibiotics were continued and you were monitored closely.you received one unit of red blood cells you were evaluated by radiation oncology and you underwent mapping for radiation treatment which was started today( . change in medications: aspirin decreased to 81 mg albuterol neb treatments as needed for shortness of breath /cough. pantoprazole followup instructions: 1. radiation oncology: . 2.department: hematology/oncology when: thursday at 9:30 am with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: thursday at 9:30 am with: dr. building: sc clinical ctr campus: east best parking: garage Procedure: Thoracentesis Thoracentesis Non-invasive mechanical ventilation Arterial catheterization Endoscopic excision or destruction of lesion or tissue of lung Other radiotherapeutic procedure Central venous catheter placement with guidance Diagnoses: Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Secondary malignant neoplasm of pleura Personal history of tobacco use Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Pulmonary collapse Other and unspecified hyperlipidemia Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Malignant neoplasm of bronchus and lung, unspecified Disorders of phosphorus metabolism Unspecified disorder of kidney and ureter Other complications due to other vascular device, implant, and graft Retention of urine, unspecified Mechanical complication due to other implant and internal device, not elsewhere classified Other diseases of lung, 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 Accidents occurring in residential institution Accidents occurring in unspecified place Secondary malignant neoplasm of bone and bone marrow Anemia in neoplastic disease Ischemic optic neuropathy Bacterial pneumonia, unspecified Shock, unspecified Systemic inflammatory response syndrome, unspecified Acquired absence of organ, lung Monoclonal paraproteinemia Acute venous embolism and thrombosis of superficial veins of upper extremity Malignant pleural effusion |
allergies: zosyn attending: chief complaint: hypotension major surgical or invasive procedure: intubation, cvvh, dialysis catheter placement arterial line placement tracheostomy () - general sugery history of present illness: 48 f with id-t2dm, trisomy 21, osa, presents with hypotension and hyperglycemia, found in septic shock. . ms. developed vomiting on saturday am. many adults in her family who spent the holidays together had a gastroenteritis. patient continued to vomit or dry heave all night every 15 minutes. persisted this am. bs > 250 yesterday and > 500) today. she was able to take small amounts of fluids but felt lightheaded and had a dry mouth this am. . on presentation to the ed, her vs: 97.8 63 108/78 22 95%. she had a lactate 6.0, gluc 500. fluid resuscitation was attempted with over 6l of crystalloid (4lns, 2l lr total). a right ij cordis was placed. pressors were begun with levo and then neosynephrine, however sbp remained in the 70's. she was intubated for agitation during a-line placement. zosyn and vancomycin were started and urine and blood cultures were sent, though it was unclear whether it was before the abx. insulin 10 u was provided at the outset, followed by a 10 u/hr insulin drip. at the time of transfer, an abg was 7.05/32/134/9 with lactate 3. vital signs at the time of transfer were hr 104, bp94/43, 100% on 100% . past medical history: # type ii diabetes: last a1c 8.3% in # down syndrome. # cardiac complications of trisomy 21 including: () # septum primum asd (repaired at age 15). persistent small asd # residual cleft anterior mitral leaflet with moderate mr and #. possible subaortic membrane # duodenal stricture with regular ballooning () # barrett's esophagus # osa on cpap # osteoporosis: # vitamin d insufficiency # hypothyroidism # cervical spondylosis c/b leg weakness # sciatica # onychomycosis social history: lives with parents. non smoker. non drinker family history: non-contributory. physical exam: presenting: 97.8 63 108/78 22 95% transfer: hr 104, bp94/43, 100% on 100% admission: hr 100's, sbp 94 gen: intubated, sedated heent: perrl, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd appreciable, no carotid bruits, no thyromegaly or thyroid nodules resp: soft wheezes b/l with good air movement throughout cv: trr, s1 and s2 wnl, 2/6 sem at lusb abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: brawny edema diffusely skin: no rashes/no jaundice/no splinters neuro: sedated. no posturing. pertinent results: labs: 12:10pm blood wbc-6.7 rbc-3.00* hgb-10.3* hct-34.6* mcv-115*# mch-34.2* mchc-29.7*# rdw-13.3 plt ct-259 12:10pm blood neuts-89.7* lymphs-6.4* monos-3.6 eos-0.1 baso-0.2 09:38pm blood pt-13.8* ptt-24.6 inr(pt)-1.2* 12:10pm blood glucose-1155* urean-58* creat-2.6*# na-126* k-6.4* cl-83* hco3-8* angap-41* 12:10pm blood calcium-7.8* phos-7.7*# mg-2.4 05:20pm blood alt-145* ast-375* alkphos-65 amylase-19 totbili-0.3 . 04:53am blood ld(ldh)-708* ck(cpk)-3464* totbili-0.2 08:17pm blood ck(cpk)-3062* 04:07am blood ck(cpk)-2828* 04:36am blood ck(cpk)-* 05:20pm blood lipase-11 04:53am blood ck-mb-202* mb indx-5.8 ctropnt-8.06* 08:17pm blood ck-mb-126* mb indx-4.1 ctropnt-3.70* 04:07am blood ck-mb-92* mb indx-3.3 ctropnt-3.05* 04:36am blood ck-mb-32* mb indx-1.7 ctropnt-3.29* 12:16pm blood ck-mb-18* mb indx-1.2 ctropnt-3.70* . 05:20pm blood vitb12-> 04:53am blood folate-greater th 11:19am blood hapto-145 04:53am blood tsh-0.46 08:08pm blood acetone-negative . 05:20pm blood cortsol-40.9* 04:53am blood cortsol-61.7* . 05:33pm blood type-art po2-134* pco2-32* ph-7.05* caltco2-9* base xs--21 12:56pm blood glucose-greater th lactate-6.0* k-5.6* . microbiology: 12:05 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): budding yeast. respiratory culture (final ): commensal respiratory flora absent. . sparse growth. identification per dr. , pager . (torulopsis) glabrata. sparse growth. 2nd type. . 2:41 am urine source: catheter. **final report ** urine culture (final ): (torulopsis) glabrata. >100,000 organisms/ml. . blood cultures: negative aerobic/anerobic/mycolitic cultures wound cultures: negative c.diff: negative . studies: . cxr (): findings: midline sternotomy wired noted. right cp angle is excluded. there is a new right ij line with the catheter tip at the expected location of the svc. there is no pneumothorax. there is no focal lung consolidation though there is mild central pulmonary vascular congestion. there is no pleural effusion. heart size appears mildly enlarged. bones are intact. . impression: 1. new right ij in place with tip at the cavoatrial junction. 2. mild pulmonary congestion. ct chest/abd/pelvis (): 1. low lung volumes. bilateral patchy opacities with interlobular septal thickening concerning for moderate bilateral pulmonary edema. 2. endotracheal tube too low with tip at the carina. dr. discussed with the icu nurse, at 8:00 p.m. on . according to nurse ett was repositioned immediatly prior phone conversation. dr. was paged with no success. 3. fat stranding about the pancreas and part of duodenum could suggest pancreatitis or duodenitis in appropriate clinical setting and if there is correlation with enzymes or can be due to generalized edema. 4. small amount of free fluid. 5. foci of air in the urinary bladder, likely from foley placement correlate with urinary analysis. 6. fatty liver. . echo (): the left atrium and right atrium are normal in cavity size. no definite right-to-left shunting is seen after intravenous injection of agitated saline. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (?#) appear mildly thickened with no aortic regurgitation. aortic stenosis could not be adequately assessed, but unlikely to be severe. the mitral valve leaflets and supporting structures are thickened. mild to moderate (+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: suboptimal image quality. normal biventricular cavity sizes with preserved global biventricular systolic function. mild-moderate mitral regurgitation. compared with the prior study (images reviewed) of , the current study is of lower technical quality. if clinically indicated, a follow-up study when the patient can be transported to the echo lab may be more definitive. . renal us (): findings: note is made that this is a very limited study due to the patient's body habitus. the right kidney measures 12.1 cm and the left kidney measures about 11.0 cm. no hydronephrosis is present. the urinary bladder could not be imaged as a foley catheter is in place. impression: extremely limited study technically due to the patient's body habitus, but no hydronephrosis identified. . echo (): the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. there is no pericardial effusion. . ct abd/pelvis (): 1. increasing bibasilar consolidations, raising the possibility of aspiration and infection. persistent small bilateral pleural effusions and septal thickening, consistent with volume overload. 2. newly apparent hypodense lesions within segment iv, which were not seen on prior ct of or ultrasound . given the clinical scenario, septic emboli and abscesses are a possibility and correlation with ultrasound is recommended. . lower ext dopplers: no deep venous thrombosis in either lower extremity. nonvisualization of the deep veins in the left calf. . abd u/s :. no evidence of hepatic abscess. 2. small echogenic areas in the liver corresponding to hypodense region seen on ct, possibly areas of focal fatty infiltration or hemangiomata. . video speech/swallow: findings: penetration and trace aspiration were seen with thin liquids. no penetration or aspiration is seen with thick liquids. for further details, please refer to the speech and swallow division note in omr. impression: aspiration of thin liquids. brief hospital course: 48 f with id-t2dm, trisomy 21, osa, presents with hypotension and hyperglycemia, found in septic shock. . #. septic shock/fevers: prior to presentation patient had symptoms of gastroenteritis. on presentation to the ed, her vs: 97.8 63 108/78 22 95%. she was found to have a lactate 6.0, gluc 500. fluid resuscitation was attempted with over 6l of crystalloid (4lns, 2l lr total). a right ij cordis was placed. pressors were begun with levo and then neosynephrine, however sbp remained in the 70's. she was intubated for agitation during a-line placement. zosyn and vancomycin were started and urine and blood cultures were sent, though it was unclear whether it was before the abx. cxr revealed mild pulmonary congestion though no obvious infiltrate. repeat lactate after volume resucitation was 3. vital signs at the time of transfer were hr 104, bp94/43, 100% on 100%. in the icu her antibiotics were broadened to include atypical pneumonia. she was resusitated with 9 liters of fluid her first hospital day. she continued to require levophed to maintain map>60. on patient was briefly started 50 mg iv hydrocort, while awaiting am cortisol and stim test, which revealed normal adrenal function. vigeleo hemodynamic monitoring was placed and patient had no evidence of cardiogenic failure, with excellent cardiac output. cv02 sat was 86% further ruling out cardiogenic failure and confirming likely sepsis and distributive shock. evaluation for sources of infection continued though proved unfruitful. patient was ruled out for influenza. ct of the abdomen and pelvis were performed to further evaluate for source of infection and fat stranding about the pancreas and part of duodenum was found which could suggest pancreatitis or duodenitis. ruq ultrasound was without evidence of hepatic abscess or cholecystitis. given findings of duodentitis cipro and flagyl were started. blood cultures, urine, sputum cultures were negative, though later urine a sputum cultures revealed colonization with . on patient started on a trial of vasopressin in an attempt to wean from levophed. patient continued to intermittently wean from pressors and it was felt that much of her pressor requirement was dependent on sedation. on was briefly off of pressors. on vancomycin and zosyn were dc'd and picc line placed. later that day patient became febrile and b-glucan and galactomannan were sent and she was started aztreonam, micafungin and vancomycin. cipro/flagyl were continued. on abx pared down and aztreonam was dc'd leaving flagyl, cipro, vanc, micafungin. on vancomycin, ciprofloxacin, and flagyl were stopped, though later that day the patient spike to 101.3 and became tachycardic and hypotensive, intermittently requiring levophed. random cortisol was rechecked and low compared to admission at 8.7. steroids were not started given improvement in blood pressure. at that time vancomycin, cefepime, ciprofloxacin, flagyl were restarted. to further evaluate for source of fever leni's were performed and negative. ruq ultrasound repeated and again was without evidence of hepatic abscess or cholecystitis. on antibiotics were stopped given no source of infection. . #. respiratory failure: patient was intubated during ed course given altered mental status in the setting of hypotension. during her early icu course the patient was supported with assist control given her nstemi and pressor requirement. these were felt to be contraindications to extubation. as her sepsis resolved the patient the patients urine output dropped off and became 27 liters positive with evidence of pulmonary edema on chest xray. as noted below patient was aggressively diuresed with iv lasix then eventually cvvh with improvement in respiratory status and reassuring rsbis and sbt. on patient was eventually extubated, intially did well, joking with family, then developed stridor, and was re-intubated. the cause of her stridor was felt to be multifactorial as anesthesia thought that she had an arytenoid dislocation (from traumatic intubation) and edematous upper airway. diuresis was continued and the possibility of another trial of extubation was considered though it was felt this would be high risk given the patient's difficult intubations previously. on thoracic surgery placed perc trach. patient quickly weaned to trach mask and was eventually transferred to the floor. on the floor, the tracheostomy was reduced in size and a pmv was placed. the patient was saturating 100% on room air via the tracheostomy collar at the time of discharge. . #. arytenoid dislocation: ent came by an evaluated the patient. there was terrific edema; it was also too difficult to see the subglottic area. the epiglottis was plump. additionally, there was a gap in her vocal cords. essentially, nothing was found that could explain airway difficulties; the vocal cord gap can be addressed as an outpatient endoscopically. and additional history implies that some degree of her difficulties talking were present before the hospitalization. finally, ent reccommended a ppi to protect the cords from acid. she has ent followup at 2 weeks post discharge. . #. acute kidney injury: patient presented in acute kidney injury with creatinine of 2.6. through her stay in the icu her creatinine worsened to 7.1 on before she was started on cvvh. nephrology was consulted and felt that was secondary to atn in the setting of sepsis. urine sediment revealed muddy brown cast. renal ultrasound was without obstruction. prior to starting cvvh patient was trialed on lasix gtt and intially put out well though was not able to keep up with her daily intake. prior to transfer to the floor the patient was off cvvh for several days and continued to make excellent urine with stabilization in her creatinine. upon discharge, her creatinine was 2.0 and down-trending. she may establish a new baseline (higher than her baseline of 0.9 prior to admission). she has pcp to recheck her chem-7 and restart her lisinopril if her kidneys will tolerate it. . #. t2dm with dka vs. honk: uncertain dka vs. honk. interestingly acetone negative on admission. insulin gtt was initiated and patient was supported with ivf, lab monitored every 4 hours with resolution of anion gap. was consulted and helped manage glucose control. her insulin regimen was uptitrated (see attached insulin flowchart). upon discharge, she was getting lantus 25 units with breakfast in addition to an humalog insulin sliding scale qac/hs. . #. hypothyroidism: 125 mcg of levothyroxine was continued. tsh was measured during icu course and revealed likely sick euthyroid with tsh of 15. . #. dyslipidemia: patient was continued on home simvastatin. . #. nstemi versus demand ischemia: on day one of hospitalization ekg was repeated with concerning depressions anterolaterally which were new, however no documentation of ekg in emergency department was found. cardiac enzymes were measured and elevated, enzymes peaked with ck: 3000, ckmb: 200, troponint: 8. cardiology was consulted. patient was given full dose aspirin, statin, and heparin gtt. heparin was continued for 72 hours. cardiac enzymes trended down. of note, she was not started on a beta-blocker because of her labile blood pressure. a beta-blocker will need to be started as an outpatient by cardiology or her pcp (she has followup for both). an acei can be considered after her renal failure resolves and based on her new baseline creatinine. . #. rash: macular rash diffuse and blanching across the abdomen. derm consulted and confirmed concerns for drug rash. sarna was applied to abdomen and zosyn was stopped as this is the most likely culprit. rash improved slowly over the following days. . #. nutrition: patient was supported with tube feeds during her icu course. nutrition recs: nutren pulmonary at 30mg/hr with 21 grams of benprotein. . #:left ue swelling: us without dvt. medications on admission: clotrimazole cream ergocalciferol - 50,000 unit capsule every other week fluocinonide-emollient - 0.05 % cream - hands glucagon (human recombinant) - q-hypoglycemia insulin glargine 9 units at bedtime insulin lispro - ss: levothyroxine - 125 mcg tablet lisinopril - 2.5 mg qd nystatin repaglinide - 2 mg tablet - 2 tablet(s) before meals simvastatin - 20 mg tablet qd medications - otc ammonium lactate - aspirin ] - 81 mg tablet dextrose - 40 % gel - 1 gel(s) by mouth qhypogyl magnesium hydroxide prn discharge medications: 1. simvastatin 10 mg tablet : two (2) tablet po daily (daily). 2. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 3. acetaminophen 500 mg tablet : two (2) tablet po q8hrs prn as needed for fever. 4. miconazole nitrate 2 % powder : one (1) appl topical (2 times a day) as needed for skin fold rash. 5. olanzapine 5 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po bid (2 times a day). 6. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : 1-2 puffs inhalation q4hrs prn as needed for wheezing. 7. ipratropium bromide 0.02 % solution : one (1) inhalation q6hrs prn as needed for wheezing. 8. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 9. miconazole nitrate 2 % cream : one (1) appl topical (2 times a day). 10. levothyroxine 125 mcg tablet : one (1) tablet po daily (daily). 11. famotidine 20 mg tablet : one (1) tablet po q24h (every 24 hours). 12. lorazepam 0.5 mg tablet : one (1) tablet po q4hrs prn as needed for agitation/anxiety. 13. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 14. loperamide 2 mg capsule : one (1) capsule po qid (4 times a day) as needed for diarrhea. 15. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 16. insulin regimen please see the insulin and blood glucose flowchart for management strategy. this includes: glargine 25 units at breakfast, in addition to a humalog sliding scale (as indicated in the flowchart) at breakfast, lunch, dinner, and bedtime. note that the bedtime scale is a lower dose scale. discharge disposition: extended care facility: hospital - discharge diagnosis: septic shock acute hypoxemic respiratory failure diabetic ketoacidosis acute kidney injury down's syndrome duodenal stricture hypothyroidism 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: dear ms. , it was a pleasure taking care of you at . you came to the hospital because you were in septic shock and respiratory failure. for these reasons, you were treated in the medical intensive care unit. you required intubation to protect your airway, in addition to a tracheostomy. the thoracic surgeons, ear, nose and throat specialists, and speech/swallow specialists, and cardiologists participated in your care. you were treated with antibiotics and medications to support your blood pressure. you worked with physical therapy. you will have to spend some time at a rehabilitation facility in order to regain your strength. you will need a repeat vidoe speech and swallow evaluation to be done at your rehabilitation facility with the pmv in place over your tracheostomy. this will alow us to know how far to advance your diet. please see your current medication list, which is attached, and will be communicated to your rehabilitation facility. the list has all of the dosage information. also, please see the insulin flowchart for your insulin requirements. the following changes have been made to your medication regimen: 1. started olanzapine 2. started albuterol inhaler 3. started atrovent nebulizers 4. started lansoprazole 5. started famotidine 6. started loperamide as needed for diarrhea 7. increased your insulin regimen. you will take lantus 25mg with breakfast, in addition to the humalog insulin sliding scale (see attached flowchart) 8. stopped lisinopril due to your kidney failure. this medication may be restarted by your primary doctor upon further blood tests. 9. stopped replaginide followup instructions: department: sleep unit neurology when: monday at 9:30 am with: , m.d. building: campus: east best parking: garage department: when: thursday at 8:20 am with: , m.d. building: sc clinical ctr campus: east best parking: garage department: cardiac services when: tuesday at 11:00 am with: echocardiogram building: sc clinical ctr campus: east best parking: garage ear, nose and throat dr. , 2pm 1244 number 303 , ma phone Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Temporary tracheostomy Dilation of intestine Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Thrombocytopenia, unspecified Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Anemia, unspecified Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Ostium secundum type atrial septal defect Long-term (current) use of insulin Septic shock Dermatitis due to drugs and medicines taken internally Glucocorticoid deficiency Barrett's esophagus Rhabdomyolysis Down's syndrome Unspecified vitamin D deficiency Candidiasis of skin and nails Cervical spondylosis without myelopathy Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Chronic ulcer of other specified sites Edema of larynx Penicillins causing adverse effects in therapeutic use Other obstruction of duodenum Dermatophytosis of nail |
allergies: no known allergies / adverse drug reactions attending: chief complaint: pancreatic mass major surgical or invasive procedure: whipple procedure history of present illness: mr. is a very nice 60-year-old gentleman who was kindly referred by dr. in transplant hepatology. mr. has a history of autoimmune hepatitis with child a cirrhosis. he was noted to have an abnormal pancreatic and common bile duct dilatation on surveillance endoscopic ultrasound. he underwent an ercp and endoscopic ultrasound. this demonstrated an approximately 1.5 cm mass in the head of the pancreas by endoscopic ultrasound. fine-needle aspiration was nondiagnostic, but common bile duct brushings and ercp were suspicious for malignancy. he presents for evaluation of operative intervention. past medical history: past medical history: 1. autoimmune hepatitis. 2. psoriasis. 3. small esophageal varices. 4. history of hepatitis b virus. 5. hypertension. 6. chronic lack lower back pain. 7. gastroesophageal reflux disease. 8. history of pancreatitis demonstrated on laboratory function. 9. seasonal allergies. surgical history: 1. tonsillectomy. 2. urethral surgery. 3. vasectomy. 4. right rotator cuff and biceps repair. 5. hernia repair in the right inguinal region. social history: retired electrician. no alcohol for over 25 years; no tobacco for over 15 years (smoked ~20 years total). family history: negative for liver, biliary, pancreatic diseases. physical exam: at time of discharge: general: polite and interactive. aaox3, nad heent: ncat neuro: cn2-12 grossly intact card: rrr w/u mrg pulm: cta b/l abd: incision with steri-strips in place. c/d/i without surrounding erythema. no drainage. interval jp removal with tegaderm and gauze covering site without drainage. no palpable masses, rebound or guarding. ext: right upper extremity with large ecchymosis from antecubital fossa to upper third of biceps without fluctuance or erythema. mildly tender. pertinent results: duplex ultrasound : 1. significantly reduced peak velocities in the right hepatic artery which arises from the proper hepatic. the left gastric has normal arterial velocities, however this is arising from the left gastic prior to the transection site. 2. patent main portal vein, left and right portal. cta: impression: near complete occlusion /thrombosis of the proximal common hepatic artery with resultant decreased arterial perfusion to the right lobe of the liver including segment 4. the right hepatic artery receives reduced flow either through a severely attenuated common hepatic or small collaterals. left hepatic artery is not affected as it arises from the left gastric. brief hospital course: the patient was admitted to the general surgical service for evaluation and treatment. on (), the patient underwent a whipple procedure. the proper hepatic artery was injured during the procedure and was primarily reconstructed by vascular sugery (reader referred to operative notes for details). he was transferred to the icu post-operatively and remained intubated/sedated overnight. he received fluid boluses for low blood pressure with good effect. on pod #1 he received 1u prbcs for hct 24. he was successfully extubated and his lfts were stable. he remained npo with iv fluids and ng tube. his prednisone for autoimmune hepatitis was tapered off. on pod #2 he underwent a duplex ultrasound showing decreased blood flow to the right liver which was subsequently confirmed on cta. vascular surgery was involved, and he was started on aspirin and a heparin drip. the heparin drip was closely monitored with ptt checks every 6 hours and adjustments as necessary. the heparin was stopped for 4 hours in order to remove his epidural and central line. the heparin was discontinued and the patient was started on therapeutic lovenox. he was taught to administer these injections. he will require 3 months of therapeutic anticoagulation with lovenox in addition to lifelong aspirin to reduce the risk of arterial thrombosis. on pod#3 he was started on sips but developed nausea and vomiting. an ng tube was placed with relief of nausea. he was started on erythromycin and reglan to improve gi motility. the patient was unable to tolerate clamping of the ng tube until , and when the output was minimal and the patient was without nausea it was removed on pod #7. his home antiviral medications were restarted. on pod #8 the patient was advanced to a clear liquid diet which he tolerated. he was passing flatus. he was ambulating and voiding without difficulty. jp drain amylase was sent when patient was tolerating full liquids and was 17. jp was discontinued and patient was advanced to a regular diet which was well tolerated. at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, ambulating independly, voiding without assistance, and pain was well controlled with po pain medication. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. patient was discharged to home with aspirin, lovenox, metoclopromide, po pain medication and instructed to resume his home medications including prednisone at 10 qday and epivir. patient was instructed to call the clinic for a follow up appointment in 2 weeks. medications on admission: norvasc 5 mg once a day, 180 mg once a day, epivir 100 mg once a day, omeprazole 20 mg once a day, prednisone 15 mg reduced down to 10 mg at today's clinic, aspirin, calcium and vitamin d discharge medications: 1. enoxaparin 80 mg/0.8 ml syringe sig: seventy (70) mg subcutaneous q12h (every 12 hours) for 3 months. disp:*60 syringes* refills:*3* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. lamivudine 100 mg tablet sig: one (1) tablet po daily (daily). 4. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po daily (daily). disp:*30 capsule, ext release 24 hr(s)* refills:*2* 5. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). disp:*160 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. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 8. hydromorphone 2 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* 9. 180 mg tablet sig: one (1) tablet po once a day. 10. prednisone 10 mg tablet sig: one (1) tablet po once a day. 11. epivir hbv 100 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: pancreatic mass discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: general discharge instructions: please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. you will be taking lovenox for three months as an injection twice daily. you were instructed how to do this in the hospital. you will also need to take lifelong aspirin 325mg. 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, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until your follow-up appointment. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. *if you have steri-strips, they will fall off on their own. please remove any remaining strips 7-10 days after surgery. followup instructions: please contact dr. clinic to arrange follow-up in 2 weeks. Procedure: Parenteral infusion of concentrated nutritional substances Radical pancreaticoduodenectomy Cholecystectomy Removal of T-tube, other bile duct tube, or liver tube Suture of artery Central venous catheter placement with guidance Diagnoses: Acidosis Esophageal reflux Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Personal history of other infectious and parasitic diseases Personal history of tobacco use Accidental puncture or laceration during a procedure, not elsewhere classified Nausea with vomiting Other and unspecified hyperlipidemia Hypotension, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Family history of ischemic heart disease Embolism and thrombosis of other specified artery Dehydration Other psoriasis Unspecified disease of pancreas Vascular complications of other vessels Autoimmune hepatitis Vasectomy status |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bile duct stricture major surgical or invasive procedure: left hepatic lobectomy, common bile duct excision, cholecystectomy, roux-en-y hepaticojejunostomy over 10-french silastic catheter. history of present illness: per dr note: the patient is a 53-year-old male with a recent history of painless jaundice, fatigue and diarrhea while hunting in . he was found to have elevated liver function tests including ast 121, alt 259, alkaline phosphatase 752, total bilirubin 4.1. ercp demonstrated diffuse narrowing of the confluence of the right and left hepatic ducts and the proximal common hepatic duct. there was more marked dilatation of the left side intra- hepatic ducts, particularly the medial segment. a ct scan demonstrated a dense calcification measuring 18 mm in the anterior aspect of the dome of the right lobe and diffuse mild dilatation of the intra-hepatic biliary tree, but no obvious masses. he underwent a preoperative percutaneous transhepatic cholangiogram and placement of a transhepatic catheter across the stricture into the duodenum. brushings demonstrated no evidence of malignancy. he also has a history of hodgkin's disease in for which he was treated chemotherapy and radiation and splenectomy and extensive lymphadenectomy. it is believed that this most likely represents a benign radiation-induced stricture. he now presents for surgery. past medical history: hodgkin's disease in the s/p radiation c/b recurrence s/p chemotherapy, hypothyroidism, gerd - splenectomy and extensive lymphadenectomy in the for hodgkin's disease, l and r inguinal hernia repairs, l and r shoulder rotator cuff tear repairs social history: works as arborist, lives alone family history: sister:multiple sclerosis brother: brain tumor father: died at age 70 of lung cancer. physical exam: vs: 98.3, 93, 104/65, 18, 100% heent: no scleral icterus noted, mmm, no lesions in oropharynx lungs: cta bilaterally cardiac: rrr, s1s2 no m/r/g abdomen: soft, diffusely/appropriately tender, diminished bowel sounds. dressing c/d/i extr: no edema skin: no rashes pertinent results: on admission: wbc-18.0*# rbc-3.23* hgb-10.1* hct-29.0* mcv-90 mch-31.2 mchc-34.7 rdw-15.5 plt ct-388 pt-14.6* ptt-27.1 inr(pt)-1.3* glucose-136* urean-19 creat-0.7 na-139 k-4.1 cl-110* hco3-22 angap-11 alt-140* ast-136* alkphos-78 totbili-1.1 calcium-8.1* phos-4.8* mg-1.7 lipase-13 wbc-14.4* rbc-2.93* hgb-9.2* hct-27.3* mcv-93 mch-31.4 mchc-33.8 rdw-15.5 plt ct-890* glucose-88 urean-16 creat-1.7* na-136 k-4.6 cl-101 hco3-28 angap-12 alt-53* ast-39 alkphos-178* totbili-0.5 albumin-2.9* calcium-8.5 phos-4.0 mg-2.4 brief hospital course: 53 y/o male who is admitted following left hepatic lobectomy, common bile duct excision, cholecystectomy, roux-en-y hepaticojejunostomy for radiation induced bile duct stricture. he was taken to the or with dr . at the time of surgery he was noted to have a relatively normal-looking liver except an atrophic left lobe, particularly the medial segment. the dome of the liver was biopsied due to calcification and ws reported as fibrous tissue on the frozen section. the common bile duct was narrowed proximally near the confluence. biopsies of the distal margin and proximal margin were negative for malignancy and showed only chronic inflammation. there was no abnormal lymphadenopathy. he was extubated and transferred to pacu in stable condition. please see the operative note for further surgical detail. ebl was 1200 cc and he received colloid and 1 unit rbcs intra-op. he initally did well post-operatively. jp draiange was minimal and sero-sanguinous without evidence of bile. ptc producing about 200 cc/day. on pod 3 it was decided to remove his central line and when this was performed, he almost immediately reported floaters in his vision, left side hemisensory loss, left paralysis lasting for 4min maximum. he was improving after being placed in trendelenburg yet symptoms recurred when sitting up for portal cxr. the symptoms of left hemiparalysis and hemisensory recurred, and he was transferred to the sicu for further management. cta of the chest did not reveal evidence of a pe and ct of the head showed no evidence of infarction, hemorrhage, edema, or shift of normally midline structures. cardiac echo did not show a pfo or asd and a carotid series showed 40-59% stenosis in the left internal carotid artery and less than 40% stenosis in the right internal carotid artery. mra was done showing "unremarkable cranial and cervical mra, with no flow-limiting stenosis". ck and troponins ewre cycled x 3 with all being negative. he stayed in the sicu for two days and then was transferred back to 10 where he continued to recover. his mobility improved and he was back to baseline prior to discharge. a tube cholangiogram was performed on showing no evidence of leak. the tube was capped and in the setting of unchangd but slightly elevated lfts the jp drain was removed the following day. he remained afebrile. he had return of bowel function, was tolerating diet and was ambulating. the pathology was available prior to discharge and showed chronic cholecystitis, marked fibrosis in the gall bladder and common bile duct. there was focal bile duct proliferation with fibrosis in the liver. there was no evidence of tumor on any of the pathology specimens submitted. incisional erythema was noted and a swab was sent. there is a corrected report in omr showing rare growth of yeast, with no other organisms seen. patient sent home with vna for monitoring of incision and 10 day course of po cephelexin medications on admission: ciprofloxacin 500 mg p.o. daily, levothyroxine 150 mcg p.o. daily, oxycodone 5-10 mg p.o. every 4-6 hours p.r.n., ursodiol 300 mg p.o. twice daily, and omeprazole 20 mg p.o. daily. discharge medications: 1. levothyroxine 150 mcg po daily 2. aspirin 81 mg tablet, one (1) tablet po daily 3. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. disp:*30 tablet(s)* refills:*0* 4. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). 5. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 10 days. disp:*40 capsule(s)* refills:*0* 6. prilosec 20 mg capsule,(e.c.)one(1)capsule, po daily discharge disposition: home with service facility: vna, discharge diagnosis: biliary radiation stricture transient l hemiparesis sinus tachycardia incision cellulitis discharge condition: good discharge instructions: please call dr. office if fever, chills, nausea, vomiting, jaundice, worsening abdominal pain, incision/wound redness/bleeding/drainage or any shortness of breath/left sided numbness/immobility of limbs no driving while taking pain medication no heavy lifting visiting nurse services for wound care arranged via vna followup instructions: please call dr. clinic coordinator , rn md, Procedure: Cholecystectomy Other cholangiogram Anastomosis of hepatic duct to gastrointestinal tract Lobectomy of liver Other excision of common duct Diagnoses: Esophageal reflux Other postoperative infection Cellulitis and abscess of trunk Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Other specified cardiac dysrhythmias Other specified disorders of biliary tract Obstruction of bile duct Air embolism as a complication of medical care, not elsewhere classified Other chronic nonalcoholic liver disease Effects of radiation, unspecified Chronic cholecystitis Other specified transient cerebral ischemias Personal history of hodgkin's disease |
allergies: no allergies/adrs on file attending: chief complaint: s/p cardiac arrest major surgical or invasive procedure: expired history of present illness: 42m with unknown history transferred to s/p cardiac arrest. per reports, patient has possible heroin overdose this evening at 7-8pm when found unresponsive in bathroom. bls was called and he was noted to have agonal breathing. initially went to widdham where he went into cardiac arrest requiring chest compressions, 3 rounds of epinephrine, 2 rounds of vasopressin with return of pulse. reported downtime 40 minutes. ct head reported to be normal. transferred to for cooling. on arrival, initial viatls 97 74/38 100% cmv 550x14 5 fio2 100%. arrest team was notified and recommended cooling. osh ekgs were notable for st elevation in v2-v4,resolved and ekg here unremarkable except for st depressions. cardiology stated that no heparin was required at this time. prior to transfer, patient was on maximum levophed and neo with vitals of 132/72 94 100% on vent. cooling started. right ij placed. past medical history: unable to obtain patient sedated social history: unable to obtain patient sedated family history: unable to obtain patient sedated physical exam: hr: 98 (97 - 98) bpm bp: 81/53(64) {81/53(64) - 81/53(64)} mmhg rr: 14 (14 - 15) insp/min spo2: 97% heart rhythm: sr (sinus rhythm) eyes / conjunctiva: pupils dilated, non-reactive pupils head, ears, nose, throat: normocephalic, poor dentition, endotracheal tube, large hematoma over right subclavian line cardiovascular: (s1: normal), (s2: normal), (murmur: no(t) systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (breath sounds: clear : ) abdominal: soft, non-tender, bowel sounds present extremities: right lower extremity edema: absent, left lower extremity edema: absent skin: cool neurologic: responds to: not assessed, movement: not assessed, sedated, tone: not assessed pertinent results: 10:40pm blood wbc-11.0 rbc-4.40* hgb-14.1 hct-42.7 mcv-97 mch-32.0 mchc-32.9 rdw-13.8 plt ct-243 04:01am blood wbc-19.0* rbc-3.24* hgb-10.3* hct-31.7* mcv-98 mch-31.8 mchc-32.5 rdw-13.9 plt ct-216 10:40pm blood pt-18.2* ptt-74.1* inr(pt)-1.6* 04:01am blood pt-32.9* ptt-132.3* inr(pt)-3.3* 10:40pm blood fibrino-151 01:04am blood fibrino-63*# 01:04am blood glucose-128* urean-17 creat-1.9* na-141 k-5.7* cl-109* hco3-14* angap-24* 01:04am blood alt-3032* ast-2473* ck(cpk)-1063* alkphos-273* totbili-0.9 10:40pm blood lipase-203* 01:04am blood ck-mb-60* mb indx-5.6 ctropnt-2.55* 10:40pm blood asa-neg ethanol-45* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:53pm blood type-art ph-7.09* 03:52am blood type-art temp-33 rates-30/ tidal v-500 peep-5 fio2-100 po2-99 pco2-38 ph-7.09* caltco2-12* base xs--17 aado2-603 req o2-95 intubat-intubated vent-controlled 10:40pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg brief hospital course: mr. was admitted to icu s/p cardiac arrest. at time of transfer to , he was intubated and requiring 2 pressors. in the ed, his central line from osh was pulled and new right ij placed. pressors were changed to levophed and phenylephrine. cooling pads were placed in the ed and actualy had to be warmed to 33 degrees c for the cooling protocol. on arrival to the micu, patient appeared to be in normal sinus rhythm with blood pressure in systolic 80's. levophed and phenylephrine were at maximum doses. he was administered ivf for resuscitation. labs were notable for worsening acidosis, started on bicarb gtt pending further studies. vent changed to increase ventilation in effort to improve acidosis. patient began to ooze from all line sites, most notably the right ?subclavian site from osh line that was pulled in the ed. dic labs were positive, he was given ffp and cryopreciptate with minimal improvement. surgery was contact given worsening bleeding and hematoma at right line site - recommended applying continued pressure. hypotension continued to worsen, requiring continuous ivf at maximum rates. oxygenation was maintained with mechanical ventilation on the vent. after discussion with ex-wife and step daughter, were able to contact patient's father and brother. after discussion of clinical course and prognosis, decision was made to withdraw care and make comfort measures. all medications were stopped and patient passed away at 5:05 am on . medical examiner accepted the case. medications on admission: unknown discharge medications: none discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Arterial catheterization Diagnoses: Hematoma complicating a procedure Opioid type dependence, continuous 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 Defibrination syndrome Anoxic brain damage Accidental poisoning by heroin Accidents occurring in residential institution Acute myocardial infarction of other specified sites, initial episode of care Home accidents Poisoning by heroin Mixed acid-base balance disorder |
allergies: no known allergies / adverse drug reactions attending: chief complaint: pneumonia, afib with rvr, major surgical or invasive procedure: arterial line placement ij line placement bronchoscopy picc line placement history of present illness: mr. is a 50-year-old m with a h/o paf (previously on metoprolol), myasthenia (antibody positive ocular) on prednisone and hypothyroidism, history of headache x 2 months (on advil), presented to pcp's office with 3 days of fevers as high as 103 and a 2 weeks of constant headache. patient has been taking aspirin which brings down the fever, but then the fever goes back up. headache is of a chronic nature and never really resolved, he was seen in urgent care for his ha two weeks prior to admission and given im toradol with some relief. he has had some difficulty sleeping due to his headache. he also notes that he developed some loose stools yesterday, also complaining of decreased po intake for the past few days. he also denies any nausea/vomiting, abdominal pain, bloody stools, urinary symptoms. denies any sore throat, ear pain, chest pain, sob, cough, rashes. he has no known sick contacts and has not had any recent travel. reports no neck pain/stiffness, no focal neurologic symptoms. . at his pcp's office, he was febrile to 102.9 and hypotensive to 92/61, labs showed a cr of 1.7 from a baseline of 1.2 to 1.1 and a white count of 14.1, urinalysis was positive for blood and protein. he was given tylenol and sent to the er for further evaluation. . in ed, initial vitals 100.3 90 125/73 16 97%. his labs were noteable for creatinine of 1.5, na of 132, wbc of 12.9. he was given levofloxacin 750mg, acetaminophen 1000mg. he went into afib w/ rvr to 160, was given diltiazem iv 20, then po 30. he had no response to 2l of ns so was started on a diltiazem gtt. vs at 2:30am were 160s/af, rr: 33, 99% 3l, 147/112. ekg in the er was atrial fibrillation at 151bpm with twi in iii and avf. he then desaturated to 87% on 3lnc with a hr in the 160's, so he underwent a cta, which was negative for pe but confirmed the lll pna that was seen on cxr. as he still required a diltiazem gtt he was admitted to the icu, so his antibiotic coverage was broadened to include ceftriaxone and he was started on liters 3 and 4 of normal saline. vs on transfer were: 101.1, 120s, 154/90, 27, 93% on 6lnc. . in the icu initial vs were: 99.7, 152, 125/87, 26, 89% on 6lnc. he is currently complaining of some worsening shortness of breath, but denies any palpitations, chest pain/pressure/tightness, also says that his ha has improved. . review of systems: (+) per hpi (-) denies night sweats, recent weight loss or gain. denies sinus tenderness, rhinorrhea or congestion. denies wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, constipation, abdominal pain. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: esophageal reflux urinary frequency hypercholesterolemia obesity atrial fibrillation myasthenia hypothyroidism social history: - tobacco: non-smoker - alcohol: rarely - illicits: denies family history: father died of an mi in his 50's physical exam: physical exam on admission: vitals: t:99.7 bp:125/87 p:152 rr: 26 spo2: 89% ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . physical exam on discharge: pertinent results: labs on admission: 08:30pm wbc-12.9* rbc-4.02* hgb-13.2* hct-36.6* mcv-91 mch-32.9* mchc-36.1* rdw-12.7 08:30pm neuts-88.6* lymphs-7.7* monos-2.7 eos-0.7 basos-0.2 08:30pm alt(sgpt)-45* ast(sgot)-57* ld(ldh)-211 alk phos-46 tot bili-2.0* 08:30pm tsh-4.8* 08:30pm glucose-145* urea n-18 creat-1.5* sodium-132* potassium-3.7 chloride-98 total co2-23 anion gap-15 08:37pm lactate-1.7 09:30pm urine rbc-6* wbc-1 bacteria-none yeast-none epi-0 09:30pm urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 09:30pm urine color-yellow appear-clear sp -1.009 . microbiology: urine legionella ag (): neg 6:21 pm bronchoalveolar lavage bronchial lavage. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. legionella culture (preliminary): no legionella isolated. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. respiratory viral antigen screen (final ): less than 60 columnar epithelial cells;. specimen inadequate for detecting respiratory viral infection by dfa testing. blood cultures 8/9,8/11,: neg other pertinent labs: imaging: . cxr : left lower lobe pneumonia. possible chronic bronchial inflammation. . ct head w/o contrast : there is no acute intracranial hemorrhage, edema, mass effect, or vascular territorial infarct. the ventricles and sulci are normal in size and morphology. midline structures are preserved. paranasal sinuses are well aerated; mild mucosal thickening is noted in the ethmoid air cells and minimal fluid/mucosal thickening in the sphenoid sinus. mastoid air cells and middle ear cavities are clear, with under-pneumatization noted on the right. apparant mild proptosis on the rigth side may be positional- correlate clinically. impression: no acute intracranial hemorrhage or mass effect. mild mucosal thickening in the ethmoid and sphenoid sinuses. . tte : left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is mild global left ventricular hypokinesis (lvef = 50%). 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. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: limited study. mild global left ventricular systolic dysfunction in the setting of significant tachycardia. . cta chest : the visualized pulmonary vasculature shows no evidence of filling defects to suggest pulmonary embolus. the aorta shows no evidence of intramural hematoma or dissection. heart and pericardium are within normal limits. there are bilateral small pleural effusions, left greater than right. opacifications at the left lung base with air bronchograms as well as small opacification in the right lung base are consistent with pneumonia. 8-mm opacification in the right lung (2,27) most likely represents infectious process; however, recommend attention to this area on followup imaging to determine resolution and to exclude presence of parenchymal process. this study is not optimized for subdiaphragmatic evaluation. within this limitation, the upper abdominal structures appear grossly unremarkable. no focal lytic or sclerotic osseous lesions suspicious for malignancy are identified. impression: 1. bilateral pleural effusions. 2. consolidation in the left lower lobe with air bronchograms as well as patchy opacities in the right lower and upper lobe are consistent with pneumonia. . bronchoscopy: airways: observation of entire bronchial tree to segmental level with minimal. carina was sharp. no evidence of purulent secretions. secretions were minimal throughout. bal performed in left lower lobe anterior segment with two aliquots of 60 ml sequentially (total of 120 ml) with return of approximately 30% of instilled lavage. general impression: 1) overall normal mucosal appearance with minimal friability in all sements. 2) scant secretions. 3) bal performed in lll anterior segement. . cxr : relatively symmetric peribronchial opacification has worsened on the left, now accompanied by moderate bilateral pleural effusions. in the setting of moderate cardiomegaly, this is almost certainly pulmonary edema and there are no findings prior to the onset of edema on to suggest pneumonia. et tube is in standard placement and nasogastric tube passes below the diaphragm and out of view. no pneumothorax. . cxr : (post extubation) comparison is made with prior study from the same date earlier in the morning. right ij catheter tip is in the lower svc. there is no pneumothorax. there are low lung volumes. cardiomediastinum is unchanged. left lower lobe collapse is unchanged. multiple opacities in the right lower lobe and left perihilar regions are also stable. there are no new lung abnormalities. . lueni : findings: the study is limited in evaluation due to left upper extremity swelling. grayscale and doppler son of the left internal jugular, left subclavian, left brachial, and left basilic veins were performed. there is a lack of flow and compressibility through the left basilic vein suggestive of left basilic vein clot. otherwise, the remainder of the veins appear patent. the cephalic vein was not well visualized. impression: limited study due to overlying soft tissue swelling. however, there is evidence of a left basilic vein thrombus. discharge labs: 07:45am blood wbc-13.7* rbc-3.60* hgb-11.8* hct-34.5* mcv-96 mch-32.7* mchc-34.1 rdw-13.0 plt ct-591* 07:45am blood glucose-96 urean-17 creat-1.4* na-136 k-4.5 cl-100 hco3-26 angap-15 08:30pm blood tsh-4.8* 01:32pm blood hiv ab-negative brief hospital course: mr. is 50 y/o m with a h/o paf not on any medications, predominantly ocular myasthenia who presented from his pcp's office with fever and arf, found to have a lll pna and to be in af with rapid ventricular response. . #) community acquired pneumonia: patient with cxr and chest ct with contrast showing evidence of lll pna. patient was treated with cap coverage, ceftriaxone and levofloxacin to cover s.pneumo and atypicals. in the setting of diarrhea and abdominal pain, legionella was on differential, but urine and sputum legionella were negative. initially, patient was doing well and did not have an oxygen requirement. on , patientdesatted to med 80s on face mask and abg demonstrated a respiratory alkalosis (ph 7.47 pco2 35 po2 57. oxygen saturations did not improve, so proceeded with elective intubation. intubation was complicated by flash pulmonary edema and patient was given lasix 80mg iv. his sbp was low, and he had a pressor requirement briefly. a stat tte was obtained which demonstrated reduced cardiac function, and mild global hypokinesis. a rij cvl was placed for access. given hazy appearance/bilateral infiltrates of cxr which persisted along with pao2/fio2 <200, likely there was ards secondary to an infectious etiology. tte demonstrated mild global left ventricular hypokinesis (lvef = 50%), so may have mild cardiogenic component but this is less likely. patient met ards criteria, and ventilator was moved to ardsnet protocol. urine strep pneumo antibody negative. although urine legionella assay was negative, per id, the urinary assay only identifies 70% of strains, so patient was treated with high dose ceftriaxone (2g iv q2) through . a bronchoscopy was done which did not demonstrate any purulent secretions. bal gram stain, legionella cultures, pneumocystis jirovecci, fungal culture and acid fast smear were all negative. on , patient was extubated. following extubation, hypertensive to 170s. given lasix and hydralazine, came down to 140s-150s. hiv test negative. --complete 10d course of levofloxacin through . --repeat cxr in weeks to document improving infiltrate #) atrial fibrillation with rapid ventricular response: patient does report prior history of afib, back in and was seen at . he recalls being put on toprol xl as well as coumadin, but came off coumadin after a year or so, but he doesnt recall any serious bleeding. his outpatient cardiologist at the time was dr. has been on full dose asa and had came off toprol xl in when his rx ran out and he never refilled it on admission, he was started on a diltiazem gtt at 5mg/hr with a hr in the 140's to 160's at rest. blood pressure tolerated the dilt gtt well, uptitrated to 15mg still with no effect on hr. he was started on metoprolol 25mg po tid. tsh was checked and came back at 4.8 so hyperthyroidism not thought to be cause of afib. heart rate was diffiucult to control with diltiazem and metoprolol as his blood pressure was not tolerating it in the icu, so he was startd on amiodarone ggt and then oral amio, which was d/c'd on as he had remained in nsr on the floor on both amio and metoprolol 50mg tid. i spoke with dr. (pcp) who agrees that patient will be discharged on full dose aspirin rather than resume anticoagulation. --discharged on toprol xl 100mg qd and full strength aspirin #transaminitis: alt and ast rose to low 100s on day of discharge from 45 and 50 on admission. suspected cause is med effect from amiodarone that was used in icu for afib and that was stopped on because patient was in nsr. no ruq pain and normal bilis and alk phos. --repeat lfts in one week. #) acute kidney injury: cr in the er was 1.5 from a baseline of 1.1, likely prerenal in the setting of decreased intake from his recent illness, u/a with microscopic hematuria. cr trended down with hydration. repeat lab on day of discharge with creat 1.4, but he had been on lisinopril 20-30mg daily for several days prior --repeat chem7 within one week of discharge . #)hypertension: patient was hypertensive in the icu to sbp of 190s. he was started on lisinopril 20mg po daily and blood pressures normalized. elevated bps when bp cuff used on legs because of r arm picc and l arm thrombophlebitis. --discharged on lisinopril 10mg qd (monitor creatinine) . #)lue thrombophlebitis: on , patient developed erythema/swelling/tenderness at lue piv site. did not improve with warm compresses, elevation of lue. a ueni was obtained which showed left basilic vein thrombus. patient was not anticoagulated given clot was superficial. . #) myasthenia : no history of respiratory complications, has never been intubated, mainly has ocular manifestations. continued his home dose prednisone 7.5mg every other day. because this is a low dose regimen he was not started on pcp . . #) hyponatremia: thought to be hypovolemic, however considered it could be related to possible legionella. legionella testing was neg and sodium normalized. . #) hypothyroidism: his levothyroxine dose was recently uptitrated by his pcp, his tsh was mildly elevated at 9.34 in . continued his home dose of levothyroxine 176mcg daily and rechecked a tsh to make sure he is not currently hyperthyroid (tsh 4.8, not hyperthyroid) medications on admission: levothyroxine 88 mcg oral tablet take 2 tablets daily prednisone 7.5mg every other day multivitamin one tablet daily aspirin 325 mg tab 1 tablet daily fish oil daily discharge medications: 1. levofloxacin 750 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 days. disp:*2 tablet(s)* refills:*0* 2. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. levothyroxine 175 mcg tablet sig: one (1) tablet po daily (daily). 5. prednisone 5 mg tablet sig: 1.5 tablets po every other day (every other day). 6. multivitamin tablet sig: one (1) tablet po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. toprol xl 100 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:*0* 10. lisinopril 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 11. outpatient lab work chem7 cbc lfts discharge disposition: home discharge diagnosis: pneumonia hypertension atrial fibrillation superficial thombosis in l arm related to iv discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: med changes: new: levofloxacin new: full dose aspirin new: lisinopril (blood pressure pill) items for follow up you will need to have your lfts and cbc add chem7 checked next week blood pressure control discuss afib and decision to use aspirin vs. coumadin with your pcp repeat cxr in weeks because of l lung infiltrate you were hospitalized for a serious pneumonia, which required treatment with antibiotics and icu care involving pulmonary support on a ventilator. you should continue your home dose of prednisone unless instructed by your physicians. please complete your course of antibiotics (levofloxacin) to end on . followup instructions: name: , location: address: , , phone: appointment: tuesday 1:00pm 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 Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Esophageal reflux Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Congestive heart failure, unspecified Long-term (current) use of steroids Other pulmonary insufficiency, not elsewhere classified Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Atrial fibrillation Other and unspecified hyperlipidemia Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Urinary frequency Other complications due to other vascular device, implant, and graft Headache Acute on chronic systolic heart failure Phlebitis and thrombophlebitis of upper extremities, unspecified Mixed acid-base balance disorder Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Myasthenia gravis without (acute) exacerbation |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: complex pelvic mass. major surgical or invasive procedure: total abdominal hysterectomy, bilateral salpingo-oophorectomy, extensive pelvic adhesiolysis, pelvic and periaortic lymphadenectomy, omentectomy. history of present illness: this patient, a 67 year old female, with a past medical history significant for multiple small bowel obsructions and ventral hernia and known left ovarian mass for 10 year was admitted to for a small bowel obstruction. her symptoms resolved with consrevative therapy, however a mr enterography performed. an as an incidental finding, a complex left adnexal mass was seen. this imaging was then followed by a dedicated pelvic mr. this was read here at by dr. . the uterus and right adnexa were unremarkable. in the expected location of the left adnexa, a 4 x 6 x 4 cm complex lesion was noted with an avidly enhancing 2 cm component. the mri impression included in the differential diagnosis was an epithelial neoplasm of the ovary, versus an endometrioma with an associated malignancy. a recent ca-125 was 11 on a scale of 0-35. the mr enterography showed a 6 cm lower abdomen wide neck ventral hernia containing multiple loops of small bowel. she was asymptomatic. the patient was seen in consultation concurrently by dr. , who planned abdominal exploration with abdominal wall reconstruction and also by gyn oncology. surigcal excision tah-bso and frozen section were recommended. the patient presented to for surgical intervention. past medical history: pmh: breast ca, morbid obesity, pre-dm, dizzy spells, htn, hiatal hernia, gerd, mild anemia, arthritis/gout, glaucoma, bowel obstructions. social history: ex-smoker, but having quit over 40 years ago. drinks socially. denies substance abuse. lives with her husband, . family history: family history is negative for breast, colon, uterine, or ovarian cancer. physical exam: physical examination inpatient vitals: t: 96.9 degrees farenheit, bp: 98/46 mmhg supine, hr 80 bpm, rr 18 bpm, o2: 100% on 2l nc. gen: mildly lethargic, arousable, nad heent: no conjunctival pallor. mmm. op clear. neck: supple, no lad. jvp low. normal carotid upstroke cv: pmi in 5th intercostal space, mid clavicular line. rrr. nl s1, s2. ii/vi <> sys murmur. + s4. lungs: ctab. no wheezes, rales, or rhonchi. abd: nabs. surgical dressing in place. soft, nt, nd. no hsm. ext: wwp. 2+ le edema. full distal pulses bilaterally. skin: scattered ecchymoses neuro: a&ox3. cn 2-12 grossly intact. moving all extremities at discharge: general: patient appears well, nad, vss, tolerating a regular diet. cardiac: rrr pulm: no issues, cta abd: obese abd, no nausea, no vomiting, surgical wound intact, left jp drain removed on day of discharge, right jp drain draining 95cc overnight and to remain in place until follow-up. lower extremities: obese, no significant edema noted. pertinent results: 05:35am blood wbc-7.4 rbc-2.82* hgb-8.8* hct-26.5* mcv-94 mch-31.3 mchc-33.4 rdw-14.1 plt ct-383 08:55pm blood hct-26.9* 08:30am blood wbc-7.1 rbc-2.44* hgb-7.5* hct-23.2* mcv-95 mch-30.9 mchc-32.5 rdw-12.8 plt ct-386 12:45pm blood wbc-7.5 rbc-2.44* hgb-7.8* hct-23.4* mcv-96 mch-32.0 mchc-33.4 rdw-12.8 plt ct-349# 06:55am blood wbc-7.3 rbc-2.52* hgb-8.3* hct-24.2* mcv-96 mch-32.9* mchc-34.2 rdw-12.2 plt ct-183 09:57am blood wbc-7.2 rbc-2.62* hgb-8.8* hct-24.9* mcv-95 mch-33.6* mchc-35.3* rdw-12.2 plt ct-195 09:16am blood pt-25.4* ptt-27.2 inr(pt)-2.4* 02:45am blood pt-22.6* ptt-69.2* inr(pt)-2.1* 09:50am blood ptt-82.4* 05:35am blood plt ct-383 05:35am blood pt-19.7* ptt-150* inr(pt)-1.8* 10:55pm blood ptt-62.9* 08:30am blood pt-13.7* ptt-64.9* inr(pt)-1.2* 12:45pm blood pt-12.2 ptt-23.5 inr(pt)-1.0 06:29pm blood pt-11.9 ptt-24.3 inr(pt)-1.0 01:06am blood pt-12.8 ptt-23.8 inr(pt)-1.1 07:35am blood glucose-125* urean-13 creat-0.6 na-142 k-4.4 cl-103 hco3-31 angap-12 02:11am blood na-143 k-3.4 cl-103 05:35am blood glucose-122* urean-9 creat-0.7 na-145 k-3.6 cl-105 hco3-30 angap-14 08:30am blood glucose-154* urean-11 creat-0.7 na-135 k-4.0 cl-99 hco3-25 angap-15 03:10pm blood ck(cpk)-177 11:21pm blood ck(cpk)-234* 03:10pm blood ck-mb-2 ctropnt-0.04* 01:52pm blood ctropnt-0.04* 05:50am blood ctropnt-0.04* 11:21pm blood ck-mb-3 ctropnt-0.06* 07:35am blood calcium-8.9 phos-3.1 mg-1.8 02:11am blood mg-1.6 05:35am blood calcium-8.5 phos-4.0 mg-1.4* 08:30am blood calcium-8.5 phos-3.6 mg-1.6 06:10am blood calcium-8.4 phos-3.5 mg-1.9 01:52pm blood calcium-8.2* phos-2.6* mg-2.4 pathology : 1. uterus and cervix, right tube and ovary (a-d): - uterus with atrophic endometrium and adenomyosis. - unremarkable cervix. - ovary with benign simple cyst. - unremarkable fallopian tube. 2. left tube and ovary (e-j): clear cell carcinoma, see synoptic report. 3. pannus (k): skin and fibroadipose tissue with focal fibrosis. 4. abdominal wall (l): dense fibroconnective tissue with foreign body giant cell reaction and scar. 5. left pelvic lymph node (m-s): seven lymph nodes, no malignancy identified (0/7). 6. left peri-aortic lymph node (t): one lymph node, no malignancy identified (0/1). 7. omentum (u): unremarkable fibroadipose tissue. ecg : regular svt @ ~ 160 bpm. no obvious pws.- per cardiology ecg1 : atrial fibrillation at 58. -per cardiology ecg2 : sinus @ 80. nl a/i. low voltage. compared to prior, now in sinus, otherwise findings similar. - per cardiology cta chest impression: 1.bilateral pulmonary emboli with new linear atelectasis in the lower lobes. 2.small dependent fluid postoperative collection surrounding the spleen. the findings of the pulmonary emboli were conveyed to dr. at the time of reporting. brief hospital course: the patient was admitted to the intensive care unit after total abdominal hysterectomy, bilateral salpingo-oophorectomy, extensive pelvic adhesiolysis, pelvic and periaortic lymphadenectomy omentectomy intubated for observation on . all tissues from the case were sent to pathology for evaluation. the patient was in the icu the patient received boluses of intravenous fluids for low urine output with good affect. the patient was extubated and started on a pca for post-operative pain control, and transferred to the inpatient floor where she was placed on telemetry. she was followed closely by general surgery as well as gyn oncology. on the inpatient the patient developed atrial fibrillation with a heart rate up to 150s. she noted nausea and diaphoresis with the episode but was otherwise asymptomatic and the episode was hemodynamically tolerated. she received lopressor 5 mg iv x 3 with decrease in her hrs to <100. however, rates returned to the 150s and she was given diltiazem 10 mg iv which reportedly dropped her hrs to the 30s and sbps to 60s. however, this was transient and resolved without intervention. she again had ventricular rates into the 150s and she received an additional 5 mg of iv lopressor with hr drop to <100. this am, she spontaneously converted to sinus rhythm. cardiology was consulted for further management which recommended continuing lisinopril 20mg daily, initiating lopressor 25mg three times daily, aspirin 325mg daily, echocardiogram which showed lvef >55%, no aortic regurgitation, mitral mildly thickened mitral valve leaflets. mild (1+) mitral regurgitation, mild pulmonary artery systolic hypertension, and no pericardial effusion, control of surgical pain, hold dyazide diuretic, continue statin, and check tsh which was normal at 2.5mg. the patient recovered well from surgery, increased her activity as tolerated, progressed her diet, and remained in normal sinus rhythm. on , the gyn oncology surgical team became concerned that the patient may have had atrial fibrillation related to pulmonary emboli given her prolonged operative case, new diagnosis of cancer, and obesity. the patient was not short of breath, expressing complaints of chest pain, hypoxic, or tachycardic at this time. a cta was obtained which showed bilateral pulmonary emboli with new linear atelectasis in the lower lobes and small dependent fluid postoperative collection surrounding the spleen. the patient was a started on intravenous heparin and warfarin therapy was initiated with the inr goal of . the heparin gtt was monitored closely with every six hour ptt values. the patient remained on telemetry on the inpatient floor without issue on intravenous heparin and warfarin po until when, after missing approximately two doses of lopressor by mouth developed short bursts of sinus tachycardia which resolved with lopressor by mouth. the patient was monitored with daily inr values and dosed with 5 mg of warfarin. on discharge the patient's inr was 2.4 and she was discharged on 4mg of warfarin daily with follow up with her primary care provider on thursday for inr check and dose adjustment. the patient's bowel function returned appropriately post-operatively and she was tolerating a regular diet on discharge. on discharge, the left - drain was discontinued however, the right drain remained in place with the intention of the drain being discontinued at follow-up. the surgical incision was closed and remained stable. the patient was discharged home with appropriate medical instruction and follow-up. dr. , the patient's primary care provider, and aware of the hospital coarse and discharge. medications on admission: arimidex 1 mg daily azopt 1% 1gtt od twice daily keflex prior to dental work lisinopril 20 mg daily meclizine 25 mg tid prn simvastatin 20 mg daily timolol eyedrops 0.5% ou triamteren-hydrochlorothizide 37.5/25 vitamin c 1000 mg daily aspirin 81 mg daily vitamin d 1000 iu biotin 2500 mg calcium with d multivitamins omega fish oils discharge medications: 1. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. acetaminophen 500 mg tablet sig: two (2) tablet po every eight (8) hours as needed for pain: do not take more than 4000mg of tylenol daily. 5. oxycodone 5 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain for 5 days: please do not drink alcohol or drive a car while taking this medication. take as prescribed. disp:*40 tablet(s)* 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:*0* 7. dorzolamide 2 % drops sig: one (1) drop ophthalmic tid (3 times a day). 8. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 9. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 10. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 11. anastrozole 1 mg tablet sig: one (1) tablet po daily () as needed for br ca hx. 12. warfarin 2 mg tablet sig: two (2) tablet po once a day: please take daily at 400pm. please follow-up with your primary care who will be managing this medication. . disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: complex pelvic mass, malignant ovarian neoplasm on frozen section. 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 surgical managment of the complex mass located in your pelvis. you had quite an extensive surgery as listed below. pathology reports indicated that the left ovary showed cancerous tissue. you were admitted to the intensive care unit overnight after your surgery for monitoring and then your were transfered to the inpatient floor. you have a very low abdominal incision which is closed with staples. this may be left open to air, you may apply a dry sterile gauze if the skin becomes irritated. monitor for signs of infection including; white/green drainage, incresing warmth or redness of the skin, increased pain, or if you develop a fever. call the office if you develop these symptoms or report the emergency room if severe. you had 2 / drains in your incision, one of them was removed prior to your discharge. the other remains in place. please follow the instructions given to you by the nurses. if you have than 100 cc of drainage in the blub of the drain in one day please call the office, if the drain begins to ooze outside on the dressing incertion site onto the gauze dressing please call the office. the dressing should remain intact and do not shower until after you see dr. . this drain will be removed at the same time as your staples at your first follow-up visit. watch for similar signs of infection at the jp drain site. no heavy lifting for lbs unless instructed otherwise by dr. . on the floor you had a rapid heart rate in an irregular rythm called atrial fibrillation. the surgical team consulted the cardiology team who recommended we start you on the medication lopressor. this fast heart rate was controlled with this medication. it is important that you follow-up with your primary care provider for blood pressure monitoring as this is a new medication. you may want to consider purchasing a blood pressure cuff which you can monitor your blood pressure at home with. normal blood pressure is 120/80, if the top number is ever higher than 160 or lower than you should call the doctor. if your top number is very low wait to consult the primary care office's nurse prior to taking this medication. the cause of this atrial fibrillation was determined to be multiple small blood clots in your lungs called pulmonary emboli. these can happen when peaople are immobile or have conditions that make them more likely to develop a blood clot. cancer can do this. you were started on a heparin drip to thin the blood to prevent the clot from growing and transitioned to coumadin a medication you will take by mouth for 6months-1 year. you will take 4mg of this medication by mouth daily preferably, in the afternoon around 4pm, however this will be up to you. it is good to take it at this time if you will go ot have your blood drawn in the monring. you will require frequent blood laboratory value monitoring which will be preformed by your primary care provider. is very important that you take this medication as presecribed and report to the office to have your laboratory values checked because you will be at increased risk to bleed. your primary care provider will be managing the dose of your coumadin, it is important that you follow their recommendations exactly. you are at increased risk for bleeding, please follow the coumadin and food teaching sheets and monitor yourself for brusing, bloody stools, fast heart rate, or low blood pressure. you have an appointment with your primary care provider as listed below and it is important that you see her. please keep this appointment. monitor your bowel function and eat small frequent meals.stay well hydrated. if you become nauseated, constipted, vomit, or your abdomen becomes distended call your doctor. if severe come to the emergency room. you will see gyn oncology as written below. your oncologist is planning on adressing the plan for further care at this visit. you have not been taking your dyazide (water pill) during this admission. please discuss this with your primary care physician. hold of on restarting your other vitamins besides the iron and folic acid you were taking here and discuss with your primary care. take care! followup instructions: provider: , md phone: date/time: 12:00 provider: , m.d. phone: date/time: 10:30 provider: , md phone: date/time: 9:30 md, Procedure: Other and unspecified partial excision of large intestine Suture of laceration of large intestine Attachment of pedicle or flap graft to other sites Other removal of both ovaries and tubes at same operative episode Excision or destruction of peritoneal tissue Other lysis of peritoneal adhesions Division or crushing of other cranial and peripheral nerves Regional lymph node excision Excision of lesion of other soft tissue Incisional hernia repair Size reduction plastic operation Other and unspecified total abdominal hysterectomy Diagnoses: Other iatrogenic hypotension Anemia, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of malignant neoplasm of breast Accidental puncture or laceration during a procedure, not elsewhere classified Pulmonary collapse Acute respiratory failure 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 Morbid obesity Iatrogenic pulmonary embolism and infarction Other respiratory complications Accidents occurring in other specified places Accidents occurring in residential institution Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other complications due to other internal prosthetic device, implant, and graft Incisional ventral hernia with obstruction Accidental cut, puncture, perforation or hemorrhage during surgical operation Malignant neoplasm of ovary Other and unspecified ovarian cyst Scar conditions and fibrosis of skin Localized adiposity Endometriosis of uterus Malignant neoplasm of fallopian tube |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with one drug eluting stent placed history of present illness: patient is a 71yo male w/ history of hypertension, hyperlipidemia, diabetes mellitus who presents with chest pain. he had an episode of cp yesterday, lasting 2-3 minutes, that resolved on it's own. this was thought to be heartburn so the patient did not seek medical attention. this afternoon, he again experienced chest pain at around 2pm. he was pouring water into a pan to cook a . the pain lasted 45 minutes and was not relieved by resting or sitting down. it was located was at the upper sternum, without radiation to jaw or arms and was accompanied by lightheadedness, diaphoresis and clamminess. the sweating/clamminess lasted 30 minutes, but chest pain persisted. denies shortness of breath, heart palpitations, nausea, vomiting, radiation of pain. given concerning chest pain, his friend brought him to the for further evaluation. . in the ed, initial vital signs were t 96.9, hr 72, bp 150/88, rr 20, sao2- 96%. pain was relieved with administration of sublingual nitroglycerin. ekg concerning for stemi as he had st-elevations in v2, v3 and v4. code stemi was called and patient was taken to the cath lab. he was given plavix 300 mg, metoprolol , 324 mg, sl ntg x 2, eptifibatide 20 mg x2 and was started on heparin gtt prior to transfer to the cath lab. . in the cath lab, patient was found to have mid-lad lesion that was angioplastied and des was placed. he remains chest pain free after procedure with subseqent ekg's demonstrating improvement in st elevations. . on arrival to the floor, vital signs were t- 98.0, hr- 92, bp- 148/94, rr- 21, sao2- 91%. patient remains chest pain-free and asymptomatic. . 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 (at this time) is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: (+)diabetes, (+)dyslipidemia, (+)hypertension 2. cardiac history: - cabg: n/a - percutaneous coronary interventions: n/a - pacing/icd: n/a 3. other past medical history: hypertension, dyslipidemia, diabetes (last a1c 7.8%), benign prostatic hypertrophy, erectile dysfunction social history: works as custodian, very active at work, can climb 6 flights of stairs without chest pain or difficulty. no hcp, but says we can talk to his friend, . never smoker, never alcohol, never drugs. family history: father with mi at 75 years old - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission physical examination: vs: t- 98.0, hr- 92, bp- 148/94, rr- 21, sao2- 91% general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. +right eye cataract neck: supple with no jvd. cardiac: regular rate and rhythm, 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: obese, soft, ntnd. no hsm or tenderness. no abdominial bruits. extremities: no c/c/e. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ . discharge physical exam: vs: t- 97.5, hr- 78, bp- 127/79, rr- 16, sao2- 98%ra general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. +right eye cataract neck: supple with no jvd. cardiac: regular rate and rhythm, 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: obese, soft, ntnd. no hsm or tenderness. no abdominial bruits. extremities: no c/c/e. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: admission labs: . 03:20pm blood wbc-11.7* rbc-4.63 hgb-14.4 hct-42.6 mcv-92 mch-31.1 mchc-33.8 rdw-12.5 plt ct-350 03:20pm blood neuts-86.3* lymphs-10.9* monos-2.0 eos-0.5 baso-0.3 03:20pm blood glucose-214* urean-22* creat-1.1 na-137 k-6.5* cl-103 hco3-21* angap-20 04:33pm urine color-yellow appear-clear sp -1.019 04:33pm urine blood-sm nitrite-neg protein-tr glucose-300 ketone-40 bilirub-neg urobiln-neg ph-5.0 leuks-neg 04:33pm urine rbc-1 wbc-1 bacteri-none yeast-none epi-0 04:33pm urine mucous-rare . pertinent labs: . 03:20pm blood ctropnt-0.10* 11:06pm blood ck-mb-210* ctropnt-6.30* 06:25am blood ck-mb-107* mb indx-7.7* ctropnt-4.27* 06:36am blood triglyc-201* hdl-42 chol/hd-5.0 ldlcalc-129 . discharge labs: . 06:36am blood wbc-9.4 rbc-4.26* hgb-13.3* hct-39.0* mcv-92 mch-31.1 mchc-34.0 rdw-12.7 plt ct-281 06:36am blood glucose-173* urean-20 creat-1.0 na-138 k-3.9 cl-106 hco3-23 angap-13 06:36am blood triglyc-201* hdl-42 chol/hd-5.0 ldlcalc-129 . micro/path: . blood culture x 2 : ngtd ucx : probable enterococcus ~1000/ml mrsa screen : pending . imaging/studies: . c.cath : final diagnosis: 1. successful pci to the mlad lesion with promus des. 2. no complications of the procedure. 3. patient to remain on aspirin indefinite and clopidogrel for at least 1 year, unterrupted. . cxr portable : impression: mild bibasilar atelectasis. no pneumonia or pneumothorax seen. . tte : lvef 30%. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is an apical left ventricular aneurysm. lv systolic function appears depressed (ejection fraction 30 percent) secondary to inferior and posterior hypokinesis, and anterior and apical akinesis with focal dyskinesis (no thrombus seen with optison contrast). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic arch is moderately dilated. there are focal calcifications in the aortic arch. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. brief hospital course: 71m with hx of htn, hyperlipidemia and dm presents with chest pain, found to have anterior stemi s/p cath with des to mid lad lesion without complications. . # stemi: pt admitted to the ccu following immediate c.cath after code stemi was called in the ed with st elevations in the anterior leads. he was given full dose aspirin, 300mg loading plavix, and started on heparin and integrillin drips. the pt was found to have diffuse disease in the proximal lad and 95% stenosis in distal lad. des placed and patient continued on integrillin for a total of 18 hours upon arrival to the unit. he was chest pain free and remained hemodynamically stable without significant ectopy or arrythmias on telemetry. echo showed lvef of 30% with significant wma in the lad distribution. he was started on metoprolol to decrease myocardial oxygen demand and continued on lisinopril for afterload reduction. he was discharged with follow-up arranged with cardiology and his pcp with instruction to continue taking aspirin 325mg and plavix 75mg for at least 1 year. he was also discharged with warfarin and lovenox twice daily as a bridge to prevent mural thrombus from forming given his low lvef on echo. . # hypertension: stable. patient was started on metoprolol following his stemi and was continued no his home lisinopril. his chlorthalidone was discontinued (he was poorly compliant given side effects). . # poorly controlled niddm: he was managed with hiss while in-house and continued on his home glypizide and metformin at the time of discharge. he would benefit from lifestyle modification and perhaps an increased medical regimen given his recent a1c of 7.8. . # hyperlipidemia: undermanaged with a total cholesterol of 211 and an ldl of 129. patient on rousuvastatin at home (recently switched from simvastatin). he was switched to pravastatin at the time of discharge given its lower cost and his financial concerns and compliance issues. . transitional issues: -he will need close follow-up of his inr and his lovenox bridging can be discontinued once therapeutic for an adequate amount of time -he will need tighter control of his hld and dm to prevent further myocardial events -he cannot interrupt taking aspirin or plavix as he may risk another mi or in-stent restenosis medications on admission: 1. 81 mg daily 2. glipizide 10 mg daily 3. lisinopril 40 mg daily 4. chlorthalidone 25 mg daily (recent switched from hctz) 5. metformin 1000 mg 6. rosuvastatin 10 mg daily (recent switched from simvastatin) discharge medications: 1. enoxaparin 100 mg/ml syringe sig: one (1) injection subcutaneous (2 times a day) for 3 days. disp:*6 injection* refills:*0* 2. 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* 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*1* 5. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). 6. glipizide 10 mg tablet sig: one (1) tablet po once a day. 7. enoxaparin 100 mg/ml syringe sig: one (1) injection subcutaneous twice a day for 4 days. disp:*8 * refills:*0* 8. plavix 75 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 9. metoprolol succinate 100 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* 10. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 11. pravastatin 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary diagnoses: st elevation myocardial infarction left ventricular aneurysm . secondary diagnoses hypertension hyperlipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr , . it was a pleasure taking part in your medical care. you were in the hospital because you had a heart attack. a procedure was done to open the blocked artery and a stent was placed to keep the artery open. you will need to take aspirin and plavix (clopidogrel)every day to prevent the stent from being blocked until you are told to stop by your cardiologist. stopping these medications even for one day may result in a large heart attack. because a large part of your heart is not pumping properly you will need to take blood thinning medications to prevent a clot from forming in your heart and causing a stroke. you should inject your self with lovenox (enoxaparin) like you were instructed twice a day until a doctor tells you to stop. you will also need to take coumadin (warfarin) daily. you will need frequent blood tests to ensure that the warfarin level is correct. weigh yourself every morning, md if weight goes up more than 3 lbs. . we suggested that you stay in the hospital for a couple more days to prevent complications from your heart attack. you told us that you understand the risks and decided to leave anyway. . medication changes summary: please start plavix (clopidogrel) 75mg daily please start pravastatin 40 mg daily please start lovenox 100units twice daily until directed to stop by your primary doctor please start warfarin 5 mg daily please start metoprolol succinate 100 mg daily please increase aspirin to 325 mg daily . please stop chlorthalidone please stop rosuvastatin . continue all other medications as directed followup instructions: please call ( on monday to set up an appointment with your primary doctor. name: , location: /east address: , e/cc-6, , phone: fax: email: please call to schedule an appointment with your cardiologist, , md, mph, rpvi, facp within the next 2 weeks. Procedure: Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute myocardial infarction of other anterior wall, initial episode of care Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Impotence of organic origin |
allergies: morphine / ciprofloxacin attending: chief complaint: duodenal perforation, choledocholithiasis major surgical or invasive procedure: : ercp . : 1. repair of duodenal perforation. 2. repair of colotomy. 3. placement of feeding gastrojejunostomy tube. history of present illness: mrs. is a year old woman with history of paroxysmal atrial fibrillation on coumadin, s/p pacemaker placement for sick sinus syndrome, hypertension, gallstones and choledocholithiasis has underwent ercp for removal of stones in common bile duct. she underwent ercp on . bile duct was found to be dilated to 12 mm distally. several stones were found in proximal duct causing complete obstruction. the largest one was 2 cm in size. cholangioscopy was performed with a spyglass. large stones noted in common hepatic duct. the duct wall was inflamed due to prior stent/stones. stones were fragmented with and several fragments were removed with a balloon catheter. majority of the stone was fragmented and removed but not all of the stones could be removed. a 5cm by 10fr double pigtail biliary stent was placed successfully. the last ercp was done on . it was found that the biliary tree was severely dilated with evidence of large 2 cm stone in the common hepatic duct. there were also multiple smaller filling defects in the cbd consistent with stones and sludge. multiple small stones and sludge were extracted successfully using a balloon. cholangioscopy was performed using the spyglass spyscope and extensive sludge and debris were found in the bile ducts. copious irrigation was performed. the large 2 cm stone was encountered and was attempted. some fragmentation was achieved. however, due to machine malfunction, we were unable to completely fragment the stone. a 5cm by 10fr single pigtail biliary stent was placed successfully. today she presented for repeat ercp with discontinuation of coumadin of 5 days. the regular side-viewing ercp scope was used. the mucosa of stomach appeared edematous and friable. mild bleeding was noted when advancing the scope. the scope was advanced to reach the duodenal bulb. multiple ulcers were found and one of the ulcers appeared deep. given the unknown nature of the ulcer, the scope was withdrawn. a regular gastroscope was inserted with no difficulty. in the stomach, some heme was seen. there was no evidence of active bleeding. multiple ulcers were found in the duodenal bulb. one ulcer on the posterior wall of the duodenal bulb appeared deep. given the unknown nature of the ulcer, the decision was made to abort the procedure. in the recovery, patient noticed severe diffuse abdominal pain. stat ct scan with gastrograffin was ordered. it was found to have marked pneumoperitoneum suggestive of perforation. patient was started on zosyn and metronidazole. urgent consultation with pancreas surgeon was requested. the decision was made to proceed with emergent surgery for repair. patient was transported straight to operation room. past medical history: paroxysmal atrial fibrillation on warfarin (known since ) s/p pacer (dual chamber) , with sick sinus syndrome hypertension (> 40 years) gallstones, choledocholithiasis social history: tobacco, former (quit , 1ppdx30 years). son (. patient is widowed. family history: 2 children with gallstones, and/or removal of gallbaldder. physical exam: on transfer: t 96.8, hr 63, bp 167/67, rr 20, o2sat 99%2l gen: in acute distress from the pain; awake and alert and responding to questions heent: perrla, no scleral icterus, dry mucous membranes cc: irregular rhythms, s1, s2, chest: clear to ausculation bilaterally, no wheezing or crackles abdomen: mildly to moderately distended, diffusely tenderness on palpation. extremities: no pedal edema on discharge: vs: 96.6, 60, 110/60, 14, 98%ra gen: nad, comfortable, aao x 3 cv: irregularly irregular rhythm, pacing pulm: diminished lung sounds bilateraly extr: warm, no c/c/e pertinent results: 07:10am blood wbc-6.6 rbc-3.08* hgb-10.5* hct-30.8* mcv-100* mch-34.0* mchc-34.0 rdw-16.8* plt ct-189 07:10am blood glucose-117* urean-23* creat-0.7 na-132* k-4.6 cl-101 hco3-27 angap-9 04:30am blood alt-24 ast-35 alkphos-134* amylase-107* totbili-1.3 07:10am blood calcium-7.8* phos-2.4* mg-2.1 5:17 am mrsa screen source: nasal swab. **final report ** mrsa screen (final ): positive for methicillin resistant staph aureus. ct abd: impression: 1. marked retroperitoneal as well as omental and mesenteric air, suggesting duodenal perforation. 2. most of the stomach is seen in the left thoracic cavity, compatible with the documented large hiatal hernia in the atrius note. 3. no evidence of extraluminal oral contrast. 4. biliary stent in place. moderate left pneumobilia. 5. moderate bilateral effusions. small-to-moderate pelvic fluid. 6. severe l1 compression fracture, of uncertain chronicity. recommend clinical correlations. ecg: baseline artifact. low voltage throughout. atrial activity is difficult to discern - possibly atrial fibrillation. on the previous tracing of atrial pacing was seen. qrs complexes are quite similar. pacemaker interrogation may be helpful. ugi sgl: impression: no evidence of duodenal leak. small diverticulum in second portion of the duodenum and a larger diverticulum of the proximal jejunum were observed. kub: impression: non-specific bowel gas pattern. nn evidence of ileus or obstruction. no contrast leakage into abdominal cavity. ct abd: impression: 1. an intra-abdominal fluid collection with enhancing rim is seen anterior to the liver extending medial to the gallbladder measuring 10 x 4 mm (2:22) and containing air which is concerning for abscess. 2. normal appendix. 3. scattered colonic diverticulosis without evidence of diverticulitis. 4. no extravasation of oral contrast to suggest leakage or perforation. 5. pneumobilia consistent with prior ercp. 6. residual retroperitoneal air with the largest collection seen inferior to the left kidney. 7. moderate bilateral pleural effusions. 8. intrathoracic herniation of the superior stomach and pancreatic tail into the chest. 9. the uterus is enlarged with heterogeneous material filling the endometrial canal which is concerning for malignancy. a followup pelvic and transvaginal ultrasound would be recommended for further evaluation if clinically indicated. 10. severe compression fracture at l1. brief hospital course: the patient was transferred to the west 2a surgical service for emergent laparotomy and duodenal perforation repair. on , the patient underwent repair of duodenal perforation, repair of colotomy and placement of feeding gastrojejunostomy tube, which went well without complication (reader referred to the operative note for details). post op, the patient was transferred in icu, on iv fluids and antibiotics, with a foley catheter, and iv dilaudid for pain control. the patient was started on phenylephrine gtt for hypotension and low urine output. the patient received one unit of prbc on and one unit of rbc on , and albumin on . the blood pressure and urine output improved on , neo gtt was discontinued and patient was transferred on the floor. neuro: the patient received iv dilaudid with good effect and adequate pain control. when tolerating oral intake, the patient was transitioned to oral pain medications. cv: the patient has a history of paroxysmal atrial fibrillation. she was started back on her regular dose of coumadin on pod # 8. inr was monitored and still subtherapeutic prior discharge. the patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored with telemetry device. pulmonary: the patient was extubated postoperatively and remained stable from a pulmonary standpoint. crx revealed bilateral pleural effusion, thought to be fluid overload. the patient received several doses of lasix for diureses. repeat ct scan demonstrated improvement of pleural effusions. good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. gi: post-operatively, the patient was made npo. tube feed was started on pod # 3. on pod # 6, the patient underwent upper gi test for leak and test was negative. the patient's diet was advanced to clears. diet was advanced when appropriate, which was well tolerated. patient's intake and output were closely monitored, and iv fluid was adjusted when necessary. electrolytes were routinely followed, and repleted when necessary. the patient has two jp drains placed intraoperatively, they both continue to have large output (r>l). repeat ct scan on pod # 9 demonstrated intra-abdominal fluid collection and residual retroperitoneal air. the patient was discharged in rehab tolerating regular diet her tf was discontinued. gu: immediately post op the patient developed acute kidney injury prolong hypotension. patient's cr increased to 1.5 on pod # 2 and her urine output decreased. she was treated with fluid boluses. cr and uop improved to normal on pod # 3 and remained stable. gyn: the ct scan on admission revealed endometrial thickening. repeat ct on pod # 9 demonstrated enlarged uterus with heterogeneous material filling the endometrial canal. pelvic ultrasound was done and final read wasn't available prior discharge. radiology reviewed the study and thinks that findings most likely a hypoplastic endometrial polyps than malignancies. the patient was scheduled to follow up with dr. (ob/gyn oncology) on . id: the patient underwent empirical treatment with iv zosyn x 7 days. her peritoneal fluid and urine were negative for any growth. the patient's white blood count and fever curves were closely watched for signs of infection. wound was evaluated daily and no signs and symptoms of infection were noticed. endocrine: the patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. hematology: the patient's complete blood count was examined routinely. she received 2 units of rbc while in icu for hct 22.3 and to treat her hypotension. patient's hct remained stable low and was 32 on day of 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: nadolol 40', simvastatin 10', warfarin 2.5' discharge medications: 1. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*80 tablet(s)* refills:*0* 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. warfarin 2.5 mg tablet sig: one (1) tablet po once daily at 4 pm. 4. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. nadolol 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: life care center of discharge diagnosis: 1. choledocholithiasis 2. duodenal perforation 3. hypotension 4. acure kidney injury 5. bilateral pleural effusions discharge condition: condition: good. mental status: aaox3 ambulatory: able to ambulate with help/walker discharge instructions: please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until your follow-up appointment. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. *if you have staples, they will be removed at your follow-up appointment. *if you have steri-strips, they will fall off on their own. please remove any remaining strips 7-10 days after surgery. . jp drain care x 2: *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *maintain suction of the bulb. *note color, consistency, and amount of fluid in the drain. call the doctor, nurse practitioner, or vna nurse if the amount increases significantly or changes in character. *be sure to empty the drain frequently. record the output, if instructed to do so. *you may shower; wash the area gently with warm, soapy water. *keep the insertion site clean and dry otherwise. *avoid swimming, baths, hot tubs; do not submerge yourself in water. *make sure to keep the drain attached securely to your body to prevent pulling or dislocation. followup instructions: provider: , md phone: date/time: 10:15 3, . at time of followup, will review plans for gi follow up once recovery completed. . please follow up with dr. (pcp) at 2-3 weeks after discharge. call to schedule a follow up appointment with dr. . . please continue to follow up with clinic to monitor your inr . provider: , phone: date/time: 2:00 ob/gyn 8, Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Suture of laceration of large intestine Other gastroenterostomy without gastrectomy Endoscopic retrograde cholangiopancreatography [ERCP] Suture of laceration of duodenum Diagnoses: Unspecified pleural effusion Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Accidental puncture or laceration during a procedure, not elsewhere classified Septic shock Long-term (current) use of anticoagulants Cardiac pacemaker in situ Pulmonary congestion and hypostasis Accidents occurring in residential institution Calculus of gallbladder and bile duct without cholecystitis, with obstruction Other specified disorders of peritoneum Accidental cut, puncture, perforation or hemorrhage during surgical operation Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction Diverticulosis of small intestine (without mention of hemorrhage) Polyp of corpus uteri |
allergies: atorvastatin attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization placement of 3 drug eluting stents history of present illness: 52 year old male with diet controlled diabetes, htn treated with lisinopril, active smoker who developed chest tightness and difficulty breathing after a strenuous wokrout at the gym yesterday morning. the chest tightness and difficulty breathing became more progressive and constant at 4am and this prompted him to seek emergency room care. in the er he was found to have st elevations in the inferior leads and was sent to the cath lab after being placed on heparin gtt, asa, plavix load. of note right sided leads showed no involvement of the right ventricle. past medical history: diabetes- diet controlled htn asthma hypertriglyceridemia right inguinal hernia repair on social history: patient smokes 1 ppd since age 19. rare etoh. works as a desk clerk and lives with his niece and a longtime friend with progressive cancer. family history: father had mi in his 40s and suffered a cva later on. mother died of lung cancer. physical exam: general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no appreciable jvd. 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. 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: 09:30am blood alt-27 ast-36 ld(ldh)-232 ck(cpk)-170 alkphos-79 totbili-0.3 09:30am blood ck-mb-7 ctropnt-0.02* 04:00pm blood ck(cpk)-4119* 04:00pm blood ck-mb-399* mb indx-9.7* ctropnt-8.62* 10:19pm blood ck(cpk)-2885* 10:19pm blood ck-mb-245* mb indx-8.5* 05:51am blood ck(cpk)-1727* 05:51am blood ck-mb-115* mb indx-6.7* ctropnt-5.58* 06:33am blood ck(cpk)-466* 06:33am blood ck-mb-17* mb indx-3.6 ctropnt-3.48* 06:40am blood ck(cpk)-208* 06:40am blood ck-mb-6 ctropnt-3.35* 06:40am blood glucose-108* urean-15 creat-0.8 na-141 k-4.3 cl-106 hco3-26 angap-13 06:40am blood wbc-9.8 rbc-4.16* hgb-12.7* hct-35.9* mcv-86 mch-30.4 mchc-35.3* rdw-13.2 plt ct-243 lhc/rhc comments: 1. coronary angiography in this right dominant system revealed single and branch vessel coronary artery disease. the lmca was patent. the lad had diffuse 20-30% stenosis in the mid portion with a 70% stenosis in the mid portion of d1. the lcx was patent with a 30-40% stenosis in om2. the rca was totally occluded distally with an ulcerated 50% plaque in its mid portion and a 70% stenosis in the r-pl branch. 2. resting hemodynamics demonstrated elevated right and left sided filling pressures with an rvedp of 17 mmhg and a mean pcwp of 20 mmhg. there was moderate pulmonary arterial systolic hypertension with a pasp of 37 mmhg. the cardiac index was preserved at 5.7 l/min/m2. there was moderate systemic arterial systolic hypertension with an sbp of 153 mmhg. 3. successful suction atherectomy and direct stenting of the mid and distal rca with a 3.5 x 18mm and 3.5 x 15mm promus drug eluting stent respectively. 4. successful direct stenting of the r-plv with a 2.25 x 15mm promus drug eluting stent. final angiography revealed no residual stenosis, no angiographically apparent dissection, and timi 3 flow. (see ptca comments for details) . final diagnosis: 1. single and branch vessel coronary artery disease. 2. left ventricular diastolic dysfunction. 3. elevated right ventricular filling pressures consistent with rv infarction. 4. successful suction atherectomy and direct stenting of the mid and distal rca. 5. successful direct stenting of the r-plv. 6. successful deployment of an angioseal closure device. . tte . the left atrium and right atrium are normal in cavity size. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal to mid inferolateral and inferior segments and of the basal inferior segment. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. . impression: mild focal lv systolic dysfunction consistent with one-vessel cad (lcx or rca). no pathologic valvular abnormality seen. ef 50-55%. . ekg . sinus rhythm. the p-r interval is prolonged. there are q waves in the inferior leads with minimal st segment elevation and terminal t wave inversion consistent with acute or evolving myocardial infarction. compared to the previous tracing early transition is no longer present. brief hospital course: in the cath lab, pt was found to have thrombus and complete occlusion of distal rca. he underwent thrombectomy and stent placement, subsequently he still had st elevations and the proximal/mid rca was ulcerated and thought to be the culprit lesion with embolization to the distal rca. hence, the patient underwent placement of another 2 to the mid, and distal rca with resolution of st elevations. timi 3 flow achieved and 30% stenosis remained in distal vessel beyond mid stent. . lmca- no sig disease lad- diffuse 20-30, d1 70% mid lcx- om2 30-40 rca- to distal, ulcerated mid lesion . during the reperfusion process the patient was transiently bradycardic and hypotensive and was given atropine and was briefly on dopamine but taken off prior to transfer. . the patient remained stable during his time in the ccu and his ce peaked at ck 4100, troponin 8.6. he had a few runs of asymptomatic nsvt during the first 36 hours s/p reperfusion but no other abnormalities on telemetry. . the patient was started on bb, acei, asa/plavix. initially the patient refused treatment with statin as he has had myalgias with several statins in the past. after further discussion, patient agreed to try low-dose crestor (5 mg/d). . smoking cessation was strongly stressed to this patient. medications on admission: (pt unclear of doses) lisinopril advair albuterol discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*90 tablet, delayed release (e.c.)(s)* refills:*3* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*3* 3. nicotine 7 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*30 patch 24 hr(s)* refills:*1* 4. rosuvastatin 5 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*1* 5. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*30 tablet(s)* refills:*0* 8. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q6h (every 6 hours) as needed for wheezing. 9. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*3* 10. metoprolol succinate 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*90 tablet sustained release 24 hr(s)* refills:*3* discharge disposition: home discharge diagnosis: primary: inferior st elevation myocardial infarction secondary: diabetes hypertension dyslipidemia smoker discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you were admitted with a big heart attack. you will need to be on many new medications to help prevent another heart attack. you will also be on 2 extremely important medications to prevent the newly placed stents in your heart from clotting. you also need to stop smoking as this increases your risk of having another heart attack. you will need to follow up with your primary care doctor next week and you will also be set up for an appointment with a cardiologist (heart doctor) in the next week. return to the er if you experience any chest pain, shortness of breath or any worrisome symptoms. followup instructions: follow up with your primary care doctor next week. you will be set up with a cardiologist in the upcoming week, if you do not hear from anyone by tuesday contact your primary care doctor to ensure you have an appointment. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of drug-eluting coronary artery stent(s) Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Insertion of three vascular stents Procedure on two vessels Procedure on vessel bifurcation Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Asthma, unspecified type, unspecified Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Acute myocardial infarction of other inferior wall, initial episode of care Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain, nausea, vomiting, poor oral intake associated with lethargy and confusion x 2days. transferred to from hospital with respiratory distress. major surgical or invasive procedure: none history of present illness: 76 year old male with copd, cad, htn, long history of smoking transferred from hospital for respiratory distress in the setting of recent ercp complicated by post-ercp pancreatitis. mr. is an resident, who recently underwent an ercp on , and subsequently developed abdominal pain, nausea, vomiting, poor po intake, lethargy, and confusion. he was admitted on to hospital. the ercp findings were noteable for a dilated bile duct, cyst duct stump, and pancreatic ducts s/p stent placement in cbd. at the time of the hospital admission, he was febrile to 101, with a leukocytosis of 19k and amylase greater than 2400, lipase greater than 2600, but normal lfts. the patient was admitted and treated presumptively for post-ercp pancreatitis with npo diet, aggresive ivf and antibiotics (ertapenem x2 doses) for a question of cholangitis. the patient did undergo a ct scan that revealed, per report, peripancreatic fat stranding. on , the patient was seen in gi consultation. over night he developed respiratory distress and was placed on bipap. due to failure to improve, the patient was transferred to for further evaluation and care. on , his arterial blood gases were 7.48/26/79/19/97%. upon admission, the patient complained of difficulty breathing and feeling short of breath. he was intubated shortly thereafter for increasing tachypnea and work of breathing. past medical history: cad, s/p stent x2 (echo ef 65%), copd, s/p cholecystectomy, s/p appendectomy, chronic lower back pain s/p lumbar laminectomy x3 complicated by left foot drop (wears brace), htn, dvt, pe s/p ivc filter placement, aaa 3.6cm, orthostatic hypotension. social history: elderly care facility resident. ex-smoker 35 pk-yr hx; quit 25yrs ago. family history: non-contributory physical exam: vs: t: 99.9 po, bp: 110/79, hr: 64, rr: 17, sao2: 100% ra gen: alert, arousable with mental status at baseline in nad. heent: sclerae anicteric. eomi. o-p intact. neck: supple. no lymphadenopathy. lungs: cta(b). cardiac: rrr; nl s1/s2. abd: normoactive bsx4. soft/nt/nd. extrem: no c/c/e. skin: intact. no rashes/lesions. neuro: alert, arousable, baseline. pertinent results: 11:36pm type-art po2-164* pco2-19* ph-7.46* total co2-14* base xs--6 11:36pm glucose-73 k+-2.3* 07:10pm alt(sgpt)-21 ast(sgot)-38 ck(cpk)-258* alk phos-51 tot bili-0.9 07:10pm lipase-91* 07:10pm calcium-6.1* phosphate-1.7* magnesium-2.0 07:10pm cea-1.9 07:10pm wbc-15.8* rbc-4.25* hgb-12.8* hct-38.1* mcv-90 mch-30.2 mchc-33.7 rdw-14.3 07:10pm neuts-91.0* lymphs-5.8* monos-3.0 eos-0 basos-0.1 07:10pm plt count-180 07:10pm pt-15.7* ptt-31.3 inr(pt)-1.4* . torso ct with contrast: 1. worsening of pancreatitis, though the imaging findings often lag behind the patient's clinical status. there is moderately extensive peripancreatic fluid and stranding; however, no evidence of pancreatic necrosis, vascular complication or discrete fluid collection. 2. new small-to-moderate left and tiny right pleural effusions with associated atelectasis. 3. small ground-glass focus in the left upper lobe may represent inflammation or infection. 4. cbd stent in situ, with expected pneumobilia and minimal intrahepatic bile duct dilation. 5. moderate axial hiatal hernia. 6. 3 cm infrarenal aaa . admission pa cxr: midline gas collection just above the diaphragm is presumably a loop of bowel or gastric fundus in a midline hernia. lungs clear. heart size normal. no pleural effusion, pneumothorax or upper mediastinal abnormality. stomach is below the diaphragm is severely distended. . ap/lat cxr: examination is limited due to low lung volumes. within this limitation, the hiatal hernia unchanged. compressive atelectasis at the left lung base is noted adjacent to the hernia. the lungs are otherwise clear without focal opacity. the heart size is likely exaggerated due to low lung volumes and lordotic position. the mediastinal and hilar contours are normal. the right- sided central line and nasogastric tube have been removed. biliary stent and ivc filter are again seen. impression: no acute cardiopulmonary abnormality. . cxr line placement: existing picc line repositioned, now with tip in the svc. the picc line is ready to use. brief hospital course: the patient was transferred from hospital and admitted to with post-ercp pancreatitis with tachypnea and difficulty breathing. npo on iv fluids. baseline portable ap cxr taken. arterial blood gases were 7.48/26/79/19/97%. intubated and placed on mechanical ventilation. fentanyl drip for pain started with good effect. midazolam drip started for sedation while intubated. flexiseal fecal management system placed, foley maintained. icu protocols implemented. : received fluid rescusitation. electrolytes repleted. abgs and ap cxr repeated. vent settings adjusted. cvl placed. : day #1 tpn initiated. continued on ventilator. : diuresis started with lasix drip. given albulin infusion. day #2 tpn. started on fentanyl patch for pain control. : diamox added to facilitate diuresis. continued on tpn. spiked fever; pan cultured. cultures negative. fentanyl drip discontinued; continued on patch. : bal performed. successfully extubated. : re-intubated for respiratory distress. torso ct performed. : cvl discontinued; tip sent for culture. new cvl placed. continued on vent, tpn, ivf. : extubated successfully. spiked fever. plan continued. : developed epigastic (r)uq abdominal pain asscoiated with increased lfts. lasix drip discontinued. agressive respiratory toilet. physical therapy following. : ngt and a-line discontinued. transferred to floor npo, on iv fluids, with a foley in place. continued on fentanyl patch for pain control with good effect. continued on tpn. started clear liquids on with good tolerability.no events. : triggered for low systolic blood pressure; responded well to 1l fluid bolus. cvl discontinued; tip sent for culture. on ppn while central line out. diet advanced to full. iv vancomycin started for empiric line sepsis. mentation improved. repeat cxr normal. : mental status further improved. geriatrics conulted. home medications started. picc placed; tpn restarted. : iv vancomycin discontinued; started on cipro for possible uti. : continued on tpn. full liquids with excellent intatke; no nausea, vomiting. lfts improving. : continues on tpn. tolerating full liquid diet. foley remains in place due to incontinence. : (l) picc site erythematous with cephalic vein clot identified; picc discontinued and tip sent for culture, (l) upper extremity elevated with warm compresses applied. new (r) picc placed. foley discontined. voided. medications on admission: ativan 0.5 po qhs, cymbalta 30mg daily, feso4, prilosec 20mg daily, zocor 80mg daily, singulair 10mg daily, vitd, asa 81mg daily, avapro 150mg daily, florinef 0.05mg daily, toprol 50mg daily, calcium carbonate 500mg chewable tid discharge medications: 1. fentanyl 100 mcg/hr patch 72 hr sig: one (1) transdermal q72h (every 72 hours). 2. fentanyl 25 mcg/hr patch 72 hr sig: one (1) transdermal every seventy-two (72) hours: place with 100 mcg patch. 3. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours) as needed for wheeze. 4. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 5. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 6. salmeterol 50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 8. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po qmon (every monday): for 10 weeks total then 800 iu po daily after that. 11. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 12. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 13. vicodin hp 10-660 mg tablet sig: one (1) tablet po every six (6) hours as needed for severe pain. 14. fludrocortisone 0.1 mg tablet sig: one-half tablet po once a day. 15. ativan 0.5 mg tablet sig: one (1) tablet po at bedtime. 16. toprol xl 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 17. avapro 150 mg tablet sig: one (1) tablet po once a day. 18. cymbalta 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 19. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever or pain: do not exceed 4000mg acetaminophen daily. discharge disposition: extended care facility: & rehab center - discharge diagnosis: post-ercp pancreatitis discharge condition: stable 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 driving or operating heavy machinery while taking pain medications. followup instructions: provider: scan phone: date/time: 10:00 provider: , md phone: date/time: 11:45; location 3, , pa (ercp) will call dr. with arrangements for follow-up ercp with stent removal to be scheduled with dr. in 6 weeks. ms. contact information: : (, pager: . Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Obstructive chronic bronchitis with (acute) exacerbation Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Alcohol abuse, unspecified 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 Other complications due to other vascular device, implant, and graft Personal history of venous thrombosis and embolism Alcoholic polyneuropathy Hypovolemia Lumbago Delirium due to conditions classified elsewhere Diverticulosis of colon (without mention of hemorrhage) Acute pancreatitis Other acquired deformities of ankle and foot Orthostatic hypotension Mixed acid-base balance disorder Nonspecific abnormal electrocardiogram [ECG] [EKG] |
allergies: mold extracts attending: addendum: please discontinue the lasix (furosemide) and po potassium chloride on patients admission to your facility per dr . it has been determined to continue to hold these medications until further outpatient review. discharge disposition: extended care facility: - md, Procedure: Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Percutaneous abdominal drainage Excision or destruction of other lesion or tissue of heart, open approach Incision of vessel, abdominal veins Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Urinary tract infection, site not specified Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Hyposmolality and/or hyponatremia Secondary malignant neoplasm of other specified sites Diaphragmatic hernia without mention of obstruction or gangrene Long-term (current) use of anticoagulants Other ascites Malignant neoplasm of liver, primary Esophageal varices in diseases classified elsewhere, without mention of bleeding Alcohol abuse, continuous Barrett's esophagus Below knee amputation status Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Jaundice, unspecified, not of newborn Other ill-defined heart diseases Chronic pulmonary embolism Other secondary thrombocytopenia Hypersplenism |
allergies: mold extracts attending: addendum: please note the following medication was discontinued at time of discharge. he had not been receiving this medication due to potential for causing lethargy/alterned mental status please remove from d/c medication list. 8. cyclobenzaprine 10 mg tablet sig: 0.5 tablet po tid (3 times a day) as needed for pain. discharge disposition: extended care facility: - md, Procedure: Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Percutaneous abdominal drainage Excision or destruction of other lesion or tissue of heart, open approach Incision of vessel, abdominal veins Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Urinary tract infection, site not specified Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Hyposmolality and/or hyponatremia Secondary malignant neoplasm of other specified sites Diaphragmatic hernia without mention of obstruction or gangrene Long-term (current) use of anticoagulants Other ascites Malignant neoplasm of liver, primary Esophageal varices in diseases classified elsewhere, without mention of bleeding Alcohol abuse, continuous Barrett's esophagus Below knee amputation status Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Jaundice, unspecified, not of newborn Other ill-defined heart diseases Chronic pulmonary embolism Other secondary thrombocytopenia Hypersplenism |
allergies: mold extracts attending: chief complaint: right atrium mass and inferior vena cava mass. major surgical or invasive procedure: exploratory laparotomy, mobilization of the liver, mobilization inferior vena cava, inflow occlusion. (dr. ) the remainder of the procedure performed by dr. from cardiovascular surgery included cardiopulmonary bypass, median sternotomy and resection of the right atrial tumor thrombus. history of present illness: is a 54 year old male with hepatocellular carcinoma and a right atrial tumor thrombus extending into the inferior vena cava and hepatic veins. in short, mr. has a history of hepatitis c and alcoholic cirrhosis who was found to have a 5 cm mass on ct scan in which was shown to be expanding in to 9x6 cm with multiple pulmonary nodules. afp levels were greater than 600,000 ng/ml. further imaging in , however, failed to show a mass and afp had then decreased to 2177 ng/ml. when hospitalized in for an ugi bleed he was found to have a right atrial mass on echocardiogram, confirmed to be hcc on biopsy in . he was started on multiple chemotherapy regimens thereafter which were interchanged due to side-effects and presented in with a pulmonary embolism. workup showed concern for tumor progression. he presents now for resection in a combined procedure with hepatobiliary and cardiac surgery. past medical history: # hcc - has a history of hepatitis c and alcoholic cirrhosis complicated by grade ii-iii varices - initial surveillance ct performed at an outside hospital in showed a 5-cm mass in the left liver as well as multiple satellite lesions. afp on was greater than 100,000 ng/ml. - at ct on showed a 9 x 6 cm enhancing mass in the left liver as well as innumerable pulmonary nodules, the largest measuring 9-10 mm. afp was >600,000ng/ml. however, further imaging showed improved in infiltrating liver process and afp decreased to 2177ng/ml on . no lesion was identified by chest ct, liver ct, u/s, or mri for biopsy. - he was hospitalized in with upper gi bleed, and echocardiogram during that hospitalization diagnosed a right atrial mass. hcc diagnosis was confirmed on the right atrial mass biopsy on . - he began sorafenib . dose was reduced after two weeks due to severe hand/foot syndrome and thrombocytopenia to 200mg . - mr. self discontinued sorafenib due to progressive leg cramps. his afp had begun to rise. - he began second line treatment with capecitabine . exploratory laparotomy, mobilization of the liver, mobilization inferior vena cava, inflow occlusion. the remainder of the procedure performed by dr. from cardiovascular surgery included cardiopulmonary bypass and removal of the right atrial tumor thrombus. other medical history: hepatitis c /etoh cirrhosis c/b 2 cords grade 3 esophageal varices s/p banding most recently . barrett's esophagus. hypertension. gerd. status post right bka after a motorcycle collision in requiring eight surgeries. history of hospitalization for pneumonia. h/o upper gi bleed s/p hospitalization social history: mr. is divorced and has two children. he lives with his father, mother, and brother. previously worked in an automotive repair and as a driver delivering auto parts but is currently out of work. tobacco: 35 years x1 pack per day. he continues to smoke about 1.5 ppd. alcohol: history of abuse, now about 2 beers per day. denies history of withdrawals. illicits: none. family history: the patient's father is alive at 84. the patient's mother is alive at 85 with dementia. he has a brother and sister and two children without health concerns. there is no family history of liver disease or malignancy. physical exam: 97.8 89 127/86 20 100% ra nad, aaox3 cta rrr abd soft, non-tender, non-distended right leg bka stump, well healed with skin fold extending at mid portion of stump and running to medial aspect of stump, no drainage or signs of opening no lower extremity edema 5.2>31.6<48 pertinent results: 05:25am blood wbc-7.6 rbc-3.57* hgb-11.1* hct-33.3* mcv-93 mch-31.1 mchc-33.3 rdw-21.9* plt ct-133* 07:55am blood wbc-3.3* rbc-2.88* hgb-9.6* hct-27.5* mcv-96 mch-33.4* mchc-35.0 rdw-21.7* plt ct-88* 07:05am blood wbc-3.6* rbc-2.94* hgb-9.7* hct-27.7* mcv-94 mch-32.9* mchc-35.0 rdw-21.5* plt ct-78* 05:25am blood pt-26.5* inr(pt)-2.6* 05:25am blood pt-22.3* inr(pt)-2.1* 07:55am blood pt-24.7* ptt-34.8 inr(pt)-2.4* 07:05am blood pt-26.0* ptt-35.7* inr(pt)-2.5* 05:25am blood glucose-95 urean-15 creat-0.6 na-128* k-3.7 cl-95* hco3-28 angap-9 07:55am blood glucose-90 urean-12 creat-0.6 na-126* k-4.0 cl-94* hco3-27 angap-9 07:05am blood glucose-86 urean-11 creat-0.5 na-128* k-3.8 cl-96 hco3-23 angap-13 05:40am blood alt-21 ast-60* alkphos-159* totbili-2.5* 05:25am blood alt-28 ast-65* alkphos-171* totbili-2.2* 05:25am blood alt-27 ast-58* alkphos-149* totbili-2.1* 06:12am blood lipase-30 07:05am blood calcium-8.2* phos-2.6* mg-2.0 07:50pm blood caltibc-558* ferritn-39 trf-429* 1:04 pm urine source: cvs. **final report ** urine culture (final ): citrobacter freundii complex. >100,000 organisms/ml.. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. sensitivities: mic expressed in mcg/ml _________________________________________________________ citrobacter freundii complex | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 32 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s brief hospital course: 54 year old male with a tumor thrombus from his right atrium into his inferior vena cava to hepatic veins, involving the liver. he was admitted for procedural workup prior to his operation on . arrangements for cardiac catheterization and carotid duplex ultrasound on were made prior to his operation on . cardiac catheterization demonstrated the following: no angiographically apparent flow-limiting coronary disease. 2. catheter-induced spasm at ostium of rca with 60% mid-segment 3. normal systemic arterial pressures. 4. vagal reaction/hypotension secondary to ic ntg administration, resolved with ivf and atropine. tee was also performed noting ef of 55-65% and a large spherical mass of 5.9 cm diameter was seen in the right atrium and a mass was seen in the liver at the junction of the hepatic vein with the ivc. carotid duplex demonstrated less than 40% stenosis in the internal carotid arteries bilaterally. he was preop'd and taken to the or on . he underwent exploratory laparotomy, mobilization of the liver, mobilization of inferior vena cava, inflow occlusion. surgeon was dr. . the remainder of the procedure was performed by dr. from cardiovascular surgery that included median sternotomy, cardiopulmonary bypass and removal of the right atrial tumor thrombus. please refer to operative reports for further details. postop, he was taken intubated with a chest tube to the cv icu under the care of dr. . on , a liver duplex was done noting the following: poor evaluation of the left hepatic vein, and residual tumor in this area cannot be excluded. 2. patent inferior vena cava as well as middle and right hepatic veins. 3. reversal flow within the left portal vein which is otherwise patent. 4. gallbladder sludge with minimal gallbladder wall thickening, the latter of which may be due to underlying chronic liver disease. a tte was then done noting ef of >55% and no residual right atrial mass seen. normal global and regional biventricular systolic function. repeat liver duplex on was performed again demonstrating the following: 1. appropriate flow is seen in the ivc and the right and middle hepatic veins. again the left hepatic vein is not well visualized which might relate to residual tumor or occlusion as previously noted. there is no change in the appearance. reverse flow again noted in the left portal vein. 2. no focal hepatic lesion and no biliary dilatation seen. 3. sludge in the gallbladder. given the liver duplex findings, a ct was performed to evaluate the hepatic vasculature. ct on showed interval right atrial and ivc tumor thrombectomy with persistent pulmonary emboli, persistent middle and left hepatic venous occlusion, unchanged from ct. no definite focal lesions were seen in the liver. portal, splenic and superior mesenteric veins were patent with gastric, splenic and esophageal varices. bibasilar ground glass opacities were demonstrated, likely mild pulmonary edema; however superimposed infection could not be excluded. he was started on heparin drip then coumadin was initiated on . heparin was stopped. inr became therapeutic on with inr 2.4. overall, he did well postop. chest tube was removed. he was transferred out of the icu. for many days, he experienced high jp ascites output for which he received albumin and iv fluid. jp output decreased to 1200. diet was slowly advanced and tolerated. he was eventually passing bms. pain management was difficult as he experienced back pain as well as abdominal pain. oxycontin was started in addition to oral pain mediation with prn dilaudid iv for break thru. he became somewhat confused and the oxycontin and dilaudid were stopped. flexeril was not given. lfts increased slightly then trended down. mental status improved. jp was removed on . the insertion site was sutured and remained dry/intact. abdomen increased in size a day after the jp was removed . home diuretics were resumed. he required potassium supplementation. the chevron incision remained intact, dry and without redness. the sternotomy site was also intact, without redness or drainage. two days after the jp drain was removed, he started to experience hyponatremia with sodium decreasing to 127 then as low as 125. abdomen appeared to have developed ascites. an attempt was made to do a therapeutic paracentesis. a diagnostic paracentesis was performed. fluid was sent for gram stain, cell count and culture. 1+ pmr were noted without organisms. hepatology was consulted for hyponatremia on . it was felt that the patient was dry. diuretics were then held. recommendations were to restrict sodium and fluid. albumin was administered. sodium trended back up to 128. on , abdomen appeared larger and patient felt a little sob. vital signs were stable. weight was up one kg as well. lasix 20 mg daily and potassium chloride 20 meq were restarted on . hepatology did not want sodium or fluid restricted. pt was initially consulted noting difficulty mobilizing patient secondary to sternal and upper abdomen (chevron)incision. his right leg was very edematous and needed pt to apply a "stump shrinker". this was successful and prosthesis was applied. his prosthesis had a belt that wrapped around his waist below the chevron. due to the two incisions, sternal precautions and bka, ambulation was difficult. please refer to pt notes. at time of discharge he was easier to move but required assist due to sternal precautions. pt recommended rehab and a bed was sought at in . a bed became available on . coumadin inr goal is . he will require daily pt/inrs until goal range is stable then ~ 3x per week. of note, he developed foul smelling urine, ua/ucx were sent isolating citrobacter on . this was pan sensitive to cipro. cipro 500 mg was started on . a ten day course was planned. medications on admission: capecitabine 1500 mg cyclobenzaprine 5-10 mg qhs prn back pain furosemide 20 mg daily nadolol 40 mg daily omeprazole extended release 20 mg daily spironolactone 50 mg daily zolpidem 10 mg qhs prn insomnia docusate sodium 100 mg prn constipation loratadine 10 mg daily multivitamin daily discharge medications: 1. outpatient physical therapy right residual limb shrinker dx: post op edema 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. multivitamin tablet sig: one (1) tablet po daily (daily). 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). 6. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 8. cyclobenzaprine 10 mg tablet sig: 0.5 tablet po tid (3 times a day) as needed for pain. 9. nadolol 20 mg tablet sig: one (1) tablet po daily (daily): hold for hr<60, sbp<100mmhg . 10. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 11. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 12. insulin regular human 100 unit/ml solution sig: follow printed sliding scale units injection asdir (as directed). 13. warfarin 1 mg tablet sig: one (1) tablet po once a day: inr daily. 14. labs daily pt/inr. goal inr 15. labs weekly labs, start wed : cbc, chem 10, ast, alt, alk phos, t.bili, albumin, pt/inr fax to attn: , rn coordinator 16. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days: started . end uti. 17. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 18. potassium chloride 10 meq capsule, extended release sig: two (2) capsule, extended release po daily (daily): while on lasix. discharge disposition: extended care facility: - discharge diagnosis: right atrial tumor thrombus uti, citrobacter discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. (patient has right leg prosthesis) sternal precautions discharge instructions: you will be transferring to in for rehab please call dr office at for fever, chills, confusion, nausea, vomiting, diarrhea, constipation, incisional redness, drainage or bleeding, increased ascites, bleeding followup instructions: provider: , md, phd: date/time: 10:40 ( , rn coordinator for dr. ) provider: , md phone: date/time: 1:15 dr. (oncologist) (please schedule a follow up appointment) md, Procedure: Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Percutaneous abdominal drainage Excision or destruction of other lesion or tissue of heart, open approach Incision of vessel, abdominal veins Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Urinary tract infection, site not specified Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Hyposmolality and/or hyponatremia Secondary malignant neoplasm of other specified sites Diaphragmatic hernia without mention of obstruction or gangrene Long-term (current) use of anticoagulants Other ascites Malignant neoplasm of liver, primary Esophageal varices in diseases classified elsewhere, without mention of bleeding Alcohol abuse, continuous Barrett's esophagus Below knee amputation status Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Jaundice, unspecified, not of newborn Other ill-defined heart diseases Chronic pulmonary embolism Other secondary thrombocytopenia Hypersplenism |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: ventricular tachycardia major surgical or invasive procedure: -vt ablation -icd generator change history of present illness: this morning, the patient was having breakfast when he heard a loud, banging noise and dropped his cup of tea. this episode was not accompanied by any other symptoms. the patient denied any chest pain. his baseline does involve symptoms of exertional dyspnea with moderate physical activity, but no symptoms of dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea (he consistently sleeps on two pillows), or lower extremity edema. he has not had any episodes of dizziness or syncope. . the patient reported for a routine icd outpatient check and was discovered to be in sustained ventricular tachycardia at about 160-170 beats per minute. the patient's son was told that the 4 shocks in the recent past; however, the patient's symptoms of hearing a loud, banging noise only matched up to a single shock. (the patient received a shock during his stay at ; he reported hearing a loud noise then as well.) the patient went to hospital briefly and was then transfered here for ablation. on review of systems, he denies any recent headache, dizziness, dysphagia, cough, palpitations, nausea, vomiting, constipation, diarrhea. the patient has had no change in appetite and has been able to consume his usual amounts of food and liquid. past medical history: 1. cardiac risk factors: htn, hyperlipidemia, history of stroke 2. cardiac history: two mis (, ) -cabg: -percutaneous coronary interventions: -pacing/icd: 3. other past medical history: - cad s/p anterior stemi with vf arrest, imi, and cabg (lima to lad, saphenous vein graft to first diagonal, saphenous vein graft to first obtuse marginal, jump saphenous vein graft to om2 and om3. - ischemic cardiomyopathy with ejection fraction of % - s/p prophylactic fibrillator - non-sustained ventricular tachycardia - hypertension - hyperlipidemia - ckd (estimated gfr 49ml/min) - history of stroke - gerd - depression social history: -tobacco history: quit in after long history of pack-per-day smoking. the patient is a native of . family history: no known history of premature cardiac disease. physical exam: general: nad. resting in bed heent: ncat. sclera anicteric. perrl, eomi. neck: supple. cardiac: irregualr rhythm, s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, non-tender, bowel sounds positive. extremities: no cyanosis, clubbing, edema. radial/pedal pulses 2+ pertinent results: 02:10am blood wbc-10.7 rbc-4.72 hgb-14.8 hct-42.6 mcv-90 mch-31.4 mchc-34.7 rdw-13.8 plt ct-166 groin ultrasound impression: no evidence of a right groin pseudoaneurysm or av fistula. brief hospital course: 82 yo man with history of cad, cabg, and ischemic cardiomyopathy s/p pacer icd placement presenting to with episode of vt and subsequent pacer firing. ventricular tachycardia: patient was taken to the ep lab and found to have an arrhythmogenic focus in the left ventricle. ablation was performed and the patient was returned to the floor. overnight he was noted to have multiple 10-15 beat runs of slow ns vt. ep was consulted and they felt this was secondary to radiofrequency ablation. his generator was changed on hospital day two. he was discharged on 400 mg of amiodarone twice a day for two weeks to be switched to 400 mg once a day from then on. the patient was noted to have a femoral bruit following his procedure. an us did not show any evidence of pseudoaneurysm or av fistula. he ambulated independently on the day of discharge. he will follow up with dr. at on . # hypertension continued home regimen of metoprolol, lisinopril, spironolactone. . # hyperlipdemia continued home simvastatin. . # chronic kidney disease continued on lisinopril at home doses. he tolerated amiodarone with no acute elvation in creatinine. . # depression continued home celexa and alprazolam. . # gerd continued home zantac. medications on admission: metoprolol succinate 100mg qd lisinopril 40mg qd digoxin 0.125 mg qd furosemide 40 mg qd spironolactone 12.5 mg qd asa 81 mg qd simvastatin 80 mg qd celexa 20 mg qd alprazolam 0.25 mg qhs zantac 150 mg multivitamin, calcium + vitamin d discharge medications: 1. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 4. alprazolam 0.25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. simvastatin 80 mg tablet sig: one (1) tablet po once a day. 7. spironolactone 25 mg tablet sig: 0.5 tablet po daily (daily). 8. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 9. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 10. amiodarone 400 mg tablet sig: one (1) tablet po twice a day: take one (1) tablet twice a day for two weeks then take one (1) tablet once a day from then on. disp:*60 tablet(s)* refills:*2* 11. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 12. cephalexin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 5 days. disp:*15 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: ventricular tachycardia secondary: ischemic cardiomyopathy discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure being involved in your care, mr. . you came to the hospital with ventricular tachycardia (a fast abnormal heart rate) that caused your icd (intracardiac defibrillator) to fire. because of this you were taken to the electrophysiology lab and underwent an ablation (burning of the electrical circuits of the heart to try to control the abnormal rhythm) as well as a generator change for your icd. your medications have changed as follows: 1) start taking amiodarone 400mg twice a day for two weeks. after that you should take 400mg amiodarone once a day. 2) start keflex three times a day for 5 days. you should continue taking your other medications as prescribed. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please follow-up with dr. at . an appointment has been made for you on wednesday at 3:20pm. the phone number is in case you need to make changes. please return to device clinic phone: on at 2:30 Procedure: Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach Replacement of automatic cardioverter/defibrillator pulse generator only Diagnoses: Esophageal reflux Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Aortocoronary bypass status Personal history of tobacco use Depressive disorder, not elsewhere classified Chronic kidney disease, unspecified Paroxysmal ventricular tachycardia Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Old myocardial infarction Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits |
allergies: pneumococcal vaccine / peanut attending: chief complaint: post-op hypotension major surgical or invasive procedure: open right colectomy history of present illness: 80 f w/ near obstructing colon mass, abdominal pain, and progressive intolerance to a diet. approximately 36 hours ago she noted slightly increased rlq abdominal pain. pain was dull, , non-radiating. twenty-four hours ago she began to vomit after solid foods. this quickly progressed to vomiting after taking liquids. she has not been able to tolerate po intake today. past medical history: copd hypertension osteopenia colonic polyps with severe diverticulosis polycythemia social history: used to work as a bank teller, is retired and widowed. 32 pk/yr history. drinks one per night. denies illicits. family history: no family history of cardiac disease or colon ca. physical exam: t 96.8 hr 96 bp 117/80 rr 18 sao2 95% ra general: alert, oriented x 3 no acute distress heent: sclera anicteric, perrl, eomi, dmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: on admission lungs were cta bilaterally, post-op there was poor air movement to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, mildly distended, mildly tender in the rlq to deep palpation, no rebound or guarding, normoactive bowel sounds, no palpable masses ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: 03:10pm pt-11.8 ptt-22.3 inr(pt)-1.0 03:10pm plt count-371 03:10pm neuts-88.4* lymphs-7.5* monos-3.5 eos-0.1 basos-0.5 03:10pm wbc-18.8*# rbc-5.35 hgb-13.2 hct-41.0 mcv-77* mch-24.6* mchc-32.1 rdw-16.7* 03:10pm estgfr-using this 03:10pm glucose-106* urea n-47* creat-1.2* sodium-139 potassium-3.9 chloride-96 total co2-29 anion gap-18 03:17pm lactate-1.4 08:03pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 08:03pm urine color-yellow appear-clear sp -1.013 brief hospital course: 80yo f with h/o copd who presented nausea and vomiting likely due to progression of her known near-obstructing colon mass, for which surgery was previously in the process to being scheduled. she was dehydrated at presentation to the emergency department and was admitted for volume rescusitation and was taken to the operating room for a right hemicolectomy. in the operating room her blood pressure was low and she was admitted to the icu post-op. she was placed on a phenylephrine drip, received additional volume resuscitation with 4 l crystalloid and 750 cc??????s colloid and her epidural was discontinued. post-op ekg was normal. by post-operative day 2 her blood pressure was stabilized but she experienced several oxygen desaturations leading to increased oxygen requirement. she was started on albuterol and atrovent nebulizers, pulmonary toilet, advair and her cxr suggested volume overload. she was given several doses of iv lasix and was subsequently placed on a lasix drip. over the next 3 days several liters of fluid were diuresed off and her oxygenation improved until she was able to be weaned down to 2 l o2 via nasal canula without subsequent desaturation. on post-op day 6 she was transferred out of the icu to the floor. in the icu she ambulated daily and her diet was progressively advanced from sips to clear liquids and to regulars, which she tolerated well. she began having flatus on post-operative day 3 and began having bowel movements soon afterwards. a urine culture drawn in the icu grew e.coli and she was treated on ciprofloxacin. at discharge her oxygen saturation was 98% on room air, she was ambulating with some assistance from either nursing or physical therapy, was tolerating regular diet and her pain was well controlled. medications on admission: hctz/triamterene 37.5/25 mg daily asa 81 mg daily ergocalciferol daily discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 2. triamterene-hydrochlorothiazid 37.5-25 mg capsule sig: one (1) cap po daily (daily). 3. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. psyllium 1.7 g wafer sig: one (1) wafer po daily (daily) for 5 days. disp:*5 wafer(s)* refills:*0* 5. oxycodone 5 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* 6. combivent 18-103 mcg/actuation aerosol sig: one (1) puff inhalation every six (6) hours as needed for shortness of breath or wheezing. disp:*1 canister* refills:*1* 7. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). disp:*2 disk with device(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: colon mass urinary tract infection hypernatremia atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulating without assistance. discharge instructions: you were admitted to the hospital after having an open right colectomy for obstructing ascending cecal colon cancer. you have tolerated the abdominal surgery well, you are passing gas, and you have had bowel movements. after surgery, you had some extra fluid collect in your lungs and this in combination with your copd and smoking history caused you to have respiratory difficulties and you required a stay in the intensive care unit. you recieved medications to remove this fluid and you have. you also were started on inhaled respiratory medications, which you are to continue taking at home. you were also treated for a urinary tract infection with antibiotics. you were started on metoprolol for treatment of atrial fibrillation. followup instructions: please make an appoitment to see dr. in 2 weeks. call to make this appointment. please follow up with your pcp within the next month, dr. () for management of your other medical issues, including your copd and atrial fibrillation. Procedure: Venous catheterization, not elsewhere classified Open and other right hemicolectomy Other small-to-large intestinal anastomosis Diagnoses: Other iatrogenic hypotension Unspecified pleural effusion Urinary tract infection, site not specified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Other specified intestinal obstruction Pulmonary collapse Diarrhea Malignant neoplasm of cecum Hyperosmolality and/or hypernatremia Delirium due to conditions classified elsewhere Leukocytosis, unspecified Disorder of bone and cartilage, unspecified Polycythemia, secondary |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: seizure major surgical or invasive procedure: arterial line placement subclavian central line placement history of present illness: 81 year-old man with a history of esophageal and non-small cell lung cancer presents with 10-minute absence seizure witnessed by his daughter. had urinary incontinence and was in a post-ictal state after he awoke. in the emergency department, he was found to have sbp in the 90's secondary to poor po intake from chemotherapy side effects. ivf administration raised the blood pressure to normal. review of systems: positives: patient endorses occasional nausea and feeling like something is stuck in his throat. he also reports being easily fatigued with mild exertion. he has constipation likely from narcotics. negatives: he denies all of the remaining review of systems including fevers, chills, headache, neck pain, chest pain, abdominal pain, diarrhea, blood in stool, dysuria, hematuria, joint pain, myalgias, confusion, and depression. he denies lightheadedness, orthopnea, or paroxysmal nocturnal dyspnea. past medical history: cad, history of stent placement, history of mix3 (per pt) h/o seizures in the past (per the pt) tobacco use oncologic history: : presented with sore throat unrelieved with antibiotics. seen by gi, endoscopy reported as esophageal adenocarcinoma invasion into "the mucosa and submucosa with possible invasion into the muscularis." no path of lesion but paraesophageal lymph nodes seen on endoscopic ultrasound and fna showed metastatic adenocarcinoma. : ct shows left upper lobe mass, biopsied on , showed non-small cell lung carcinoma, per report. pet/ct show fdg-avid 1.3x 1.3 cm left upper lobe nodule and avidity in the distal esophagus. there was no abnormal avidity in the abdomen or pelvis or in the head and neck regions. : seen by dr (eval for esophageal resection); seen by dr (cardiology) - stable for surgery if needed. : mediastinoscopy and port placement treatment: fluorouracil (1000 mg/m2/day) days 1, 2, 3 and 4. & cisplatin (75 mg/m2) d1, 28 day cycles with concurrent radiation. c1 d1 c2 d1 social history: retired, lives in , estranged from his wife for last 9 years. has 4 children, 1 son, 3 daughters. , his youngest daughter, is his health-care proxy. he has a 60-pack-year history of tobacco and quit 2 months ago. no current alcohol or illicit drug use. family history: 1 sister with breast cancer 1 brother with smoking-related throat cancer he is one of 16 siblings; mother lived till years old physical exam: vs: 96.4, 90/65, 68, 18, 97% on room air gen: nad, awake, talking, eating heent: eomi, mmm, no oral lesions neck: supple chest: ctab cv: rrr, distant heart sounds, normal s1 and s2 abd: soft, nontender, nondistended, bowel sounds present ext: no lower extremity edema skin: no rash neuro: cn 2-12 intact, strength 5/5 bue/ble, sensory intact, fluent speech, alert, oriented to person, place and time. psych: calm, appropriate, animated and happy pertinent results: admission labs 10:20am blood wbc-7.7 rbc-4.17* hgb-10.6* hct-33.9* mcv-81* mch-25.5* mchc-31.4 rdw-25.4* plt ct-205 10:20am blood neuts-93.7* lymphs-5.1* monos-0.7* eos-0.4 baso-0 10:20am blood pt-12.6 ptt-20.1* inr(pt)-1.1 10:20am blood glucose-109* urean-29* creat-1.7* na-138 k-3.6 cl-98 hco3-27 angap-17 10:20am blood ck(cpk)-30* 10:20am blood calcium-8.5 phos-4.4 mg-2.0 uricacd-8.4* 10:46pm blood lactate-1.8 discharge labs 12:00am blood wbc-6.3 rbc-3.56* hgb-9.4* hct-30.9* mcv-87 mch-26.5* mchc-30.5* rdw-25.9* plt ct-311 12:00am blood glucose-141* urean-32* creat-1.1 na-142 k-4.6 cl-109* hco3-27 angap-11 12:00am blood calcium-8.4 phos-4.2 mg-2.0 granulocyte count 12:00am gran ct-2820 12:00am gran ct-600* 01:24am gran ct-200* 03:30am gran ct-140* 12:00am gran ct-140* 12:00am gran ct-410* 12:00am gran ct-1292* 12:00am gran ct-3021 cardiac enzymes 03:30pm ck(cpk)-47 ck-mb-2 ctropnt-<0.01 02:05am ck(cpk)-44* ck-mb-2 ctropnt-<0.01 12:57am ck(cpk)-64 ck-mb-2 ctropnt-<0.01 other labs 03:30pm blood fibrino-439* 01:24am blood lipase-16 12:57am blood caltibc-163* vitb12-755 folate-9.2 ferritn-377 trf-125* 03:30pm blood hapto-165 10:20am blood phenoba-18.6 urine studies 08:12am urine color-straw appear-clear sp -1.010 08:12am urine blood-tr nitrite-neg protein-30 glucose-tr ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 08:12am urine rbc-<1 wbc-<1 bacteri-none yeast-none epi-0 08:12am urine casthy-1* 04:02pm urine hours-random urean-324 creat-60 na-166 04:02pm urine osmolal-519 microbiology - beta glucan and galactomannan negative - 1 blood cx (+) for coag negative staph on - all other blood, urine, and stool cultures negative radiology ct head () - impression: 1. two 6-mm lesions in the left cerebellar hemisphere unchanged from likely represent old infarcts. the appearance is not typical for metastatic disease. no additional large masses identified with no shift of midline structures. mr is more sensitive for detection of small masses and should be considered if clinically indicated. 2. no evidence of hemorrhage or major vascular territory infarction. cta chest () - impression: 1. multifocal subsegmental pulmonary emboli in vessels supplying the left lower lobe, lingula, and right lower lobe. segmental nonocclusive embolus in a blood vessel supplying right middle lobe. some of these have a more peripheral locale within the vessel suggesting subacute time course. no right heart strain or pulmonary infarct. 2. atelectasis and emphysematous changes in the lungs. 3. interval decrease in size of left upper lobe nodule. ct abdomen/pelvis () - impression: 1. elevated and rotated cecum compared to prior imaging, configurational change consistent with volvulus, with new segmental wall thickening and edema of the ascending colon in the involved segment. given the abnormal configuration of the cecum, and the presence of underlying vascular disease, findings are concerning for mesenteric ischemia. however, there is no portal venous gas, and mesenteric vessels appear normally opacified. an alternative etiology is infection, particularly typhlitis in this neutropenic patient. diffuse distention of remainder of colon is nonspecific but given concerns for ischemia requires monitoring. recommend correlation with lactate level and close monitoring/surgical consult. 2. acute occlusive thrombus in the left common femoral vein, extending proximally into the left common iliac vein. this is extensive residual clot burden in a patient with known pe (refer to cta chest ), placing the patient at risk for further embolization. 3. hiatal hernia, unchanged. 4. small hepatic hypodensity, too small to characterize, unchanged from prior ct. cxr () - findings: in comparison with the previous study of this date, there is little change. the patchy area of opacification in the right lung apex is unchanged and quite similar to recent chest ct examination. otherwise, no interval change. ecg () - baseline artifact makes interpretation difficult. there appear to be sinus beats with premature atrial contractions, although this could also be atrial fibrillation. poor r wave progression non-specific st-t wave changes. compared to the previous tracing of artifact is more pronounced and makes interpretation difficult. brief hospital course: prior to transfer to oncology service pt was initially admitted on after he was noted by his daughter to have a witnessed partial complex seizure, which lasted 10 minutes. he was noted to be post-ictal, had urinary incontinence. on admission to the ed, he was noted to be hypotensive to the 90s, which was attributed to poor po intake and was responsive to fluids. on the floor he was followed by the hospitalist service and underwent xrt . on that day, he was also noted to have a 400cc bright red bloody bowel movement with no decrease in hct. gi were consulted and were concerned for possible ischemic colitis (r/t hypotensive episode) versus chemo versus c. diff. he was placed, per gi recs, on a clear diet with stools sent for culture. throughout the day, he was intermittently febrile to 101 as well as hypotensive to the 80s. that evening, his blood cultures grew out gpcs, and pt was also noted to be hypotensive to the mid 70s with minimal response to 80s after 1l of ns. micu team was consulted and noted that patient appeared lethargic. he was started on vancomycin and transferred to the for question of hypovolemia vs septic shock. in the micu, he was treated with iv fluids. a subclavian line was placed initailly due to concern for contaminated port. however, his gpcs were coag negative staph and thought to be a contaminant as subsequent cultures did not grow anything. after transfer to oncology service # hypotension ?????? by the time the patient was transferred from the icu to the oncology service, his hypotension had largely resolved. on the floor, he was noted to have atrial fibrillation (see below). at times, when his heart rate would increase, he would have episodes of hypotension. once his rate was better controlled with metoprolol, his blood pressure became more stable. # diarrhea/abdominal pain ?????? the patient had an episodes of gi bleeding that prompted transfer to the . of note, after this initial episode, he did not have any further significant episodes of gi bleeding. gi was consulted and felt that this was likely infectious or inschemic in etiology (considering the pateint??????s hypotension on arrival). on transfer from the micu to the oncology service, the patient was on zosyn/flagyl. this was changed to cipro/flagyl to provide better gi coverage. throughout the rest of his hospital stay, the patient did not have any further episodes of significant gi bleeding. he did, however, have some intermittent trace guaiac positive stools. of note, the patient did have worsening of his abdominal pain on . ct scan was performed and showed malrotation of the cecum, which was concerning for mesenteric ischemia. at this time, the patient was already on broad spectrum antibiotic coverage for his neutropenic fever (see below). he was seen by surgery and gi. stool cultures were sent and were again negative. he was treated conservatively with iv fluids and bowel rest, and his symptoms improved. # atrial fibrillation ?????? the patient was noted to have new atrial fibrillation while he was in the micu. this continued after his transfer to the oncology service. initially, his atrial fibrillation was difficult to control because attempts at rate control would result in hypotension. during this time that his rate was difficult to control, cta of the chest was performed and revealed a pulmonary embolus (see below). eventually, his rate was controlled with a regimen of po metoprolol. at the time of discharge, he is anticoagulated with lovenox. # pulmonary embolism ?????? after transfer from the micu to the oncology service, the patient was noted to have repeated episodes of atrial fibrillation with rapid ventricular rate that was somewhat difficult to control cta of the chest was performed and revealed a pulmonary embolism. he was placed on a heparin drip. while he did have some trace guaiac positive stools, he was not noted to have any evidence of significant bleeding while he was on the heparin drip. this was ultimately transitioned to lovenox. at the time of discharge, he remains on lovenox for anticoagulation. # fever / neutropenia ?????? while on the oncology service, the patient began to spike fevers. at the same time, he became progressively neutropenic secondary to his recent chemotherapy. his antibiotics were broadened to vanc and cefepime. because of his gi problems, he was also placed on flagyl. when he became more neutropenic and still continued to spike fevers, micafungin was also added to the patient??????s regimen. while he did have one positive blood culture prior to his neutropenia (a contaminant), no other cultures grew out any bacteria. as his neutropenia improved and his fevers lessened, the patient??????s antibiotics were scaled back. at the time of discharge, the patient is no longer neutropenic, and he has not had a fever for several days. he is being discharged on cipro/flagyl for 9 more days (to complete a course of 14 days of antibiotics since his last fever). # anemia ?????? on transfer to the micu after his episode of gi bleeding, the patient was not transfused, as it was felt that his decreased hematocrit was more representative of the large amount of iv fluids he had received. however, after transfer to he oncology service, the patient continued to have anemia that was likely related to his recent chemotherapy treatment. he was ultimately transfused with 6 units of prbcs during his hospital course. at the time of discharge, the patient was still anemic; however, his hematocrit was stable. iron studies were sent prior to discharge and did not show evidence of iron deficiency. . # thrombocytopenia ?????? on transfer to the oncology, the patient was noted to have worsening thrombocytopenia. this corresponded to his anemia and neutropenia and was likely related to his recent chemotherapy. his platelet count was followed and ultimately recovered. # ?????? on presentation, the patient??????s creatinine was elevated above his baseline, likely because of hypovolemia. this improved with the iv fluids he received during his icu stay. of note, urine electrolytes also suggested some component of atn to the patient??????s renal insufficiency, likely related to his hypotension early in his hospital course. by the time of discharge, his creatinine had been at his baseline of around 1.0 for a while. . # seizure ?????? the patient was admitted after a witnessed seizure at home. of note, he has a known history of seizures. he was continued on his home phenobarbitol regimen as well as seizure precautions. he was not noted to have any further seizures during his hospitalization. # esophageal and nsclc ?????? the patient had recently received chemotherapy prior to this hospitalization (c2d1 was ) as well as radiation therapy. his radiation treatments were continued in-house. his most recent radiation treatment was . while hospitalized he complained of heartburn and throat pain, likely related to his radiation therapy. he was treated with magic mouthwash as well as nystatin swish and swallow. for pain control, he was initially giving oxycontin with oxycodone for breakthrough pain. however, this was ultimately switched to fentanyl patch with oxycodone for breakthrough pain. at the time of discharge, he is to get a pet scan in several weeks. he will also meet with his outpatient oncologist to discuss further treatment plans. # code - the patient remained full code throughout his hospitalization. medications on admission: aprepitant prn nausea atenolol 100 mg daily dexamethasone 4 mg 2 tabs daily prn nausea diazepam 5 mg tid prn anxiety furosemide 40 mg daily gabapentin 300 mg mylanta:benadryl:2%lidocaine 1 tbsp qachs prn omeprazole 40 mg daily ondansetron hcl 8 mg prn nausea oxycodone 5 mg q6 hours for breakthru pain oxycodone 20mg (has not been on recently because he ran out) phenobarbital 30mg, 1 tab in am and 4 tabs in pm) prochlorperazine maleate 5 mg q6 hours simvastatin 40 mg daily aspirin 81 mg daily bisacodyl 5 mg prn docusate sodium 100 mg psyllium 1 tablespoon as needed daily senna 8.6 mg discharge medications: 1. phenobarbital 30 mg tablet sig: four (4) tablet po qpm (once a day (in the evening)). 2. phenobarbital 30 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 3. gabapentin 300 mg capsule sig: one (1) capsule po q12h (every 12 hours). 4. diazepam 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety: hold for sedation or rr<12. tablet(s) 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for diarrhea. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: tablet, delayed release (e.c.)s po daily (daily) as needed for constipation. 8. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 9. lidocaine-diphenhyd--mag- 200-25-400-40 mg/30 ml mouthwash sig: five (5) ml mucous membrane three times a day as needed for mucositis. 10. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain: hold for sedation or rr<12. tablet(s) 11. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for mouth or throat pain. 12. oral wound care products gel in packet sig: fifteen (15) ml mucous membrane tid (3 times a day) as needed for mouth pain. 13. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 14. chlorpromazine 25 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for hiccups. 15. acetaminophen 160 mg/5 ml solution sig: six y (650) mg po q6h (every 6 hours) as needed for pain, fever. 16. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 17. enoxaparin 100 mg/ml syringe sig: one hundred (100) mg subcutaneous q12h (every 12 hours). 18. metoprolol tartrate 50 mg tablet sig: one (1) tablet po every six (6) hours: hold for sbp<90 or hr<55. please give with 12.5 mg dose as well. 19. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po every six (6) hours: hold for sbp<90 or hr<55. please give with 50 mg dose as well. 20. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 9 days: please take for 9 more days to complete a total of 14 days, ending on . 21. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 9 days: please take for 9 more days to complete a total of 14 days, ending on . 22. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 23. heparin flush 10 unit/ml kit sig: five (5) ml intravenous prn as needed for line flush: indwelling port (e.g. portacath), heparin dependent: flush with 10 ml normal saline followed by heparin as above daily and prn per lumen. . 24. heparin lock 100 unit/ml solution sig: five (5) ml intravenous prn as needed for de-accessing port: indwelling power port (e.g. portacath), heparin dependent: when de-accessing port, instill heparin as above per lumen. . 25. insulin regular human 100 unit/ml solution sig: as directed injection every six (6) hours: please check fingersticks every 6 hours and provide insulin per the provided sliding scale. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis - seizure disorder - esophageal cancer - non-small cell lung cancer - pulmonary embolism - fever and neutropenia 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: you presented to the hospital after you experienced a seizure while at home. while in the hospital, you had some low blood pressures and one episode of gi bleeding. for this, you were transferred to the icu briefly. after your blood pressures stabilized, you were transferred from the icu to the oncology floor. your hospital course was complicated by anemia (for which you received blood), neutropenia (low white blood cells), low platelets, fevers (for which you were given bload antibiotics), a blood clot to the lungs, and some concerning findings on an abdominal ct scan. you were treated for all of these complications and were stabilized. by the time of discharge, you were doing better. many of your medications have been changed from your medications prior to your admission. please take all medications as directed in your discharge paperwork. it was a pleasure taking part in your medical care. followup instructions: you should follow-up with drs. and . you need to have a pet scan performed within the next 2-3 weeks. dr. office should contact you to arrange a follow-up appointment. if you do not hear from them or have any questions, please call the office at . md, Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Arterial catheterization Other radiotherapeutic procedure Diagnoses: Coronary atherosclerosis of native coronary artery Acute kidney failure, unspecified Atrial fibrillation Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Hypopotassemia Hypotension, unspecified Malignant neoplasm of upper lobe, bronchus or lung Blood in stool Old myocardial infarction Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Hypovolemia Drug induced neutropenia Other pulmonary embolism and infarction Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Malignant neoplasm of other specified part of esophagus Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute pharyngitis Fever presenting with conditions classified elsewhere Antineoplastic chemotherapy induced anemia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: none this hospitalization history of present illness: mr. is a 52yo male with a past medical history of non-ischemic cardiomyopathy (lvef 30%-35%), insulin-dependent diabetes mellitus, hepatitis c infection, htn, hld, schizophrenia and depression who is presenting in acute respiratory distress after recent admission to the micu/gen med () for similar presentation. the patient reports that he was smoking crack cocaine earlier 2 days ago began to have chest pain and progressive shortness of breath over the past 2 days. he also reports worsening of productive cough (white sputum) which has been present since his discharge from the hospital on . he says that he felt that he never truly returned to his baseline after his last hospitalization. he says that he has had worsening orthopnea, with use of 3 pillows instead of his usual 2 last night. he denies edema, pnd. he denies fevers/chills or other uri sx, chest pain/pressure, pleuritic pain. he has had a vna and reports that his weight has decreased from 183 to 180, he has avoided salt in his diet and he has been fully compliant with this medications. he does think that the crack that he smoked 2 days ago had "less baking soda in it." the patient also does have a past medical history of mrsa pna requiring tracheostomy. . he also had admission from in which he was intubated and ct showed multifocal pneumonia. because the radiographic evidence of this pneumonia cleared quickly within 2 weeks, it was felt that this was crack lung as opposed to infectious. he was treated with broad spectrum abx and his respiratory status returned to baseline. during his admission , the patient was felt to have crack lung/hypersensitivity pneumonitis given parenchymal abnormality seen on chest ct, he was treated with one dose of methylprednisone 125mg but had hyperglycemia requiring insulin gtt and was thus not treated with steroids. he did not receive antibiotics. there may have been a component of chf during this presentation and the patient was treated with lasix gtt during this prior admission. . in the ed, initial vs were: rr 40s, o2 sat: 75% on nrb. the patient received nitro gtt, was placed on bipap with dramatic improvement. the patient was also treated with levofloxacin and vancomycin. he received lasix 40mg iv x1, aspirin and tylenol 1000mg po. blood cultures were obtained. . on arrival to the micu, the patient is still tachypneic but completing full sentences. he is alert, oriented and does not appear in acute distress. . review of systems: (+) per hpi. endorses headaches. endorses diarrhea which resolved 2 days ago. (-) denies fever, chills, night sweats, recent weight gain. denies sinus tenderness, rhinorrhea or congestion. denies wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, 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: 1. cardiac risk factors: type ii diabetes, hyperlipidemia, htn 2. cardiac history: 3. other past medical history: - nonischemic dilated cardiomyopathy (-lvef 20%, lvd 6.4cm, mild rv dilation, borderline function, 1+ mr) - hepatitis c antibody positive - mrsa pneumonia (requiring trach) - copd - substance abuse (cocaine) - tobacco abuse - schizophrenia social history: - history of multiple incarcerations (>6 months in ) - lives with sister - walks w/ cane due to right sided foot drop - tobacco history: current smoker, 1 cig per day - etoh: denies - illicit drugs: crack cocaine three days ago family history: - father: pacemaker, deceased physical exam: admission exam: . vitals: t: 98.6 bp: 98/61 p:95 r: 31 18 o2: 100% cpap with fio2 100% and peep of 5 general: alert, oriented, no acute distress with cpap on heent: sclera anicteric, mmm, poor dentition, eomi, perrl neck: supple, jvp not able to be assessed, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops appreciated lungs: diffuse dry crackles, no wheezes. air movement throughout. no use of accessory muscles with cpap in place. abdomen: soft, minimal diffuse tenderness, mild distended, bowel sounds present, obese gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . discharge exam: . vitals: 98.8 98.7 115/68 100 20 94% 1l nc bg: 77-239 mg/dl i/os: 1300 | 1000 + brp (-0.5l los) general: appears in no acute distress. alert and interactive. able to speak in full sentences. heent: normocephalic, atraumatic. eomi. perrl. nares clear. mucous membranes moist. neck: supple without lymphadenopathy. jvd just above clavicle at 90-degrees. cvs: regular rate and rhythm, without murmurs, rubs or gallops. s1 and s2 normal. resp: faint breath sounds bilaterally with inspiratory crackles at bases; rhonchi in upper airways bilaterally. no wheezing. stable inspiratory effort. abd: soft, non-tender, non-distended, with normoactive bowel sounds. no palpable masses or peritoneal signs. extr: no cyanosis, clubbing; no peripheral edema, 2+ peripheral pulses neuro: cn ii-xii intact throughout. alert and oriented x 3. strength 5/5 bilaterally, sensation grossly intact. gait deferred. pertinent results: admission labs: . 09:30pm blood wbc-13.6* rbc-4.20* hgb-11.1* hct-35.4* mcv-84 mch-26.4* mchc-31.4 rdw-15.3 plt ct-333 09:30pm blood neuts-74.1* lymphs-18.8 monos-2.5 eos-4.2* baso-0.4 09:55pm blood pt-11.4 ptt-35.1 inr(pt)-1.1 09:30pm blood glucose-127* urean-12 creat-0.9 na-144 k-4.0 cl-108 hco3-26 angap-14 03:06am blood alt-19 ast-23 ld(ldh)-360* ck(cpk)-98 alkphos-65 totbili-0.4 03:06am blood albumin-3.1* calcium-8.5 phos-3.9 mg-1.4* 09:30pm blood asa-neg ethanol-17* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 09:31pm blood lactate-2.2* 10:35pm blood lactate-1.2 05:07am urine cocaine-pos . discharge labs: . 07:25am blood wbc-6.4 rbc-3.55* hgb-9.2* hct-30.1* mcv-85 mch-26.0* mchc-30.7* rdw-15.1 plt ct-335 03:06am blood pt-12.6* ptt-32.4 inr(pt)-1.2* 06:55am blood glucose-112* urean-9 creat-0.8 na-143 k-4.3 cl-108 hco3-29 angap-10 06:55am blood calcium-8.9 phos-4.3 mg-1.8 . microbiology data: blood culture (x 2) - pending mrsa screen - negative urine legionella - negative . imaging: chest (portable ap) - in addition to a severe infiltrative abnormality, with probable confluence in the lung bases, there are many small discrete nodular opacities, which have grown appreciably since , probably entirely new since . pattern strongly suggests widespread infection, possibly septic emboli. heart is moderately enlarged, unchanged. at least small bilateral pleural effusions are presumed. brief hospital course: impression: 52m with a pmh significant for non-ischemic cardiomyopathy (lvef 30%-35%), insulin-dependent diabetes mellitus, hepatitis c infection, htn, hld, schizophrenia and depression with recent hospitalization for crack lung, who presented with acute hypoxic respiratory distress found to have bilaterally diffuse airspace opacification with suspected component of chf exacerbation, in the setting of recent illicit substance use. . # diffuse, bilateral lung opacification and acute respiratory decompensation - consistent with his prior hospitalizations, mr. was admitted with acute hypoxic respiratory failure requiring nippv in the setting of recent crack cocaine use, attributed to acute crack inhalation lung injury. in , he presented with a picture concerning for multifocal pneumonia, although his rapid resolution of symptoms without antibiotics was more consistent with hypersensitivity pneumonitis or crack lung. three days preceding admission, he notes crack cocaine use. he was admitted to the micu for respiratory monitoring and required a period of bipap use with improvement with symptomatic treatment, namely nebulizers and agressive respiratory therapy. he was not intubated during this admission. while he received a single dose of iv vancomycin in the ed, these were discontinued, and steroids were deferred given his similar presentation with rapid improvement in the past despite minimal intervention. his admitting cxr showed bilateral opacifications, despite a normal wbc and no fevers. a chest ct on prior admission showed marked diffuse bilateral airspace opacities, ground-glass in appearance, with confluent consolidation -- but subsequent cxrs noted rapid improvement despite limited therapy, supporting a crack lung or hypersensitivity etiology. over several days, his supplemental oxygen was weaned and he ambulated 100 feet without destaurations, maintaining his oxygen saturations in the 92-94% range on room air (which is his baseline). he had no cough or respiratory symptoms and he resumed all of his home medications. . # insulin-dependent diabetes mellitus - patient previously managed with lantus dosing (taking 40 units at home) - intermittently checks his glucose at home, has been under the 200 mg/dl range per the patient. last hba1c 7.4% in 11/. no evidence of retinopathy, renal failure (baseline creatinine 0.9-1.1) or neuropathy. we titrated his lantus to 50 units sc at nighttime for tighter glucose control. . # non-ischemic cardiomyopathy / chronic systolic heart failure - patient with known moderate global left ventricular hypokinesis (lvef = 30-35%), lvd 6.4-cm, mild rv dilation, borderline function, 1+ mr on 2d-echo from 12/. his respiratory decompensation was attributed to a pulmonary source predominantly. he was tolerating his home po lasix, and returned to room air with adequate oxygen saturations prior to discharge. we continued his lisinopril 10 mg po daily, metoprolol succinate xl 100 mg po daily, maintained his home dose of furosemide 40 mg po daily and kept him on a fluid restriction of 1500 ml daily. he was monitored with daily weights, monitored i/os, and his goal for diuresis was 0.5-1l daily. . # hypertension - managed as an outpatient with acei, beta-blocker. discharged on home regimen without changes. . # hyperlipidemia - we continued atorvastatin 20 mg po qhs. . # substance, tobacco abuse history - he has multiple prior episodes of relapse with resulting hospitalizations; patient notes mostly crack-cocaine use (2-3 days prior to admission) in lieu of alcohol use. lives with sister who is supportive and is a probation officer. we offered him a nicotine patch for tobacco use and provided smoking cessation counseling. social work consultation was provided and motivational support was offered; he may benefit from outpatient addiction program assistance, which he is strongly considering. he does not qualify for dual diagnosis admission since his psychiatric illness is compensated. . # hepatitis c infection - he has a history of positive hcv antibody documented in . no evidence of sequelae of chronic liver disease. liver synthetic function appears maintained (plt 424, albumin 2.8). lfts: ast 29 and alt 13 with t-bili 0.4 from prior lab studies. hiv negative, ama and smooth negative in . abdominal u/s in was normal. hcv viral load 20,101,696 iu/ml in 11/. will need follow-up as outpatient for afp, serial ultrasounds, candidacy for possible anti-viral therapy (likely poor candidate) given his hepatitis c infection. . transition of care issues: 1. social work consultation was provided and motivational support was offered; he may benefit from outpatient addiction program assistance given his substance abuse history. 2. has outpatient follow-up with primary care physician and pulmonology scheduled. 3. will need follow-up as outpatient for afp, serial ultrasounds, candidacy for possible anti-viral therapy (likely poor candidate) given his hepatitis c infection. 4. will also need outpatient pfts and pulmonology follow-up to evaluate for other underlying lung disease. medications on admission: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. atorvastatin 20 mg tablet sig: one (1) tablet po at bedtime. 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 4. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 5. insulin lispro 100 unit/ml solution sig: units subcutaneous per sliding scale. 6. insulin glargine 100 unit/ml solution sig: forty (40) units subcutaneous at bedtime. 7. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. lisinopril 10 mg tablet sig: one (1) tablet po once a day. 9. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 11. sertraline 50 mg tablet sig: 0.5 tablet po once a day. 12. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 13. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po twice a day. 14. codeine sulfate 30 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 15. seroquel 100 mg tablet sig: 0.5-1 tablet po at bedtime. discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 4. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 5. novolog 100 unit/ml solution sig: units subcutaneous once a day: per insulin sliding scale. 6. lantus 100 unit/ml solution sig: fifty (50) units subcutaneous at bedtime. 7. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 9. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 11. sertraline 50 mg tablet sig: 0.5 tablet po daily (daily). 12. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 13. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 14. codeine sulfate 30 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 15. quetiapine 100 mg tablet sig: 0.5-1 tablet po hs (at bedtime). discharge disposition: home with service facility: vna discharge diagnosis: primary diagnoses: 1. acute pulmonary syndrome (presumably related to crack-cocaine use) 2. acute on chronic exacerbation of non-ischemic cardiomyopathy . secondary diagnoses: 1. history of polysubstance abuse 2. insulin-dependent diabetes mellitus 3. hypertension 4. hyperlipidemia 5. positive hepatitis c antibody 6. chronic obstructive pulmonary disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: patient discharge instructions: . you were admitted to the internal medicine service at on cc7 regarding management of your acute respiratory issues. you were first admitted to the medical intensive care unit given concern for worsening heart failure in the setting of your illicit substance use, but this resolved with supportive therapy. you should avoid all illicit substance use in the future and take all necessary steps to obtain motivational assistance and substance abuse program assistance to promote healthy living. . please call your doctor or go to the emergency department if: * you experience new chest pain, pressure, squeezing or tightness. * you develop new or worsening cough, shortness of breath, or wheezing. * you are vomiting and cannot keep down fluids, or your medications. * if you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit, or have a bowel movement. * you experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * your pain is not improving within 12 hours or is not under control within 24 hours. * your pain worsens or changes location. * you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. * you develop any other concerning symptoms. . changes in your medication reconciliation: . * upon admission, we added: none . * upon admission, we changed: we changed: lantus from 40 to 50 units subcutaneously in the evenings for better glucose control . * the following medications were discontinued on admission and you should not resume: none . * you should continue all of your other home medications as prescribed, unless otherwise directed above. followup instructions: department: pulmonary function lab when: thursday at 9:10 am with: pulmonary function lab building: campus: east best parking: garage . department: medical specialties when: thursday at 9:30 am with: , m.d. building: campus: east best parking: garage . department: pft when: thursday at 9:30 am ** please contact our registration department at to update your information.** . department: internal medicine when: friday at 10:45 am with: , md building: (, ma) campus: off campus best parking: free parking on site md Procedure: Drug detoxification Diagnoses: Other primary cardiomyopathies Tobacco use disorder Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified viral hepatitis C without hepatic coma Obstructive chronic bronchitis with (acute) exacerbation Other and unspecified hyperlipidemia Acute respiratory failure Long-term (current) use of insulin Chronic systolic heart failure Cocaine dependence, continuous Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted Poisoning by cocaine Other specified allergic alveolitis and pneumonitis |
allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: intubation right internal jugular central venous line history of present illness: mr. is a 52 year-old man with nicm (-lvef 20% and 1+ mr), and type 1 diabetes mellitus who presented to ed with sob. patient reports running out of lasix 4 days pta. he further described cough, sob, orthopnea and slightly worse le edema 2 days pta. and presented to the ed on with worsened sob at rest. in the ed, initial vitals 130/91 139 36 99% cpap. his exam notable for 2 sentence dyspnea, crackles to bl mid-lung fields. labs notable for wbc count of 11.3 w/ 85% pmns, hct 32.1, bnp 2361, creatinine 0.9, trop 0.02. abg: 7.43 pco2 34 po2 324 on bipap. cxr with diffuse bilateral airspace opacities initally though to be asymetric pulmonary edema. the patient was started on nitro gtt and given lasix 80iv. he was then admitted to the ccu. in the ccu, he was continued on lasix iv in the ccu and achieved 1l liter length of stay fluid balance without significant improvement in respirtory status. a cta chest was performed that identified bilateral parenchymal opacities consistent with multifocal pna and inconsistent with pulmonary edema. the patient was started on cefepime, azithromycin, vancomycin and bactrim. the patient was febrile to 101.2 on and the decision was then made to transfer the patient to the miuc. vitals on transfer were 100.0 103 82/51 96% 6l nc. past medical history: 1. cardiac risk factors: type i diabetes, hyperlipidemia, htn 2. cardiac history: 3. other past medical history: - nonischemic dilated cardiomyopathy (-lvef 20%, lvd 6.4 cm, mild rv dilation, borderline function, 1+ mr) - hepatitis c antibody positive - mrsa pneumonia (requiring trach) - copd - substance abuse (cocaine) - tobacco abuse - schizophrenia social history: - history of multiple incarcerations (>6 months in ) - lives with sister - walks w/ cane due to right sided foot drop - tobacco history: current smoker, 1 cig per day - etoh: denies - illicit drugs: crack cocaine three days ago family history: - father: pacemaker, deceased physical exam: admission exam: vs: 115/81 119 22 92% 4l nc general: nad. oriented x3. mood, affect appropriate. frequent yawns. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. poor dentition neck: supple with jvp of 7 cm. cardiac: tachycardia, normal s1, s2. no m/r/g. no thrills, lifts. 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. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ neuro: strength 5/5 bilaterally ue and le except r foot: strength in dorsiflexion. cn ii-xii intact. discharge exam: vs: tm 98 / tc 98, bp (105-130)/(65-85), hr 75 (75-95), rr 18, pox 97%ra fs glucose 172-300 general: nad. oriented to self, hospital name, year, month. cardiac: s1 and s2, no murmur. lungs: clear to auscultation throughout all fields bilaterally neuro: chronic right-sided foot drop; gait stable with cane pertinent results: admission labs 02:35am blood wbc-11.3* rbc-3.95* hgb-10.4* hct-32.1* mcv-81* mch-26.5* mchc-32.5 rdw-13.7 plt ct-286 02:35am blood neuts-85.6* lymphs-9.5* monos-3.4 eos-1.2 baso-0.4 04:15am blood pt-13.8* ptt-38.7* inr(pt)-1.3* 01:58am blood glucose-256* urean-8 creat-0.9 na-139 k-3.3 cl-105 hco3-20* angap-17 01:58am blood alt-20 ast-27 ld(ldh)-299* ck(cpk)-249 alkphos-54 totbili-0.2 01:58am blood calcium-8.3* phos-4.1 mg-1.4* 02:37am blood type-art po2-324* pco2-34* ph-7.43 caltco2-23 base xs-0 pertinent labs 08:36pm blood caltibc-203* ferritn-679* trf-156* 08:49pm blood tsh-3.2 04:15am blood hiv ab-negative 02:45am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-pos amphetm-neg mthdone-neg micro data 02:45am urine color-straw appear-clear sp -1.009 02:45am urine blood-tr nitrite-neg protein-100 glucose-300 ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 02:45am urine rbc-1 wbc-2 bacteri-few yeast-none epi-<1 02:45am urine casthy-1* 02:45am urine mucous-rare 8:30 am blood culture x2 **final report ** blood culture, routine (final ): no growth. 6:55 pm bronchoalveolar lavage left upper bal. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. legionella culture (final ): no legionella isolated. potassium hydroxide preparation (final ): this is a low yield procedure based on our in-house studies. if pulmonary histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis or mucormycosis is strongly suspected, contact the microbiology laboratory (7-2306). no fungal elements seen test requested per dr. . immunoflourescent test for pneumocystis jirovecii (carinii) (final ): specimen combined. please refer to specimen #337-2463b . patient credited. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. viral culture: r/o cytomegalovirus (preliminary): no cytomegalovirus (cmv) isolated. cytomegalovirus early antigen test (shell vial method) (final ): negative for cytomegalovirus early antigen by immunofluorescence. refer to culture results for further information. 6:55 pm rapid respiratory viral screen & culture bal. **final report ** respiratory viral culture (final ): no respiratory viruses isolated. 5:58 am urine source: catheter. **final report ** urine culture (final ): no growth. 10:05pm blood aspergillus galactomannan antigen-negative 10:05pm blood b-glucan-negative brief hospital course: mr. is a 52y/o gentleman with nonischemic cardiomyopathy who presented from home with progressively worsening shortness of breath for two days and was found to be in hypoxic respiratory distress due to multifocal pna. he was intubated, stabilized in the micu with antibiotics, and was transitioned to the medical floor where he was weaned to room air and was discharged home. active issues #. acute respiratory failure: due to multifocal pna. he was intubated and at first his presentation was concerning for chf exacerbation. was initially admitted to the cardiac icu and was diuresed, but when he spiked a fever and became tachycardic in the setting of leukocytosis as well, a cta was performed which ruled out pe but showed multifocal pna so diuresis was stopped and he was started on antibiotics and transferred to the micu for further management (see below). #. multifocal pneumonia: clinically resolved by discharge. he has a history of mrsa pneumonia requiring tracheostomy during prior admission to osh in summer . here, he was started on vanc/cefepime/cipro/azithro as well as bactrim given concern for potential pcp (he has been in prison and has a h/o ivdu). his hiv test was negative. ppd was placed and was negative. bronchoscopy was done and he was ruled out for tb and pcp so his were changed to vanc/cefepime/cipro. was extubated without complication. was transitioned to the medical floor where he remained afebrile, hemodynamically stable, with leukocytosis resolved. he was weaned to room air and ambulated without desaturating. he completed an 8 day regimen () and was discharged home. #. non-ischemic cardiomyopathy: euvolemic. lvef 20%, mild rv dilation, 1+ mr. as discussed above, he was initially diuresed due to concern for chf exacerbation, but he was euvolemic. he was transitioned back to his home dose of lasix 40mg po daily. he was also continued on his home ace inhibitor and beta-blocker. #. elevated troponin: possibly represented demand ischemia. troponin was mildly elevated with peak of 0.05 which was thought to be related to demand from his persistent tachycardia. he ruled out for mi with declining troponins. no ekg changes. #. acute kidney injury: likely prerenal; resolved. creatinine baseline is 0.9 but peaked at 2 on . was likely to spesis and over-diuresis. also, possibly related to brief rx with treatment-dose bactrim. his cr then trended down and was back to baseline at 0.9 upon discharge. #. dm2: stable at the time of discharge. he was initially continued on glargine and iss. on he required insulin drip for fs persistently in the 400s despite sc insulin, but this quickly resolved. he was discharged on his home dose of medications and will follow up with his pcp. #. schizophrenia/depression: with depressed mood/affect and hallucinations this admission. after he was stabilized and extubated, he was noted to respond to questions with single-word answers, with flat affect and poor eye contact. ct head was negative. however, after a visit from his sister and sister's boyfriend, he tearfully admitted that he had been lonely and felt that nobody was visiting him (especially since he had been in the icu on ). after this, he was alert/interactive and was fully conversant. he admitted that while he was in the icu he saw a tiger in his room. it is unclear if this was related to intubation/sedation or his untreated schizophrenia. no further hallucinations. at the time of discharge, he denied si/hi and desired follow-up with a mental health provider so an appointment was made for him. #. substance abuse: utox positive for cocaine. he was counseled on the importance of abstinence from drugs. inactive issues #. hyperlipidemia: stable. he was continued on home atorvastatin. #. copd: stable. he was continued on home albuterol, ipratropium. transitional issues #. emergency contact: () #. code status: full code medications on admission: - lasix 40 daily - metoprolol succinate 100mg daily - lisinopril 5mg daily - lipitor 20mg daily - aspirin 81mg daily - seroquel 25m qhs - insulin 40u lantus qhs, 12u novolug am - atrovent 250/50 - ipratropium q6 prn sob - albuterol prn sob - doxepin 20mg qhs (not taking) discharge medications: 1. lasix 40 mg tablet sig: one (1) tablet po once a day. 2. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 3. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 4. lipitor 20 mg tablet sig: one (1) tablet po once a day. 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. seroquel 25 mg tablet sig: one (1) tablet po at bedtime. 7. lantus 100 unit/ml solution sig: forty (40) units subcutaneous at bedtime: please use 1/2 dose if not eating well; call your doctor for any blood sugars less than 80. 8. novolog 100 unit/ml solution sig: twelve (12) units subcutaneous every morning: please use 1/2 dose if not eating well; call your doctor for any blood sugars less than 80. 9. advair diskus 250-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. 10. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. discharge disposition: home discharge diagnosis: multifocal pneumonia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you presented with shortness of breath and cough, and were admitted to the icu where you required intubation (breathing tube) for pneumonia. you were treated with antibiotics and were able to be extubated and transferred to the medical floor to complete your antibiotics. now you are stable for discharge home with primary care follow-up. while you were here, you were depressed and had a hallucination. you did not feel that you were a harm to yourself or others. we made you an appointment with a mental health provider (please see appointment below). we did not make any changes to your medications. followup instructions: primary care department: internal medicine when: wednesday at 10:30 am with: , md building: (, ma) campus: off campus best parking: free parking on site psychiatry/social work department: health center when: thursday at 10:30 am with: , licsw building: (, ma) campus: off campus best parking: free parking on site 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 Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Tobacco use disorder Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Unspecified viral hepatitis C without hepatic coma Obstructive chronic bronchitis with (acute) exacerbation Unspecified schizophrenia, unspecified Acute respiratory failure Long-term (current) use of insulin Septic shock Paralytic ileus Personal history of noncompliance with medical treatment, presenting hazards to health Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Acute on chronic systolic heart failure Cocaine dependence, continuous Other nonspecific abnormal serum enzyme levels Tracheostomy status Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled Other specified episodic mood disorder |
allergies: no known allergies / adverse drug reactions attending: chief complaint: respiratory distress major surgical or invasive procedure: none history of present illness: 52m with h/o non-ischemic dilated cardiomyopathy (lvef 20%), copd, who presents with shortness of breath, worsening acutely today while at home, but getting progressively worse since . pt also reports malaise for the past couple of days, without fevers but with chills, no nausea or vomiting. he does report some diffuse chest tightness in association with his acute dyspnea. the pain does not radiate and has resolved somewhat with oxygen therapy. he reports cough productive of yellowish white sputum over the last three days. there have been no other upper respiratory symptoms. patient has history of similar episodes of dyspnea, usually after smoking crack cocaine, but reports that this time he was not. his last reported crack cocaine use was five days prior to admission (thursday). when ems found him, he was found to 70% on ra with sbps in 120s, respiratory rate about 40. he was placed on a non-rebreather and transported to . . patient was recently admitted to and discharged on for acute respiratory decompensation and bilateral lung opacifications requiring icu admission, thought to be due to acute crack inhalation lung injury. he was admitted to the micu for respiratory monitoring and required a period of bipap use with improvement with symptomatic treatment, namely nebulizers and agressive respiratory therapy. . in the ed, initial vs were 99.0 116 123/66 40 96% nr. patient had jvd while sitting upright, and lung sounds with rales in bases. he was tachycardic to the 140-150, with o2 saturations 88% on nrb, with supraclavicular retractions. ecg was consistent with prior with no st or t-wave changes. cxr was performed and significant for new alveolar opacities suspicious for pulmonary edema. he was placed on a nitro gtt and bipap, and administered furosemide 40 mg iv x 1, urine output was not recorded. labs were significant for initial venous blood gas of 7.29/53/45/27. troponin was 0.03. bnp was measured at 8381. there was leukocytosis with wbc count. 13.1 with 80% neutrophils. arterial blood gas after being on bipap was 7.45/35/63/25. on transfer, vs were 103, 118/66, rr34 100% on 50% cpap 5+5, nitro gtt @ 0.667. there are two 20g peripheral ivs in place. he has put out about 1.3 liters of urine after receiving his dose of lasix. . 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 or rigors. he does report some chills. he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: past medical history: 1. cardiac risk factors: + type i diabetes, + hyperlipidemia, + htn 2. cardiac history: 3. other past medical history: - nonischemic dilated cardiomyopathy (-lvef 30-35%, mild rv dilation, borderline function, 1+ mr) - hepatitis c antibody positive - mrsa pneumonia (requiring trach) - copd - substance abuse (cocaine) - tobacco abuse - schizophrenia social history: - history of multiple incarcerations (>6 months in ) - lives with sister - walks w/ cane due to right sided foot drop - tobacco history: current smoker, 1 cig per day - etoh: denies - illicit drugs: crack cocaine three days ago family history: - father: pacemaker, deceased physical exam: vs: t= 97.5 bp= 117/76 hr= 104 rr= 31 o2 sat= 100% on bipap general: nad. oriented x3. mood, affect appropriate. appears uncomfortable. heent: ncat. mask on face. sclera anicteric. perrl, eomi. conjunctiva are pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of up to jaw line. cardiac: tachycardic, rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp are labored with supraclavicular retractions. rales are present halfway up lung fields bilaterally, louder on right with decreased bs on left. no wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: trace edema to 1/3 up shins bilaterally. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: on admission: 03:40am blood wbc-13.1*# rbc-3.76* hgb-10.1* hct-30.8* mcv-82 mch-26.9* mchc-32.8 rdw-16.5* plt ct-346 03:40am blood neuts-80.8* lymphs-12.0* monos-2.5 eos-4.1* baso-0.6 03:40am blood pt-12.8* ptt-37.2* inr(pt)-1.2* 03:40am blood glucose-66* urean-13 creat-1.1 na-142 k-5.0 cl-106 hco3-24 angap-17 03:40am blood ck-mb-5 ctropnt-0.03* probnp-8381* 06:39am blood ck-mb-5 ctropnt-0.04* 03:00pm blood ck-mb-5 ctropnt-0.05* 03:40am blood ck(cpk)-259 06:39am blood alt-15 ast-29 ld(ldh)-464* alkphos-73 totbili-0.5 06:39am blood calcium-8.3* phos-4.6* mg-1.3* 03:49am blood type- po2-45* pco2-53* ph-7.29* caltco2-27 base xs--1 comment-green top 04:58am blood type-art temp-36.4 fio2-50 po2-63* pco2-35 ph-7.45 caltco2-25 base xs-0 intubat-not intuba comment-cpap imaging: please add final report of ct brief hospital course: 52m with h/o non-ischemic dilated cardiomyopathy (lvef 20%), copd, presenting with acute respiratory decompensation. # hypoxia secondary to crack pneumonitis: patient presents with acute respiratory decompensation, over the course of hours, associated with hypoxemia, with bilateral opacifications in the bilateral lung fields consistent with likely pulmonary edema and pneumonitis/pneumonia. in the past, patient has had similar presentations, usually following crack cocaine use, thought to be due to acute crack lung inhalation injury. his most recent reported crack cocaine use was five days prior to admission, and his symptoms of dyspnea started 3 days prior to admission, which is consistent with crack cocaine pneumonitis. patient also had elevated jvp, rales on lung exam, and imaging suggestive of fluid overload, making chf exacerbation a likely diagnosis. the patient was aggresively diuresis 4.5 litter over the next 36 hours until his creatinine bumped and he was at his dry weight. his respiratory status did not marketly improved with diuresis (continue to require 50-100% o2 by face mask) and pulmonary was consulted. per pulmonary, the patient's clinical presentation was most consistent with crack cocaine pneumonitis, but an atypical penumonia could not be ruled out. he was started on levofloxacin on for a 7 day course. he was also started on solumedrol 60mg q6 hours and was tappered to oral prednisone and stopped 2 days prior to discharge. the patient's oxygen requirement decreased and was weaned off oxygen. a repeat chest x-ray showed marked improvement in his lung fields. patient was discharged with a normal ambulatory oxygen saturation. # acute systolic congestive heart failure, non-ischemic dilated cardiomyopathy: the patient has a history of lvef 20%. despite his clinical presentation (see above), the patient reported taking his medication faithfully without dietary indiscretions. given his clinical presenation, the patient was given lasix 40mg iv and started on an lasix gtt. the patient was aggresively diuresis 4.5 litter over the next 36 hours until his creatinine bumped and he was at his dry weight. his home medications were intially held. he was initally started on captopril 6.25 mg tid. on the floor the patient was euvolemic and additional doses of iv lasix were held. patient was transitioned to carvedilol and discontinued the metoprolol as he is at risk for continued cocaine abuse. he remained euvolemic during his stay and was discharged without oxygen requirement. # diabetes mellitus: it is unclear whether patient actually has type 1 or type 2 diabetes but he has been able to go extended periods of time without medications making it more likely he has type 2 diabetes. due to his high steriod dosing patient had significant increases in his insulin requirements. diabetes consult was placed and assisted in dosing insulin. there was no evidence of dka while he was inpatient. eventually after he came off of steriods he was able to be transitioned back to his home insulin regimen. # hyperlipidemia: continue home atorvastatin dose # copd: patient with history of copd. he was started on albuterol and ipratropium nebulizers. his home fluticasone-salmeterol was held and he was started on fluticasone . # acute on chronic normocytic anemia: patient hematocrit around baseline. # substance abuse: patient with history or cocaine use and tobacco use. patient was counseled on risks of continued cocaine abuse including readmission and even death. he was also discharged for prescription for nicotine replacement therapy and he seemed agreeable to stopping both the tobacco use and cocaine abuse. medications on admission: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 4. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 5. novolog 100 unit/ml solution sig: units subcutaneous once a day: per insulin sliding scale. 6. lantus 100 unit/ml solution sig: fifty (50) units subcutaneous at bedtime. 7. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 9. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 11. sertraline 50 mg tablet sig: 0.5 tablet po daily (daily). 12. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 13. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 14. codeine sulfate 30 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 15. quetiapine 100 mg tablet sig: 0.5-1 tablet po hs (at bedtime). discharge medications: 1. ipratropium bromide 0.02 % solution sig: one (1) unit inhalation q6h (every 6 hours) as needed for wheeze. disp:*qs for 30 days unit* refills:*0* 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. sertraline 25 mg tablet sig: one (1) tablet po daily (daily). 4. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 5. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 6. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) unit inhalation q6h (every 6 hours). disp:*qs for 30 days unit* refills:*0* 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 9. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily): use 1 patch daily for 2 weeks then one patch every other day for one week then stop. disp:*30 patch 24 hr(s)* refills:*0* 10. quetiapine 100 mg tablet sig: one (1) tablet po hs (at bedtime). 11. furosemide 40 mg tablet sig: one (1) tablet po once a day. 12. nebulizer please dispense 1 nebulizer machine 13. carvedilol 6.25 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 14. insulin glargine 100 unit/ml solution sig: fifty (50) units subcutaneous at bedtime. 15. novolog 100 unit/ml solution sig: as directed per sliding scale units subcutaneous three times a day: please resume usual sliding scale with meals. 16. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily): you can also take of your 10mg tablet if it is scored. disp:*30 tablet(s)* refills:*1* discharge disposition: home with service facility: vna discharge diagnosis: pneumonitis acute on chronic systolic heart failure diabetes substance abuse (cocaine) chronic conditions: copd schizophrenia 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 for pneumonitis, which is inflammation of your lung tissue secondary to your use of crack cocaine. this caused you to be very short of breath and to require oxygen for a short period of time. it is important that you stop smoking crack cocaine as this is the cause of your lung inflammation. we also treated you for worsening congestive heart failure. you required iv medications to remove fluid from your lungs. your symptoms improved after a few days. weigh yourself every morning, md if weight goes up more than 3 lbs. the following changes were made to your medications: add carvedilol 6.25 mg by mouth twice a day stop metoprolol 100mg daily decrease lisinopril to 5mg followup instructions: department: pulmonary function lab when: monday at 4:10 pm with: pulmonary function lab building: campus: east best parking: garage department: medical specialties when: monday at 4:30 pm with: , m.d. building: campus: east best parking: garage department: pft when: monday at 4:30 pm department: internal medicine when: friday at 10:45 am with: , md building: (, ma) campus: off campus best parking: free parking on site Procedure: Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Diagnoses: Other primary cardiomyopathies Anemia, unspecified Tobacco use disorder Congestive heart failure, unspecified Unspecified essential hypertension Adrenal cortical steroids causing adverse effects in therapeutic use Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Unspecified viral hepatitis C without hepatic coma Unspecified schizophrenia, unspecified Other and unspecified hyperlipidemia Acute respiratory failure Long-term (current) use of insulin Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Acute on chronic systolic heart failure Cocaine dependence, continuous Other and unspecified alcohol dependence, continuous Bronchitis and pneumonitis due to fumes and vapors |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cc: major surgical or invasive procedure: none history of present illness: 54m who was found down by friends outside. pt was brought to an osh where a cspine xray showed concern for c3,c4,c5 fx along with lue/lle weakness and was intubated and transferred to for further management. upon arrival, a ct cspine was performed which did not show any cervical fracture. + etoh past medical history: unknown social history: unknown. + etoh now family history: unknown physical exam: physical exam: o: t: bp: 95/74 hr: 81 r 21 o2sats 97% ett gen: intubated, on profolol heent: multiple small lacs neck: hard cervical collar extrem: warm and well-perfused. neuro: mental status: awakes to noxious stim motor initially: rue: delt 3, bic 2, tri 0, grasp 0, we/wf 0 lue: delt 2, bic 0, tri 0, grasp 0, we/wf 0 rle: triple flexion to stim lle: no mvmt to noxious on repeat exam: rue: antigravity, appears stronger than lue lue: localizes, but weaker than rue rle: withdraws lle: withdraws l>r sensation: pt grimaces to noxious stim throughout, nods yes to sensation to light touch and noxious. proprioception intact. reflexes: b t br pa ac right 0 0 0 2 2 left 0 0 0 2 2 toes: mute on left, upgoing on right rectal exam normal sphincter control exam upon discharge: motor exam slowly improving daily - weak distally in ues right weaker than left; and weaker distally les but full proximally pertinent results: ct cspine: no fracture noted, c5-6 osteophytes impinging on the thecal sac. ct head: no acute bleed, incidental finding of a right frontal sinus osteoma mri cspine: cord impingement at c4-5 with hyperintensity on t2 imaging. brief hospital course: pt was admitted to the tsicu and monitored closely. his thoracic/lumbar spine was cleared in order to attempt extubation. he was febrile on admission and blood, urine and sputum cultures were obtained. urine cultures were negative and sputum gram stain showed 1+ gpc's and he was started on levofloxacin and completed 5 day course. he was safely extubated on without difficulty and was kept in the icu overnight for continued observation and neuro checks. he did complain of burning sensation in his rue and was started on neurontin 300mg three times daily which was then further increased to 600mg tid. his physical exam at this time was full strength in lle, rle weakness 2/5 proximally and gastroc, rue 3 biceps and 2 in deltoid and triceps with no finger movements. his lue had 2 in grips with no other motor function. he was transferred to the floor in stable condition on . his exam continued to slowly improve. he was kept in cervical collar. he was evaluated by pt/ot and suitable candidate for rehab. he was on neurontin for neurogenic pain and this can be titrated slowly to off as it resolves. medications on admission: unknown discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day): may dc when activity increases. 2. acetaminophen 650 mg/20.3 ml solution sig: po q6h (every 6 hours) as needed for pain or fever. 3. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every monday). 4. diazepam 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for muscle spasm. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. oxycodone 5 mg tablet sig: 1-3 tablets po q4h (every 4 hours) as needed for pain. 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day). 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 10. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for no bm>24hr. 11. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. discharge disposition: extended care facility: discharge diagnosis: cervical cord contusion discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: ?????? do not smoke ?????? you are required to wear cervical collar at all times. ?????? you may shower briefly daily without the collar. ?????? take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation followup instructions: please call to schedule an appointment with dr. to be seen in 6 weeks. you will not need xrays prior to your appointment Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other bronchoscopy Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Alcohol abuse, unspecified Pneumonitis due to inhalation of food or vomitus Unspecified accident C1-C4 level with unspecified spinal cord injury |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: giant paraesophageal hernia. major surgical or invasive procedure: : laparoscopic reduction of giant paraesophageal hernia, toupet fundoplication with gastroplasty. history of present illness: ms. is a 77-year-old woman with dyspnea and diffuse interstitial changes as well as emphysema on ct scan. she also suffers from extremely symptomatic reflux and was noted to have a very large incarcerated hiatal hernia. on barium swallow she was noted to have frank reflux of barium with the mild valsalva maneuvers. her manometry was near normal though did show some slight decreased motility. she is being admitted for incarcerated hiatal hernia. past medical history: pulmonary hypertension hypertension depression lyme disease osteopenia social history: married lives with husband. history of tobacco or etoh family history: non-contributory physical exam: vs: t: 96.3 hr: 72 sr bp: 130/80 sats: 92 2l general: 78 year-old female no apparent distress heent: normocephalic neck: supple card: rrr resp: decreased breath sounds with crackles 1/3 up bilateral gi: obese, bowel sound positive extr: warm 3+ edema incsions: abdominal lap clean/dry/intact neuro: non-focal pertinent results: wbc-7.5 rbc-3.48* hgb-10.1* hct-30.5* plt ct-418 wbc-8.6 rbc-3.52* hgb-10.3* hct-30.2* plt ct-457* wbc-16.6*# rbc-3.78* hgb-11.2* hct-32.9* plt ct-531* glucose-147* urean-8 creat-0.6 na-140 k-3.7 cl-100 hco3-35* glucose-129* urean-11 creat-0.6 na-141 k-3.8 cl-97 hco3-34* glucose-107* urean-11 creat-0.5 na-141 k-4.5 cl-103 hco3-31 calcium-8.8 phos-2.8 mg-2.1 calcium-8.9 phos-2.1* mg-1.9 calcium-8.3* phos-2.5* mg-2.1 cxr: : interval worsening of fluid overload. persistent left lower lobe atelectasis. interval worsening of the findings with more pronounced left retrocardiac opacity and enlarging left-sided opacity probably represent a combination of atelectasis, pneumonia. 2. interval worsening of patchy interstitial opacities particularly on the right side and this may suggest failure. the patient's interstitial lung disease on ct is noted, however, that within the last appearances appear slightly worse when compared to prior radiograph. 08:25am blood calcium-8.8 phos-2.8 mg-2.1 03:35pm blood calcium-8.9 phos-2.1* mg-1.9 brief hospital course: mrs. was admitted on for laparoscopic reduction of giant paraesophageal hernia, toupet fundoplication with gastroplasty. while in the operating room she became hypotensive requiring pressors and stress steroids. cardiac enzymes were negative. she was extubated in the operating room monitored in the pacu. weaned of pressors with sbp in the 90-100's. the nasogastric tube was removed. she transferred to the floor in stable condition. her home medications were titrated as tolerated. on pod 1 a barium swallow was done with no leak. she was started on a clear liquid diet and advanced to full which she tolerated. overnight she become volume overloaded and was diuresed. on pod 2 she continued to diuresis. was seen by physical therapy who recommended rehab. her electrolytes were repleted as needed. she continue to make steady progress and was dishcarged to at . medications on admission: prednisone 5mg daily, hyzaar 50-12.5 mg daily, pantoprazole 40 mg daily, dertraline 25mg daily, asa 81 mg daily, zolpidem 5 mg qhs, alendronate 70mg daily, calcium daily, vit d daily discharge medications: 1. fluticasone 50 mcg/actuation spray, suspension sig: one (1) spray nasal daily (daily). 2. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 3. hyzaar 50-12.5 mg tablet sig: one (1) tablet po once a day. 4. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 5. oxycodone 5 mg/5 ml solution sig: five (5) po q4h (every 4 hours) as needed. disp:*400 * refills:*0* 6. colace 100 mg capsule sig: one (1) capsule po twice a day. 7. sertraline 25 mg tablet sig: one (1) tablet po daily (daily). 8. lasix 40 mg tablet sig: one (1) tablet po once a day for 5 days: daily weights. 9. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 5 days: give w/lasix monitor lytes. 10. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 11. ipratropium bromide 0.02 % solution sig: three (3) inhalation q4h (every 4 hours) as needed for wheezes. 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: three (3) ml inhalation q4h (every 4 hours) as needed. 13. docusate sodium 50 mg/5 ml liquid sig: five (5) po bid (2 times a day). 14. diphenhydramine hcl injection discharge disposition: extended care facility: of discharge diagnosis: giant paraesophageal hernia gerd hypertension osteopenia depression lyme disease pulmonary hypertension discharge condition: stable discharge instructions: call dr. office if experience: -fever > 101 or chills -increased difficulty or painful swallowing, nausea/vomiting -chest pain -full liquid diet until seen by dr. followup instructions: follow-up with dr. 11:00am in the building i chest disease center. provider: , md phone: date/time: 11:30am i chest disease center. follow-up with your pcp . Procedure: Laparoscopic procedures for creation of esophagogastric sphincteric competence Laparoscopic repair of diaphragmatic hernia, abdominal approach Diagnoses: Other iatrogenic hypotension Esophageal reflux Other chronic pulmonary heart diseases Postinflammatory pulmonary fibrosis Other emphysema Disorder of bone and cartilage, unspecified Acute edema of lung, unspecified Diaphragmatic hernia with obstruction |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: none history of present illness: 80f w/ c/o abdominal pain and distension for 4 days prior to presentation in ed of osh. unknown severity, quality, location, radiation. undocumented whether tender on initial exam but later on evaluation by gastroenterologist patient reported no pain. ct scan revealing distended/dilated small bowel and stomach with sbo and lower abdominal wall hernia. unable to pass ngt (from esophageal tortuosity?). decision made to place ngt under endoscopic assistance given prior paraesophageal hernia repair. for this she required intubation and her dnr order was rescinded after discussion with her husband. she was electively intubated and an egd performed with decompression of the stomach and 1l of gastric liquid contents aspirated. also noted large amount of fluid in distal esophagus with tortuous esophagus and difficult to intubated ge junction. an ngt was placed under direct vision in the stomach and the patient was then tranferred to for further management. past medical history: past medical history: paraesophageal hernia, spinal stenosis, osteoporosis, chronic lbp, chronic constipation, chronic leukocytosis, chf with diastolic dysfunction, idiopathic pulmonary fibrosis, copd, htn, gerd, depression, htn, h/o pna, h/o lyme disease, insomnia, former chronic steroid use past surgical history: paraesophageal hernia repair (laparoscopic repair with toupet fundoplication and gastroplasty) , csection social history: married lives with husband. history of tobacco or etoh family history: non-contributory physical exam: upon presentation to : temp:98.1 hr:115->90s bp:114/60 resp:18 o(2)sat:100 on fio2 1.0 on vent cmv setting gen: intubated, sedated heent: no scleral icterus, mucus membranes moist, ngt with serosanguinous drainage turning to bilious later cv: rrr/tachycardic pulm: coarse b/l abd: soft, distended and tympanytic, some wincing with palpation, no obvious rebound or guarding, positive bowel sounds, no palpable masses, soft and easily reducible lower abdominal wall hernia dre: decreased tone, very small stool in vault, guaiac negative ext: trace ue/le edema, feet cool b/l but pink with 3-4s cap refill pertinent results: 03:53pm glucose-85 urea n-10 creat-0.5 sodium-137 potassium-3.8 chloride-105 total co2-27 anion gap-9 03:53pm calcium-8.2* phosphate-2.8 magnesium-2.1 02:58am ck(cpk)-63 02:58am ck-mb-6 ctropnt-0.03* 02:58am calcium-7.8* phosphate-2.6* magnesium-1.7 02:58am wbc-8.1 rbc-4.64 hgb-12.6 hct-40.0 mcv-86 mch-27.1 mchc-31.4 rdw-16.9* 02:58am plt count-353 09:26pm alt(sgpt)-10 ast(sgot)-17 alk phos-44 tot bili-0.7 09:26pm ctropnt-0.02* 09:26pm pt-13.0 ptt-35.0 inr(pt)-1.1 09:26pm plt count-284 imaging: cxr: endotracheal tube and nasogastric tube in standard positions. low inspiratory lung volumes with increased interstitial markings bilaterally, right greater than left, which is suggestive of underlying chronic lung disease. there is likely atelectasis as well in both lung bases. ct abdomen (from osh): unable to load, cd in chart : cxr-pulmonary edema resolving, low lung volumes. brief hospital course: she was admitted to the acs and transferred to the trauma icu. she remained vented, sedated and on pressors to maintain her blood pressure. her ng was placed to suction. she was extubated, her pressors were weaned and on the second hospital day she was transferred to the regular nursing unit. the pulmonary team was made aware that she was in house as she is followed by dr. for her ipf. she was continued npo for another 1-2 days along with maintenance ivf. it was reported that her ng accidentally fell out; the decision to not replace it was made. she was eventually started on sips and advanced to clear liquids, then to a regular diet for which she is tolerating. she was evaluated by physical therapy and is being recommended for rehab after her acute hospital stay. at the time of she was tolerating a regular diet, out of bed, and voiding. medications on admission: (on list from osh): alendronate 70mg qwk, aspirin 81mg qday, colace 100mg , arixtra 2.5mg sq qday, lopressor 12.5mg , protonix 40mg qday, zoloft 200mg qday, miralax, trazodone 50mg qhs, calcium 500mg , vitamin d 1000mg , fentanyl patch 25mcg/td q3d, kcl 20meq qday, percocet q4h prn (another list from osh documents): dulcolax pr prn qday, zofran po q8h prn, ativan 0.5mg q6h prn, mom 30ml daily prn, atrovent inh q6h prn, albuterol q6h prn, effexor xr 150mg po daily, percocet q4h prn, colace 100mg , vitamin d 1000mg , miralax 17grams qday, kcl 40meq daily, protonix 40mg qday, arixtra 2.5mg sq qday, trazodone 50mg qhs, ritalin 5mg , lopressor 12.5mg , tums 500mg , tylenol prn, compazine 25mg prn, fosamax 70mg qwk, aspirin 81mg daily, fentanyl patch q72hr medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 2. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation qid (4 times a day). 3. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 6. milk of magnesia 800 mg/5 ml suspension sig: thirty (30) ml po twice a day as needed for constipation. 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. sertraline 50 mg tablet sig: four (4) tablet po daily (daily). 10. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q6h (every 6 hours). 11. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for sbp>110 or hr<60 . disposition: extended care facility: healthcare center - diagnosis: small bowel obstruction condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. instructions: you were hospitalized because of an obstruction in your bowels. a special tube called a nasogastric tube was placed through your nose an into your stomach in order to suction out extra contents/fluids. over the course of your hsoptial stay your bowel function returned and the obstruction resolved on it's own without any operations. followup instructions: follow up with your primary care doctor from rehab; you or your family will need to call for an appointment. for any concerns related to your recent bowel obstruction you may contact the clinic to determine if you needto be seen; the clinic number is . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Diagnoses: Esophageal reflux Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Depressive disorder, not elsewhere classified Osteoporosis, unspecified Pressure ulcer, lower back Diastolic heart failure, unspecified Unspecified intestinal obstruction Pressure ulcer, stage II Spinal stenosis, lumbar region, without neurogenic claudication Other dependence on machines, supplemental oxygen |
allergies: ambien / adhesive tape attending: chief complaint: chronic shortness of breath major surgical or invasive procedure: atrial septal defect closure with bovine pericardial patch via right thoracotomy. history of present illness: 57 year old gentleman with a significant past medical history which includes cornary artery disease status post bypass surgery, diabetes, obesity, peripheral vascular disease, atrial arrythmias and pacemaker insitu who has a secundum atrial septal defect. he has noted significant shortness of breath and wheezing which seems to have gotten worse over the past several months. he was seen by an allergist who who feels he has signficant seasonal allergies which are likely contributing to his symptoms. although his shortness of breath is likely multifactorial, there has been some speculation that the asd could be contributing to it. his pa pressures are in the 50's, were they were 5 years ago and his qp:qs shunt has remained fairly low at 1.3 5 years ago and now around 2.0 (using only ivc sats). he was evaluated at for catheter based repair however did not have an adequate shelf for a device closure. he presents now for surgical consultation regarding whether repair of his asd will significantly help his dyspnea. he has been hospitalized twice with pna this year as well as heart failure with severe dyspnea. past medical history: secundum atrial septal defect pmh: - cad s/p cabg - atrial septal defect - chronic diastolic heart failure - insulin-dependent diabetes mellitus - hypothyroidism - obesity - asd - atrial flutter s/p ablation and cardioversions - obstructive sleep apnea ( does not use his cpap) - tia - peripheral vascular disease - ble varicosities - prior chronic l pleural effusions - l hand neuropathy - depression - gastroesophageal reflux disease - dyslipidemia past surgical history - cabg x3 ( center) lima to lad, svg "y" graft to ramus and om) - av node ablation - pacemaker placement - r cea - r ankle - l knee arthroscopy - l posterolateral thoracotomy/ pleurodesis social history: lives with:wife contact: phone # occupation:retired cigarettes: smoked no yes last cigarette 20 yrs ago;35 pack year hx other tobacco use:none etoh: < 1 drink/week drinks/week >8 drinks/week -none illicit drug use-none family history: premature coronary artery disease + father mi < 55 mother < 65 physical exam: pulse:58 resp: 18 o2 sat: 96% b/p right:133/76 left: height: 5' 10 " weight:275lbs general:obese, noticeably short of breath with all activities skin: dry intact heent: perrla eomi neck: supple full rom no jvd noted. right lateral scar well healed chest: lungs coarse rales on r base; decreased bs at l base; healed l posterolat. thoractomoy incision and sternal incision heart: rrr irregular murmur 2/6 systolic abdomen: soft non-distended non-tender bowel sounds + ;no hsm, obese, non-tympanic extremities: warm , well-perfused edema 1+ ble; lle evh site at knee well-healed varicosities: ble with chronic venous stasis changes neuro: grossly intact , nonfocal exam, mae strengths pulses: femoral right: trace left:trace dp right: 1+ left:1+ pt :np left:np radial right: 2+ left:2+ carotid bruit : murmur radiates to b carotids pertinent results: intra-op tee conclusions pre bypass the left atrium is dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. the right atrium is dilated. a left-to-right shunt across the interatrial septum is seen at rest. a large secundum atrial septal defect (1.5 cm) is present. there is mild regional left ventricular systolic dysfunction with mild apical and distal anterior hypokinesis . overall left ventricular systolic function is low normal (lvef 50-55%). the right ventricle is dilated and displays normal free wall contractility. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is a minimally increased gradient consistent with trivial mitral stenosis. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. drs. and were notified in person of the results in the operating room at the time of the study. post bypass after first separation from bypass, two significant jets of residual left to right flow at the edges of the patch placed to close the asd were seen. patient was returned to full bypass. after final separation. there is overall normal biventricular systolic function though focal abnormalities of the left ventricle as noted in the pre-bypass study persist. a patch is seen in the interatrial septum. there is a very small jet (pin-hole sized) of left to right interatrial flow at one edge of the patch. the tricuspid regurgitation appears somewhat improved - now mild to moderate. the rest of valvular function is essentially unchanged from the pre-bypass study. the thoracic aorta is intact after decannulation. 03:20am blood wbc-9.5 rbc-3.27* hgb-9.8* hct-29.7* mcv-91 mch-30.0 mchc-33.1 rdw-14.8 plt ct-135* 04:10am blood wbc-10.0 rbc-3.29* hgb-9.8* hct-29.7* mcv-90 mch-29.7 mchc-32.8 rdw-14.8 plt ct-95* 05:28am blood wbc-10.6 rbc-3.31* hgb-9.8* hct-30.1* mcv-91 mch-29.5 mchc-32.4 rdw-14.9 plt ct-85* 03:20am blood glucose-73 urean-32* creat-1.1 na-138 k-3.9 cl-103 hco3-27 angap-12 04:10am blood glucose-81 urean-32* creat-1.3* na-140 k-4.4 cl-105 hco3-28 angap-11 05:28am blood glucose-122* urean-27* creat-1.2 na-138 k-4.6 cl-104 hco3-27 angap-12 brief hospital course: the patient was brought to the operating room on where the patient underwent asd repair via right thoracotomy with dr. . 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. preoperative medications were resumed. the patient was transferred to the telemetry floor for further recovery. chest tubes were discontinued without complication. coumadin was resumed for history of atrial fibrillation. ep interrogated the patient's ppm. he was started on colchicine and indomethacin for 1 month for pericarditis prophylaxis per request of cardiologist. 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 home with vna services in good condition with appropriate follow up instructions. medications on admission: albuterol sulfate 1puff prn citalopram 20mg daily esomeprazole magnesium 40mg daily eszopiclone 2mg at hs fenofibrate - 160mg daily fexofenadine 180 mg daily fluticasone 100 mcg disk with device - 1 puff inh once a day fluticasone 2 puffs inh prn glyburide 2.5mg insulin glargine 15 units at bedtime levothyroxine 75mg daily metformin 1000mg metoprolol tartrate 50mg potassium chloride - 40meq crestor 40mg daily valsartan 80mg daily lisinopril 5mg daily zoloft 50mg daily spiriva 18mcgs daily ****warfarin - 7.5mg 3 times per week ****warfarin - 5mg 4 times per week omega-3 fatty acids 2000mg discharge medications: 1. fenofibrate micronized 145 mg tablet sig: one (1) tablet po q pm (). disp:*30 tablet(s)* refills:*0* 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). disp:*30 cap(s)* refills:*0* 3. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for wheezing. disp:*1 * refills:*1* 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*1* 6. fexofenadine 60 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*0* 7. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. rosuvastatin 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 9. fluticasone 110 mcg/actuation aerosol sig: one (1) puff inhalation (2 times a day). disp:*1 1* refills:*0* 10. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 13. glyburide 2.5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 14. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 15. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 16. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 17. zoloft 50 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 18. valsartan 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 19. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily) for 1 months. disp:*30 tablet(s)* refills:*0* 20. indomethacin 25 mg capsule sig: one (1) capsule po tid (3 times a day) for 1 months. disp:*90 capsule(s)* refills:*0* 21. lasix 40 mg tablet sig: one (1) tablet po once a day for 10 days. disp:*10 tablet(s)* refills:*0* 22. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 10 days. disp:*10 tablet, er particles/crystals(s)* refills:*0* 23. coumadin 5 mg tablet sig: 1.5 tablets po once a day: take 5-7.5 mg for inr goal 2.0-3.0. take 7.5 mg on with inr draw . disp:*60 tablet(s)* refills:*0* 24. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 25. insulin glargine 100 unit/ml cartridge sig: fifteen (15) units subcutaneous at bedtime. disp:*qs 1 month units* refills:*0* discharge disposition: home with service facility: amedisys of discharge diagnosis: secundum atrial septal defect pmh: - cad s/p cabg - atrial septal defect - chronic diastolic heart failure - insulin-dependent diabetes mellitus - hypothyroidism - obesity - asd - atrial flutter s/p ablation and cardioversions - obstructive sleep apnea ( does not use his cpap) - tia - peripheral vascular disease - ble varicosities - prior chronic l pleural effusions - l hand neuropathy - depression - gastroesophageal reflux disease - dyslipidemia past surgical history - cabg x3 ( center) lima to lad, svg "y" graft to ramus and om) - av node ablation - pacemaker placement - r cea - r ankle - l knee arthroscopy - l posterolateral thoracotomy/ pleurodesis discharge condition: alert and oriented x3 nonfocal ambulating, gait steady thoracotomy pain managed with oral analgesics thoracotomy incision - healing well, no erythema or drainage edema 1+ le bilaterally 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 2 weeks 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 4 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 1:00 pm cardiologist dr. on at 2:20p please call to schedule the following: primary care dr. , r. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr coumadin for afib goal inr 2-2.5 first draw day after discharge () then please do inr checks monday, wednesday, and friday for 2 weeks then decrease as directed by dr. clinic results to phone - spoke to at coumadin clinic Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Repair of atrial septal defect with tissue graft Diagnoses: Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Atrial fibrillation Aortocoronary bypass status Other specified cardiac dysrhythmias Ostium secundum type atrial septal defect Long-term (current) use of insulin Obesity, unspecified Fitting and adjustment of cardiac pacemaker Chronic diastolic heart failure |
allergies: shellfish derived / peanut attending: chief complaint: crush injuries to legs major surgical or invasive procedure: : 1. open reduction left ankle dislocation. 2. arthrotomy ankle with debridement and removal of foreign body 3. washout and debridement of open fibula fracture inclusive of bone. 4. washout and debridement open tibia fracture down to and inclusive of bone. 5. closed reduction tibia shaft fracture with manipulation. 6. application of multiplanar external fixator. 7. application of vac sponge greater than 50 cm2. 8. washout and repair of left distal femur skin laceration. 9. diagnostic arteriogram lle : 1. removal of external fixator under anesthesia. 2. debridement open tibia fracture down to and inclusive of bone. 3. intramedullary nail left tibia fracture. 4. debridement left open fibula fracture down to bone. 5. orif left fibula fracture with fibular nail. 6. repair distal tib-fib syndesmosis disruption. 7. application of vac sponge. : 1. irrigation and debridement, open fracture, down to and inclusive of tibial bone. 2. irrigation and debridement with pulse lavage. 3. replacement of large vacuum sponge. : 1. ultrasound-guided puncture of right common femoral artery. 2. contralateral third-order catheterization of left superficial femoral artery. 3. serial arteriogram of the left lower extremity. : 1. extensive debridement of skin, soft tissue, muscle and muscle fascia from the left lower extremity. 2. complex partial wound closure left lower extremity measuring approximately 4 cm. 3. free microvascular transfer of right rectus muscle flap to the left lower extremity. 4. application uniplanar external fixator : 1. left lower extremity debridement. 2. left lower extremity split-thickness skin grafting from the right thigh measuring over 200 cm2. 3. debridement right lower extremity skin and subcutaneous tissue with placement of vac dressing on the right lower extremity. : right leg vacuum-assisted closure device change. : dressing change under anesthesia left lower extremity and split-thickness skin grafting less than 100 cm2 right leg/ankle. : 1. removal of vac dressing under anesthesia right lower extremity. 2. dressing change of left lower extremity with removal of staples and sutures. 3. removal of external fixation device left foot and ankle. 4. application of small vac dressing, left posterior ankle. history of present illness: 29 yom s/p b/l le crush injuries after being pinned between two automobiles. patient endured prolonged extrication, including - per report - his lle being caught beneath a wheel. on arrival to he was intubated, and exam was performed which showed an open left medial calf wound, with exposed compound fracture of the tibia. there was a further open compound fracture of the ankle, and his foot was angled in a non anatomic valgus deformity. his rle had ecchymosis of the right ankle, but no obvious deformities or lacerations. past medical history: osa adhd social history: pt lives with his parents. he works at as a parking attendant in . family history: non-contributory physical exam: intubated, sedated tachycardic, no mrg ventilator, no rrw soft, nt, nd lle: open left medial calf wound, with exposed compound fracture of the tibia. open compound fracture of the ankle. left foot angled in a non anatomic valgus deformity. rle: ecchymosis of the right ankle, but no obvious deformities or lacerations pulse exam: fem dp pt : p3+ p2+ p2+ p2+ left: p2+ p1+ - - pertinent results: 12:27pm wbc-9.3 rbc-4.70 hgb-14.9 hct-43.0 mcv-92 mch-31.6 mchc-34.5 rdw-13.2 12:27pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 12:27pm glucose-229* urea n-16 creat-1.2 sodium-137 potassium-5.1 chloride-105 total co2-15* anion gap-22* 12:57pm pt-14.5* ptt-29.1 inr(pt)-1.3* . radiographic studies: plain films b/l feet: right foot: study is somewhat limited by the overlying boot. there are no signs for acute fractures. surgical clips are seen in the medial and lateral soft tissues of the right ankle. mineralization is normal. left foot: there is an intramedullary rod in the distal tibia. a small pin is also seen in distal fibula. there are two syndesmotic screws. the fracture otherwise demonstrates no significant bridging callus. there is a large amount of soft tissue swelling. extensive surgical clips are identified. percutaneous pins are seen of the forefoot. cxr impression: ap chest compared to : lungs are clear though low in volume. heart size exaggerated by low lung volumes probably normal. no pleural abnormality or evidence of central adenopathy. bilat lower ext veins impression: no dvt in bilateral common femoral and superficial femoral veins. brief hospital course: pt was rushed to by ambulance after sustaining a major crushing injury to his left leg in the parking lot in . he was intubated, and immediately evaluated by the trauma surgery, orthopaedic surgery, vascular surgery, and plastic surgery teams, and rushed to the or emergently. the orthopaedic surgery team took him for the following: 1. open reduction left ankle dislocation. 2. arthrotomy ankle with debridement and removal of foreign body 3. washout and debridement of open fibula fracture inclusive of bone. 4. washout and debridement open tibia fracture down to and inclusive of bone. 5. closed reduction tibia shaft fracture with manipulation. 6. application of multiplanar external fixator. 7. application of vac sponge greater than 50 cm2. 8. washout and repair of left distal femur skin laceration. vascular surgery also performed a diagnostic arteriogram at the time, which showed the anterior tibial artery was severely compromised. he was brought to the trauma icu, and broad spectrum anti-biotic therapy was initiated. he was also given multiple units of prbcs to balance his blood loss. he remained intubated in the icu and on was brought to the or again by orthopaedics for: 1. removal of external fixator under anesthesia. 2. debridement open tibia fracture down to and inclusive of bone. 3. intramedullary nail left tibia fracture. 4. debridement left open fibula fracture down to bone. 5. orif left fibula fracture with fibular nail. 6. repair distal tib-fib syndesmosis disruption. 7. application of vac sponge. he tolerated the procedure well, extubated and brought back to the tsicu. he was also underwent sciatic and femoral nerve blocks for pain control. he was also closely followed by the acute pain service during his stay. on , he was evaluated by psychiaty for post-traumatic stress disorder from the trauma he sustained. they made some recommendations for medications including clonidine patch, amytiptyline. on , he was brought back to the or by orthopaedics for: 1. irrigation and debridement, open fracture, down to and inclusive of tibial bone. 2. irrigation and debridement with pulse lavage. 3. replacement of large vacuum sponge. he tolerated the procedure well. the plan by dr. from plastic surgery was to flap this large defect, however, vascular surgery evaluation was required to assess the tibial vessels to determine if a flap would take. on , he was brought back to the or by the vascular surgery team, where he underwent: 1. ultrasound-guided puncture of right common femoral artery. 2. contralateral third-order catheterization of left superficial femoral artery. 3. serial arteriogram of the left lower extremity. the findings indicated that all 3 tibial vessels are suitable vessels to provide as inflow for the free flap. the anterior tibial artery although occluded above the level of the fracture is a widely patent vessel to that level. it can be assumed that the did injury to the anterior tibial artery is much more distal at the level of the fracture and at the more proximal non opacified portion of the anterior tibial artery was thrombosed. he was brought back to the or on by both ortho and plastics, where plastics performed: 1. extensive debridement of skin, soft tissue, muscle and muscle fascia from the left lower extremity. 2. complex partial wound closure left lower extremity measuring approximately 4 cm. 3. free microvascular transfer of right rectus muscle flap to the left lower extremity. ortho also applied a uniplanar external fixator to protect the soft tissues. the flap was monitored closely, and found to have excellent doppler flow from the flap and excellent color. the patient remained stable in the icu until when he was transferred to the general floor post-operatively and remained on the floor for the remainder of his stay. at this time, the patient was followed by the plastic surgery, trauma, orthopedics, psychiatric, acute pain mangement, and social work services. on the patient returned to the or with the plastic surgery team for the following operations: 1. left lower extremity debridement. 2. left lower extremity split-thickness skin grafting from the right thigh measuring over 200 cm2. 3. debridement right lower extremity skin and subcutaneous tissue with placement of vac dressing on the right lower extremity. on , he was brought back to the or for vac dressing change to his rle which was performed w/out incident. on , he returned to the or for a dressing change under anesthesia of the left lower extremity and a split-thickness skin grafting of the right leg/ankle. the patient had several days during the following week with low-grade fever with unclear source. cxr, ua, and lenis were negative. this fever then spontaneously resolved. in addition, he had several issues with pain management in his lle which were thought to be due primarily to nerve re-growth were managed by the acute pain service with a sciatic nerve catheter, oral and iv narcotic pain medicines, gababpentin, and local lidoderm patches. on , he returned to the or for his final surgery, which entailed the following procedures: 1. removal of vac dressing under anesthesia right lower extremity. 2. dressing change of left lower extremity with removal of staples and sutures. 3. removal of external fixation device left foot and ankle. 4. application of small vac dressing, left posterior ankle. for the next 2 days, the patient did well. he was weaned off of his regional pain catheter and his antibiotics were stopped. in addition, the patient was evaluated by physical therapy in preparation for his discharge. medications on admission: none discharge medications: 1. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for itching/insomnia. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 7. enoxaparin 30 mg/0.3 ml syringe sig: one (1) subcutaneous q12h (every 12 hours). 8. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday) as needed for pain. 9. tizanidine 2 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for muscle spasm. 10. gabapentin 300 mg capsule sig: three (3) capsule po qid (4 times a day) as needed for nerve pain. 11. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical q daily (). 12. amitriptyline 10 mg tablet sig: 0.5 tablet po daily at 1900 () as needed for sleep, neuropathic pain. 13. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for anxiety, insomnia. 14. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. discharge disposition: extended care facility: - discharge diagnosis: severe crush injury left lower extremity de-gloving injury to right lower extremity discharge condition: stable discharge instructions: return to the er if: * if you are vomiting and cannot keep in fluids or your medications. * if you have shaking chills, fever greater than 101.5 (f) degrees or 38 (c) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * do not drive or operate heavy machinery while taking any narcotic pain medication. you may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. followup instructions: you will need a change of your vac dressing on friday or saturday of this week. please follow-up with dr. in 1 week. please call ( to make that appointment. please also call dr at ( to make a follow up appointment for the next week. you will need xrays before this visit, please let dr office know when you call to schedule an appointment. Procedure: Arteriography of femoral and other lower extremity arteries Arteriography of femoral and other lower extremity arteries Arterial catheterization Other skin graft to other sites Other skin graft to other sites Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Debridement of open fracture site, tibia and fibula Debridement of open fracture site, tibia and fibula Debridement of open fracture site, tibia and fibula Debridement of open fracture site, tibia and fibula Application of external fixator device, tibia and fibula 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, tibia and fibula Closure of skin and subcutaneous tissue of other sites Closed reduction of fracture without internal fixation, tibia and fibula Application of other wound dressing Application of other wound dressing Application of other wound dressing Application of other wound dressing Application of other wound dressing Application of other wound dressing Application of other wound dressing Removal of implanted devices from bone, tibia and fibula Removal of implanted devices from bone, tibia and fibula Excision of lesion of muscle Muscle transfer or transplantation Diagnoses: Obstructive sleep apnea (adult)(pediatric) Open fracture of shaft of tibia alone Posttraumatic stress disorder Open wound of hip and thigh, complicated Motor vehicle traffic accident involving collision with pedestrian injuring passenger in motor vehicle other than motorcycle Fracture of lateral malleolus, open Crushing injury of ankle |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: weakness and dehydration, found to have nstemi and transferred for further management major surgical or invasive procedure: cardiac catheterization history of present illness: mr. is a yo m admitted to on monday with weakness and dehydration. he has had no chest pain. he describes feeling severe generalized weakness and fleeting numbness of jaw lasting 5 minutes at at time. although pt denied, family states they noticed episodes of diaphoresis and sob. his ekg seemed unchanged. he was ruled in for mi with 1st troponin of 2.13 and 2nd of 1.62. since his osh admission, his hct and platelets have trended down: hct 35-->29, plt 150-->105. a cardiac catheterization showed 85-90% rca above rv branch and he is now transferred to for rca intervention. of note, osh transfer notes mentioned oozing and a small hematoma around the right femoral artery sheath site. . at time of transfer, vitals were: bp 120/66, hr 64 sinus, rr 18, o2 sat: 95%ra. ekg showed. cxr showed. he was given plavix load monday , received 75 mg plavix, 325 mg asa, and lisinopril 10 mg today prior to transfer. . review of systems: he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional leg pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. cardiac history: none. 3. other past medical history: - history of bladder cancer, s/p radical bladder resection and urostomy . - history of prostate cancer s/p radical prostatectomy and radiation . - status post cholecystectomy. social history: married, lives with his wife in . he stopped smoking 40 years ago, ~10 pack year smoking history. he almost never drinks alcohol with holidays being the only exception. he is a retired businessman and banker. he fought as an artillaryman in the european theater including the battle of the bulge in wwii. no history of drug or alcohol use. family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: vs: 98.2 63 105/73 16 98%2lnc general: pale elderly man appeared younger than stated age in nad. appears younger than his stated age. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl. neck: supple with jvp of 6 cm. no carotid bruits. cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, bibasilar crackles, wheezes or rhonchi. abdomen: soft, ntnd. nabs. extremities: wwp. no c/c/e. +1 dp bil les. right inguinal fold without e/o bleeding or bruising. very small hematoma, stable; not ttp. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: cbc 07:12pm blood wbc-6.4 rbc-3.75* hgb-9.9* hct-29.5* mcv-79* mch-26.3* mchc-33.5 rdw-15.9* plt ct-186 09:08pm blood wbc-5.8 rbc-3.66* hgb-9.7* hct-28.8* mcv-79* mch-26.5* mchc-33.7 rdw-15.8* plt ct-146* 03:34am blood wbc-7.1 rbc-4.46* hgb-12.0* hct-35.6* mcv-80* mch-26.8* mchc-33.6 rdw-15.8* plt ct-163 04:48am blood wbc-5.0 rbc-3.41* hgb-9.1* hct-27.1* mcv-80* mch-26.7* mchc-33.5 rdw-16.1* plt ct-135* coags 09:08pm blood pt-18.9* ptt-51.5* inr(pt)-1.7* 03:34am blood pt-13.3 ptt-27.3 inr(pt)-1.1 chem 7 09:08pm blood glucose-127* urean-10 creat-0.5 na-142 k-3.5 cl-111* hco3-23 angap-12 03:34am blood glucose-118* urean-11 creat-0.7 na-144 k-3.8 cl-109* hco3-25 angap-14 04:48am blood glucose-133* urean-21* creat-0.9 na-142 k-3.9 cl-108 hco3-25 angap-13 lfts 09:08pm blood alt-6 ast-12 ck(cpk)-17* alkphos-87 cardiac biomarkers 03:34am blood ck(cpk)-32* 09:08pm blood ck-mb-notdone ctropnt-0.30* 03:34am blood ck-mb-notdone ctropnt-0.25* other chemistry 09:08pm blood albumin-3.4* calcium-7.8* phos-3.4 mg-1.9 03:34am blood calcium-8.5 phos-3.9 mg-2.4 04:48am blood calcium-8.2* phos-3.3 mg-2.2 09:08pm blood %hba1c-5.7 eag-117 cardiac catheterization: 1. successful pci of the proximal rca with a 3.5x23mm vision bare metal stent, post-dilated to 4.0mm. final diagnosis: 1. one vessel coronary artery disease. 2. successful pci of the rca with bms. echocardiogram : the left atrium is moderately dilated. there is mild (non-obstructive) focal hypertrophy of the basal septum. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with focal basal inferolateral and inferior hypokinesis (rca territory). the remaining segments contract normally (lvef = 45-50%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the ascending aorta is moderately 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. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: mild regional left ventricular systolic dysfunction, c/w cad. no clinically-significant valvular disease seen. brief hospital course: assessment and plan: mr. is a yo m with a history of diabetes, hyperlipidemia, and hypertension who presented to an osh with weakness and jaw numbness and had troponin elevations consistent with an nstemi. . # nstemi: mr. has no prior cardiac history. he was found to have elevated biomarkers at an outside hospital and a cardiac catheterization performed there revealed 80-90% stenosis of the rca. he was transferred here for rca percutaneous intervention. in the cath lab, the procedure was long and difficult due to a calcified, tortuous vessel. he ultimately received a 3.5x23mm vision bms. his post-procedure sbp dipped to the mid 80s. his hypovolemia was suspected to be from hypovolemia due to blood loss (hematoma, ooze around sheath, and long procedure). he received iv fluids and 1 unit of prbcs and was transferred to the ccu for overnight observation. his blood pressure returned to . on evaluation on the floor, pt reported feeling well. he denied any chest pain or sob. he was started on plavix 75 mg, atorvastatin 80 mg, and aspirin 325 mg. his lisinopril was reduced because of the hypotension and he was started on a low dose of metoprolol that he tolerated. he had a transthoracic echocardiogram which showed mild regional left ventricular systolic dysfunction (ef 45-50%), consistent with cad. he also was noted to have rate dependent widening of his qrs. he will call his cardiologist to an appointment in the next 2 weeks. . # hypotension: as stated above, the patient developed transient hypotension that responded briskly to fluid and 1 unit of prbcs. serial hematocrits were drawn and showed fluctuating hct which were thought to be spurious. the patient had no other signs of bleeding. his lisinoril dose was decreased to 10 mg once a day due ot the hypotension. he was also started on low dose metoprolol for his nstemi. . # diabetes: the patient has a history of diabetes that is largely diet controlled. he is also on glyburide at home. his glyburide was held and he was started on iss with qid fingersticks. he was restarted on his home dose glyburide at discharge. . # generalized weakness: unclear etiology, although likely related to cardiac disease and dehydration. osh reports mentioned transient diarrheal illness one week ago, which the patient continued to have. he is without leukocytosis or fever. he had no focal neurological symptoms and his mental status was intact. . # diarrhea: the patient continued to have symptoms of diarrhea which he has chonically. he had a c diff toxin sent that was negative. given the low suspicion of c diff, he was given loperamide for symptomatic releif. . # anemia/thrombocytopenia: per osh reports, patient's hct and plts noted to be trending down since admission there. he had a guaiac negative stool on at the osh. his hcts were treneded and - as above - varied widely and were thought to be spurious as he had no other evidence of bleeding besides a stable small hematoma noted at the osh from his catheterization. medications on admission: home medications (confirmed with patient): lisinopril 40 mg daily. glyburide 2 mg daily. medications upon transfer: aspirin 325mg po daily clopidogrel 75mg po daily diazepam 10mg on call cath lab enoxaparin 90mg sc q12h sliding scale insulin aspart lisinopril 10mg po 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. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. pneumococcal 23-valps vaccine 25 mcg/0.5 ml injectable sig: one (1) ml injection asdir (as directed). 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. trazodone 50 mg tablet sig: 0.25 tablet po hs (at bedtime) as needed for insomnia. 6. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea. 7. metoprolol succinate 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:*2* 8. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tab sublingual prn as needed for chest pain. disp:*30 2* refills:*0* 10. glyburide 1.25 mg tablet sig: two (2) mg po once a day. discharge disposition: home discharge diagnosis: non st elevation myocardial infarction hypertension hyperlipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you had a heart attack and required cardiac catheterization and stents placed in one of your coronary arteries. you will need to take many new medicines from now on to prevent the stents from clotting off and prevent another heart attack. you will also need to follow up with your cardiologist in 2 weeks and should consider attending cardiac rehabilitation after you see him. medication changes: 1. increase aspirin to 325 mg daily. do not stop taking or miss any doses. 2. start clopidogrel (plavix) daily for 5 more days, then once daily for at least one year. do not stop taking or miss s. 3. start atorvastatin (lipitor) to lower your cholesterol. 4. decrease your lisinopril to 10 mg daily 5. start metoprolol to lower your heart rate and help prevent another heart attack. 6. take nitroglycerin if you have chest pain at home that is similar to your previous chest pain. sit down, take one tablet under your tongue 5 minutes apart. if you still have chest pain after 3 doses, call 911. followup instructions: cardiology: please call your cardiologist to an appointment in two weeks. , md. ( primary care: please call your primary care doctor an appointment in two to four weeks. , md Procedure: Insertion of non-drug-eluting coronary artery stent(s) Other and unspecified coronary arteriography Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Other iatrogenic hypotension Thrombocytopenia, unspecified Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery 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 Hematoma complicating a procedure Other and unspecified hyperlipidemia Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Personal history of malignant neoplasm of bladder Other postprocedural status Diarrhea Dehydration Hypovolemia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain and dyspnea major surgical or invasive procedure: aortic valve replacement with #21mm percardial valve coronary artery bypass graft x1 lima-lad history of present illness: history of present illness:the patient is an 81 year old male with a history of diabetes mellitus, hypertension, hyperlipidemia, and bph who presented to the ed for evaluation of new exertional chest pain and dyspnea. he was found to have severe aortic stenosis murmur and moderate mr ef. past medical history: # cardiac risk factors: diabetes, dyslipidemia, hypertension # cad -- no known diagnosis, but on multiple cardiac meds # aortic stenosis -- no known diagnosis, but apparent on exam # hypertension # hyperlipidemia # diabetes mellitus type 2 -- on metformin and glyburide # bph # gout social history: # alcohol: none # tobacco: none # drugs: none family history: # father -- died of "old age" # mother -- died from mi at age 70 # brother -- died from mi at age 45 no family history of cancer, arrhythmia, cardiomyopathy, dvt, pe, bleeding disorders, or clotting disorders. physical exam: physical exam pulse:61 resp:20 o2 sat:98/ra b/p right:110/53 left: height:5'5" weight:151 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade 3 abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema trace b/l varicosities: none neuro: grossly intact pulses: femoral right: palp left: palp dp right: palp left: palp pt : palp left: palp radial right: palp left: palp carotid bruit right: - left: - pertinent results: 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. the ascending aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. moderate (2+) mitral regurgitation is seen. there is no pericardial effusion. post-cpb: the patient is av-paced, on no inotropes. biventricular systolic fxn. there is a prosthetic aortic valve with no leak and no ai. mr is now 1+. tr is 1+. aorta intact. i certify that i was present for this procedure in compliance with hcfa regulations. interpretation assigned to , md, interpreting physician 05:27am blood wbc-7.3 rbc-3.09* hgb-8.7* hct-26.6* mcv-86 mch-28.2 mchc-32.9 rdw-13.4 plt ct-201 03:00am blood pt-13.7* ptt-31.0 inr(pt)-1.3* 05:27am blood glucose-106* urean-21* creat-0.6 na-141 k-4.2 cl-101 hco3-35* angap-9 05:27am blood calcium-8.5 phos-3.1 mg-2.1 06:48am blood wbc-7.5 rbc-3.26* hgb-8.9* hct-27.9* mcv-86 mch-27.2 mchc-31.9 rdw-13.3 plt ct-256 06:48am blood wbc-7.5 rbc-3.26* hgb-8.9* hct-27.9* mcv-86 mch-27.2 mchc-31.9 rdw-13.3 plt ct-256 03:00am blood pt-13.7* ptt-31.0 inr(pt)-1.3* 06:48am blood glucose-144* urean-24* creat-0.7 na-143 k-4.1 cl-101 hco3-36* angap-10 06:48am blood glucose-144* urean-24* creat-0.7 na-143 k-4.1 cl-101 hco3-36* angap-10 06:48am blood calcium-9.0 phos-3.9 mg-2.1 brief hospital course: the patient was admitted to the hospital and brought to the operating room on where the patient underwent avr with #21 percardial valve and cabg x1 lima-lad please see operative report for details. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. vanco and ancef were used for surgical antibiotic prophylaxis. in the immediate post-op period he remained hemodynamically stable, his anesthesia was reversed he was neurologically intact and was extubated. pod 1 found the patient hemodynamically stable, extubated, alert and oriented and breathing comfortably. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery on pod#1. chest tubes and pacing wires were discontinued according to cardiac suregy protocol without complication. narcotics were minimized due to mild confusion. once on the floor the patient worked with nursing and physical therapy service to enhance with strength and mobility. he failed his first voiding trial on pod2 and foley was replaced for post-void residual of 800cc. he has history of bph and was restarted on his finasteride. repeat voiding trial was done on pod#4 which he also failed, he was started on and prazosin and a urology followup appointment was scheduled. by the time of discharge,the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was cleared for discharge to heathwood at rehab on pod #6. at that time he was in good condition with follow up instructions to see dr in one month and he will f/u with dr. (outpt. urologist) in one week. medications on admission: at home: aspirin 81 mg po daily dipyridamole 25 mg po -- unknown times daily losartan 25 mg po daily amlodipine 5 mg po daily prazosin 5 mg po -- unknown times daily atorvastatin 10 mg po daily nitroglycerin er 6.5 mg po -- unknown times daily metformin 500 mg po -- unknown times daily glyburide 5 mg po -- unknown times daily finasteride 5 mg po daily multivitamin 1 tab po daily calcium+vitd (500 mg-200 unit) po daily vitamin e 400 units po daily celadrin -- unknown times daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. 3. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 4. acetaminophen 325 mg tablet sig: two (2) tablet po every six (6) hours as needed for pain/fever. 5. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily) for 2 weeks. 8. glyburide 5 mg tablet sig: one (1) tablet po at bedtime. tablet(s) 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day): hold for hr <55 or sbp <90 and call medical provider. 10. losartan 25 mg tablet sig: one (1) tablet po daily (daily). 11. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for dyspnea. 13. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for dyspnea. 14. metformin 500 mg tablet sig: one (1) tablet po daily (daily). 15. furosemide 40 mg tablet sig: one (1) tablet po once a day for 10 days. 16. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 10 days. 17. insulin lispro 100 unit/ml solution sig: sliding scale dosing ( see attached) subcutaneous asdir (as directed). 18. glyburide 5 mg tablet sig: two (2) tablet po once a day. 19. prazosin 5 mg capsule sig: one (1) capsule po once a day. discharge disposition: extended care facility: livingcenter - heathwood - discharge diagnosis: aortic stenosis coronary artery disease hypertension hyperlipidemia diabetes mellitus type 2 bph /urinary retention gout discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with tramadol edema:1+ bilaterally discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than 10 pounds for 10 weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours* followup instructions: please call to schedule appointments with: surgeon: dr. wed. at 2:00pm cardiologist:dr. on at 9:40am urologist: dr. thursday @ 4:45 pm , 3 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* please call cardiac surgery if need arises for evaluation or readmission to hospital Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Gout, unspecified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Other and unspecified angina pectoris Mitral valve insufficiency and aortic valve stenosis |
allergies: chantix attending: chief complaint: shortness of breath major surgical or invasive procedure: 1. coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the posterior descending coronary artery; reverse saphenous vein single graft from the aorta to posterior left ventricular coronary artery; and reverse saphenous vein graft from the aorta to the first obtuse marginal coronary artery. 2. endoscopic right greater saphenous vein harvesting. history of present illness: 58 year old male with complaints of shortness of breath with exertion, abnormal stress tests, referred for cardiac catheterization. he was found to have coronary artery disease and referred for surgical evaluation past medical history: hyperlipidemia hiv- diagnosed , followed by dr. , last viral load 1 month ago peripheral vascular disease- left femoral and popliteal occlusive arterial disease gerd copd/emphysema- mild, to f/u with pulm in asthma ventricular tachycardia sleep apnea- does not use cpap seizure disorder (last 35 years ago) osteopenia arthritis degenerative joint disease raynaud's phenomenon psoriasis tertiary syphilis - now resolved depression social history: lives with:alone occupation:works in an office tobacco:+ 1.5ppd x 40 yrs etoh:denies recreational drugs: denies family history: father died of aortic aneurysm in his 70s physical exam: pulse:68 resp:16 o2 sat:97% ra b/p right:113/81 left:112/76 height:6'2" weight:160lbs general: nad, wgwn, anxious skin: dry intact heent: perrla (slowly reactive to light) eomi neck: supple full rom chest: lungs clear bilaterally slightly diminished throughout heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema- none varicosities- prominent le veins with moderate spider veins neuro: grossly intact x pulses: femoral right: 2+ left: 2+ dp right: 2+ left: np pt : 2+ left: 1+ radial right: 2+ left: 2+ carotid bruit right: left: no bruits pertinent results: 08:15am blood wbc-6.2 rbc-2.99* hgb-10.3* hct-29.6* mcv-99* mch-34.4* mchc-34.8 rdw-13.5 plt ct-190 08:15am blood glucose-101* urean-12 creat-0.6 na-138 k-3.8 cl-104 hco3-27 angap-11 intra-op tee pre cpb: no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. 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. there are three aortic valve leaflets. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. dr. was notified in person of the results. post cpb: there is preserved biventricular systolic function. there is trace mr. there is mild ai. the contours of the thoracic aorta are intact. 08:15am blood wbc-6.2 rbc-2.99* hgb-10.3* hct-29.6* mcv-99* mch-34.4* mchc-34.8 rdw-13.5 plt ct-190 08:15am blood glucose-101* urean-12 creat-0.6 na-138 k-3.8 cl-104 hco3-27 angap-11 12:33pm blood alt-38 ast-42* ld(ldh)-216 alkphos-115 amylase-41 totbili-0.3 08:15am blood mg-2.0 12:33pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-neg brief hospital course: he was admitted same day surgery and underwent coronary artery bypass graft surgery. see operative report for further details. post operatively he was transferred to the intensive care unit for management and received cefazolin for surgical antibiotic prophylaxis. in the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. post operative day one he was progressing well and weaned from inotropic and vasopressor support. he was transferred to the floor for the remainder of his care. physical therapy worked with him on strength and mobility. he was started on betablockers on post operative day three and epicardial wires removed post operative day four. he was doing well and was ready for discharge to rehab ( rehab for the aged ). medications on admission: acyclovir 400mg po bid clobetasol 0.05% ointment emtricitabine-tenofovir(truvada) 200-300mg table po daily metoprolol succinate 25mg po daily dilantin 200mg po bid simvastatin 80mg po daily asa 81mg po daily psyllium dosage uncertain discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. acyclovir 400 mg tablet sig: one (1) tablet po q12h (every 12 hours). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. hydromorphone 2 mg tablet sig: 1-3 tablets po q3h (every 3 hours) as needed for pain. 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 6. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 7. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 8. motrin 400 mg tablet sig: one (1) tablet po every eight (8) hours as needed for pain for 1 weeks. 9. simvastatin 80 mg tablet sig: one (1) tablet po once a day. 10. clobetasol 0.05 % ointment sig: one (1) appl topical (2 times a day). 11. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 2-4 puffs inhalation q6h (every 6 hours). 12. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po daily (daily). 13. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days. 14. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 5 days. 15. phenytoin 100 mg/4 ml suspension sig: eight (8) ml po twice a day: 200 mg twice a day . discharge disposition: extended care facility: discharge diagnosis: coronary artery disease s/p cabg hyperlipidemia peripheral vascular disease gastroesophageal reflux disease emphysema asthma ventricular tachycardia sleep apnea - does not use cpap seizure disorder osteopenia arthritis degenerative joint disease raynaud's phenomenon psoriasis tertiary syphilis - now resolved depression discharge condition: alert and oriented x3 nonfocal ambulating with assistance sternal pain managed with dilaudid and motrin prn sternal incision - healing well, no erythema or drainage right leg evh no erythema no drainage edema none 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. date/time: 1:00 cardiologist dr. at 3:45 pm please call to schedule the following: 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 Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Asthma, unspecified type, unspecified Peripheral vascular disease, unspecified Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Other emphysema Epilepsy, unspecified, without mention of intractable epilepsy Asymptomatic human immunodeficiency virus [HIV] infection status |
allergies: bactrim attending: chief complaint: diarrhea and brbpr major surgical or invasive procedure: endoscopy colonoscopy history of present illness: 62m with h/o aka, presenting with 1 mo of increasing freq and urgency of bowel movements, >10/day, occationally bloody. not diarrhea but looser than usual. starting monday (1 week ago) developed occational brbpr w/bms, assoc w/incr generalized weakness and fatigue. has had years of luq pain, no change in character of abdom pain. saw gi last week who sched an outpt colonoscopy next week but was extremely fatigued and had incr brbpr w/stools over the past 2d so presented to ed. denies fevers, vomiting, recent travel or new food exposures. h/o "stomach ulcer" last egd 8yrs ago, on ppi chronically. also heavy etoh use, 2 bottles wine daily for a two months due to stress of job at . in the ed, initial vs were 100.8 94 133/75 20 100% ra. 2 18-gauge piv were placed. the patient was given 2l of ns. a ng lavage was neg. a ct of the abdomen was performed, which demonstrated colitis of the descending colon. he recieved 1 unit of blood on transfer from the ed and a second unit after arrived to micu. blood cultures were obtained. ua was negative. cxr was neg. no antibiotics were started. . on arrival to the micu, his vitals were: 99.1 72 106/58 16 99% on ra. past medical history: narcotics agreement for persistent pain at site of aka dyspepsia right side above-the-knee amputation due to septic shock s/p appy skin lesion on nose social history: - tobacco: never - alcohol: 2 bottles of wine daily for 2 months, no h/o withdrawal sx. - illicits: mj, cocaine last used in the 70's both parents were also alcoholics family history: negative for colon cancer or prostate cancer physical exam: admission exam vitals: 99.1 72 106/58 16 99% on ra gen: nad, axox3 skin: no rash. no jaundice. heent: anicteric, no pallor. o/p w/o injection or exudates. neck: supple, no thyromegaly or nodule. he has a well-healed scar on the anterior aspect of his neck lungs: ctab. heart: rate regular, heart sounds normal. no murmur. abdomen: soft, nontender, no organomegaly or mass, no cvat. extremities: no peripheral edema, cyanosis, or clubbing. aka on right neurologic: normal. . discharge exam vitals: 97.8 80 126/62 18 99% on ra gen: nad, axox3 skin: no rash. no jaundice. heent: anicteric, no pallor. no o/p lesions lungs: ctab. heart: rate regular, heart sounds normal. no murmur. abdomen: soft, nontender, no organomegaly or mass, no cvat. extremities: no peripheral edema, cyanosis, or clubbing. aka on right neurologic: normal. pertinent results: admission labs: 05:37pm blood wbc-13.1*# rbc-2.51*# hgb-8.1*# hct-23.4*# mcv-93 mch-32.4* mchc-34.7 rdw-12.1 plt ct-456* 05:37pm blood neuts-83.6* lymphs-11.8* monos-4.0 eos-0.1 baso-0.4 07:30pm blood pt-12.2 ptt-24.5 inr(pt)-1.0 05:37pm blood glucose-94 urean-13 creat-1.0 na-131* k-3.8 cl-95* hco3-24 angap-16 05:37pm blood alt-24 ast-24 ld(ldh)-156 alkphos-68 totbili-0.4 02:15am blood calcium-7.9* phos-2.9 mg-2.0 04:22am blood caltibc-169* vitb12-1332* folate-16.7 ferritn-157 trf-130* 01:08am blood lactate-1.2 05:46pm blood hgb-8.1* calchct-24 12:08pm blood freeca-1.13 discharge labs: 06:40am blood wbc-5.5 rbc-3.47* hgb-10.6* hct-31.6* mcv-91 mch-30.6 mchc-33.6 rdw-14.8 plt ct-485* 06:30am blood pt-12.3 ptt-26.4 inr(pt)-1.0 06:40am blood glucose-136* urean-13 creat-0.7 na-136 k-4.2 cl-103 hco3-26 angap-11 06:40am blood albumin-2.8* calcium-8.4 phos-3.9 mg-2.0 u/a: negative imaging: cxr chest, single ap portable view.no previous chest x-rays on pacs record for comparison. rotated positioning. allowing for this, the heart is not enlarged. there is no chf, focal infiltrate, or gross effusion. minimal atelectasis at the right lung base and obscuration and blunting of the right costophrenic angle is noted. probable also minimal left base atelectasis. an old healed left seventh posterior rib fracture is incidentally noted. no free air is seen beneath the diaphragm on this upright film. ct abd/pelvis abdomen: included views of the lung bases demonstrate calcified pleural-based plaques bilaterally (2:4, 1). there is no pleural effusion. no nodules or masses are seen. the heart size is normal, and there is no pericardial effusion. the liver, gallbladder, spleen, pancreas, adrenal glands, kidneys, stomach, and intra-abdominal loops of small bowel are normal. there is no mesenteric or retroperitoneal lymphadenopathy, and no free air or free fluid. a long segment of the descending colon and proximal sigmoid demonstrates wall thickening with neighboring stranding (602b:54, 2:48). the remaining large bowel appears normal. pelvis: the rectum, sigmoid colon, urinary bladder, and prostate are normal. there is no intrapelvic lymphadenopathy or free fluid. osseous structures: there is no acute fracture. no concerning blastic or lytic lesions are identified. there is mild levoscoliosis of the lumbar spine (601b:30). impression: mild wall thickening and stranding of the distal transverse, descending and sigmoid colon, which may reflect colitis secondary to infection or ibd. the distribution is less compatible with ischemia. egd : 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 third 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: normal esophagus. stomach: normal stomach. duodenum: normal duodenum. other procedures: cold forceps biopsies were performed for histology at the second part of the duodenum. cold forceps biopsies were performed for histology at the stomach antrum. impression: (biopsy, biopsy) otherwise normal egd to third part of the duodenum recommendations: will mail a pathology report in weeks continue prior dose of ppi colonoscopy : the patient was placed in the left lateral decubitus position.the digital exam was normal. the colonoscope was introduced through the rectum and advanced under direct visualization until the splenic flexure was visualized at distance of 70 cm. careful visualization of the colon was performed as the colonoscope was withdrawn. the colonoscope was retroflexed within the rectum. the procedure was not difficult. the quality of the preparation was good. the patient's tolerance to the procedure was fair. there were no complications. findings: mucosa: ulceration, granularity, friability, erythema and congestion of the sigmoid colon to splenic flexure (70cm) were noted. no transition to normal mucosa was noted. the scope could not be traversed beyond 70cm given inflammation and poor patient tolerance. the rectum was normal endoscopically. cold forceps biopsies were performed for histology at the random colon. excavated lesions multiple diverticula were seen in the sigmoid colon. diverticulosis appeared to be of moderate severity. other procedures: cold forceps biopsies were performed for histology at the rectum. impression: ulceration, granularity, friability, erythema and congestion in the colon (biopsy) diverticulosis of the sigmoid colon otherwise normal colonoscopy to splenic flexure recommendations: will mail pathology report in weeks follow-up with inpatient gi team for recommendations re: treatment. he will need a follow-up colonoscopy when inflammation has decreased under mac. this can be scheduled after he follows up in clinic. the findings account for the symptoms and are consistent with colitis likely ibd. additional notes: the procedure was performed by the fellow and the attending. the attending was present for the entire procedure. final diagnoses are listed in the impression section above. estimated blood loss = zero. specimens were taken for pathology as listed above. micro: fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. fecal culture - r/o vibrio (final ): no vibrio found. fecal culture - r/o yersinia (final ): no yersinia found. fecal culture - r/o e.coli 0157:h7 (final ): no e.coli 0157:h7 found. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). blood cultures 10/23: ngtd brief hospital course: ============== brief hospital summary ============== this is a 62 yo m with a history of a partial bowel rsxn after ruptured appy, hx of "flesh eating infection" of rle leading to aka in , who presented with increasing freq and urgency of bowel movements, fever and brpbr. he was found to have colitis on ct scan in the descending colon and a colonoscopy suspicious for ibd. he was started on prednisone and asacol and will f/u w/ gi as an outpt. . =============== active issues =============== brbpr: pt with acute anemia to 23, was stabilized w/ blood products to hct 32 in micu. after brief stay in micu, pt transferred to floor w/ stable vitals. unremarkable egd is reassuring that bleeding not from proximal of ligament of treitz. colonoscopy showed a large amount of inflammation and irritation from rectum to splenic flexure, likely result of ibd, but infection cannot be ruled out. biopsies pending. have started prednisone/asacol for presumed ibd. pt has realized some relief in abd pain and frequency of bowel movements in past 24 hrs. stool cxs negative. we appreciated the input of our gi colleagues throughout this admission. . #alcohol abuse: paitent has been drinking 2 bottles of wine a night for several week2 months. pt had a social work consult. no signs or symptoms of withdrawal. pt was on ciwa scale. ===================== inactive issues ===================== #chronic pain: from aka will kept patient on his home vicoden regimen per his narcotics contract. ===================== transitional issues ===================== 1. f/u path on /egd biopsies 2. f/u gi 3. f/u pcp 4. prednisone taper 5. added asacol medications on admission: -prilosec otc 20mg q.d. p.r.n. -vicoprofen qd to p.r.n. -ambien prn -sudafec pe qd prn - taking daily for years discharge medications: 1. hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po q12-24hrs as needed for pain. 2. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 3. prednisone 20 mg tablet sig: two (2) tablet po daily (daily). disp:*50 tablet(s)* refills:*0* 4. mesalamine 400 mg tablet, delayed release (e.c.) sig: four (4) tablet, delayed release (e.c.) po tid (3 times a day). disp:*360 tablet, delayed release (e.c.)(s)* refills:*2* 5. 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* 6. metronidazole 500 mg tablet sig: one (1) tablet po every eight (8) hours for 4 days. disp:*12 tablet(s)* refills:*0* 7. cipro 500 mg tablet sig: one (1) tablet po twice a day for 4 days. disp:*8 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: likely inflammatory bowel disease bright red blood per rectum (acute anemia) discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you. you were admitted to the hospital because you have had increasing frequency and urgency of bowel movements, with blood in your stools. your blood counts were down and you were stabilized in the medical intensive care unit with fluids and blood products. you were then admitted to the general medicine floor, and underwent an upper endoscopy and a colonoscopy. the upper endoscopy was essentially normal. the colonoscopy showed significant inflammation, which could be consistent with inflammatory bowel disease. we started you on prednisone and asacol, which seemed to have improved your symptoms. going home, you should continue to take the asacol and prednisone as directed. also, you should try to avoid alcohol. it will be important for you to follow closely with the gastroenterologists, appointments have been made. 1. start prednisone 40mg daily (to be tapered by your gi physicians) 2. start mesalamine dr 1600 mg three times a day 3. start protonix 40mg twice a day (to be tapered by your gi physicians) 4. continue metronidazole for 4 additional days 5. contininue ciprofloxacin for 4 additional days followup instructions: department: when: thursday at 2:10 pm with: , m.d. building: campus: east best parking: garage department: div. of gastroenterology when: wednesday at 3:30 pm with: , md building: ra (/ complex) campus: east best parking: main garage md, Procedure: Esophagogastroduodenoscopy [EGD] with closed biopsy Closed [endoscopic] biopsy of large intestine Closed [endoscopic] biopsy of rectum Diagnoses: Other chronic pain Acute posthemorrhagic anemia Depressive disorder, not elsewhere classified Diverticulosis of colon (without mention of hemorrhage) Other and unspecified alcohol dependence, continuous Above knee amputation status Other ulcerative colitis |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: slurred speech major surgical or invasive procedure: l crani for tumor resection history of present illness: 79 f with no past oncologic history who presented with a transient episode of speech slurring. work up included an mri that demonstrated a 2 cm left frontal parietal lesion with peri-lesion edema. subsequent oncologic work up revealed no evidence of systemic cancer. the patient presents for consideration of craniotomy for resection and tissue diagnosis. since the episode of speech slurring, the patient's family noted a change in the quality of her voice. the review of system is otherwise unremarkable. past medical history: htn, hypercholestrolemia, gerd, vulva lesion (resected). meds: gemfibrozil, amoldipine, atenolol, kcl,zantac, mvi, asa (discontinued for the past week) allergy: nkda social history: n/a family history: fh: mother died of chf. two children died of metastic cancer. sh: 25-30 pk/year smoking history, no significant alcohol use. denied ilicit drug use. physical exam: on examination, the patient is awake, alert, and appropriate. ltm: intact to birthday and home address stm: items at 3 minutes as: difficulty with serial 3's after the first two digits speech fluent though with squeaky pitch. followed simple and complex commands named objects. intact repetition. eomi. vff. perrl 3 mm. fs. ss/hearing symmetric. t/u midline. normal bulk and tone. full strength throughout. sensation intact to lt. symmetric reflex 1+. normal ftn and romberg. normal gait. mri: 2.4 x 1.4 x 2.1 cm superficial left frontal mass (contrast enhancing) anterior to the motor strip with peri-mass edema discharge exam: as above. slight expressive aphasia. full motor/sensory. pertinent results: admission labs: 09:03am hgb-11.3* calchct-34 09:03am glucose-103 lactate-1.6 na+-136 k+-3.6 cl--103 discharge labs: 05:30am blood wbc-4.9 rbc-3.58* hgb-11.0* hct-33.3* mcv-93 mch-30.6 mchc-33.0 rdw-13.9 plt ct-252 05:30am blood pt-12.2 ptt-25.0 inr(pt)-1.0 05:30am blood glucose-114* urean-20 creat-0.6 na-140 k-3.9 cl-105 hco3-27 angap-12 imaging: mri head : preoperative planning study demonstrates a 1.8 cm left frontal lobe mass which appears dural-based and intra-axial. the differential diagnosis includes a metastasis. the appearances lthough not typical for meningioma, it should also be considered in differential diagnosis. head ct : expected appearance, status post craniotomy. no evidence of new hemorrhage, infarct or hydronephrosis. mri is better able to detect acute infarct if clinically suspected mri : 1. post-surgical changes in the left frontal lobe with blood products at the surgical site and pneumocephalus. 2. restricted diffusion is identified at the margin of surgical cavity which would be postoperative in nature but there is also noted a linear component which extends further deep into the white matter from the surgical cavity and could be related to associated area of ischemia. clinical correlation recommended. 3. extensive changes of small vessel disease. 4. left frontal lobe edema unchanged from previous study. 5. no evidence of hydrocephalus. brief hospital course: the patient tolerated her procedure well, and following extuabtion was transferred to the pacu. her sbp was kept less that 160, and her neuro exam was closely followed. her post op head ct demonstrated edema. on examination, patient's speech garbled with expressive aphasia. she was transferred to sicu and mri was ordered to rule out infarct. mri showed increase in edema and steriods were kept at 4mg q6h. she was monitored closely for one more day in the sicu and transfer orders for the floor were written. she remained in the sicu while awaiting a floor bed and her aphasia improved to her baseline speech by pod2. patient had full strength throughtout and was otherwise non-focal. physical and occupational therapy were consulted on and the felt she needed another day prior to being discharged. she was trasnferred to the floor on . she was discharged to home on . medications on admission: tylenol, atenolol, amlodopine, bactrim, decadron, lopid, lorazepam, k-dur, premarin, protonix discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for fever. disp:*30 tablet(s)* refills:*0* 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po 3x/week (mo,we,fr). 5. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). 6. atenolol 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. conjugated estrogens 0.625 mg tablet sig: one (1) tablet po 2x/week (mo,we) for 3 weeks. 8. amlodipine 2.5 mg tablet sig: one (1) tablet po bid (2 times a day). 9. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 10. dexamethasone 4 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*0* 11. levetiracetam 250 mg tablet sig: four (4) tablet po bid (2 times a day). disp:*240 tablet(s)* refills:*0* 12. oxycodone 5 mg capsule sig: capsules po every 4-6 hours as needed for pain. disp:*40 capsule(s)* refills:*0* discharge disposition: home with service facility: , discharge diagnosis: metastatic brain tumor discharge condition: . mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: general instructions wound care: ?????? you or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? keep your incision clean and dry. ?????? you may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? do not apply any lotions, ointments or other products to your incision. ?????? do not drive until you are seen at the first follow up appointment. ?????? 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. if 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. ?????? 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. 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. . followup instructions: follow up appointment instructions ??????please return to the office in days (from your date of surgery) for 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 3 pm. 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 with/ or without gadolinium contrast. Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Arterial catheterization Diagnoses: Esophageal reflux Pure hypercholesterolemia Unspecified essential hypertension Other malignant lymphomas, unspecified site, extranodal and solid organ sites Cerebral edema Aphasia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: perirectal abscess major surgical or invasive procedure: drainage of perirectal abscess on history of present illness: 66m transferred from with 4 weeks of perirectal pain and purulent drainage from his rectum. patient didnt go to the ed before with the hope that this would resolve, but pain has been steady and worsening during the past 3 days. the purulent drainage started 3 weeks ago, associated with fevers, chills and diaphoresis, and it has been increasing during the past week. patient went to ed and was found to have a t 102.2, a wbc of 12 and glucose of 490 requiring insulin boluses. here on arrival with new onset of a.fib with rvr up to 150s. past medical history: htn, chf, dm, gerd social history: smoker of 1 1/5 packs a day for 30 years. drinks etoh occasionally. family history: mother had cancer in the 60s. physical exam: on discharge: vitals: 98.8 77 154/80 18 96% ra gen: a&o, nad cv: rrr, no m/g/r pulm: clear to auscultation b/l abd: soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds re: drainage coming out of the rectum around penrose drain. no erythema. slightly ttp (appropriate). no fluctuant masses ext: no le edema, le warm and well perfused dependent rubor pertinent results: ct pelvis : 1. interval perirectal abscess drainage without residual fluid collection. the drain remains in place. 2. mild-to-moderate proctocolitis. 3. chondroid lesion in the right iliac bone which has a benign appearance and might represent an enchondroma. if the patient complains of regional pain this could be further evaluated with mri to exclude a more aggressive lesion brief hospital course: mr. was admitted to the acs surgery service for of the perirectal abscess. on he underwent an i/d of the large perirectal abscess and placement of a penrose drain. intraop he was in afib with rvr and was transferred to the icu for . the following day, he was hemodynamically stable and was in nsr with betablocker so he was transferred to the floor. he was put on broad spectrum antibiotics. he was also having significant hyperglycemia requiring insulin boluses. was consulted for glycemic control. also, nutrition was consulted for diabetic diet education. the atrial fibrillation recurred postoperatively after a brief period in nsr. a ct scan was obtained to rule out ongoing infection/undrained perirectal abscess. the ct showed that the abscess was adequately drained. cardiology was consulted for assistance in of the paroxysmal atrial fibrillation. they recommended continuation of home metoprolol xl 100mg po daily, anti-coagulation for paroxysmal af, of heart monitor on discharge, f/u with cardiology in weeks, continuing asa, acei and statin for chf. he was discharged in good condition, tolerating a regular diet, afebrile, ambulating, pain well controlled. medications on admission: furosemide 40 mg daily, omeprazole 20 mg daily, simvastatin 40 mg daily, metoprolol succinate er 100 mg daily, actos 45 mg tab daily, aspir-81 81 mg daily, lisinopril 40 mg daily, glipizide 20 mg discharge medications: 1. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*35 tablet(s)* refills:*0* 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 5. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 6. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 7. insulin syringes (disposable) 1 ml syringe sig: syringe miscellaneous four times a day. disp:*100 syringes* refills:*12* 8. insulin safety needles (disp) 29 x needle sig: needle miscellaneous four times a day. disp:*100 needle* refills:*2* 9. glucometer sig: glucometer four times a day. disp:*1 glucometer* refills:*0* 10. test strips sig: for glucometer four times a day. disp:*100 test strips* refills:*2* 11. lantus 100 unit/ml cartridge sig: twenty six (26) units subcutaneous at bedtime. disp:*30 cartridge* refills:*2* 12. humalog kwikpen subcutaneous 13. insulin sliding scale check blood glucose 4 times a day. take 26 units of lantus every night. blood glucose 100-160 take 10 units of humalog blood glucose 161-200 take 13 units of humalog blood glucose 201-240 take 16 units of humalog blood glucose 241-280 take 19 units of humalog blood glucose 281-320 take 22 units of humalog blood glucose 321-360 take 25 units of humalog blood glucose >360 seek medical attention discharge disposition: home with service facility: vna discharge diagnosis: perirectal abscess diabetes paroxysmal atrial fibrillation discharge condition: ms: intact. alert and oriented x 3 ambulating discharge instructions: -you have a perirecatal abscess. a penrose drain was placed to facilitate drainage of the abscess and allow for it to heal properly. the penrose drain will be removed in surgery clinic. in order to ensure that this heals well, you must control your diabetes and see a primary care doctor of the diabetes. you also developed atrial fibrillation or an irregular heart rate. cardiology wants you to have a heart monitor and start anticoagulation. you should follow up with them for of the atrial fibrillation. followup instructions: -follow up with a primary care doctor of diabetes and atrial fibrillation -follow up with cardiology for of atrial fibrillation in weeks. call for an appointment -follow up in clinic in weeks. call for an appointment. md Procedure: Incision of perirectal tissue Diagnoses: Esophageal reflux Tobacco use disorder Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Polyneuropathy in diabetes Long-term (current) use of insulin Retention of urine, unspecified Obesity, unspecified Diabetes with neurological manifestations, type II or unspecified type, uncontrolled Abscess of anal and rectal regions |
allergies: no known allergies / adverse drug reactions attending: chief complaint: aphasia and right hemiparesis major surgical or invasive procedure: iv tpa and merci device history of present illness: the patient is a 67 year old right handed man with a past medical history significant for a.fib (not on coumadin - for unclear period of time, possible not since ), htn, hld, dm - on insulin, heavy smoking history who presents with a sudden onset of right sided weakness, determined to have a lmca syndrome at an osh, given tpa and sent to for further evaluation. the story is not clear (he was unable to provide details and the family was not present for the event). he was apparently in his usual state of health and went out for a drive. per report (not clear how this was obtained) he felt ill and pulled over to the side of the road. he was found by the fire service at ~11:30-40 to have right sided weakness and unable to speak and was taken to -. he was in the window and was given tpa after consultation with tele-service. he got 81mg of tpa at ~1:50pm and transferred here. there nih scale was reported to be 21. here on examination he continued to have severe deficits, given a stroke scale of 23. he had a cta which showed a persistent l mca clot and he was taken to the angio suite for intervention. past medical history: - afib w rvr, only on asa not on coumadin (unclear if ever was) - chf - htn - dm on insulin - peri-rectal abscess treated a few months ago social history: lives by himself in . he is not employed. he has a long 40 year x 3ppd smoking history, etoh use and uses pain pills that are not his according to his daughter. (ex wife) c: h:. () . () c: family history: mother with ca, father who fell and had cerebral hemorrhage secondary to etoh in his 40s. physical exam: admission physical exam: physical exam: vitals: t: 98 p:95 r: 16 bp:119/76 sao2: 95 general: awake, moaning, no following commands, obese heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: lungs clear anteriorly cardiac: abdomen: soft, nt/nd, obese extremities: mild erythema on both calves, likely venous stasis . neurologic: -mental status: alert, aphasic, occasionally would curse, not following commands although did squeeze hands and open eyes on command one time. . -cranial nerves: i: olfaction not tested. ii: left eye fixed, appears surgical, right eye 2mm reactive, r field cut iii, iv, vi:left visual pref, cannot get him to cross midline to right vii: right facial droop, lower half of face ix, x: palate elevates symmetrically. xii: tongue protrudes in midline. . -motor: normal bulk, tone throughout. right arm - minimal effort against gravity, slight withdrawal to pain (flexor), no movement in hand, leg slight withdrawal to pain no effort against gravity. left arm/leg moving spontaneously appear full . -sensory: decreased on right side to painful stim, o/w appears grossly intact . -dtrs: tri pat ach l 1 1 1 0 0 r 1 1 1 0 0 plantar response was mute bilaterally. . -coordination and gait: not tested . . physical examination upon pronounciation of death: gen: elderly male lying in bed. unresponsive. heent: pupils unreactive bilaterally. lungs: no breath sounds. heart: no heartbeat. extremities: cool extremities. skin: pale. pertinent results: admission labs: 01:30pm wbc-11.5* rbc-4.71 hgb-12.4* hct-36.7* mcv-78* mch-26.4* mchc-33.8 rdw-15.4 01:37pm glucose-348* na+-134 k+-3.2* cl--95* tco2-26 05:07pm calcium-7.5* phosphate-3.9 magnesium-1.6 05:07pm ck-mb-2 ctropnt-<0.01 . admission imaging: ecg : atrial fibrillation with a rapid ventricular response. non-specific st-t wave changes. no previous tracing available for comparison. . ct brain perfusion : impression: 1. left m1 cutoff with increased mtt thoughout the left m1 territory. the perfusion studies are limited and evaluation for mismatch and territory at risk is not possible. this was discussed with dr. of the stroke service and dr. of interventional neuroradiology, and the patient was brought for an interventional procedure. 2. ground glass opacities throughout the visualized lung apices are non-specific and if clinically indicated might be better evaluated with chest ct. 3. mediastinal lymphadenopathy. . 59 distinct procedural service : findings: . right internal carotid artery injection, preprocedure: there is complete proximal m1 occlusion with distal collateral flow provided by aca branches and scant leptomeningeal collaterals. . left internal carotid artery injection, post-procedure: the left internal carotid artery and its distal branches are patent with the exception of a proximal m2 branch, which demonstrates sluggish flow indicating more distal occlusion. lenticulostriate luxury perfusion is noted. the anterior cerebral artery is widely patent and provides collateral flow to the left cerebral hemisphere. . impression: successful left mca m1 division thrombectomy using a combination of 10 mg of iv tpa and a merci retrieval device. there is residual sluggish flow and distal occlusion within a proximal m2 branch. . portable cxr : findings: the tip of the endotracheal tube projects 3.8 cm above the carina. the tip of the nasogastric tube is projecting over the stomach. mild bilateral areas of atelectasis. no overt pulmonary edema. low lung volumes. the presence of minimal pleural effusions cannot be excluded. the size of the cardiac silhouette is at the upper range of normal. portable cxr : findings: the position of the various lines and tubes is unchanged. cardiac size is within normal limits. the lung fields are clear. there is no evidence of failure. . labs on day of expiration: 02:17am blood wbc-11.7* rbc-3.93* hgb-10.0* hct-32.3* mcv-82 mch-25.4* mchc-30.9* rdw-15.7* plt ct-415 02:17am blood pt-16.3* ptt-29.4 inr(pt)-1.4* 02:17am blood glucose-172* urean-26* creat-1.0 na-152* k-3.6 cl-124* hco3-21* angap-11 02:17am blood calcium-7.9* phos-1.3* mg-2.0 02:17am blood osmolal-321* 03:32am blood type-art po2-170* pco2-34* ph-7.42 caltco2-23 base xs--1 . brief hospital course: *)neuro: patient was admitted s/p large left mca stroke with resultant aphasia and right sided weakness. he received tpa at an osh and was transferred to the for interventional angiography which was able to partially recanalize his posterior vessels. he was intubated for protection of his airway and cared for in the nicu. the rest of his care proceeded according to the stroke protocol including continued anticoagulation with asa and heparin and appropriate imaging. over the course of his hospitalization, the patient exhibited anisocoria (left 3nn, right 2mm, only reactive on left), eyes that were closed at baseline and he did not open them spontaneously, with symmetric grimace to pain in upper extremities. he exhibited no spontaneous movements. at the decision of his family, he was terminally extubated the afternoon of and died peacefully within 40 minutes of his extubation with his family at the bedside. they denied autopsy. . *)pulm: following admission for acute left mca stroke, patient was intubated for protection of his airway. he was never able to be successfully extubated during the course of his hospitalization. at the decision of his family, he was terminally extubated the afternoon of . . *)cardio: during this hospitalization, the patient exhibited atrial fibrilation which was controlled with amiodarone 200 mg and hypertension which was controlled with labetolol 10 mg iv. the patient also was placed on statin therapy for control of his ldl levels. . *)infectious disease: patient had pneumonia and e. coli positive uti which were controlled with broad spectrum antibiotics including vancomycin 100mg, tobramycin 740 mg, and cefepime 2 g iv. . *)endocrine: patient was placed on an insulin sliding scale during this hospitilzation due to history of dm2 and per stroke protocol. time of death: 3:30pm on . medications on admission: - asa 81 - omeprazole 20mg qd - toprol 100mg - zocor 40mg qd - lisinopril 40mg - insulin discharge medications: n/a, pt expired on . discharge disposition: expired discharge diagnosis: primary: l mca stroke secondary: atrial fibrillation discharge condition: n/a pt expired. discharge instructions: n/a pt expired peacefull with family at bedside at 3:30pm on . dr. was called to perform the death prounouncement. please see physical exam section for further details. followup instructions: n/a pt expired Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Injection or infusion of thrombolytic agent Closed [endoscopic] biopsy of bronchus Other diagnostic procedures on lung or bronchus Procedure on two vessels Endovascular removal of obstruction from head and neck vessel(s) Diagnoses: Tobacco use disorder Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Subarachnoid hemorrhage Compression of brain Other and unspecified hyperlipidemia Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Long-term (current) use of insulin Cerebral edema Diarrhea Cerebral embolism with cerebral infarction Do not resuscitate status Encephalopathy, unspecified Ventilator associated pneumonia Aphasia Other and unspecified alcohol dependence, continuous Chronic respiratory failure Alcohol withdrawal Hemiplegia, unspecified, affecting dominant side Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache, r visual field cut, r arm and leg numbness, non-fluent aphasia. major surgical or invasive procedure: iv tpa history of present illness: 31 yo rh female with history of depression and headaches, on ocps, p/w acute onset non-fluent aphasia, right facial droop, right visual field cut, and right-sided numbness. when patient was leaving work last evening at 6 pm she noticed a right visual field cut and subsequently felt numbness progressing from her right hand to her arm and then her leg. she was then unable to talk, having difficulty thinking of words as well as producing words. her comprehension was also somewhat limited, but could recognize some of the words being spoken to her, and she also reported a left-sided headache. the patient originally presented to the ed and was transferred to for further evaluation. a code stroke was called at 20:17 and was found to have nihss of 5 for facial droop, non-fluent aphasia, right visual field deficit, and numbness of right side. of note, the patient does have a history of headache. she did recall a visual field cut associated with a headache during pregnancy but otherwise has never had any other corresponding sensory phenomenon. she has had mild increase in headache frequency over past month, with symptoms occurring weekly and she takes excedrin or ibuprofen for relief. this morning at the time of examination, the patient reports that her language production and comprehension have returned to baseline over the course of the night. she still reports mild left-sided headache, and did not note any visual changes or sensory phenomenon this morning. past medical history: depression headaches- episode of visual phenomenon associated with headache during pregnancy, but no prior diagnosis of migraine. social history: rare etoh, no tobacco, occasional marijuana family history: no known history of strokes, miscarriages, migraines, autoimmune disorders, seizures, or blood clots physical exam: vs; t 98.7 bp 94/49 p 77 rr 19 97% ra gen; young female, nad cv; rrr, +s1,s2, no murmurs pulm; cta b/l abd; soft, nt, nd extr; no edema neuro; mental status; a&ox3, cooperative, attentive. language fluent, naming, repetition, and comprehension intact. able to read and write. no extinguishing to dss. no apraxia or neglect. cn; perrl 4mm->3mm, eomi, no nystagmus. visual fields full, v1-v3 sensation intact, face symmetric, palate symmetric, hearing intact bilateral, scm and trap equal, tongue midline. motor; normal bulk and tone, no drift. 5/5 strength in r and l delts, bicep, tricep, wre, wrf, ip, ham, quad, df, pf sensory; intact to light touch throughout. mild decreased sensation to pinprick in rue, rle (80% compared to left side). proprioception intact. reflexes; 2+ bicep, tricep, 3+ patellars, symmetric, downgoing toes coordination; fnf intact. pertinent results: wbc 9.1, hct 34.0, platelets 229 na 138, k 3.9, cl 107, co2 23, bun 8, cr 0.6, gluc 122 pt 12.0, inr 1.0, ptt 25.1 ck 49 trop < 0.01 tsh 1.7 ldl 76 u tox pending, serum tox neg ua neg ct head; no acute intracranial process cta head/neck; no vascular occlusion, thrombosis, or aneurysm mri head (awaiting official read); no evidence of acute stroke tte; the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. agitated saline contrast study revealed evidence of intracardiac shunt with cough (but not at rest) suggestive of a patent foramen ovale. brief hospital course: ms. is a 31-year-old right-handed female with history of depression and headaches (likely history of migraine), also on contraceptives, presented with r visual phenomenon and subsequent field cut, r-sided numbness, r facial droop, and non-fluent aphasia. she was noted to have an nihss of 4 and arrived within three hours of onset of symptoms and was given iv tpa on arrival. however, imaging has been negative for acute stroke and patient is now back at baseline, stating her symptoms gradually improved over the night. hospital course by problem; 1) neuro; patient was administered iv tpa upon arrival as described above. she was admitted to the icu and sbp has been well within the parameters set forth in tpa protocol during her hospital course. clinically, the patient improved over the course of the night and currently feels back at her baseline. ct head, cta head/neck, and mri brain did not show any abnormalities. it was thought the event was possibly a migraine, or less likely, a tia. the patient was initially started on zocor 40 mg but was found to have an ldl of 76 and this was subsequently discontinued. a transthoracic echocardiogram revealed a patent foramen ovale. lupus anticoagulant, anticardiolipin antibody, protein c, protein s, antithrombin iii, beta 2 glycoprotein, prothrombin gene, and factor v leiden were sent and can be followed up as an outpatient. as patient did receive tpa at approximately 8 pm on and therefore she has not received any antiplatelet or anticoagulation medication since admission. it is not thought that her pfo is not of clinical relevance and hence antiplatelet were discontinued. hypercoagulability profile was pending at time of discharge. she was started on amitriptyline 25mg each night for migraine prophylaxis. it was recommended the patient discontinue taking buproprion to avoid being on two antidepressants simultaneously, but it was her preference to continue. she should discuss stopping this medication with her psychiatrist. for acute headache pain she should take ibuprofen 800mg at onset of headaches along with compazine 5mg po. she was warned regarding the sedating side effects of compazine. she should avoid taking acute headache medications more than 3-4 times per week to avoid rebound headaches. the patient should follow up with dr. in the stroke neurology division at in weeks. 2) cv- patient was monitored on telemetry with no major events and tte results are described above. her blood pressure was well-controlled during the hospital course and ldl was 76. 3) benefits of continued smoking cessation were reinforced. medications on admission: wellbutrin 150 qd trazadone qhs (started two weeks prior to admission) nuvaring (contraceptive) ibuprofen prn headache excedrin prn headache discharge medications: 1. amitriptyline 25 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 2. ibuprofen 200 mg tablet sig: four (4) tablet po once a day as needed for headache: take at earliest sign of migraine headache onset. 3. compazine 5 mg tablet sig: one (1) tablet po every four (4) hours as needed for headache: take at earliest sign of migraine headache onset. avoid driving after taking this medication. disp:*10 tablet(s)* refills:*1* 4. nuvaring 0.12-0.015 mg/24 hr ring sig: one (1) ring vaginal every month: may continue as taking prior to admission. discharge disposition: home discharge diagnosis: complicated migraine headache. discharge condition: a&o x3, language fluent, comprehension, naming, repetition intact, able to read and write, no apraxia or neglect. perrl 4->3mm, eomi, vff, face symmetric, tongue midline. normal bulk and tone, no drift, 5/5 strength throughout, sensation intact to light touch. 2+ reflexes at bicep, tricep, 3+ at patellar, symmetric, downgoing toes, fnf and intact bilaterally. discharge instructions: you were admitted for evaluation of a facial droop and speech difficulties. you were treated for a possible stroke. images of your did not identify any deficits and your symptoms have resolved. it is possible that your symptoms were due to a complicated migraine. because of your headache history, we recommend that you start taking amitriptyline. we also recommend that you consider alternate birth control methods as oral contraceptives can cause blood clots and stroke, particularly in woman with history of migraine. you may also want to consider discontinuing your use of trazadone which can cause spasm of blood vessels in some patients. please follow up with dr. as indicated below and continue to take your medications as prescribed. please return to the emergency department immediately for any new weakness, sensory changes, language production or comprehension changes. followup instructions: please follow up with dr. (neurology). ( md Procedure: Injection or infusion of thrombolytic agent Diagnoses: Depressive disorder, not elsewhere classified Disturbance of skin sensation Ostium secundum type atrial septal defect Aphasia Visual field defect, unspecified Other forms of migraine, without mention of intractable migraine without mention of status migrainosus Lack of coordination Facial weakness |
allergies: no known allergies / adverse drug reactions attending: chief complaint: abdominal pain major surgical or invasive procedure: none history of present illness: dr is a 57 yo man with stage ivb hodgkin lymphoma s/p 6 cycles of chemotherapy with avd (bleomycin held due to depressed dlco at baseline) starting in of this year. on started the second cycle with the addition of bleomycin. he has tolerated the chemotherapy overall well, without significant side effects. patient presenting with r sided chest wall pain wrapping around torso and right upper quadrant pain, that began earlier this week and is not improving. he has tried som heat pads, flexeril, percocet, and dexamethasone for pain without relief. he denies any n/v/d, constipation, worsening pain with food, fever, sweats, chills. he also complains of being tired. in the er the patient received morphine for pain. he also had an episode of shaking chills and a temp of 100.8 which came down to 99 within the hour. ros: otherwise negative past medical history: past oncologic history: hodgkin's lymphoma diagnosed after presenting with fatigue, night sweats and increased lymphadenopathy. started on avd (modified abvd) on . past medical history: -left neck adenopathy s/p biopsy negative for malignancy in -sarcoidosis - diagnosed in based on hilar lymphadenopathy and erythema nodosum. treated with steroids with resolution of symptoms. in in the setting of lymphadenopathy he had an ace level of 114. -pulmonary embolism -glucose intolerance social history: works as a primary care doctor locally. he works primarily at the va in and nearby rehab facilities. his wife is a librarian at the law school, and he has a 14yo son. has not travelled outside the us. he denies any past or present tobacco, alcohol, or iv drug use. no known tick exposures. family history: no family history of colon, lung, pancreatic, blood cancer. physical exam: physical exam: vs 98.2, 150/87, 102, 18, 98% ra weight 227 gen: aaox3, nad heent: perrla, eomi, mmm, no thrush, no op erythema or lesions neck: supple, no lad, no jvd cvs: rrr, no m/r/g lungs: reg resp rate, breathing unlabored, no accessory muscle use, lungs clear to auscultation bilaterally abd: soft, nabs , mild left upper quadrant tenderness without rebound or guarding chest: mild r sided lower rib pain chest and back ext: 2+ pulses, no c/c/e skin: no rashes neuro: cn 2-12 intact, strength 5/5 in ue and le bilat. ltsi in ue and le. finger to nose intact, rapid alt. movements intact, heel to shin intact, gait normal, no pronator drift, no asterixis. discharge physical exam: vs 98.5, 108/70, 85, 18, 98% ra gen: aaox3, nad heent: perrla, eomi, mmm, no thrush, no op erythema or lesions neck: supple, no lad, no jvd cvs: rrr, ns1s2, no m/r/g lungs: reg resp rate, breathing unlabored, no accessory muscle use, lungs clear to auscultation bilaterally abd: soft, non-tender,normoactive bowel sounds, no masses, no hsm ext: 2+ pulses, no c/c/e skin: crusted r t9 dermatomal herpetic rash, resolving neuro: cn 2-12 intact, strength 5/5 in ue and le bilat pertinent results: admission labs: 10:10am wbc-4.3 rbc-3.15* hgb-10.3* hct-30.5* mcv-97 mch-32.7* mchc-33.7 rdw-18.5* 10:10am neuts-87.1* lymphs-6.4* monos-3.8 eos-1.8 basos-0.9 10:10am plt count-162 10:10am pt-10.7 ptt-29.9 inr(pt)-1.0 10:10am glucose-242* urea n-11 creat-0.8 sodium-138 potassium-3.9 chloride-101 total co2-24 anion gap-17 10:10am alt(sgpt)-45* ast(sgot)-24 alk phos-163* tot bili-0.3 09:44am lactate-2.5* 01:00pm urine blood-neg nitrite-neg protein-tr glucose-300 ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 01:00pm urine color-yellow appear-clear sp -1.014 01:00pm urine rbc-0 wbc-1 bacteria-none yeast-none epi-0 10:10am lipase-30 discharge labs: 07:50am blood wbc-4.0 rbc-2.98* hgb-9.4* hct-28.4* mcv-95 mch-31.4 mchc-33.0 rdw-17.7* plt ct-307 07:50am blood neuts-78.8* lymphs-17.0* monos-3.5 eos-0.5 baso-0.3 07:50am blood pt-11.4 ptt-43.8* inr(pt)-1.1 12:40pm blood lmwh-pnd 07:50am blood glucose-147* urean-14 creat-0.8 na-140 k-4.6 cl-106 hco3-24 angap-15 07:50am blood alt-44* ast-25 ld(ldh)-219 alkphos-246* totbili-0.3 07:30am blood ggt-409* 07:50am blood calcium-9.2 phos-3.9 mg-2.0 04:20am blood tsh-7.6* 03:59am blood t4-8.9 ruq u/s:study date of impression: 1. gallbladder sludge without evidence of cholecystitis. 2. splenomegaly. 3. hyperechoic area in the left lobe of the liver is also seen on the ct from the same day. differential includes old lymphomatous infiltration, area of greater fatty infiltration, or possibly an unusual appearance of a benign lesion such as an atypical hemangioma could be considered. there has been no definite recent change although the lesion is easier to visualize on this study. if further characterization is desired, then mr imaging may be useful. cxr chest: study date of impression: patchy new left mid and lower lung opacities, typical in morphology for atelectasis, although an infectious etiology is difficult to completely exclude based on the imaging. ct chest and abdomen study date of impression: 1. chronic pulmonary embolism with no evidence of new acute pulmonary embolism. 2. geographical distribution of a hypodense area in the left lobe of the kidney, also seen on the ultrasound of the same day. while the relative degree of hypoenhancement is more striking on today's exam, the etiology is uncertain. this was not avid on recent pet scan. differential includes old lymphomatous infiltration with marked atrophy involving the left lobe or atrophy of other etiology; there may be relative fatty infiltration at the site and an unusual benign lesion such as a hemangioma could also be involved. 3. overall, extensive mediastinal, retroperitoneal, celiac and pelvic lymphadenopathy appears to be stable to slightly decreased in size since the pet-ct from . 4. splenomegaly. 5. no acute intra-abdominal or intrathoracic process to explain the patient's pain. radiology chest (pa & lat) findings: since the prior radiograph there are now small bilateral pleural effusions. left retrocardiac opacity likely represents lower lobe pneumonia. there is no pneumothorax. the cardiomediastinal silhouette is similar in appearance to the prior radiograph. bony structures are intact. impression: 1. interval development of bilateral pleural effusions. 2. retrocardiac opacity likely represents left lower lobe pneumonia. radiology chest (pa & lat) findings: pa and lateral chest radiographs are obtained. heart is normal size and cardiomediastinal contours are unchanged. lungs do not demonstrate significant changes compared to the prior radiograph. opacification of the left base represents atelectasis or consolidation. persistent small right pleural effusion with increased small left pleural effusion. no pneumothorax. impression: 1. persistent small pleural effusions bilaterally. 2. left lower lobe atelectasis or consolidation. micro: 4:19 pm direct antigen test for herpes simplex virus types 1 & 2 negative for herpes simplex by immunofluorescence. 4:19 pm direct antigen test for varicella-zoster virus direct antigen test for varicella-zoster virus (final ): positive for varicella zoster. brief hospital course: # paroxysmal atrial fibrillation: patient has history of atrial fibrillation in setting of hodgkin's lymphom diagnosis. he experienced intermittent atrial fibrillation starting with rates up to 150's. he had numerous conversions into and out of afib: he was first converted to sinus rhythm with 5mg iv metoprolol, however went back into atrial fibrillation with rates in the 130's to 150's. he was converted a second time with iv diltiazem drip, but returned to atrial fibrillation after trying to transition to po diltiazem. he was rate controlled on metoprolol 25mg q6h, and self-converted to sinus rhythm overnight . with recommendations from cardiology, he was also started on sotalol 80mg for addtional rate control. his blood pressures were supported with iv fluid boluses, and he never require pressors. he had been on lovenox for pe in , and was increased from 75mg to 100mg to account for his weight. # abdominal pain: luq abdominal pain and rib pain. laboratory values notable for mildly elevated alk phos, alt and lactic acid (2.5). per records, his alk phos had been elevated in the past few months, likely secondary to his chemotherapy. ruq ultrasound showed biliary sludge without any evidenc of cholecystitis. no acute processes seen on cxr. ct abdomen and chest notable for hypodense area in liver, chronic pe and stable lad. ecg nsr without any evidence of ischemia. patient spiked fever to 102.7 and was started on unasyn and cultured. antibiotics were subsequently discontinued due to low suspicion for infection. etiology unclear, but no evidence of acute processes; may have been due to mild ileus from chemotherapy. # zoster: patient had right sided chest pain wrapping around torso during week prior to admission. he developed a herpetic rash in t9 dermatome during admission consistent with zoster. he was seen by dermatology who did a biopsy (positive for varicella zoster) and was started on iv acyclovir 1000mg q8hrs and put on precautions. the rash did not disseminate and crusted over prior to discharge. he was subsequently transitioned to po acyclovir 800 mg po 5x/day and will complete total 10 days. # hodgkin's lymphoma: patient has stage iv hodgkin's lymphoma. he is being treated by dr. with a modified abvd. he finished his last infusion of chemotherapy on . he will continue prophylaxis with bactrim ss daily and complete course of acycovir for zoster. he will complete 7 days of neupogen treatment starting 24 hours after infusion and follow up with dr. in . transitional issues: -lovenox dosing and duration of treatment, to be discussed as outpatient with dr. up with dr. ggt, unknown etiology medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. allopurinol 100 mg po daily 2. enoxaparin sodium 70 mg sc q12h 3. sulfameth/trimethoprim ss 1 tab po daily 4. ondansetron 8 mg po q8h:prn nausea 5. prochlorperazine 10 mg po q6h:prn nausea 6. omeprazole 40 mg po daily discharge medications: 1. allopurinol 100 mg po daily rx *allopurinol 100 mg 1 tablet(s) by mouth once a day disp #*30 tablet refills:*2 2. enoxaparin sodium 100 mg sc q12h rx *enoxaparin 100 mg/ml inject 1 syringe subcutaneous every 12 hours disp #*60 syringe refills:*2 3. ondansetron 8 mg po q8h:prn nausea 4. prochlorperazine 10 mg po q6h:prn nausea 5. sulfameth/trimethoprim ss 1 tab po daily rx *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day disp #*42 tablet refills:*0 6. acyclovir 800 mg po 5x/day rx *acyclovir 800 mg 1 tablet(s) by mouth five times a day disp #*25 tablet refills:*0 7. docusate sodium 100 mg po bid 8. gabapentin 200 mg po q8h please hold for sedation rx *gabapentin 100 mg 2 capsule(s) by mouth every eight (8) hours disp #*90 capsule refills:*0 rx *gabapentin 100 mg 2 capsule(s) by mouth every eight (8) hours disp #*180 tablet refills:*2 9. sotalol 80 mg po bid please hold for hr < 60 rx *sotalol 80 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*2 10. omeprazole 40 mg po daily:prn reflux 11. dexamethasone 4 mg po bid duration: 2 days rx *dexamethasone 4 mg 1 tablet(s) by mouth twice a day disp #*4 tablet refills:*0 12. filgrastim 480 mcg sc q24h duration: 7 days take for 7 days after chemotherapy discharge disposition: home discharge diagnosis: primary: atrial fibrillation, abdominal pain, herpes zoster secondary: hodgkin's lymphoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dr. , it was a pleasure taking care of you at . you were admitted for abdominal pain of unclear etiology. you also developed atrial fibrillation during your admission which has converted back into sinus rhythm. on discharge you will need to follow up with dr. ep cardiology. please call his office to make a follow up appointment in the next two weeks. you will also follow up with dr. as detailed below. new/changed medications: -sotalol 80 mg po bid -dexamethasone 4 mg po bid for 2 days -enoxaparin 100 mg/ml subcutaneous injection every 12 hours -acyclovir 800 mg tab 5 times per day for 5 days (last day wed ) -gabapentin 100 mg, 2 tabs every 8 hours -neupogen 480 mcg/1.6ml one time daily for 7 days after chemo followup instructions: dr. cardiology view map , phone: department: hematology/oncology when: monday at 10:30 am with: , md, phd building: sc clinical ctr campus: east best parking: garage department: hematology/bmt when: monday at 10:30 am with: , md building: sc clinical ctr campus: east best parking: garage department: nuclear medicine when: tuesday at 12:30 pm with: nuclear medicine building: sc clinical ctr campus: east best parking: garage Procedure: Injection or infusion of other therapeutic or prophylactic substance Other conversion of cardiac rhythm Injection or infusion of cancer chemotherapeutic substance Diagnoses: Other iatrogenic hypotension Atrial fibrillation Sarcoidosis Long-term (current) use of anticoagulants Lung involvement in other diseases classified elsewhere Other fluid overload Chronic pulmonary embolism Hodgkin's disease, unspecified type, intrathoracic lymph nodes Varicella without mention of complication |
allergies: nsaids / percocet / morphine sulfate / ativan / adhesive tape attending: chief complaint: tongue and mouth swelling major surgical or invasive procedure: none history of present illness: 40 year old male with history of recurrent bone lymphoma (dlbcl on path) s/p 6 cycles of r-, chronic hbv on lamivudine, crohn's disease who underwent excision of left submandibular duct stones yesterday by ent, now with significant submandibular swelling l>r and difficulty speaking starting last night. he has been handling his secretions without difficulty and complains of some mild tongue swelling as well. some difficulty with swallowing as well, but no fevers, chills, or nausea/vomiting. he called his ent surgeon (dr. and was instructed to report to the ed for further management. he was admitted to the onco-hospitalist service earlier this month with presumed sbo, started on cefepime and flagyl, discharged on moxifloxacin through his wbc nadir. in the ed, initial vs were: 99 100 120/76 18 97% ra. patient was given one dose of zosyn 4.5 gm iv and solumedrol 125mg iv. ent was consulted and did not appreciate any swelling in the vocal cords, recommended administration of unasyn and dexamethasone, and to admit to the icu overnight for airway monitoring. the ed physicians were concerned about ludwig's angina, based on the appearance of the tongue and mucosa in the submandibular area. vitals on transfer: 114/72, 72, 14, 95% ra in the icu, he is feeling a bit better, swallowing easier, and breathing without extra effort. past medical history: oncologic history: initial diagnosis of primary bone lymphoma back in . pathology was consistent with diffuse large b-cell lymphoma with some small lymphoid aggregates, initially treated with two cycles of r-chop with severe gi toxicity but changed a complete response, had relapsed disease approximately five years treated with a cycle of rcvp with severe gi toxicity with the small bowel obstruction requiring resection, did obtain another remission for two years. he relapsed in , did have radiation to some bony sites, does have multiple fdg avid lesions on his most recent pet scan from . initial right femur biopsy was negative. removal of the right rib did not demonstrate any lymphoma. he did have a ct-guided bone biopsy of his right femur which demonstrated recurrent disease with diffuse large b-cell lymphoma. other medical history: # crohn's disease - s/p 6mp and small bowel resections x3, no clear flares in 10 years though chemotherapy associated bouts of enteritis only on mesalamine. # chronic hepatitis b - likely due to transfusion, dx , currently on lamivudine. # chronic lbp/sciatica # nsvt recent treatment history: cycle 1 of -, first dose of rituxan was on cycle 2 r- cycle 3 r- rituximab , complicated by tachycardia cycle 4 r- cycle 5 r- cycle 6 r- social history: he denies alcohol, tobacco, or illicit drugs. he is quite physically active at baseline with biking. works in it. married, he lives with his wife and a dog. family history: aunt with ovarian ca. sister has asthma. otherwise family history unremarkable and markedly negative for inflammatory bowel disease. physical exam: on admission: vitals: t 97.1, hr: 66, bp: 115/74(83), rr: 13, spo2: 95% general: alert, oriented, no acute distress, soft voice heent: perrl, sclera anicteric, mmm, oropharynx clear; increased erythema and swelling underneath tongue, especially over left side with no obvious exudate neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1/s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema on discharge: heent: improved swelling beneath tongue with improved speech and pain, easier swallowing otherwise, unchanged pertinent results: labs: 10:58am blood wbc-13.5* rbc-4.16* hgb-12.4* hct-36.2* mcv-87 mch-29.9 mchc-34.4 rdw-18.1* plt ct-357 11:50am blood wbc-11.6* rbc-3.71* hgb-11.2* hct-32.7* mcv-88 mch-30.2 mchc-34.2 rdw-19.2* plt ct-311 11:50am blood neuts-80* bands-2 lymphs-8* monos-7 eos-0 baso-0 atyps-0 metas-2* myelos-1* 11:50am blood glucose-89 urean-8 creat-0.9 na-141 k-3.9 cl-101 hco3-29 angap-15 11:50am blood calcium-8.5 phos-4.9* mg-1.8 10:58am blood alt-20 ast-28 ld(ldh)-274* alkphos-72 totbili-0.4 11:59am blood lactate-1.2 micro: blood cultures x2 - pending imaging: none brief hospital course: 40 year old male with history of nhl/dlbcl s/p and on neupogen, presenting on pod #1 for submandibular duct stone removal with tongue swelling and difficulty speaking, admitted to the icu for airway monitoring. # tongue/submandibular swelling: he was pod #1 from his ent procedure, with resulting submandibular swelling. per ent, they were concerned about his airway and recommended monitoring in the icu to ensure airway management if necessary. he has been handling his own secretions and ent evaluation confirmed that there was no vocal cord edema. there was some concern for ludwig's angina, with his concomitant neck pain and location of his inflammation (submandibular), but his presentation was most consistent with post-operative swelling. we continued antibiotic coverage with unasyn 3g iv q6hrs and dexamethasone 10mg iv q8hrs x2 to control the swelling. a nasal trumpet was kept by the bedside in the event of respiratory distress. he will be discharged on 10 days of augmentin. his exam improved and the patient felt noticeably better on the day of discharge. # pain control: we tried to control his pain with fentanyl boluses, as he felt this was most helpful for him. we would advise to continue at home with his as-needed regimen of oxycodone, and to contact ent for further pain options if this is not adequately controlling his pain. medications on admission: -budesonide 3 mg capsule, three (3) capsule daily -sulfamethoxazole-trimethoprim 800-160 mg mwf -lamivudine 100 mg daily -mesalamine dr 800 mg tablet, 6 tablets daily -cholestyramine-sucrose 4 gram -simethicone 40-80 mg qid prn -ondansetron hcl 4-8 mg q8h prn -prochlorperazine maleate 10 mg q6h prn discharge medications: 1. budesonide 3 mg capsule, ext release 24 hr sig: three (3) capsule, ext release 24 hr po daily (daily). 2. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po mwf (monday-wednesday-friday). 3. lamivudine 100 mg tablet sig: one (1) tablet po daily (daily). 4. mesalamine 400 mg tablet, delayed release (e.c.) sig: four (4) tablet, delayed release (e.c.) po tid (3 times a day). 5. cholestyramine-sucrose 4 gram packet sig: one (1) packet po bid (2 times a day). 6. simethicone 80 mg tablet, chewable sig: 0.5-1 tablet, chewable po qid (4 times a day) as needed for pain. 7. ondansetron hcl 4 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea. 8. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. 9. augmentin 875-125 mg tablet sig: one (1) tablet po twice a day for 10 days. disp:*20 tablet(s)* refills:*0* 10. oxycodone 5 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. discharge disposition: home discharge diagnosis: post-operative submandibular duct swelling discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure caring for you at the . you were admitted to the icu for tongue and mouth swelling shortly after your ent procedure. we monitored you closely to make sure that your breathing was not compromised and felt that you were safe to return home since your symptoms have improved and you have not had any respiratory distress. followup instructions: please follow-up with your ent physician as previously scheduled. you have the following appointments scheduled at already: department: bmt/oncology unit when: friday at 1:30 pm building: fd building (/ complex) campus: east best parking: main garage department: radiology when: friday at 3:40 pm with: xmr building: cc campus: west best parking: garage department: radiology when: friday at 4:20 pm with: xmr building: cc campus: west best parking: garage md Procedure: Incision of salivary gland or duct Incision of salivary gland or duct Diagnoses: Anemia of other chronic disease Other malignant lymphomas, unspecified site, extranodal and solid organ sites Long-term (current) use of other medications Swelling, mass, or lump in head and neck Ulcerative colitis, unspecified Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Personal history of other diseases of digestive system Sialolithiasis |
allergies: no known allergies / adverse drug reactions attending: chief complaint: hematemesis major surgical or invasive procedure: none history of present illness: 64 y/o m with a history of alcoholic cirrhosis with grade i varices on egd . pt presented to his pcp this am endorsing a 2 day history of chest pain. at pcp office he had emesis which was gastroccult positive and he was sent to the ed. in the ed he was noted to be tachycardic to 130s and htn to 170s, with limited response to 3l ivf. hct increased to 52.1 from 46 also with elevated bun/cr ratio. also with anion gap of 24 with serum osms sent. ua negative for glucose, 40 ketones, no evidence infection. serum etoh 246, folic acid, vitamins, thiamine given. ng lavage performed, with tea colored fluid fluid noted, cleared after 400cc with ngt dc'd. zofran, ceftriaxone and ppi given. brown stools guiac positive. pt with vague diffuse abdominal pain, kub and cxr wnl. morphine given. ekg showed sinus tachycardia with troponins sent, no asa given gi bleed. ppi and ceftriaxone given.given persistent tachycardia, history of varices and evidence of gi bleeding patient transferred to the icu. 2 18 guage ivs for access. notes that he stumbled onto door 2 days ago when getting out of bed onto left side. did not fall to ground, no head trauma. states frequent falls shooting feet pain. denies nsaid use. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes on arrival to the micu pt oriented to person, place, disoriented to time. no chest pain, no nausea, feeling dehydrated, abdominal pain resolved. past medical history: cirrhosis with hx varices- egd screening showed grade 1 varices and antral gastritis hep c negative thyroid disease arthritis depression anxiety lung nodule seen stable at 3month serial ct, plan for reimage social history: fluoxetine 20 mg daily flonase nasal spray 2 sprays each nostril qday gabapentin 200mg q8 proair 2 puffs q 4-6 prn family history: non contributory physical exam: vitals: t: 98.5 bp:154/87 p: 112 r: 18 o2: 93% 3l general: alert to person and place, disoriented to time, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl, dry mucouse membranes,poor dentition no jaundice neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger to toe deferred, no asterixis skin: dry eschar right leg, diffuse xerosis pertinent results: 03:00pm glucose-168* urea n-18 creat-0.6 sodium-142 potassium-4.1 chloride-103 total co2-21* anion gap-22* 12:30pm urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg 12:30pm urine blood-tr nitrite-neg protein-30 glucose-neg ketone-40 bilirubin-neg urobilngn-neg ph-5.5 leuk-neg 10:00am glucose-220* urea n-26* creat-1.0 sodium-141 potassium-4.2 chloride-97 total co2-20* anion gap-28* 10:00am alt(sgpt)-198* ast(sgot)-167* alk phos-80 tot bili-1.8* 10:00am lipase-35 10:00am ctropnt-<0.01 10:00am albumin-4.4 10:00am osmolal-366* 10:00am asa-neg ethanol-246* acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 10:00am wbc-5.4 rbc-5.31 hgb-17.4 hct-52.2* mcv-98 mch-32.7* mchc-33.2 rdw-15.0 10:00am wbc-5.4 rbc-5.31 hgb-17.4 hct-52.2* mcv-98 mch-32.7* mchc-33.2 rdw-15.0 06:55am blood wbc-3.4* rbc-4.22* hgb-14.0 hct-42.2 mcv-100* mch-33.2* mchc-33.3 rdw-14.6 plt ct-63* 06:55am blood pt-11.5 ptt-30.3 inr(pt)-1.1 06:55am blood glucose-231* urean-9 creat-0.6 na-138 k-3.6 cl-101 hco3-31 angap-10 06:55am blood alt-106* ast-76* alkphos-115 totbili-1.9* 10:00am blood lipase-35 03:55am blood ck-mb-15* mb indx-2.1 ctropnt-<0.01 06:55am blood calcium-9.3 phos-2.5* mg-1.7 brief hospital course: summary: 64 y/o m with history of alcoholic cirrhosis presenting with gastroccult positive emesis, hematochezia, concerning for gi bleeding. . # gi bleeding/abdominal pain: he has a history of alcoholic cirrhosis, with grade 1 varices on egd . initial concern was for bleeding varices with emergent endoscopy performed at bedside by hepatology. no varices were noted, with gastropathy observed likely an alcoholic gastropathy, accounting for his abdominal pain. he was started on a proton pump inhibitor, and transitioned from ceftriaxone given in the ed to ciprofloxacin for 5 day course for sbp prophylaxis. he was advanced to a regular diet and serial hct were stable. prilosec 40mg was recommended, as was avoidance of chocolate, peppermint, alcohol, caffeine, onions, aspirin and elevation of the head of the bed 3 inches, going to bed on empty stomach. at the time of discharge, his hct was stable at 42.2. . # anion gap acidosis: he had an initial anion gap of 24 on lab evaluation with serum osms 366. the osm gap was accounted for by etoh level of 246 and mild ketonuria was also observed suggesting some starvation ketoacidosis. he received 3l of ivf and 1l from a banana bag with improvement in gap to 18. on discharge from icu and the hospital, his gap was closed. . # etoh cirrhosis and etoh abuse: he has presumed etoh cirrhosis (no biopsy), with well compensated portal hypertension on last eval with hepatologist dr in and grade i varices on egd although none observed on egd today.synthetic function is preserved. recently started drinking again following several months abstinence. he was placed on a ciwa scale with positive with valium given as needed. he complained on bilateral shooting foot pain with sensation intact. a vitamin b level in was 1561, on recheck this admission this was 1159. he received iv thiamine, folate and a multivitamin to protect from wernickes encephalopathy. his gabapentin and fluoxetin were initially held but were restarted. he was discharged on po thiamine, folate, and multivitamin. . # elevated lfts: he had a history of alcoholic cirrhosis, of interest, ast/alt ratio is not c/w with alcohol alone. pt with prior +ve hepc antibody with subsequent indeterminant riba, but negative hcv viral load indicating exposure with viral clearance. prior positive, hepb surface antigen positive (hepb immune). prior anit-smooth anitbody positive but non specific. no fam history or prior eval for hemochromatosis although patient noted to have some hyperpigmentation. lfts were trended inhouse and improved. hep serologies and workup for hemochromatosis can be considered for the outpatient setting. . # hypoxia: initially requiring 4l nc with prior evidence emphysema on ct, currently smoking, with unremarkable cxr on admission. he was weaned off 02 as he became less intoxicated and continued his home proair. a nicotine patch was given and smoking cessation is encouraged. . # chest pain: endorses several months of intermittent mid epigastric chest pain, non exertional, unclear if related to food, now with mild reproducible left sided chest pain following hitting left side on door after stumbling. reproducible chest pain likely musculoskeletal, improved with valium for ciwa, mid epigasric pain likely secondary to alcoholic gastritis for which he was placed on a ppi. serial ekgs showed only sinus tachycardia and troponins x 2 were <0.01. . # pulmonary nodule he had a 9 mm solid, non-calcified, nodule in the right lower lobe observed on ct in . serial imaging 3 months later in showed that the nodule was unchanged. he is scheduled for repeat imaging of the nodule in . . # hyperglycemia: noted to be hyperglycemic, with hga1c of _6.4. he was placed on insulin sliding scale while inhouse and will follow up with his pcp regarding glycemic control. . follow-up issues: 1. please check his blood pressure, as they were elevated during this admission, possibly secondary to alcohol withdrawal. we did not start him on a beta-blocker as his pressures may have been transiently elevated in the setting of hospitalization. 2. please follow up on his gi bleed, secondary to his esophagitis and gastritis. he may need a repeat egd to evaluate resolution of his inflammation. 3. please encourage the patient to stop drinking and smoking. his etoh consumption (binge for 2-3 days) likely caused his gi bleed and elevated lfts. 4. please check patient's hct and lfts to ensure that his gi bleed and etoh hepatitis has resolved. medications on admission: 1. fluoxetine 20 mg po daily 2. fluticasone propionate nasal 2 spry nu daily 3. gabapentin 200 mg po tid 4. proair hfa *nf* (albuterol sulfate) 90 mcg/actuation inhalation q4-6h:prn dyspnea, wheezing discharge medications: 1. fluoxetine 20 mg po daily 2. fluticasone propionate nasal 2 spry nu daily 3. gabapentin 200 mg po tid 4. proair hfa *nf* (albuterol sulfate) 90 mcg/actuation inhalation q4-6h:prn dpsynea, wheezing 5. ciprofloxacin hcl 500 mg po q24h duration: 2 days until rx *ciprofloxacin 500 mg 1 tablet(s) by mouth daily disp #*2 tablet refills:*0 6. folic acid 1 mg po daily rx *folic acid 1 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*1 7. multivitamins 1 tab po daily rx *multivitamin 1 tablet(s) by mouth daily disp #*30 tablet refills:*1 8. omeprazole 40 mg po bid rx *omeprazole 40 mg 1 capsule(s) by mouth twice a day disp #*30 capsule refills:*1 9. thiamine 100 mg po daily rx *thiamine hcl 100 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*1 10. nicotine patch 21 mg td daily rx *nicotine 21 mg/24 hour use one patch as needed daily disp #*15 each refills:*1 discharge disposition: home discharge diagnosis: primary: - upper gi bleed secondary - alcoholic cirrhosis / hepatitis - alcohol withdrawal discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you in the hospital. you were admitted for coughing up blood, and were found to have a gi bleed, likely from inflammation in your esophagus and stomach. we believe this was exacerbated by your alcohol consumption. you were treated with iv fluids and a medication to reduce the acid in your stomach. you were seen by gastroenterologists, performed an upper endoscopy to find the inflammation per above. you also showed some withdrawal symptoms, and were treated with diazepam as needed. you received folate and thiamine for your vitamin deficiencies. your liver function tests were elevated on this admission, and decreased by the time of discharge. at the time of discharge, your hematocrit (blood levels) were stable, and you did not have active signs of withdrawal. please follow up with your pcp and liver specialist (appointments below). you should have your blood pressure checked, as it was high during this admission. we encourage you to stop alcohol consumption, as it has lasting effects on your liver, and may cause gi bleeding in the future. we also encourage you to stop smoking, as it has permanent effects on the lungs. we have given you a prescription for nicotine patches. followup instructions: department: medical specialties when: monday at 8:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: liver center when: wednesday at 9:20 am with: , md building: lm bldg () campus: west best parking: garage department: radiology when: monday at 11:15 am with: cat scan building: sc clinical ctr campus: east best parking: garage do 12-bdu Procedure: Other endoscopy of small intestine Diagnoses: Acidosis Tobacco use disorder Alcoholic cirrhosis of liver Chronic airway obstruction, not elsewhere classified Depressive disorder, not elsewhere classified Alcohol abuse, unspecified Hypoxemia Alcoholic polyneuropathy Other abnormal glucose Acute alcoholic hepatitis Alcohol withdrawal Other esophagitis Solitary pulmonary nodule Elevated blood pressure reading without diagnosis of hypertension Alcoholic gastritis, with hemorrhage |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: ascending aotic dissection major surgical or invasive procedure: - replacement of ascending aorta, aortic valve replacement(19 st. tissue), intra-aortic balloon pump - closure of chest history of present illness: the patient is a 57-year-old woman who was transferred by helicopter from to . we were notified when the patient was in flight that her blood pressure was 40 mmhg systolic and that she had probably tamponade from a type a aortic dissection. it was noted that she was poorly perfused. she was taken emergently to the or 1. the patient presented earlier that morning with shortnesss of breath, chest pain, and a seizure followed by nonresponsiveness. a ct showed a type a dissection involving the arch. in the or, the patient was cyanotic, in a low flow state and nonresponsive but sedated. past medical history: hypertension depression hyperlipidemia social history: smoker, unknown pack years. does not drink alcohol, and there is no history of ivda. family history: mh: aaa (not repaired), htn, hypercholesterolemia, cad fh: one daughter had a sah, and she has a son with chf physical exam: preop exam: critical condition. intubated/sedated. hypotensive. discharge vs t98.5 hr 74sr bp150/90 rr20 o2sat97%ra gen nad neuro a&ox3, nonfocal exam pulm cta bilat cv rrr, no m/r/g. sternum stable, incision cdi with staples abdm soft, nt/nd, +bs ext warm, trace pedal edema bilat pertinent results: echo pre bypass: overall left ventricular systolic function is normal (lvef>55%). the descending thoracic aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. a mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. a mobile density is seen in the aortic arch consistent with an intimal flap/aortic dissection. there is no aortic valve stenosis. mild to moderate (+) aortic regurgitation is seen. trivial mitral regurgitation is seen. there is no pericardial effusion. post bypass #1: (on infusion of epinephrine 0.03mcg/kg/min there is now moderate aortic regurgitation and mild to moderate mitral regurgitation. moderately dysfunctional rv systolic function. lv volume appears underfilled. no dissection in the descending thoracic aorta. mild tr. post bypass #2: (on infusion of milrinone and epinephrine) moderate rv dysfunction. severe aortic regurgitation. moderate to severe mitral regurgitation. overall lv systolic function was 45%. post bypass #3: moderate rv systolic function. mild global lv hypokinesis. mild to moderate mr> aortic bioprosthesis is intact in the native aortic position with reasonable gradients. after an hour of post bypass, severe rv dysfunction. lv is underfilled. overall lv systolic function may be underestimated. lvef 20% no new dissections seen in the descending thoracic aorta. mild mr> tricuspid valve could not be well visualized because of the poor views. echo during chest closure no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricle displays normal free wall contractility. there are simple atheroma in the aortic arch. there is a dissection flap seen in the aortic arch. an intramural hematoma is also seen in the aortic arch. the descending thoracic aorta is mildly dilated. there are complex (>4mm) atheroma in the descending thoracic aorta. a bioprosthetic aortic valve prosthesis is present. the aortic valve prosthesis leaflets do not fully coapt and a central defect is seen during diastole. moderate (2+) aortic regurgitation is seen through this defect. the maxim8um gradient through the valve is 33 mm hg with a mean gradient of 17 mm hg. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. an intraaortic balloon is seen with its tip 5 cm below the distal aortic arch. dr. was notified in person of the results in the operating room at the time of the study. admission 11:21pm urea n-21* creat-1.5* chloride-111* total co2-20* 11:21pm wbc-15.2*# rbc-3.31* hgb-10.3* hct-28.8* mcv-87 mch-31.0 mchc-35.7* rdw-14.6 11:21pm plt count-79* 11:21pm pt-17.3* ptt-99.4* inr(pt)-1.6* 08:20pm urea n-20 creat-1.3* chloride-110* total co2-23 08:20pm alt(sgpt)-30 ast(sgot)-75* ld(ldh)-327* alk phos-26* amylase-17 tot bili-0.5 08:20pm lipase-28 08:20pm albumin-1.4* discharge 06:35am blood wbc-13.8* rbc-3.62* hgb-11.2* hct-32.3* mcv-89 mch-30.9 mchc-34.6 rdw-15.5 plt ct-318 06:35am blood plt ct-318 02:06am blood pt-12.9 ptt-27.5 inr(pt)-1.1 06:35am blood glucose-86 urean-21* creat-0.8 na-133 k-4.0 cl-103 hco3-22 angap-12 , l f 61 radiology report chest (portable ap) study date of 9:50 am medical condition: 61 year old woman with rul atelectasis reason for this examination: r/o rul atelectasis final report reason for examination: followup of the atelectasis. portable ap chest radiograph was compared to prior study obtained on at 09:02 a.m. there is interval slight improvement of the right upper lobe opacity consistent with atelectasis that has partially resolved. aspiration would be another possibility, giving the similar appearance. the cardiomediastinal contour is stable. the right internal jugular line tip is at mid svc. there is no change in the right basal opacity consistent with atelectasis. dr. approved: mon 5:06 pm date: signed by , ms slp on affiliation: bedside swallowing evaluation: history: thank you for consulting on this 61 y/o female who was transferred to on from osh via and underwent emergent open chest type a aortic dissection repair, iabp insertion upon admission. chest closure on . patient was extubated on . hospital course c/b episodes of afib. we were consulted to evaluate patient's oral and pharyngeal swallowing function coughing on liquids. rn reported patient has been tolerating a regular diet over the weekend. pmh: htn, aaa evaluation: the examination was performed while the patient was seated upright in the chair on the cvicu. cognition, language, speech, voice: patient was awake and alert, "not feeling very well". cognition, language, speech and voice all wfl. teeth: intact dentition in appropriate condition secretions: normal oral secretions, congested baseline cough oral motor exam: tongue midline. adequate labial and lingual strength, rom and buccal tone. palatal elevation symmetrical. gag deferred. swallowing assessment: po trials included ice chips, thin liquids (tsp/cup), bites of applesauce and cracker. oral phase grossly wfl. laryngeal elevation felt timely and slightly reduced to palpation. no change in vocal quality. no throat clearing, coughing or choking was noted during po trials. o2 sats remained stable at 95%. summary / impression: ms. appeared to tolerate today's po trials without overt s/sx of aspiration at the bedside. she is recommended to continue a regular solid diet with thin liquids. however, silent aspiration cannot be r/o at the bedside and recommend continued monitoring of cxr as there is ? of aspiration immediately following extubation several days ago. if cxr appears to worsen and there is concern of aspiration with this diet, please reconsult and we will be happy to return. if patient noted with any coughing while taking pills, please give them whole with applesauce. this swallowing pattern correlates to a dysphagia outcome severity scale (doss) rating of level 6, wfl. recommendations: 1. continue po intake of thin liquids and regular solids. 2. pills may be taken whole with water or if difficulty, whole with puree. 3. please continue to monitor for any s/sx of aspiration during meals and via cxr. if cxr appears to worsen with concern for aspiration, please reconsult and we will be happy to return. these recommendations were shared with the patient, nurse and medical team. ____________________________________ , m.s., ccc-slp pager # brief hospital course: mrs. was admitted to the emergently via from on . she was taken directly to the operating room where she underwent an emergent repair of a type a aortic dissection with replacement of her ascending aorta and aortic valve as well as placement of an intra-aortic balloon pump. please see operative note for details. postoperatively she was taken to the intensive care unit in critical condition with an open chest. she required multiple blood product transfusions given her postoperative bleeding. over the next several days, her inotropes were slowly weaned off. the neurology service was consulted for assistance in her care. an eeg was negative for seizure activity. when sedation was weaned, she was able to mover her extremities and follow simple commands. on , she was taken back to the operating room where closure of her chest was performed. he iabp was removed without issue. vancomycin, ciprofloxacin and zosyn were started for a pulmonary infiltrate. a hit assay was sent given her thrombocytopenia however this remained negative. on , mrs. awoke neurologically intact and was extubated. she developed atrial fibrillation which was treated with amiodarone. diamox was used to treat metabolic alkalosis. a bedside swallowing exam was normal and she was cleared for a regular diet. on , mrs. was transferred to the step down unit for further recovry. once on the floor she had an uneventful hospital course. she was gently diuressed towards her preoperative weight. the physical therapy service was consulted for assistance with her postoperative strength and mobility. on pod 14/10 she was ready for discharge to rehabilitation. she was transferred to care center in n , ma medications on admission: lisinopril 10', propanolol sa 120", zetia 10' hctz 25', cymbalta 60', enablex 7.5' discharge medications: 1. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 2. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours): while on lasix. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. 6. insulin lispro 100 unit/ml solution sig: sliding scale subcutaneous qac&hs. 7. alprazolam 0.25 mg tablet sig: 0.5 mgs po tid (3 times a day) as needed. 8. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 9. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). 10. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 11. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 12. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 13. lasix 40 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: discharge diagnosis: ascending aortic dissection abdominal aortic aneurysm hypertension depression hypercholesterolemia discharge condition: good discharge instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimmign no lotions, creams or powders to incisions report any redness of, or discharge from incisions report any fever greater than 100.5 take all medications as directed report any weight gain greater than 2 pounds a day or 5 pounds a week no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimmign no lotions, creams or powders to incisions report any redness of, or discharge from incisions report any fever greater than 100.5 take all medications as directed report any weight gain greater than 2 pounds a day or 5 pounds a week followup instructions: 1) follow-up with dr. in 2 weeks () 2) follow-up with dr. in 2 weeks. 3) follow-up with dr. in weeks. call all providers for appointment. 4) you have an appt with dr at on at 2:30 pm. please call ( with questions. you will need a referral from your pcp. 5) see dr. in 6 months with a follow-up ct scan. call ( for an appointment. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Fiber-optic bronchoscopy Open and other replacement of aortic valve with tissue graft Resection of vessel with replacement, thoracic vessels Closed [endoscopic] biopsy of bronchus Implant of pulsation balloon Closure of skin and subcutaneous tissue of other sites Transfusion of packed cells Transfusion of other serum Transfusion of platelets Diagnoses: Thrombocytopenia, unspecified Tobacco use disorder Unspecified essential hypertension Atherosclerosis of aorta Atrial fibrillation Other convulsions Mitral valve insufficiency and aortic valve insufficiency Depressive disorder, not elsewhere classified Pulmonary collapse Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Alkalosis 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 Cardiogenic shock Nausea alone Abdominal aneurysm without mention of rupture Other and unspecified coagulation defects Dissection of aorta, thoracic Cardiac tamponade |
allergies: tetracycline / metoclopramide attending: chief complaint: altered mental status major surgical or invasive procedure: intubation, mechanical ventilation extubation lumbar puncture history of present illness: ms. is a 52 y/o woman with pmh notable for hcv cirrhosis, type 2 diabetes mellitus, and hypertension transferred from due to altered mental status. of note, the patient had an admission at in for rash (thought to be hypersensitivity/allergic), parkinsonism (attributed to metoclopramide), and difficult to control diabetes. she was discharged on to a nursing facility. she presented to southern medical center via ems earlier today from home with altered mental status. at that time, reportedly alert & oriented x 2. fsbs at that time 256 with o2 sat 96% on 2lnc. ammonia at osh 251 with platelets 59,000. vitals at the osh noted to be t 97.9, hr 103, bp 110/71. she had 100 cc of urine output. apparently, hr increased to 130-150s and patient was treated for agitation with haldol 5 mg iv x 1 and lorazepam 1 mg iv x 1 prior to transfer. she also received 40 g lactulose via ng tube. on arrival to the medical floor at , initial vitals t 96.4, hr 110, bp 122/92, fsbs 201, rr 18, 100% on ra. she was noted to be somnolent. she was treated with lactulose 120 ml via ng tube and lactulose enema. she was then noted to have rhythmic shaking movements concerning for seizure activity and was treated with lorazepam 1 mg iv x 1. neurology consultation was obtained at that time. she remained afebrile but was tachycardic to the 120s. due to concerns about somnolence and ability to protect the airway, the patient was trasnferred to the micu. on arrival to the icu, the patient is not responsive to vocal stimuli but does withdraw to pain. her oxygenation was noted to be slightly decreased low-90s on 2l nc. she is noted to have rhythmic roving lateral eye movements and twitching movements of both lower limbs. past medical history: #. hepatitis c cirrhosis - brief ivdu age 16 - hospitalized 3 times for encephalopathy - history of ascites currently controlled with diuretics - no history of gi bleeds or hematemesis - egd without varices, + portal hypertensive gastropathy and retained food consistent with gastroparesis - hep a/b immune - colonoscopy previously performed #. dm #. htn #. back pain - surgery for disc disease, walks with cane #. s/p carpal tunnel release #. s/p ulnar nerve surgery #. s/p ganglion excision social history: patient is single and lives with her daughter in . she has been on disability for 6 to 7 years. she has history of taking the care and crashing multiple times in the last months. she does not take care of the children and the family does not take good care of her either. tobacco: none etoh: stopped etoh 2 years ago illicts: ivdu at age 16, none since. was using marijuana as an appetite stimulant until 1 year ago. family history: mother: past history of breast cancer father: died from complications of heart disease. 1 brother and 1 sister: are in good health 1 brother: died at a young age from suicide sister who died from complications of lung cancer. . physical exam: vs: t 98, bp 144/74, p 119, rr 20, 100% on 3lnc gen: unresponsive to voice, lying in bed in moderate distress heent: roving eye movements, sclerae anicteric, mm slightly dry, ng tube in place, foaming slightly at the mouth lungs: coarse breath sounds bilaterally from upper airway cv: tachycardic but regular, no appreciable murmur abd: distended with normoactive bowel sounds, + fluid wave, no grimace to palpation ext: trace peripheral edema, dp pulses 2+ bilaterally skin: pinpoint papular eruption covering lower extremities > upper extremities with excoriations, no interdigital tracking neuro: unresponsive to voice with roving lateral eye movements, pupils not reactive bilaterally, + gag reflex but no blink to threat, limbs rigid lower extremities > upper extremities, + clonus bilateral lower extremities, upgoing toes bilaterally, with nailbed pressure on toes patient begins shaking of the opposit leg, hyper-reflexic in all extremities with extensor posturing pertinent results: osh labs: other labs: lactic acid:4.5 mmol/l from osh: wbc 4.5 (72n, 15l, 8m, 4e), hgb 12/hct 35.1, plt 58,000, mcv 85 pt 17.5, inr 1.5, glucose 225, bun 24, cr 1.2, na 133, k 4.8, cl 99, co2 28 ca 8.3, alk phos 121, total protein 6.3 albumin 2.1, total bili 1.3, ast 68, alt 68, ammonia 251 ua: yellow, clear, sg 1.011, neg glucose, neg bili, neg ketones, 2+ blood, ph 7, neg protein, neg nitrite, neg leuk esterase, 0-2 rbcs, 0-2 wbcs, 0-2 epis . imaging: cxr: s/p endotracheal intubation, ng tube below the diaphragm . admission ecg: sinus tachycardia. diffuse non-specific st-t wave changes are new as compared with prior tracing of the rate has increased. followup and clinical correlation are suggested. . admission labs: 11:36pm glucose-182* urea n-26* creat-1.2* sodium-137 potassium-4.3 chloride-103 total co2-24 anion gap-14 11:36pm alt(sgpt)-81* ast(sgot)-79* ld(ldh)-408* alk phos-115 tot bili-1.7* 11:36pm albumin-2.9* calcium-8.5 phosphate-4.2 magnesium-2.0 11:36pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 11:36pm wbc-9.5 rbc-4.19* hgb-12.3 hct-36.9 mcv-88 mch-29.3 mchc-33.3 rdw-16.3* 11:36pm plt count-80*# 11:36pm pt-18.1* ptt-34.9 inr(pt)-1.7*. . pertinent imagaing: cxr: () impression: 1. nasogastric tube terminates in the duodenum. 2. mild congestive failure. . eeg (): impression: this is an abnormal portable eeg due to the slow background suggestive of severe encephalopathy. infection, medications, and metabolic disturbances are among the most common causes. there were no lateralized or epileptiform features seen. of note is the sinus tachycardia . ct head without contrast: impression: no acute intracranial process. . liver ultrasound: impression: () 1. cirrhotic-appearing liver, with evidence of portal hypertension. splenomegaly and multiple splenic varices are again identified. 2. appropriate direction of flow is seen in the portal vein. hepatic veins and main hepatic artery appear patent. 3. moderate amount of ascites. 4. thickened gallbladder wall with small amount of pericholecystic fluid. this appearance could be consistent with patient's ascites and third spacing of fluid. . discharge labs: 06:00am blood wbc-3.4* rbc-3.30* hgb-9.3* hct-27.8* mcv-84 mch-28.1 mchc-33.4 rdw-16.4* plt ct-51* 06:00am blood pt-18.7* ptt-39.6* inr(pt)-1.7* 06:00am blood alt-92* ast-118* ld(ldh)-371* alkphos-92 totbili-1.2 06:00am blood albumin-2.7* calcium-8.3* phos-4.7* mg-2.0 06:15am blood tsh-3.2 06:15am blood free t4-0.59* brief hospital course: pt is a 52 y/o f with hcv cirrhosis, thrombocytopenia admitted with altered mental status. # hepatic encephalopathy leading to altered mental status and disposition: likely secondary to hepatic encephalopathy, however component may have been uti leading to sepsis. upon transfer from medical center the patient was unresponsive to voice with roving eye movements. upon transfer to the micu, the pt had twitching movements of the legs combined with rigidity of legs greater than arms. over the first night her symptoms somewhat improved. neurology was consulted and stated that the clinical picture represented a toxic-metabolic insult such as hepatic encephalopathy. in the icu (), tox screen negative, intubated for airway protection, ct head without acute intracranial process, lp performed with platelets and ffp. eeg revealed severe encephalopathy. pt started on vanc, ceftriaxone, acyclovir(later d/c'd) for suspected meningitis, lp later unrevealing. neuro stated her condition was likely a diffuse, toxic-metabolic process in setting of liver failure. initially started on tube feeds, but ng was self d/c'd as well as self-extubated. tm 100.3 overnight prior to be admitted to the floor. . upon transfer to the floor on the patient has no complaints and did not recall the events leading up to her admission to the hospital. she is speaking conversantly, appropriately and taking a regular diet. of note the pt stated that she has taken her medications as prescribed, however this was argued against by his brother and sister during a family meeting. the patients family refused to take the patient back to her home in , and thus the patient remained on the floor following a family meeting. a subsequent liver transplant meeting resulted in the patient being de-activated, but not removed, from the transplant list on conditional terms that the patient signed off on. for the rest of her admission, the pt remained appropriately oriented, respectful to staff, compliant with all medications and adherent to her contract with her hepatology team. . # tachycardia: patient tachycardic to 120-130s on arrival to icu. differential includes hypovolemia (versus infectious (though afebrile currently). patient was given 2l bolus of ns with no resolution of tachycardia. feurea suggest pre-renal even though she did not respond to boluses. it was suspected that there may have been a primary neurologic component though neurology believes nms/serotonin syndrome unlikely. thus, the patients seroquel was initially held. the patient was found to have a uti, treated with a seven day course of po antibiotics, and her tachycardia resolved. . # acute renal failure: baseline creatinine 0.7-0.8 per prior labs in omr. likely related to hypovolemia in setting of insensible losses and acute illness, especially since feurea showed a pre-renal picture. the patient was given ivf while in the unit. upon transfer to the floor the patients creatinine had stabilized to her baseline levels. her creatinine remained in the 0.7 to 0.9 range on the floor. . # hcv cirrhosis: continued lactulose/rifaximin for a long history hepatic encephalopathy secondary to medical non-compliacnce. platelets low but at recent baseline and inr up to 1.7 which is also at recent baseline. lfts otherwise appear to be at baseline with poor albumin (2.1 at osh). the patients was kept on po lactulose and rifaxamin during her hospital course and had no further encephalopathic symptoms on the floor. # dm2: patient with history of very difficult to control blood sugars on prior admission and high insulin dose requirements. the patient was initially started on a sliding scale with half doses of lantus while in the unit. however upon transfer to the floor the patients fs were in the 300' was consulted and the pt was changed from daily to lantus. the patients lantus was titrated up as was her sliding scale. at the time of discharge, the pt is usually compliant with a diabetic, low salt diet and administering her own insulin and finger sticks. her blood sugars are well controlled with levels >200 only once every other day and usually in the setting of high carbohydrate intake. . # thrombocytopenia: platelets < 100,000 which is baseline for her. heparin was avoided and the patient was encouraged to ambulate frequently in the setting of not using the prescribed pneumoboots. . # skin: diffuse pinpoint, erythematous, raised lesions that have the texture of sand paper were evident on the extremities and back throughout this admission. appears to be chronic, prior work ups suggested hypersensitivity reaction which was confirmed by eosinophils on prior derm biopsy. in addition the patient complained of pruritis that was treated with urosodiol and topical hydrocortisone with minimal results. she was discharged with sarna lotion and hydrocortisone cream. . # depression: psych was consulted this admission for the pt's depression. she was gradually up titrated on citalopram and quetiapine with good effect. at discharge, her mood is stable without significant depression. . # sick thyroid: pt's tsh 8.7 on admission. recheck , hi normal of 3.2. free t4 low at 0.59. as pt was in house, would like her to follow up on thyroid tests when she is no longer in house and thus thyroid not reflective of sick euthyroid. . # dispo: case management had difficulty placing the pt in a or alf in the area. finally, the pt's family was called in and agreed to take the pt home to be closely monitored at home by family members including the pt's mother who flew in from for this purpose. medications on admission: (per list that came with patient) xifaxan 500 mg nexium 40 mg daily seroquel 50 mg at bedtime prozac 60 mg per day lasix 80 mg per day spironolactone 100 mg lactulose 60 ml atarax 25 mg prn benadryl 25 mg prn humalog 27 u with meals lantus 80 u at bedtime discharge medications: 1. rifaximin 200 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. cyanocobalamin 100 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. lactulose 10 gram/15 ml syrup sig: forty five (45) ml po qid (4 times a day). disp:*1 bottle* refills:*2* 6. 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* 7. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed. disp:*1 bottle* refills:*2* 8. quetiapine 25 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). disp:*60 tablet(s)* refills:*2* 9. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. hydrocortisone 0.5 % ointment sig: one (1) appl topical qid (4 times a day) as needed for rash. disp:*1 bottle* refills:*0* 11. spironolactone 100 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). disp:*60 tablet(s)* refills:*2* 12. furosemide 80 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). disp:*30 tablet(s)* refills:*2* 13. lantus 100 unit/ml solution sig: one (1) dose subcutaneous twice a day: 60 units in the am, 70 units before bedtime . disp:*1 bottle* refills:*2* 14. humalog 100 unit/ml solution sig: one (1) sliding scale subcutaneous four times a day: please follow attached insulin sliding scale. disp:*1 bottle* refills:*2* 15. quetiapine 25 mg tablet sig: 0.5 tablet po at bedtime as needed for insomnia. disp:*15 tablet(s)* refills:*0* discharge disposition: home with service facility: gentiva of discharge diagnosis: primary diagnosis - acute change in mental status - hepatic encephalopathy - sepsis - urinary tract infection - diabetes mellitus . secondary diagnoses - depression - hep c cirrhosis discharge condition: good. patient ambulating without assistance, able to take adequate pos, checking own finger sticks, administering own insulin injections. mentally alert and oriented x3. discharge instructions: you were admitted to hospital for an acute change in your mental status. on arrival you were found to have very high sugars, as well as a urinary tract infection. you were intubated and placed on mechanical ventilation for a period of time. you were subsequently transfered from the intensive care unit to a hospital floor where you were followed by the liver and diabetes teams. at the time of discharge, you are doing well. your blood sugars are stable and you have recieved nutritional counselling. your ascites is stable and you are doing well on diuretics. . please continue to take all of your medications as instructed at the correct doses and frequencies without missing doses. . please be compliant with your diabetic diet as instructed. . please keep all of your appointments as listed below. . please call your doctor or return to the hospital if you experience changes in mental status, fevers, chills, headaches, visual changes, loss of consciousness, chest pain, shortness of breath, increased ascites in your belly, worsening of diarrhea or any other concerning symptoms. followup instructions: please see your pcp . at 10:30 am on friday . if you need to reschedule, please call . . please follow up with dr. office (gastroenterology)in on tuesday at 9:30am. if you need to reschedule, please call (. . please follow up in transplant clinic with dr. on wednesday at 11am. if you need to reschedule, please call . . please follow up at the diabetes center with dr. on at 3pm. if you need to reschedule, call (. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Transfusion of other serum Transfusion of platelets Diagnoses: Anemia of other chronic disease Urinary tract infection, site not specified Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Chronic hepatitis C with hepatic coma Acute kidney failure, unspecified Unspecified septicemia Sepsis Acute respiratory failure Long-term (current) use of insulin Major depressive affective disorder, single episode, unspecified Dermatitis due to drugs and medicines taken internally Other ascites Personal history of noncompliance with medical treatment, presenting hazards to health Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Metabolic encephalopathy Tachycardia, unspecified Gastroparesis Antiallergic and antiemetic drugs causing adverse effects in therapeutic use Euthyroid sick syndrome Secondary parkinsonism |
allergies: penicillins attending: chief complaint: abdominal pain major surgical or invasive procedure: exploratory laparotomy, hartmann procedure. history of present illness: 78ym with pmh of esrd, cad, aortic stenosis, afib on coumadin who presents with less than one day of acute abdominal pain. seen at lgh and was hypotensive with concerning abdominal exam, so transfer here for further eval. pt confused but complaining of abdominal pain. no nausea or vomiting. cannot give accurate history at this time. past medical history: pmh: a fib, sick sinus syndrome s/p ppm, ef 45-50%, as, chf-predominantly diastolic, cri, gout, htn psh: exploratory laparotomy, hartmann procedure. b knee replacements social history: married retired electrician former smoker, social drinker, no rec drugs family history: father died at 61 from lung ca mother died at 93 from "old age" physical exam: vs: 98.8 60 75/40 20 97 4l pe: moderate distress, uncomfortable, intermittent confusion anicteric rrr mild labored breathing, cta b/l abd is diffusely tender, rigid, with rebound and guarding no edema . labs: 133 97 97 102 agap=19 4.0 21 5.8 ∆ ca: 9.2 mg: 2.0 p: 4.7 alt: 15 ap: 115 tbili: 1.9 ast: 16 lip: 92 12.4 5.4 149 35.8 n:54 band:21 l:16 m:8 e:0 bas:0 metas: 1 pt: 37.2 ptt: 39.7 inr: 3.9 lactate 2.9 . imaging: ct abdomen->ascites moderate amount, nodular liver. no obvious source of perforation or sepsis. . pertinent results: 02:30am blood wbc-5.9 rbc-3.84* hgb-12.7* hct-36.4* mcv-95 mch-33.2* mchc-35.0 rdw-15.2 plt ct-161 06:20am blood wbc-12.4* rbc-3.46* hgb-11.2* hct-34.2* mcv-99* mch-32.4* mchc-32.7 rdw-15.2 plt ct-293 02:35am blood pt-37.2* ptt-39.7* inr(pt)-3.9* 05:05am blood pt-21.5* ptt-37.3* inr(pt)-2.0* 06:20am blood pt-21.5* ptt-32.9 inr(pt)-2.0* 02:35am blood glucose-102* urean-97* creat-5.8*# na-133 k-4.0 cl-97 hco3-21* angap-19 06:20am blood glucose-132* urean-63* creat-2.3* na-139 k-4.3 cl-105 hco3-26 angap-12 06:20am blood calcium-8.1* phos-3.3 mg-2.0 brief hospital course: he was taken emergently to the or for laparotomy and hartmann procedure on for perforated diverticulitis. surgeon was dr. . he was hemodynamically unstable in the or requiring neosynephrine and levophed. he was given ffp and developed a rash. he was transferred intubated to the sicu postop. bedside tte demonstrated heavily calcified aortic valve, mild global hypokinesis with paradoxical septal motion of lbbb. he was av paced at 50bpm. cardiology adjusted his heart rate to dddr with resting rate of 75bpm. overall picture was one of sepsis. cipro and flagyl were given. he was preload dependent and was treated with iv fluids. on , sedation was weaned, but he failed spontaneous breathing trial and desaturated. bronch was performed for mucus plugging. bal was sent and was negative. pressor requirements decreased. echo noted enlarged rv with free wall hypokinesis, 4+tr, moderate pulmonary htn, akinesis inf/lat wall. ef was 35-40%. creatinine started to decrease with improved urine output. he was weaned off pressors. on , inr had increased to 4.0. ffp and vitamin k were given. inr decreased to 1.7. sedation was decreased and he self extubated on as well as pulled out the jp drain. he remained stable post extubation. mitts were applied. the peritoneal fluid from intra op isolated gnr /bacteroides fragilis in the broth only. incision appeared red and vancomycin was started on . vancomycin was stopped on . the ostomy was working. a post pyloric feeding tube was placed and feedings were started. bedside swallow eval was done noting edentulous state and some confusion. he did not aspirate therefore, recommendations included ground solids and thin liquids which he started. urine output increased and creatinine continued to improve. cxr demonstrated volume overload and lasix was given. the incision was opened for increased redness and a wound vac applied. he was transferred out of the sicu on . on , he was less confused. wrist restraints were removed. diet was advanced as ostomy output was occurring. on , he vomited. an abdominal ct was done showing no focal fluid collection or free air to indicate new perforation, no obstruction. ascites and nodular hepatic contour were seen, raising question of cirrhosis, unchanged. diverticulosis was noted. there were increased moderate bilateral pleural effusions with more confluent appearance of right lower lobe consolidation, raising question of aspiration versus infection. vomiting resolved. levaquin was started for pneumonia on . a congested cough was present. o2 sats were 93% on room air. coumadin was resumed on at 1mg per day. inr was 2.0 on . on day of discharge, osh micro fax'd blood cultures from that were positive for fusobacterium nucleatum in the anaerobic bottle only. flagyl was resumed (had stopped on after 10 days). the plan to complete a 14 day course. blood cultures were negative on and blood cultures from were negative to date. pt evaluated and recommended rehab (refer to note). a bed was available at , and he was transferred there for rehab. medications on admission: : lovastatin 20, atenolol 25, coumadin 3', apap all: pcn discharge medications: 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours) as needed for pain. 4. warfarin 1 mg tablet sig: one (1) tablet po once a day. 5. levofloxacin 750 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 1 weeks: rll pneumonia. 6. outpatient work pt/inr 3x per week goal inr 2-2.5 7. atenolol 25 mg tablet sig: 0.5 tablet po once a day. 8. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 4 days: to complete 14 day course. discharge disposition: extended care facility: northeast - discharge diagnosis: perforated diverticulitis pneumonia rll h/o afib/pacemaker/as cri htn bacteremia, fusobacterrium nucleatum 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 are transferring to rehab please call dr. office if you experience any of the warning signs: fever, chills, nausea, vomiting, increased abdominal distension, diarrhea (increased output via ostomy), abdominal wound appears red or has increased drainage followup instructions: follow up with surgeon dr. at 1pm at , Procedure: Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Open and other sigmoidectomy Exteriorization of large intestine Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Acute on chronic diastolic heart failure Aortic valve disorders Chronic kidney disease, unspecified Septic shock Long-term (current) use of anticoagulants Rash and other nonspecific skin eruption Other ascites Septicemia due to anaerobes Knee joint replacement Fitting and adjustment of cardiac pacemaker Foreign body accidentally entering other orifice Hip joint replacement Diverticulitis of colon (without mention of hemorrhage) Other suppurative peritonitis Foreign body in main bronchus |
allergies: penicillins attending: chief complaint: melena major surgical or invasive procedure: : esophagogastroduodenoscopy with epinephrine injection and clipping at bleeding duodenal ulcer. : angiographic coil embolization of gastroduodenal artery. : exploratory laparotomy, lysis of adhesions, antrectomy, subtotal cholecystectomy, choledochocholedochostomy. history of present illness: pt is a 78m well known to this service having undergone an ex-lap, sigmoid colectomy, end colostomy & procedure on for perforated diverticulitis and associated sepsis. his hospital course included a week-long icu course for hypotension, respiratory failure, renal failure. his organ failure resolved and he was ultimately discharged from the floor to rehab on pod 11 tolerating regular food with nj tf and ostomy output. cr was back at baseline (2.2). had been doing reasonably well at rehab. however, on hct 25.2 from 32 on . guaiac +, tranfused 2u prbcs, inr 2.34 on coumadin 2, cr 2.6 (from 1.32 on ). started colchicine for joint pain. hct 29. no gross bleeding. started prednisome 30 on for gout flare unresponsive to colchicine. cr fond to be 3.52 from 2.86. colchicine & lasix were stopped. he was started on ivf. developed brb from his colostomy on . inr was 1.9 at the time (on coumadin for afib). he was given 2u ffp, vit k iv, and 2u prbcs. egd on at : mild gastritis, duodenal ulcer with deep crater (5cm) with bleeding vessel. injected with epi (3cc) and bipolar cautery perofrmed. bx were taken for h pylori. he was started on a protonix gtt & octreotide gtt along with carafate. prednisone was stopped. transferred to today for further care. pt has abdominal "discomfort". no n/v. + melena. has been hemodynamically stable. past medical history: pmh: st. pacemaker, atrial fibrillation, sick sinus syndrome, aortic stenosis, chf, ef 45-50%, cri, gout, htn psh: b knee replacements, procedure for perforated diverticulitis with sepsis social history: married retired electrician former smoker, social drinker, no rec drugs family history: father died at 61 from lung ca mother died at 93 from "old age" physical exam: afebrile 87 128/45 18 95%2l nad, ao no jaundice or icterus cta b/l rrr abd soft, nt, nd, protuberant. midline incision with good granulation tissue. ostomy bag full of dark, thin melana no le edema pertinent results: 03:44pm wbc-12.7* rbc-3.02* hgb-9.4* hct-28.2* mcv-93 mch-31.0 mchc-33.3 rdw-16.3* 03:44pm plt count-315 03:44pm pt-20.8* ptt-31.9 inr(pt)-1.9* egd : a single crate, oozing, 2x5 cm ulcer was found in the post-duodenal bulb. the ulcer was clearly demarcated and has gritty base that cound not hold the endoclip. active bleeding was seen through the base of ulcer. during the procedure, approximately 100 cc blood lost. however, pt is hemodynamic stable. 4 1 cc.epinephrine 1/ injections were applied for hemostasis with partial success. three endoclips were unsuccessfully applied to the the ulcer at post-duodenal bulb for the purpose of hemostasis. ir coil embolization : successful and uncomplicated prophylactic gastroduodenal artery embolization for bleeding duodenal ulcer (as seen on endoscopy) using a hilal coils ranging from 3 mm x 3 cm, 4 mm x 4 cm and 6 mm x 6 cm (total of eight coils). ct abdomen/pelvis : there is small-to-moderate amount of ascites. a jp drain is noted in the right abdomen. there is extensive mesenteric fat stranding and edema, without evidence of large fluid collections or abscess formation. the gastrojejunostomy site is visualized; however, its patency cannot be assessed due to lack of contrast. the oral contrast given through j-tube is visualized throughout small and large bowel and within the colostomy bag, there is no evidence of an obstruction. no extraluminal contrast. ct abdomen/pelvis : the patient is with roux-en-y bypass. there is normal opacification of the stomach and the jejunostomy, without evidence for active leak. there is no evidence of bowel obstruction. a surgical drain is seen in the right upper abdomen terminating in the sub-diaphragmatic region. there is diffuse mesenteric fat stranding and moderate amount of simple ascites seen throughout the abdomen and pelvis, stable since the prior study. no focal fluid collections or abscesses are detected. there is no intra-abdominal free air. subcutaneous air at the level of the incision site likely relates to the recent procedure. brief hospital course: : admitted to sicu, underwent egd and ir embolization of gda, transfused 5u prbc. : hct stable - no transfusions since ir. remained intubated. : extubation not attempted as pt noted to be having copious secretions. tfs started. : extubated. lasix 60mg iv x 1. : to or for exploratory laparotomy, antrectomy, roux-en-y gastroj, feeding jejunostomy, subtotal chole and anastamosis of transected cbd. intubated post-op. bronched for l lung collapse and desaturations. jp drain to ruq. : repeat echo. cc:cc repletions d/c'd and ivf rate decreased. standing albumin started w/ subsequent successful weaning of pressor requirement. : tf increased ( to 3/4 strength). negative fluid balance secondary to jp output draining bilious succus, likely from duodenal stump leak. : jp drainage sent for bili (7.9) and amylase (61,700). : adjusted tf. : transferred to floor. : pt readmitted to sicu for mental status changes. ngt placed by primary team. ct abdomen/pelvis. : given 1 ffp in preparation for ptc placement, unable to get done in ir, postponed to . getting albumin boluses for low uop. : given 2u ffp prior to ptc placement and 3u ffp during procedure. patient was intubated in ir. they were unable to place drain in bile ducts. received 2u prbc. kept intubated post-procedure on propofol and neo. oliguric with metabolic acidosis with lactate of 6.5. started on bicarb gtt and refeeding jp output through j-tube. : hypotensive, requiring second pressor. anuric with fena 6% suggesting atn. failed stim test suggesting functional adrenal insufficiency. : hypotensive, requiring third pressor. family meeting was held and patient rendered cmo. expired. medications on admission: 1. sucralfate 1gm pgt 2. lasix 20mg pgt daily 3. octreotide 25 mcg gtt 4. promod 30cc pgt q8hr 5. insulin sliding scale 6. ascorbic acid 500mg pgt daily 7. mvi 5mg pgt daily 8. saccharomyces 250mg pgt q12 9. simvastatin 20mg pgt qhs 10. atenolol 12.5 po daily 11. tylenol prn 12. coumadin -- held 13. prednisone 30mg 12/11-15/ 14. jevity 1.2 90ml cycled from 6pm to 7am discharge medications: none. discharge disposition: expired discharge diagnosis: death. discharge condition: expired. discharge instructions: he who has gone, so we but cherish his memory. followup instructions: none. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Other partial resection of small intestine Enteral infusion of concentrated nutritional substances Arterial catheterization Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Aortography Endoscopic control of gastric or duodenal bleeding Arteriography of other intra-abdominal arteries Partial gastrectomy with anastomosis to jejunum Transcatheter embolization for gastric or duodenal bleeding Other incision of other bile duct Percutaneous hepatic cholangiogram Other partial cholecystectomy Artificial pacemaker rate check Central venous catheter placement with guidance Diagnoses: Acidosis Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Unspecified septicemia Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Aortic valve disorders Chronic kidney disease, unspecified Pulmonary collapse Acute respiratory failure Calculus of gallbladder with other cholecystitis, without mention of obstruction Cardiac pacemaker in situ Other ascites Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Obstruction of bile duct Chronic diastolic heart failure Colostomy status |
allergies: proair hfa attending: chief complaint: vomiting, gastric outlet obstruction, weight loss major surgical or invasive procedure: # egd # ct-guided biopsy of the omentum # ir guided placement of port # ir guided g-tube placement # 2 attempts at ir guided g-j tube placement history of present illness: 51yo f with h/o bilateral breast ca, thyroid ca, nhl, pulmonary fibrosis s/p xrt, asthma, hypothyrodism, chronic kidney disease who presented to her pcp in early with a 1 month h/o of vomiting, palpitations, weight loss. she describes epigastric pain and "hardening" after eating and had some trouble swallowing. these symptoms have become progressively worse to the point where she is unable to keep anything down. her outpatient work-up has been significant for ugi with functional gastric outlet obstruction. she went to see her pcp again today and was referred to the ed for admission. she notes that she has been passing gas and having small bowel movements. she has not had fever, chills, nightsweats. today, she notes that she has lost her voice. she attributes this to "all the reflux". she would like something to help her sleep if possible. in er: (triage vitals: 98.0 110 102/68 16 100% ra) meds given: ondansetron fluids given: d5 1/2 ns. . pain scale: none ___________________________________________________ review of systems: constitutional: all normal fever chills sweats fatigue malaise anorexia night sweats _20____ lbs. weight loss over __2___ months * 6 lbs in last 10 days heent: all normal blurred vision blindness photophobia decreased acuity dry mouth bleeding gums oral ulcers sore throat epistaxis tinnitus decreased hearing tinnitus other: respiratory: all normal sob doe can't walk 2 flights cough wheeze purulent sputum hemoptysis pleuritic pain other: cardiac: all normal angina palpitations edema pnd orthopnea chest pain other: gi: all normal blood in stool hematemesis odynophagia dysphagia: solids liquids anorexia nausea vomiting reflux diarrhea constipation abd pain other: gu: all normal dysuria frequency hematuria discharge menorrhagia skin: all normal rash pruritus ms: all normal joint pain (chronic) jt swelling back pain bony pain neuro: all normal headache visual changes sensory change confusion numbness of extremities seizures weakness dizziness/lightheaded vertigo headache endocrine: all normal skin changes hair changes temp subjectivity recent changes in her thyroid replacement heme/lymph: all normal easy bruising easy bleeding adenopathy psych: all normal mood change suicidal ideation other: all other systems negative except as noted above past medical history: thyroid ca s/p total thyroidectomy parathyroid adenoma s/p resection two parathyroid glands fibromyalgia aortic stenosis avascular necrosis of hips and shoulders, s/p r hip replacement h/o bilateral breast cancer s/p breast reconstruction w implants hypothyroidism asthma h/o non-hodgkin's lymphoma h/o pulmonary fibrosis post xrt for nhl colon polyps social history: single, no children. lives by herself but a male friend stays with her during the week. she rarely drinks etoh. used to smoke cigarettes but quit 19 yrs ago--previously one pack per day for 15 years. she occasionally smokes marijuana but denies other illicit drugs. family history: f- pancreatic ca mother had hypertension and died from an mi at age 62. brother and a sister with hypertension. physical exam: t 99.2 p 102 bp 126/73 rr 19 o2sat 100% ra general: alert, mentating clearly eyes: nc/at, perrl, eomi, no scleral icterus noted ears/nose/mouth/throat: mmm, no lesions noted in op neck: supple, no jvd appreciated respiratory: lungs with decreased bs at r base. cardiovascular: reg s1s2, 3/6 systolic murmur gastrointestinal: soft, + bowel sounds, mildly tender in epigastric and llq. genitourinary: no flank tenderness skin: no rashes or lesions noted. no pressure ulcer extremities: no c/c/e bilaterally, 2+ radial, dp and pt pulses b/l. lymphatics/heme/immun: no cervical, supraclavicular, axillary lymphadenopathy noted. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. -cranial nerves: ii-xii intact -motor: normal bulk, strength and tone throughout. no abnormal movements noted. -sensory: no deficits to light touch throughout. no foley catheter/tracheostomy/peg/ventilator support/chest tube/colostomy psychiatric: pleasant and interactive access: piv pertinent results: #admission labs: 10:00pm wbc-15.9* rbc-4.74 hgb-14.2 hct-45.2 mcv-95 mch-30.0 mchc-31.5 rdw-14.0 10:00pm neuts-79.5* lymphs-9.7* monos-7.0 eos-3.1 basos-0.8 10:00pm plt count-313 10:00pm pt-12.3 ptt-28.2 inr(pt)-1.1 10:00pm glucose-95 urea n-31* creat-1.9* sodium-142 potassium-4.2 chloride-94* total co2-34* anion gap-18 10:00pm alt(sgpt)-16 ast(sgot)-26 ld(ldh)-257* alk phos-67 tot bili-0.4 10:00pm lipase-22 10:00pm albumin-4.8 #pertinent labs: 06:23am blood wbc-45.3* rbc-3.05* hgb-9.0* hct-30.2* mcv-99* mch-29.4 mchc-29.7* rdw-18.5* plt ct-229 06:00am blood wbc-32.6* rbc-3.01* hgb-9.2* hct-29.7* mcv-99* mch-30.4 mchc-30.8* rdw-18.0* plt ct-248 06:05am blood wbc-34.7* rbc-3.43* hgb-10.5* hct-32.7* mcv-95 mch-30.7 mchc-32.2 rdw-17.1* plt ct-277 04:50am blood wbc-19.6* rbc-3.28* hgb-10.0* hct-30.8* mcv-94 mch-30.5 mchc-32.5 rdw-15.9* plt ct-427 07:04am blood wbc-17.6* rbc-4.01* hgb-11.7* hct-37.2 mcv-93 mch-29.2 mchc-31.5 rdw-14.7 plt ct-327 01:22am blood wbc-12.3* rbc-3.67* hgb-11.1* hct-33.7* mcv-92 mch-30.1 mchc-32.8 rdw-14.4 plt ct-298 05:00am blood wbc-14.6* rbc-3.93* hgb-11.7* hct-37.3 mcv-95 mch-29.8 mchc-31.4 rdw-14.1 plt ct-270 06:00am blood neuts-57 bands-8* lymphs-4* monos-8 eos-7* baso-0 atyps-1* metas-2* myelos-6* promyel-7* other-0 04:50am blood neuts-88* bands-4 lymphs-0 monos-2 eos-0 baso-0 atyps-0 metas-3* myelos-3* nrbc-2* 05:51am blood neuts-92.0* lymphs-3.7* monos-3.9 eos-0.3 baso-0.1 05:56am blood pt-13.0* ptt-25.9 inr(pt)-1.2* 06:05am blood pt-13.1* ptt-28.2 inr(pt)-1.2* 05:20am blood pt-14.4* ptt-31.8 inr(pt)-1.3* 01:22am blood pt-16.0* ptt-25.7 inr(pt)-1.5* 06:23am blood glucose-89 urean-110* creat-2.0* na-140 k-4.9 cl-105 hco3-23 angap-17 06:00am blood glucose-94 urean-86* creat-1.6* na-140 k-4.4 cl-105 hco3-25 angap-14 03:42am blood glucose-179* urean-51* creat-1.0 na-141 k-4.0 cl-106 hco3-26 angap-13 08:50am blood glucose-106* urean-59* creat-1.4* na-133 k-3.4 cl-99 hco3-23 angap-14 05:21am blood glucose-109* urean-29* creat-1.2* na-136 k-4.3 cl-93* hco3-31 angap-16 12:11am blood glucose-114* urean-10 creat-1.3* na-140 k-3.5 cl-98 hco3-31 angap-15 #radiology: patient had many studies. please see webomr for more information. #pathology: ct guided core bx diagnosis: omentum, "nodule"; ct-guided needle core biopsy (a): adenocarcinoma, moderately to poorly differentiated (see comment). comment. the carcinoma is immunoreactive for cytokeratin cocktail and cytokeratin 7. it is non-reactive for cytokeratin 20, estrogen receptor, gcdfp, mammoglobin, ttf-1 and cdx-2. give the combined morphologic and immunohistochemical findings potential primary sites include but are not limited to breast, ovary and possibly uterus or upper gi tract. correlation with the clinical an radiologic findings is necessary. preliminary findings phoned to dr. by dr. on saturday th at 12:15 hours. brief hospital course: 51f with h/o bilateral breast ca, thyroid ca, nhl, pulmonary fibrosis s/p xrt, asthma, hypothyrodism, chronic kidney disease stage , presented with worsening vomiting and reflux symptoms and found to have metastatic ovarian cancer. . active issues: # metastatic ovarian cancer resulting in small bowel obstruction: pt presented with refractory vomiting. given the symptoms the pt underwent an egd with biopsies was performed, which showed severe erosive esophagitis and a duodenal stricture of unclear etiology. pathology from gastric and duodenal biopsies was negative for malignancy. to further evaluate the duodenal stricture, a ct torso with contrast was performed. given her ckd stage , pt received pre-contrast hydration protocol with sodium bicarbonate to minimize the risk of contrast-induced nephropathy. unfortunately, the ct scan showed significant evidence of malignancy, with "extensive soft-tissue mass involving the greater omentum. in addition, new hepatic lesions, ascites, and colonic serosal lesion are worrisome for peritoneal metastases from breast or ovarian cancer." interestingly, the etiology of the duodenal stricture was not identified on imaging. ir was consulted for biopsy of the omental-mass, and she underwent ct-guided biopsy on . pathology showed infiltrating adenocarcinoma. special stains showed a primary tumor either from the breast, ovary, uterus or upper gi tract. the oncology team at was consulted and they requested an mri brain, which was negative and a transvaginal us which showed multiple cystic lesions in the left adnexa. oncology also recomended a gyn/onc c/s for possible surgical mangement. the patient had ongoing difficulty tolerating po's and a repeat egd was done which did not show a stentable lesion. for further targeting of a lesion, a gi follow through was done which showed a partial high grade obstruction in the third portion of the duodenum. in the setting of elevated ca 125, an pelvic u/s revealing a ovarian mass and a pathological finding of adenocarcinoma, a diagnosis of metastatic ovarian ca was made. the patient had a g tube placed on that relieved her symptoms of obstruction. the initial attempt at placing a j-tube was unsuccessful and a repeat attempt was performed on , with a repeat attempt on , also unsuccessful. patient continued to deteriorate and by , the family, patient and health care proxy agreed that comfort measures only would be pursued going forward. by the afternoon, her antibiotics, maintenence fluids, and tpn were withdrawn, as were most of her non-essential medications. her comfort was maintained and she passed at 2300 on the night of . . # aspiration pneumonia: became evident when she developed acute hypoxia, tachypnea, and cough on . cxr showed new rml and rll infiltrates, and she was started on levofloxacin. her wbc was persistently elevated and her coverage was changed to vanco/ctx and flagyl which she continued for 10 days. she clinically improved with antibiotics and albuterol nebulizers. she completed the treatment and has since then been stable on 3l nc o2. she was noted to be rhonchorous and has had difficulty generating sufficient expiratory forces to help remove some of the secretions. with chest pt and time, this has steadily improved. she has a history of radiation-induced fibrosis, restrictive lung disease, and persistent r pleural effusions which all lend to a poor respiratory reserve. # atrial fibrillation: went into spontaneous afibrillation on the floor. she was tachypneic, but her blood pressure was holding. housestaff was called to evaluated the patient. she was given dilt (out of concern that beta blockade would worsen her respiratory status), abg was performed but revealed a venous gas. given the fact that her tachycardia was refactory to iv dilt, after receiving additional 90 of po dilt she was transferred to the unit for further management. the afib was attributed to recent aspiration event and was managed with metoprolol and diltiazem. her medications were continued in the icu and as pt's respiratory status and overall clinical status improved, pt re-entered sinus rhythm and was no longer tachycardic. # pleural effusions likley due to structural lung disease with overlying infection. the left pleural effusion was tapped (drained 800cc initially) by the icu team on with some releif of her symptoms. her pleural fluid was negative for malignancy and was transudative according to light's criteria and did not grow any microorganisms. # acute on chronic kidney disease, stage 4: etiology unclear. creatinine peak was 1.9 during this hospitalization and later downtrended to 1.3 before bumping back up to 1.9. # af with rvr: the patient experienced af with rvr while in the icu which was treated with b-blockers and calcium channel blockers. pt was in normal sinus rhythm, not tachycardic when transferred to the floor. # hypothyroidism: recent tsh at . stable on levothyroxine. # htn: stable, continued metoprolol succinate xl 25 mg po daily # depression: stable, continued sertraline 100 mg po daily # symptomatic hypocalcemia: evaluation led to diagnosis of probable hypoparathyroidism (confirm)based on her prior thyroid surgery for thyroid cancer. according to information from osh, the patient has some residual parathryodi tissues??? endocrinology was consulted while in the icu for syptomatic hypocalcemia and she received iv and oral repletion with vit d and caco3. # venous access: obtaining a good venous access has been a substantial challenge given poor peripheral veins. a right picc line was attempted under ir but the ir team could not advance to the svc (likely due to past xrt/lymphadectomy). a midline was placed instead. the midline was difficult . #goals of care/code status: a goals of care meeting was conducted with the patient and a friend where it was shared with the patient that she had a guarded prognosis given her metastatic cancer. quality of life was discussed and the patient voiced her preference to continue to pursue diagnostic tests and discuss treatment options. at the same time, she was interested in meeting with the palliative care physicians to discuss options. this information was also shared with the patients sister in a separate meeting. the patients decided to make herself dnr/dni. discussion while in the icu revealed pt's wish to be dnr but ok to intubate for "short periods." during her last week it was unclear if pt understood meaning of hospice. medications on admission: fluticasone levoalbuterol prn levothyroxine 125 mcg daily toprol xl 25 mg daily sertraline 100mg daily vit d3 mvi discharge disposition: expired discharge diagnosis: cardiopulmonary arrest metastatic ovarian cancer discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Insertion of intercostal catheter for drainage Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Thoracentesis Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Esophagogastroduodenoscopy [EGD] with closed biopsy Insertion of totally implantable vascular access device [VAD] Replacement of gastrostomy tube Phlebography of other specified sites using contrast material Closed [percutaneous] [needle] biopsy of intra-abdominal mass Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Anemia of other chronic disease Esophageal reflux Malignant neoplasm of liver, secondary Unspecified pleural effusion 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 Atrial fibrillation Asthma, unspecified type, unspecified Aortic valve disorders Personal history of malignant neoplasm of breast Depressive disorder, not elsewhere classified Atrial flutter Personal history of other lymphatic and hematopoietic neoplasms Acute respiratory failure Hypotension, unspecified Pneumonitis due to inhalation of food or vomitus Postinflammatory pulmonary fibrosis Hypoxemia Do not resuscitate status Myalgia and myositis, unspecified Examination of participant in clinical trial Personal history of irradiation, presenting hazards to health Leukocytosis, unspecified Unspecified vitamin D deficiency Other esophagitis Orthostatic hypotension Secondary malignant neoplasm of retroperitoneum and peritoneum Hypoparathyroidism Postsurgical hypothyroidism Personal history of malignant neoplasm of thyroid Acquired absence of breast and nipple Malignant neoplasm of ovary Acquired hypertrophic pyloric stenosis Malnutrition of moderate degree Secondary malignant neoplasm of small intestine including duodenum Other obstruction of duodenum Early satiety |
allergies: prednisone / wellbutrin / ativan attending: chief complaint: upper respiratory infection symptoms, progressive shortness of breath major surgical or invasive procedure: none history of present illness: this is a 78 yo woman with history of sclc s/p partial lobectomy, copd, pes s/p ivc filter, hl, s/p cerebral hemorrhage, gait disturbance who presented to ed with c/o 3 days of uri symptoms and progressive sob. also with associated chest congestion and increased sputum production. denies any f/ch, cp, lh, sore throat, myalgia, arthralgia, n/v, diarrhea, rash, dysuria or nasal congestion. her daughter who she lives with has had similar symptoms. she also spends time with her great grandchildren but denies any recent illnesses. has had both seasonal and h1n1 vaccination this year. unsure about prior pna immunization. using home oxygen continuously. . in ed initial vs 98.3, 131/82, 113, 25, 93/ra. she appeared mildly distressed in triage. physical exam notable for scattered wheeze. given 1l ns, foley placed. ed assessment thought to have copd flair, given azithromycin. family refusing steroids given concerned about psychosis. was off cpap for about 1.5 hours approximatley 1700. vs upon 102, 126/59, 28, 95/ra. given albuterol 0.083% neb, ipratropium bromide neb 2.5ml, azithromycin 500 mg tab, magnesium sulfate 2 g iv, ceftriaxone 1g. cxr with some concerning for features of pna so expanded to ceftriaxone. ekg with st to 110 bpm. . upon admission to micu, patient with bipap on, able to communicate. daughter and grandaughter confirm history. patient agrees. she is unsure if she truly had psychosis to steroids but is still hesistant to try. . review of sytems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. no melena or hematochezia. past medical history: 1. history of lung cancer , status-post left lower lobectomy, monitored with routine cxr with no evidence of recurrence 2. copd, chronic obstructive pulmonary disease. 3. hyperlipidemia 4. history of pulmonary embolism, status-post ivc filter placement 5. cerebral vascular disease, left mca aneurysm, small. 6. gait disorder, status-post fall. (pt attributes to prior medications) 7. emotional disorder. history of depression. 8. history of cva right midline superior cerebellar hemorrhage. 9. osteoporosis. 10. cataracts bilaterally 11. constipation . social history: living with one of her daughters, her other daughter lives in the apartment below and checks on her (she is rn and works at a nursing home down the street), retired school secretary, widowed, smoked 2 ppd x 20 years, quit in , no etoh. family history: mother died of sepsis at 62 diverticulitis and bowel perforation, father died of an mi at 74, sister died of an mi at 76, had lung ca, brother died of an mi at 62 physical exam: vitals: 96.2, 119, 124/60, 33, 95 on bipap 24% general: alert, oriented, no acute distress, cachectic appearing woman, tolerating bipap without distress heent: sclera anicteric, limited oropharynx exam face mask lungs: ronchorous b/l anteriorly and posteriorly r>l; no wheeze or rales cv: tachycardic, no appreciable murmurs abdomen: soft, non-tender, non-distended, scaphoid, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: alert and oriented x 3, moving all extremities pertinent results: admission labs: . 11:00am blood wbc-4.9 rbc-4.19* hgb-11.7* hct-37.5 mcv-90 mch-27.9 mchc-31.1 rdw-14.5 plt ct-187 02:51am blood wbc-4.1 rbc-3.93* hgb-11.1* hct-35.8* mcv-91 mch-28.3 mchc-31.1 rdw-14.6 plt ct-174 11:00am blood neuts-83.0* lymphs-11.8* monos-3.7 eos-1.3 baso-0.3 11:00am blood glucose-115* urean-10 creat-0.9 na-140 k-4.1 cl-101 hco3-33* angap-10 02:51am blood glucose-105* urean-10 creat-0.7 na-143 k-3.9 cl-106 hco3-31 angap-10 06:50am blood calcium-8.4 phos-3.5 mg-2.0 . discharge labs: . 08:06am blood wbc-12.3*# rbc-3.71* hgb-11.0* hct-32.9* mcv-89 mch-29.6 mchc-33.4 rdw-14.5 plt ct-364 06:30am blood wbc-5.9 rbc-3.92* hgb-10.9* hct-34.3* mcv-88 mch-27.9 mchc-31.9 rdw-14.1 plt ct-338 08:06am blood glucose-85 urean-12 creat-0.6 na-141 k-3.7 cl-96 hco3-34* angap-15 06:45am blood calcium-10.0 phos-4.0 mg-2.1 . blood cultures negative x4 through admission cdiff negative x1 . ekg baseline artifact. sinus tachycardia. consider right atrial abnormality. low limb lead qrs voltage. indeterminate axis. late precordial qrs transition. findings suggest chronic pulmonary disease. clinical correlation is suggested. since the previous tracing of there is probably no significant change but baseline artifact makes comparison difficult. tracing #1 read by: , w. intervals axes rate pr qrs qt/qtc p qrs t 110 136 100 320/407 90 61 37 . ekg baseline artifact. sinus tachycardia. consider right atrial abnormality. low limb lead qrs voltage. indeterminate axis. delayed r wave progression with late precordial qrs transition. findings suggest chronic pulmonary disease. clinical correlation is suggested. since the previous tracing of same date there is probably no significant change although baseline artifact on both tracings makes comparison difficult. tracing #2 read by: , w. intervals axes rate pr qrs qt/qtc p qrs t 103 146 94 338/413 86 82 18 . cxr ap and lateral radiographs of the chest are partially obscured by overlying tubes. changes of left upper lobectomy are seen with left hilar clips, scarring, volume loss, and compensatory hyperexpansion. there are new opacities in the right middle lobe, probably representing pneumonia, or less likely aspiration. there is no pleural effusion or pneumothorax. the cardiomediastinal silhouette is unremarkable. note is made of calcifications in the aortic arch. an ivc filter is noted in the upper abdomen. multiple old rib fractures are noted on the right. the remainder of the osseous structures and soft tissues appear unremarkable. impression: new right middle lobe opacities consistent with pneumonia versus aspiration. . cxr findings: single bedside ap examination labeled "semi-upright at 8:40 a.m." is compared with two views of . again demonstrated is evidence of underlying emphysema with bullous changes involving both lung apices, as well as past left upper lobectomy with architectural distortion and volume loss involving the left lung. there is now more confluent airspace opacity involving the mid-right lung base, which may represent organizing pneumonia of the right middle lobe; the remainder of this lung is clear. the distorted cardiomediastinal silhouette is unchanged and there is no pleural effusion or pulmonary vascular congestion. again demonstrated are the ivc filter and gas-filled bowel loops in the upper abdomen. impression: 1. persistent findings involving the right lung base, not clearly present on , suggestive of organizing pneumonia. 2. underlying bullous emphysema, status post left upper lobectomy. . portable abdomen findings: multiple nondistended air-filled loops of small and large bowel are present throughout the abdomen. there is a large amount of stool within the large bowel, predominantly within the ascending colon. an ivc filter is present at the level of the l2 vertebral body. there is a density overlying the region of the right middle lobe on the included view of the chest, compatible with consolidative process. there is no acute fracture or dislocation. multiple metallic clips within the lower abdomen denote prior history of surgery. impression: 1. large amount of stool within the colon, predominantly within the ascending colon. 2. multiple nondistended air-filled loops of small and large bowel, within normal limits. . cxr findings: in comparison with study of , the lungs are now essentially clear. mild elevation of the left hemidiaphragmatic contour is again seen. apparent post-surgical changes are again seen in the left upper zone with upward retraction of the hilum and displacement of the trachea to this side. of incidental note is an ivc filter in place. . ct chest without contrast findings: emphysema is severe. left hilus and bronchial stump have a normal postoperative appearance following upper lobectomy more than seven years ago. a large, partially calcified soft tissue conglomerate at the right lung apex is a large scar stable since . the new findings are multiple areas of irregular opacification, ground-glass in the anterior segment of the right upper lobe and middle lobe, bronchial wall thickening in the right lower lobe, and a combination of ground-glass opacification and interstitial thickening in the left lung base. findings are most consistent with multifocal pneumonia, probably viral, shown by the findings on recent conventional radiographs to be improving. central lymph nodes are not pathologically enlarged, and there is no pleural abnormality. tiny pericardial effusion is new, but probably of no clinical significance. the pulmonary arteries are normal size. atherosclerotic calcification is very heavy, particularly at the origin of the left subclavian artery, left main and anterior descending coronary arteries, and the imaged portion of the abdominal aorta. impression: 1. no evidence of intrathoracic malignancy. 2. probable resolving viral pneumonia, alternatively recurrent aspiration. 3. severe emphysema 4. severe atherosclerosis, most marked in left coronary and left subclavian arteries and abdominal aorta. brief hospital course: briefly, 78yof with h/o sclc s/p partial lul lobectomy, copd, pes s/p ivc filter, hl, s/p cerebral hemorrhage, gait disturbance who presented with 3 days of chest congestion and sob and found to have a new rml pneumonia causing a copd exacerbation. . # chest congestion, sob: history and physical exam most concerning for new pneumonia, possibly with mild copd exacerbation as a consequence. with h/o of pe, but history inconsistent. could also consider influenza but no fever, n/v, diarrhea or ha. no sick contacts beyond daughter with uri. last spirometry with fev1/fvc 53. steroids were initially held on admission and patient tolerated bipap. upon rehydration, cxr became more convincing for pneumonia. patient was started on community acquired pneumonia treatment with azithromycin and ceftriazone and completed full course by discharge. she was also continued on ipratropium, albuterol nebs and supplemental oxygen (face mask) as needed. sputum and blood cultures were ordered and patient's symptoms were managed with tessalon perrles and guaifenesin. on was transferred out of the icu but decompensated overnight prompting return to icu. she was then started on inhaled pulmicort steroids and tolerated this well without any evidence of psychosis despite prior history of this with systemic steroids. once improved, she transferred back to the regular medicine . . on the medicine floor, pt had several more episodes of respiratory distress and hypoxia, however did not necessitate further micu stays. these episodes were managed with aggressive albuterol and ipratropium nebulizers every six hours scheduled with albuterol as needed every 2 hours and ipratropium as needed every 4 hours and also small dose morphine 0.5 to 1 mg iv as needed for anxiolysis of air hunger, which worked well. if she has any further episodes of sob, would consider nebulizers and small amts of morphine. . furthermore, long acting beta agonist salmeterol and montelukast were added; however on discharge to rehab, montelukast was stopped she could switch to a combined advair (salmeterol and fluticasone). she was also continued on guaifenesin and tessalon perles. she was given an acapella device and an incentive spirometer and should continue to use these. . she has completed a 9 day course of ceftriaxone and azithromycin for cap. . pulmonology was consulted and ct was obtained with results as above. they recommended a trial of bipap at night which the pt did not tolerate well. also recommended n-acetylcysteine (mucomyst) nebs every 8 hours which were started. prednisone, low dose 20 mg daily, was also started cautiously as pt had h/o psychosis to systemic steroids. she received 2 doses while admitted and should continue for a total of 5 days to end on . her mental status should be monitored while on prednisone. of note, her wbc count rose from 5 to 12 on the day of discharge, which is an appropriate response to her taking the prednisone. . by the time of discharge the pt had not had any acute episodes of respiratory distress for several days. her lung sounds are chronically rhonchorous, but the wetness of her breathing had significantly improved. she was stably satting in the mid 90's on 2l and was satting well on room air as well. . # altered mental status. patient become somnolent and difficult to arouse on am following the administration of ativan 0.5 mg overnight for shortness of breath and insomnia. this was reversed with flumazenil while monitored in the icu setting without any adverse consequences. this medication was added to her allergy list and should be avoided in the future. . # fevers: on the day before discharge, the pt developed a fever to 101 with no other localizing symptoms. blood cultures were gathered which were negative to date. the ceftriaxone and azithromycin were not broadened and the fever resolved by discharge but should be monitored. . # tachycardia. likely multifactorial including albuterol, anxiety and possibly dehydration. patient with flat neck veins. no po intake since day prior to admission. on admission, patient was rehydrated with ivf and resolved. on call out to the general medicine , the pt was consistently with pulses in the low 100's, regular sinus rhythm by ekg. . # bowel changes: the pt was constipated through admission and started on aggressive bowel regimen, after which she developed diarrhea. in the setting of antibiotics and a new fever, c. difficile assay was tested and negative. her bowel regimen was stopped and her diarrhea should be further assessed. . # h/o depression. continued on home nortriptylline . # hyperlipidemia. stable. continued on home statin. . communication: patient and hcp, daughter, , rn, code: dnr/dni (confirmed on admission) medications on admission: tiotroprium daily albuterol mdi prn nortriptyline 75 mg po/ng hs atorvastatin 10 mg po/ng hs namenda 10 mg oral aspirin 81 mg po/ng daily acetaminophen 325-650 mg po/ng q6h:prn docusate sodium 100 mg po bid discharge medications: 1. nortriptyline 25 mg capsule sig: three (3) capsule po hs (at bedtime). 2. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours). 4. atorvastatin 10 mg tablet sig: one (1) tablet po hs (at bedtime). 5. memantine 5 mg tablet sig: two (2) tablet po bid (2 times a day). 6. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain or fever > 101. 8. guaifenesin 600 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). 9. prednisone 20 mg tablet sig: one (1) tablet po once a day for 3 days: please complete a 5 day course on . 10. advair diskus 500-50 mcg/dose disk with device sig: inhalations inhalation twice a day. 11. acetylcysteine 20 % (200 mg/ml) solution sig: one (1) nebulizer treatment miscellaneous q 8h (every 8 hours). 12. sodium chloride 0.65 % aerosol, spray sig: sprays nasal prn (as needed) as needed for nasal dryness. 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q2h (every 2 hours) as needed for shortness of breath. 14. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q4h (every 4 hours) as needed for shortness of breath. discharge disposition: extended care facility: hospital - discharge diagnosis: bronchopneumonia, ? viral vs bacterial copd exacerbation history of pulmonary embolism history lung ca s/p lul resection history of cva 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 with difficulty breathing and found to have pneumonia thought to exacerbate your underlying copd. you were given antibiotics, breathing treatments, and steroids with improvement in your symptoms. you are being discharged to an acute care rehab for continued recuperation. . while here you also had diarrhea and a fever, but there was no evidence of any infection in the stool or urine. you did complete a course of antibiotics (ceftriaxone and azithromycin) for pneumonia, as described above. these may have contributed to the diarrhea. . the following changes were made to your medication regimen. these medications will be managed by the rehab where you go and they will finalize your medication regimen for home when you leave: 1. hold tiotropium daily. this could be restarted when you return home, however while you are at rehab, you will be given different but similar breathing treatments. 2. start mucinex 600 mg twice daily 3. start prednisone 20 mg daily, to complete a 5 day course on 4. start n-acetylcysteine (mucomyst) nebulizer treatments every 8 hours as needed 5. start advair diskus inhalations twice a day 6. start albuterol nebulizer (instead of your albuterol inhaler), use treatments every 6 hours, with an additional nebulizer every 2 hours as needed 7. start ipratropium nebulizer treatments every 6 hours, with an additional nebulizer every 4 hours as needed followup instructions: please follow up with your primary care doctor, md, on wednesday at 10:30 am in the medical office building, of , . you also have an appointment with dr. in pulmonology on: date/ time: 7:30am location: building , ma phone number: md, Procedure: Non-invasive mechanical ventilation Diagnoses: Pneumonia, organism unspecified Acidosis Anemia, unspecified Personal history of malignant neoplasm of bronchus and lung Obstructive chronic bronchitis with (acute) exacerbation Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Osteoporosis, unspecified Other constipation Personal history of venous thrombosis and embolism Unspecified accident Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Diarrhea Injury to bladder and urethra, without mention of open wound into cavity Dehydration Foreign body in main bronchus |
allergies: cefepime attending: chief complaint: biliary colic major surgical or invasive procedure: ercp w/ sphincterotomy open cholecystectomy history of present illness: 46m with history of biliary colic, morbid obesity, htn, lower extremity edema , who presents directly from ercp where he underwent ercp and sphincterotomy. pt tolerated the procedure well. prior to the ercp pt was admitted to hospital for severe recurrent epigastric pain after eating, lasting hours, in the setting of elevated transaminases (ast:alt 370:447 ap 166, tb 4, lipase 22 ). pt does have history of similar pain just a few days prior as well as approx one year ago which resolved on its own. on and again on pt underwent ruq u/s which showed cholelithiasis but no evidence of cholecystitis. pt denies fever at any point, but does admit to recent nausea and vomiting. past medical history: obesity, depression, hypothyroidism, lower extremity edema, biliary colic social history: lives alone in , unemployed. denies cigs or drugs, +etoh (1-2 drinks a night) family history: noncontributory physical exam: upon presentation: vs: 97.6, 128/85, 68, 18, 93% ra gen: a&o, nad heent: no scleral icterus, mucus membranes dry cv: rrr, no m/g/r pulm: clear to auscultation b/l, abd: soft, obese, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses ext: severe le edema. psych: flat affect. pertinent results: renal & glucose glucose 78 urea nitrogen 9 6 - 20 mg/dl creatinine 0.6 0.5 - 1.2 mg/dl sodium 136 133 - 145 meq/l potassium 3.8 3.3 - 5.1 meq/l chloride 100 96 - 108 meq/l bicarbonate 27 22 - 32 meq/l enzymes & bilirubin alanine aminotransferase (alt) 206* 0 - 40 iu/l asparate aminotransferase (ast) 98* 0 - 40 iu/l alkaline phosphatase 121 40 - 130 iu/l bilirubin, total 0.6 0 - 1.5 mg/dl other enzymes & bilirubins lipase 24 0 - 60 iu/l chemistry calcium, total 8.4 phosphate 3.3 magnesium 2.0 imaging: ercp: a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire.cbd was sweeped with balloon catheter and sludge was extracted. impression: normal major papilla cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. contrast medium was injected resulting in complete opacification. cbd and intrahepatic biliary tree was normal in calibre. there was a filling defect that appeared like sludge in the distal cbd. a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. cbd was sweeped with balloon catheter and sludge was extracted. ble duplex u/s: no evidence of dvt in bilateral lower extremities. ct torso (non-con): impression: 1. bilateral heterogeneous opacification in the lungs, worst in the left lower , represent atelectasis; however, underlying infectious process such as pneumonia or aspiration cannot be completely excluded and should be considered in the correct clinical setting. 2. status post cholecystectomy with percutaneous biliary drain. 3. fat-containing ventral periumbilical hernia and a fluid filled right inguinal hernia. ct torso (w/ con): impression: 1. nondiagnostic examination in the evaluation of pulmonary embolism secondary to respiratory motion artifact. 2. no evidence of venous clot in the iliac veins or veins of the pelvis. 3. increasing size and number of lymph nodes both in the mediastinum and right inguinal area. clinical correlation recommended to exclude low grade hematologic malignancy. 4. areas of consolidation in bilateral lung bases and in the right upper may be on the basis of atelectasis, although superimposed infection or central obstructing lesion cannot be excluded based on this examination. echo: technically suboptimal study despite the use of definity. no clinically useful information was derived. if clinically indicated, a radionuclide ventriculogram may be better able to assess biventricular systolic function. brief hospital course: he was admitted to the acute care surgery service as a direct admission following ercp. he was given iv hydration and made npo. his lft's and bilirubin were followed closely and slowly trended downward. early discussions took place with patient for operative management with cholecystectomy for which patient wanted to discuss further with team and his family before definitively consenting for this. on the he underwent a laparoscopic converted to an open cholecystectomy. pod #1 his urinary output dropped and he received fluid along with 1 unit prbc with adequate urinary response. on pod #2 he was advanced to a regular diet. he continued to do well. however, overnight he began to drop his o2 sats and became tachycardic. in addition, his cr rose to 1.6 from 0.9 the day before. a cxr was performed which showed mild pulmonary vascular congestion. he was given a dose of lasix with no response. an abg revealed hypoxemia with po2 of 65. given the concern for pe and his ongoing hypoxia, he was transferred to the icu for close monitoring. a cta chest with pe protocol was unable to be performed because the patient's cr had bumped to 1.9. therefore, a ct torso without contrast was performed which showed a bilateral lower opacification (l>r) but was otherwise unremarkable. ble duplex u/s was negative for dvt. while in the unit, he became hypotensive with systolic blood pressures ranging between 70s-80s. he was empirically started on vanc/zosyn. the next day (), his antibiotics were changed to vanc/cipro/cefepime to cover hospital acquired pneumonia. an ngt was placed with immediate return of 500 cc of coffee ground fluid; his hct was found to be 22.8. he was transfused 2 units of prbc's. gi team was consulted regarding a potential upper endoscopy. however, they felt egd would require elective intubation and therefore the procedure was deferred. the patient was aggressively fluid resuscitated and his urine output remained adequate. the following day his cr dropped to 1.3 and he was sent for a cta with pe protocol which was indeterminate for pe due to motion artifact but did not show thrombus in the aortoiliac or pelvic veins. serial hct were trended and remained stable. an echo was attempted but the quality was suboptimal secondary to the patient's large body habitus. he still had a significant supplemental oxygen requirement. over the next few days in the icu his respiratory status remained tenuous. he was started on intermittent lasix boluses which resulted in large diuresis and he was able to be weaned to nasal cannula. on , he was started on 20mg po lasix daily and was given 40mg iv lasix as well as a dose of diamox. he again responded with a brisk diuresis but then became hypotensive overnight requiring 2.5l of fluid boluses. his hct in the am was 21 and he was transfused one unit prbc's. the patient also developed an urticarial rash on and this was attributed to having switched his cipro from iv to po. the cipro was therefore discontinued and he was started on levofloxacin. his rash has virtually resolved at time of this dictation. he remained on the vancomycin and levofloxacin for the pneumonia for a total of 7 day course, stop date . he is also receiving flagyl for a presumed c. difficile colitis given his stool volume. it should be noted that he has had 2 negative stool for c. diff cultures. his treatment with flagyl will continue for a total of 7 day course. a flexi seal system was placed rectally for stool containment and protection of patient's skin given his large body habitus. cholestyramine was started as well. he was also seen by psychiatry for his anxiety and depression and it was recommended to increase his celexa to 40 mg daily from 30 mg and to avoid benzodiazepines as this would put him at risk for delirium. he was evaluated by physical therapy and is being recommended for rehab after his acute hospital stay. medications on admission: lisinopril 10mg po daily levothyroxine 137 mcg po daily lasix 20 mg po daily celexa 30 mg po daily discharge medications: 1. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 137 mcg tablet sig: one (1) tablet po daily (daily). 3. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 4. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 6. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation every six (6) hours. 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 8. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 9. levothyroxine 75 mcg tablet sig: two (2) tablet po daily (daily). 10. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for pruritis. 11. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). 12. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 13. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 14. miconazole nitrate 2 % powder sig: one (1) appl topical three times a day: apply to skin folds. 15. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 16. cholestyramine-sucrose 4 gram packet sig: two (2) packet po bid (2 times a day). 17. vancomycin 1500 mg iv q 12h start: stop date 18. levofloxacin in d5w 750 mg/150 ml piggyback sig: seven y (750) mg intravenous q24h (every 24 hours): stop date . 19. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback sig: five hundred (500) mg intravenous q8h (every 8 hours): stop date . 20. insulin regular human 100 unit/ml solution sig: one (1) dose injection four times a day as needed for per sliding scale. discharge disposition: extended care facility: hospital - discharge diagnosis: choledocholithiasis upper gastrointestinal bleed acute blood loss anemia pneumonia anxiety depression discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hopsital with gallstones and underwent a procedure called an ercp which looks inside of your biliary system. you then had your galbladder removed. you did well in the post operative period and your diet was advanced. you should avoid fried and/or greasey foods; food choices should include those that are low in fat. you may resume your home medications as prescribed. if you have been prescribed an anitibiotic please continue the course as directed. return to the emergency room if your symptoms come back. followup instructions: follow up in weeks in acute care surgery clinic. please call for an appointment. follow up with your primary care providers as directed. Procedure: Arterial catheterization Cholecystectomy Endoscopic retrograde cholangiopancreatography [ERCP] Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Acute posthemorrhagic anemia Pulmonary collapse Dysthymic disorder Hemorrhage complicating a procedure Morbid obesity Dermatitis due to drugs and medicines taken internally Hypoxemia Hemorrhage of gastrointestinal tract, unspecified Accidents occurring in residential institution Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Laparoscopic surgical procedure converted to open procedure Other drugs and medicinal substances causing adverse effects in therapeutic use Adjustment disorder with anxiety Calculus of gallbladder and bile duct with acute and chronic cholecystitis, with obstruction Other specified pervasive developmental disorders, current or active state Unspecified delay in development Body Mass Index 60.0-69.9, adult |
allergies: hayfever attending: chief complaint: hcv cirrhosis major surgical or invasive procedure: orthotopic liver transplant history of present illness: 56m with a history of hep c diagnosed twenty years ago on routine testing complicated by cirrhosis, variceal bleeding with banding, three hepatomas s/p ablation on and biopsy confirmed hcc s/p rfa. the patient is a child's class b with a meld of 22 who is pre-op for olt. past medical history: 1) hcv with cirrhosis- genotype 1, nonresponder to pegifn/rbv therapy; complicated with variceal bleed x 1 with banding; hepatic monitoring has revealed intrahepatic lesions suspicious for hcc and has undergone rfa ablation to 2. 2) mixed cardioperfusion defects on screening sestamibi. 3) dm- well controlled 4) cervical spine disc disease with radiculopathy 5) htn 6) diverticulosis psh: tonsillectomy, adenoidectomy, hepatoma etoh ablation () social history: works as a mailman. he is married. denies drug, alcohol or tobacco use. family history: family history is significant for a brother with bipolar disorder, sister with and infantile paralysis and another brother who is alive and healthy. physical exam: vs: 97.6 123/78 67 18 99 ra general: well developed pulm: ctab cardio: rrr, no m/r/g clear s1, s2 abd: soft, obese, non tender, bowel sounds present, no hernias or masses rectal: stool in vault, no masses, g negative ext: warm well perfused, palpable dp pulses bilaterally, no edema pertinent results: alt(sgpt)-70* ast(sgot)-92* alk phos-255* tot bili-0.9 fibrinogen-330 pt-15.8* ptt-28.5 inr(pt)-1.4* albumin-3.1* glucose-405* urea n-19 creat-1.2 sodium-132* potassium-4.9 chloride-102 total co2-24 anion gap-11 hepatic duplex ultrasound: the liver demonstrates a normal echotexture. the hepatic veins and portal veins are all patent and show directionally appropriate flow. the hepatic artery demonstrates normal arterial waveforms without evidence of parvus tardus. resistive indices range from 0.5 to 0.6. gravity cholangiogram through roux tube: unable to visualize biliary structures or jejunum through roux tube injection, final read pending. brief hospital course: mr. was admitted on and taken to the operating room for olt on . please see dr. or note for details. he was admitted to the sicu postop and remained hemodynamically stable. duplex u/s on shwed patent vessels and no evidence of fluid collection. he was bolused 1.5l ivf for low uop, sedation was weaned and he was extubated. he received 2 amps of bicarbonate for metabolic acidosis with improvement and he continued on the liver transplant pathway. the patient was tranferred to the floor on . both jp drains remained serosanguinous. the lateral jp and ngt were removed on . the patient was ambulating independently and tolerating a diet. endocrine was consulted for elevated blood sugars. he was started on 30 units lantus qam and an insulin sliding scale. gravity cholangiogram was obtained on which was unable to visualize the jejunum or biliary structures. jp drain was removed prior to discharge and 2 sutures were placed, without evidence of leak. patient was discharged home with roux drain in place with instructions to follow up with dr. in clinic. medications on admission: vitamin d3-calcium carbonate ', celexa 20', welchol 3 tabs am, 4 tabs pm, humalog, nortryptiline 50', asa 81', nadolol 160', mvi,lasix 40', amlodipine 10', tylenol 1000'', mvt ' discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*30 capsule(s)* refills:*0* 2. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). tablet(s) 3. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 4. nortriptyline 25 mg capsule sig: two (2) capsule po hs (at bedtime). 5. prednisone 5 mg tablet sig: four (4) tablet po once a day. 6. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 7. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 8. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 9. tacrolimus 1 mg capsule sig: three (3) capsule po q12h (every 12 hours) for 2 doses. 10. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain for 10 days: do not drive while taking pain medication. disp:*30 tablet(s)* refills:*0* 11. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 12. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 13. insulin glargine 100 unit/ml solution sig: thirty (30) units subcutaneous qam with breakfast: hold if blood glucose is less than 110. disp:*qs units* refills:*2* 14. insulin lispro 100 unit/ml cartridge subcutaneous discharge disposition: home with service facility: discharge diagnosis: hepatitis c virus cirrhosis, status post orthotopic liver transplant discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: please call the transplant office if you have any of the following warning signs: fever, chills, nausea, vomiting, inability to take any of your medications, increased abdominal pain, please call to schedule an appointment. you will then need to have blood drawn every monday and thursday at , office medical building . no driving while taking pain medication. no heavy lifting/straining for six weeks. followup instructions: provider: , md phone: date/time: 12:50 provider: , md phone: date/time: 2:20 provider: , transplant social work date/time: 2:00 follow-up with for management of your diabetes Procedure: Other transplant of liver Other cholangiogram Anastomosis of hepatic duct to gastrointestinal tract Other operations on lacrimal gland Transplant from cadaver Diagnoses: Acidosis Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Portal hypertension Polyneuropathy in diabetes Malignant neoplasm of liver, primary Esophageal varices in diseases classified elsewhere, without mention of bleeding Diverticulosis of colon (without mention of hemorrhage) Background diabetic retinopathy Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled Personal history of colonic polyps Degeneration of cervical intervertebral disc |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sah major surgical or invasive procedure: : rt evd : distal l ica aneurysm coiling : peg placment history of present illness: 52f w/o pmh, reportedly collapsed in early evening of ; transported to osh where whe was intubated; head ct showed diffuse sah; tx to for definitive treatment past medical history: none social history: unknown family history: unknown physical exam: on admission: 102/64 107 20 100% intubated, not sedated. pupils: 3 mm, trace reactive, bilat. no eye opening. no vocal response. motor: internal rotation/flexion of ue to stim, symetrically. min. withdrawal le to stim, symetrically. dtrs 2+ throughout and symetric; toes downgoing; tone: normal; on discharge: xxxxxxxxx pertinent results: labs on admission: 10:38pm blood wbc-14.9* rbc-3.83* hgb-12.5 hct-39.2 mcv-102* mch-32.7* mchc-31.9 rdw-12.8 plt ct-258 10:38pm blood neuts-73.8* lymphs-21.1 monos-3.9 eos-0.7 baso-0.5 04:28am blood pt-13.9* ptt-23.7 inr(pt)-1.2* 10:38pm blood glucose-245* urean-22* creat-0.9 na-140 k-3.5 cl-105 hco3-20* angap-19 04:28am blood ck(cpk)-304* 04:28am blood ctropnt-0.96* 12:31pm blood ck-mb-21* mb indx-6.2* ctropnt-0.51* 09:36pm blood ck-mb-12* mb indx-4.5 ctropnt-0.31* 02:55pm blood ctropnt-0.13* 10:38pm blood calcium-7.5* phos-5.2* mg-2.0 labs on discharge: xxxxxxxxxxxxxx imaging: cta head : impression: diffuse subarachnoid hemorrhage as described above with a multilobulated left ica terminus aneurysm measuring approximately 4 x 6 mm as the presumed source. traditional angiography pending. cardiac echo : conclusions overall left ventricular systolic function is severely depressed (lvef= 20--25%). there is severe regional left ventricular systolic dysfunction with akinesis of mid-to-apical myocardioum. basal and apex areas are spared. right ventricular chamber size and free wall motion are normal. the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. the number of aortic valve leaflets cannot be determined. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. impression: severe left ventricular systolic dysfunction (ef 20-25 %) with regionality; akinesis of mid-to-apical walls with sparing of the apex. right ventricular systolic function and size is normal. moderate to severe (3+) tricuspid regurgitation. ct c-spine : impressions: 1. no acute traumatic injury seen in the cervical spine. 2. blood in the basal cisterns tracking inferiorly and anteriorly along the brainstem and upper spinal cord. thecal sac contents are not adequately assessed on the present study. mr can be considered if there is concern based on neurological examination. 3. airspace consolidation in the posterior lung apices with smooth septal thickening. findings along with chest radiograph likely represents some pulmonary edema, although aspiration cannot be excluded. ct head : findings: the diffuse subarachnoid hemorrhage appears stable in extent. overall, ventricular size has further decreased, compared to the prior study. the ventriculostomy catheter terminating in the region of the third ventricle remains present. there has been further interval progression of bilateral regions of hypoattenuation involving the medial inferior frontal lobes. there is no associated parenchymal hemorrhage. there is no shift of normally midline structures. the streak artifact produced by left distal internal carotid artery coils obscures evaluation in area. the -white matter differentiation is preserved. trace intraventricular hemorrhage layering posteriorly in the occipital horns as well as small amount in the third ventricle are stable. the mastoid air cells and imaged paranasal sinuses remain well aerated. impression: 1. slight decrease in ventricular size, compared to the prior study. 2. further evolution of bifrontal hypoattenuation, which may represent infarcts rather than non-hemorrhagic contusion, given the progression. no parenchymal hemorrhage. mr head can be considered, if necessary to assess extent and vessels as recommended earlier. 3. stable extent of diffuse subarachnoid hemorrhage. cxr final report indication: 52-year-old female with subarachnoid hemorrhage, dilated cardiomyopathy. evaluate for pulmonary edema. single ap chest radiographs compared to 13 hours prior shows no change. et tube tip is 2.3 cm above the carina. left internal jugular central venous catheter terminates in the mid svc. the ng tube tip is in the stomach, the sidehole slightly below the gastroesophageal junction. the cardiomediastinal silhouette is stable. again seen are bilateral perihilar opacities consistent with pulmonary edema, not significantly changed from prior exam. there is no pneumothorax or pleural effusion. impression: compared to prior exam from , there is no change in the extent of pulmonary edema. cardiac echo : conclusions 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. right atrial appendage ejection velocity is good (>20 cm/s). no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is severely depressed (lvef= 20-25 %). with mild global free wall hypokinesis. with focal hypokinesis of the apical free wall. there is no mass/thrombus in the right ventricle. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. trivial mitral regurgitation is seen. there is borderline 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 , left ventricular systolic function has improved. akinesis of mid-to-apical walls with sparing of the apex has resolved. final report portable chest : comparison: study of earlier the same date. indication: feeding tube assessment. findings: feeding tube tip is directed cephalad in region of gastroduodenal junction. appearance of the chest is similar to the recent radiograph of about 2 hours earlier except for minimal improved aeration in the left retrocardiac region. 12:25 pm ct head ct: axial imaging was performed through the brain without iv contrast administration. comparison: ct head . findings: there is a tract of hypodensity extending along the course of the prior right frontal approach ventriculostomy catheter (2:13). there is no hyperdensity along this tract to suggest the presence of hemorrhage. the ventricles are unchanged in size and configuration. there is streak artifact from a left ica aneurysm coil. -white matter differentiation remains well preserved. there is no evidence of prior subarachnoid hemorrhage. there is no shift of normally midline structures. there is hypodensity in the territory of the left mca related to prior infarct (2:15), which appear stable without evidence for hemorrhagic transformation. there is a right frontal burr hole otherwise osseous structures are intact. the paranasal sinuses, ethmoid, and mastoid air cells are clear. impression: 1. post-right frontal approach ventriculostomy catheter removal without evidence for hemorrhage. stable ventricular size. 2. unchanged appearance to region of infarction in the left mca distribution without hemorrhagic transformation. sat 12:08 pm final report indication: 52-year-old female with transaminitis and fevers. evaluate right upper quadrant. comparison: ct chest dated . findings: the liver is normal in contour and echotexture. there is a single 1.2-cm cyst identified in the periphery of the right dome. there are no other focal liver lesions identified. there is no intrahepatic or extrahepatic biliary ductal dilatation. the common bile duct measures 5 mm. the gallbladder is unremarkable, with no wall thickening, no pericholecystic fluid. there are no stones or sludge identified within the gallbladder. there is normal antegrade flow identified in the main portal vein. the spleen measures 8.7 cm and is normal in appearance. there is no free fluid in the abdomen. small right pleural effusion is noted. impression: 1. 1.2-cm cyst in the right lobe of the liver, as appreciated on ct of the chest dated . liver is otherwise unremarkable. 2. no son evidence for acute cholecystitis. no cholelithiasis. brief hospital course: 52f admitted to after transfer from osh following a witnessed syncopal episode. head ct performed showing diffuse sah. cta of head also performed with preliminarily identified an aneurysm at the left ica bifurcation. she was loaded with dilantin, and started on nimodipine, and emergent bedside external ventricular drain was placed. she also had a cardiac echo done for concerns of a catacholamine induced cardiomyopathy(had developed pulmonary edema), which showed significantly depressed cardic function. she was placed on a monitor to more closely monitor for this. she had an angiogram done on , when the left distal ica aneurysm was coiled. she then returned to the icu postoperatively. on (overnight) she had a icp elevation to 50 and the drain was promplty dropped to 10cm, and icp normalized. emergent head ct was done which showed likely evolving brifrontal hypoattenuations/possible stroke. she again returned to angio on to further evaluate vascualar patency given this new ct finding.the patient was febrile with a tmax 101.6 and was pan cultured,the urine and cerebral spinal fluid cultures were both neagtive. on the dobutamine intravenous drip was off, vasopressors levophed and neo cont. the nimodipine cut in to maintain goal blood pressures. the patient was brought to angio, there was no significant spasm and given 5mg verapamil-aneurysm stable. blood cultures were found to be negative. the sputum culture was positive for rare yeast.on : the patient had an acute pao2 decrease to 50%. there was a concern for pulmonary emboluse. the cta of the chest was not consistent with pulmonary embolus. the ct head was unchanged. the patient was moniotored for possible central diabetes insipidus. the urine and sputum cultures were both negative. on , the patient was pan-cultured for a fever to 102. a head ct ordered for elevated icp to 44, mannitol was initiated for increased icps. a cta was performed which was consistent with a slight decrease in intercranial vasospasm. on , the patient required 3 doses of mannitol for sustained icp levels of 23. there were no changes in the patients mental status with these icp increases.on exam the patient was intermitently following commands in the right upper extremity, the left upper extremity moved to command, the left lower extremity and right upper extremity withdrew to pain,the patients eyes were open and tracked with her eyes. on , the patient was back on a dobutamine gtt continuously to maintain a goal blood pressure, the patient had a tee which was consistent with ejection f of 20%. the lenis were negative for deep vein thrombosis, the csf and sputum cultures were negative. on , the patient underwent an angio which was consistent with mild to mod vasospasm. she recieved 2 doses of verapamil.nimodipine at 15mg every 2 hours was restarted. on , the patient was bolused with dilantin 300mg for a 7.9 level. the head ct was repeated and was stable. the patient was extubated and stopped nimodpine for systolic blood pressure in 60's.the goal map > 100 and dobutamine was restarted. ct shows:new stroke in the posterior left mca distribution cta shows diffuse, severe vasospasm involving the bilateral mcas (left worse than right)the following day she underwent a cerebral angiogram which showed mild to moderate spasm left a1,2 and m1,2 segments though her exam seemed to slightly improve with brisk localization on lue and localization on rue though not as brisk as left. she had some intermittent eye opening. a stroke neurology consult was obtained and they agreed with our continued hhh management and requested starting a statin. on , she was again febrile, and pan cultured. cvl access was changed and catheter tip sent. or was cancelled for the day for her temperature, and possibly to re-attempt or if afebrile and no positive cultures. positive blood cx from arterial line and appearance of axillary a line, concerned for line infection and she was treated for line associated bacteremia for 7 day course. peg placed by surgery team on without event. meds and diet were advanced through peg as recommended without issue. on discharge her neurological exam she preferred her eyes closed would open to voice, questionable following commands with left side. she is essentially plegic on right side but will withdraw both arm and leg to pain. her pupils are 4mm and reactive, her incision are well healed. she was tolerating her tube feeds without difficulty. speech and swallow recommends video swallow before initiating any oral feeds. medications on admission: unknown discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fevers. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). 5. ibuprofen 100 mg/5 ml suspension sig: one (1) po q8h (every 8 hours) as needed for fever. 6. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for stridor. 8. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for rash. 9. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 10. levetiracetam 100 mg/ml solution sig: one (1) po bid (2 times a day). 11. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day) as needed for constipation. 12. senna 8.6 mg tablet sig: one (1) tablet po daily (daily) as needed for constipation. 13. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 14. bupropion hcl 75 mg tablet sig: one (1) tablet po bid (2 times a day). 15. aspirin 325 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: - discharge diagnosis: sah left ica bifurcation aneurysm dysphagia pulmonary edema cerebral vasospasm cardiogenic shock d/t sympathetic surge stroke left mca distribution bifrontal strokes fever / central bacteremia / coag neg staph altered mental status mutism discharge condition: neurologically with right sided plegia and mutism intermittently follows commands discharge instructions: angiogram with embolization and/or stent placement medications: ?????? take aspirin 325mg (enteric coated) once daily. ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort. what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs. ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? after 1 week, you may resume sexual activity. ?????? after 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? no driving until you are no longer taking pain medications what to report to office: ?????? changes in vision (loss of vision, blurring, double vision, half vision) ?????? slurring of speech or difficulty finding correct words to use ?????? severe headache or worsening headache not controlled by pain medication ?????? a sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? trouble swallowing, breathing, or talking ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site *sudden, severe bleeding or swelling (groin puncture site) lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call our office. if bleeding does not stop, call 911 for transfer to closest eme followup instructions: please call to schedule an appointment to be seen by dr. in approx 4 weeks after your discharge. you will need to have a ct scan of the head without contrast at that time Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries 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 Injection or infusion of other therapeutic or prophylactic substance Intravascular imaging of intrathoracic vessels Arterial catheterization Arterial catheterization Arterial catheterization Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Anemia, unspecified Obstructive hydrocephalus Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Subarachnoid hemorrhage Constipation, unspecified 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 Bacteremia Cardiogenic shock Fever, unspecified Infection and inflammatory reaction due to other vascular device, implant, and graft Acute systolic heart failure Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Aphasia Hemiplegia, unspecified, affecting unspecified side Other drugs and medicinal substances causing adverse effects in therapeutic use Other specified disorders of liver Dysphagia, unspecified Secondary cardiomyopathy, unspecified Nystagmus, unspecified Other facial nerve disorders |
allergies: no known allergies / adverse drug reactions attending: chief complaint: elevated lfts post liver major surgical or invasive procedure: ercp drain and staple removal history of present illness: 63-y.o. male s/p olt on for hcc in segment vi in the setting of etoh cirrhosis and portal hypertension was discharged home post-op on and returns with elevated lfts as measured as an outpatient on , tbili 2.0 (0.9 on ) and ap 310 (131 on ). he feels well and has no complaints. past medical history: type 2 diabetes, htn, etoh, segment vi hepatoma s/p rfa orthotopic liver social history: stopped etoh 6 years ago. no smoking. no illicit drug use. lives with his friend . family history: non-contributory physical exam: vs: 97.7 p: 83 bp: 134/72 rr: 16 o2sat: 100% on ra general: awake, alert, nad heent: ncat, eomi, perrla, anicteric heart: rrr, nmrg lungs: ctab, normal excursion, no respiratory distress abdomen: soft, nt, nd, no mass, no hernia, well-healed subcostal incision c/d/i with staples in place, r abdominal drain with serosanguinous fluid (draining ~400 ml daily) pelvis: deferred neuro: strength intact/symmetric, sensation intact/symmetric extremities: wwp, no cce, no tenderness, 2+ b radial skin: no rashes/lesions/ulcers pyschiatric: normal judgment/insight, normal memory, normal mood/affect pertinent results: on admission: wbc-10.4 rbc-4.25* hgb-13.7* hct-39.1* mcv-92 mch-32.1* mchc-34.9 rdw-15.5 plt ct-224# pt-12.9 ptt-20.5* inr(pt)-1.1 glucose-172* urean-17 creat-1.0 na-137 k-4.6 cl-102 hco3-30 angap-10 alt-321* ast-102* alkphos-345* totbili-1.1 albumin-3.5 calcium-8.7 phos-3.9 mg-1.6 tacrofk-11.6 at discharge: wbc-8.6 rbc-3.95* hgb-12.5* hct-35.8* mcv-91 mch-31.5 mchc-34.8 rdw-15.4 plt ct-192 glucose-72 urean-16 creat-0.9 na-137 k-4.1 cl-103 hco3-27 angap-11 alt-188* ast-57* alkphos-255* totbili-0.8 calcium-8.2* phos-4.8* mg-1.4* tacrofk-18.2 brief hospital course: 63 y/o male 10 days post op from liver who has been discharged home and is found to have elevated lfts on outpatient labs. on admission a liver ultrasound was performed showing a normal-appearing liver without evidence of intra- or extra-hepatic biliary dilatation or perihepatic fluid collections. there is patent and directionally appropriate portal and hepatic venous systems with normal-appearing hepatic arterial waveforms. he is noted to have an enlarged spleen and no ascites. it appears on admission labs that he is dehydrated with elevated hct and he rceivd volume resuscitation. the lfts started to trend down, however, an ercp was arranged and on he underwent the procedure. findings included a normal appearing biliary anastomosis. the recipient bile duct appeared mildly dilated at approximately 9mm, the donor bile duct appeared normal with an approximately 7mm diameter but the intrahepatic biliary tree appeared unremarkable. there were no filling defects noted and it was concluded there were no findings to explain patient's recent lft elevations. he was kept hospitalized overnight after the ercp, lab values were continuing to trend down and he was discharged to home. was reconsulted to aid in blood sugar management and the patient was discharged to home with a new sliding scale. immunosuppression was monitored by prograf levels and cellcept and prednisone were kept at home dose. elevated prograf level on day of discharge was felt to be due to late dosing following ercp. levels to be checked per protocol upon discharge. the aptient is ambulating and tolerating diet. medications on admission: fluconazole 400 mg q24h, prednisone 20 mg daily with taper, docusate sodium 100 mg , sulfamethoxazole-trimethoprim 400-80 mg daily, metoprolol tartrate 12.5 mg , valganciclovir 900 mg daily, omeprazole 20 mg daily, mycophenolate mofetil 1000 mg , oxycodone 5-10 mg q4h prn pain, tacrolimus 2.5 mg insulin glargine 25 units sc qhs, humalog sc per sliding scale discharge medications: 1. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 2. prednisone 20 mg tablet sig: one (1) tablet po daily (daily): continue taper per clinic schedule. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 5. valganciclovir 450 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. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 9. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 10. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itch/red skin. 11. insulin glargine 100 unit/ml solution sig: twenty two (22) units subcutaneous once a day. 12. insulin lispro 100 unit/ml solution sig: per sliding scale subcutaneous four times a day: please follow new scale from . 13. tacrolimus 1 mg capsule, twice daily sig: three (3) capsule, twice daily po q12h (every 12 hours). discharge disposition: home with service facility: discharge diagnosis: elevated lfts s/p liver ; 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: partners has been arranged to assist you at home. please call the clinic at for fever, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, incisional redness, drainage or bleeding, inability to take or keep down food, fluids or medications or any other concerning symptoms. you will continue to have labwork every monday and thursday per clinic schedule no heavy lifting no driving if taking narcotic pain medication you may shower, pat incision dry and leave open to air monitor blood pressures, daily weight and write down all results including blood sugars and bring with you to clinic followup instructions: , md phone: date/time: 1:10 , center (nhb) phone: date/time: 1:25 , md phone: date/time: 1:40 diabetes appointment: (. please call to verify appointment time for follow up visit Procedure: Other transplant of liver Endoscopic retrograde cholangiopancreatography [ERCP] Other operations on lacrimal gland Transplant from cadaver Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Alcoholic cirrhosis of liver Portal hypertension Malignant neoplasm of liver, primary Other abnormal blood chemistry |
allergies: no known allergies / adverse drug reactions attending: chief complaint: etoh cirrhosis major surgical or invasive procedure: : orthotopic liver history of present illness: the patient is a 63-year-old man with cirrhosis of the liver and portal hypertension due to alcohol. he has now been abstinent for over 5 years. his liver function is stable with child- class a and meld score 9 with no features of hepatic decompensation in the past, with no variceal bleeding, no sbp, and no ascites. his major issue is a 2.2 x 1.7-cm lesion in segment vi, confirmed to be hepatocellular carcinoma radiologically and histologically. he has undergone ct-guided radiotherapy ablation on with obliteration of the tumor. his follow up ct shows the ablation site in segment vi with an adjacent focus that may be related to a perfusion defect/small tumor recurrence. currently the patient feels well. he denies any fevers, chills, nausea, vomiting, chest pain, or sob. he does admit to arthritic pain in his left knee and intermittent swelling bilaterally in his lower extremities after extended standing. he currently has two molar teeth with cavities that cause intermittent pain. there are no signs of drainage or active infection from these teeth. past medical history: type 2 diabetes, htn, etoh, segment vi hepatoma s/p rfa social history: stopped etoh 6 years ago. no smoking. no illicit drug use. lives with his friend . family history: non-contributory physical exam: v/s: t 97.6 p 60 bp 128/63 rr 18 o2 96% ra gen: resting comfortably, nad heent: mmm, no signs of active infection or drainage in mouth. neck: no lad cv: rrr, no m/g/r lungs: ctab, no r/w/r abd: soft nt/nd. +bs ext: no peripheral edema in lower extremities pertinent results: on admission: wbc-5.5 rbc-4.12* hgb-13.7* hct-37.4* mcv-91 mch-33.3* mchc-36.7* rdw-13.4 plt ct-110* pt-13.8* ptt-30.1 inr(pt)-1.2* glucose-181* urean-16 creat-0.7 na-138 k-3.5 cl-103 hco3-28 angap-11 alt-33 ast-40 alkphos-74 totbili-2.0* albumin-3.7 calcium-9.6 phos-3.8 mg-1.6 at discharge: wbc-7.0 rbc-3.76* hgb-12.0* hct-33.5* mcv-89 mch-32.0 mchc-35.9* rdw-14.8 plt ct-83* pt-13.4 ptt-26.2 inr(pt)-1.1 glucose-148* urean-30* creat-0.8 na-139 k-4.1 cl-104 hco3-28 angap-11 alt-411* ast-102* alkphos-128 totbili-1.2 albumin-3.0* calcium-8.1* phos-2.9 mg-1.8 tacrofk-10.4 brief hospital course: 63 y/o male who presents for orthotopic liver . the patient was taken to the or by dr . he received routine induction immunosuppression to include solumedrol 500mg (with ensuing taper) and cellcept. please see the operative note for surgical detail. he received 7 liters of crystalloid, 7 units of packed red blood cells, 8 units of ffp and 2 units of platelets. he had 785 ml of urine output and an estimated blood loss of 3 liters. he was transferred intubated to the sicu in stable condition. the patient was extubated on pod 1. he required two units of additional rbc's but was otherwise quite stable in the post op period. he was transferred to the regular surgical floor on pod2. prograf was started on the evening of pod 1. levels were checked daily and he was dosed according to levels. he was continued on the cellcept 1 gram without gi issues and the prednisone taper has been started. blood sugar management initially required an insulin drip, and was consulted for management. he will be going home on sc insulin and received teaching for fingersticks and insulin self administration. the patient was evaluated by pt and was deemed suitable for discharge to home with home physical therapy. the lateral drain was removed prior to discharge, the medial drain remains in place and started to increase with sero-sanguinous drainage. drain teaching was provided. the incision was clean and intact. there is a small amount of drainage at the apex. he has had return of bowel function, tolerating diet. lfts and t bili have trended down towards normal. medications on admission: metformin 500 mg qhs, hydrochlorothiazide 25 mg daily, propranolol 20 mg b.i.d., omeprazole 20 mg daily. calcium 600mg asa 81 occasionally. clotrimazole 10mg five times daily. discharge medications: 1. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 2. prednisone 5 mg tablet sig: four (4) tablet po once a day: follow outpatient taper. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 6. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 7. omeprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 8. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 9. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 10. tacrolimus 1 mg capsule sig: two (2) capsule po twice a day. 11. insulin glargine 100 unit/ml solution sig: twenty five (25) units subcutaneous once a day: same time each day. . 12. humalog 100 unit/ml solution sig: per sliding scale subcutaneous four times a day. discharge disposition: home with service facility: partners discharge diagnosis: etoh cirrhosis, hcc s/p rfa now s/p liver discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: please call the clinic at for fever, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, inability to take or keep down food, fluids or medications. monitor the incision for redness, drainage or bleeding. there is a small amount of drainage from the apex of the incision. keep this covered with a dry gauze. call if this develops a bad odor or looks like pus. you will be going home with one drain in place. drain and record the output four times daily and more often as necessary to keep the drain less than half full. call the office if the drainage amount increases greatly, appears more bloody, appears green in appearance or develops a foul odor. bring a copy of the outputs with you to clinic. no heavy lifting no driving if taking narcotic medication, and until notified you may do so you will have labs drawn every monday and thursday per schedule given to you by may shower. do not allow drain to hang freely. pat incision dry and place new dressing at apex of incision and a split sponge at the drain site. follow your medication worksheet. there are many of your old meds that should not be resumed when you go home. followup instructions: , md phone: date/time: 2:10 , md phone: date/time: 1:10 , center (nhb) phone: date/time: 1:25 Procedure: Other transplant of liver Endoscopic retrograde cholangiopancreatography [ERCP] Other operations on lacrimal gland Transplant from cadaver Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Alcoholic cirrhosis of liver Portal hypertension Malignant neoplasm of liver, primary Other abnormal blood chemistry |
allergies: zomig attending: chief complaint: right knee pain major surgical or invasive procedure: right tka history of present illness: 51 y/o woman with increased right knee pain with walking. decision made to proceed with primary right total knee arthroplasty. past medical history: htn, asthma/allergies, diabetes. social history: nc family history: nc physical exam: afebrile, all vital signs stable general: ncat, nad pulm: lungs cta bilaterally, no w/r/r card:s1/s2 clear no m/g/r abd: soft nt/nd, +bs ext: incision c/d/i calf nt nvi distally brief hospital course: ms. was admitted to on for right total knee replacement. pre-operatively, she was consented and history and physical performed. intra-operatively, she was closely monitored and remained stable. she tolerated the procedure well without any difficulty. post-operatively, she was transferred to the pacu and it was determined that she should be observed in the overnight due to hypoxia. this was determined to be related to overuse of narcotics. she was transferred to the floor on the afternoon of in stable condition. on the floor,she remained stable. her pain was well controlled. she progressed with physical therapy to improve her strength and mobility. she continued to make steady progress. she was discharged to a rehabilitation facility in stable condition. medications on admission: diovan 160 qd, hctz 12.5 qd, simvastatin 20mg qd, motrin prn discharge medications: 1. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 2. enoxaparin 40 mg/0.4 ml syringe sig: one (1) subcutaneous daily (daily) for 3 weeks. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. multivitamin tablet sig: one (1) cap po daily (daily). 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 8. valsartan 80 mg tablet sig: two (2) tablet po daily (daily). 9. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours). 11. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed): as per institution protocol. discharge disposition: extended care facility: meadowbrook - discharge diagnosis: oa right knee discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - requires assistance or aid (walker or cane) discharge instructions: keep the incision clean and dry. please apply a dry sterile dressing daily as needed for drainage or comfort. if you have any shortness of breath, increased redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. you may bear weight on your right leg. please resume all of the medications you took prior to your admission unless discussed with your provider. all medication as prescribed by your provider. continue to take your lovenox 40 mg daily for 3 weeks and then start taking aspirin 325 mg daily for 3 weeks. feel free to call our office with any questions or concerns. followup instructions: provider: , : date/time: 1:00 follow up with sleep medicine service as directed Procedure: Total knee replacement Diagnoses: Obstructive sleep apnea (adult)(pediatric) Anemia, unspecified Tobacco use disorder Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Asthma, unspecified type, unspecified Morbid obesity Hypoxemia Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Leukocytosis, unspecified Benign essential hypertension Osteoarthrosis, localized, not specified whether primary or secondary, lower leg |
allergies: penicillins / sulfa(sulfonamide antibiotics) / codeine / shellfish / morphine / ivp dye attending: chief complaint: elective admission for microvascular decompression major surgical or invasive procedure: : left craniotomy with microvascular decompression history of present illness: 58-year-old female who comes in today with facial pain. she has seen dr. in and surgery was recommended.the pain started almost 5 years ago and has been increasing in intensity. she has had a significant amount of care in and in tried several medications including oxcarbazepine, imipramine and topiramate. since her last visit in , she tried chiropractic care and massage without relief and now wants a second opinion re:surgery. she complains of intermittent left-sided facial pain, which is sharp and stabbing in nature on the left side of her face left temporal area, can radiate to the left eye causing tearing, and left lateral nose to left jaw. she also now notes that pain can start in left cervical area and then go to face. pain is initially sharp, stabbing for 15-20 minutes then transitions to a dull ache for 1-2 hours. she is averaging attacks a day. she is unable to sleep on her left side. when seen in she had triggers for the pain such as: cold wind, eating food and dental work. she now has no triggers. past medical history: hiatal hernia gerd chronic pain left temporal artery biopsy tah carpal tunnel release ovarian cystectomy ganglion cyst cholecystectomy social history: currently house sitting in , until . she is on disability due to neck pain. she denies tobacco or illicit drug use. she has a glass of wine 2-3 times a week. family history: non-contributory physical exam: on admission: gen: wd/wn, comfortable, nad. extrem: warm and well-perfused. no c/c/e. 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 finger rub bilaterally with bilateral hearing aids. 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 reflexes: upper 1+ symmetrical, right patellar and bilateral achilles tr, left patellar 3+ with distraction coordination: normal on finger-nose on discharge: intact neuro exam, incision w/sutures intact pertinent results: ct head postop: expected postop changes with pneumocephalus, no hemorrhage brief hospital course: pt was electively admitted and underwent a left suboccipital craniotomy for microvascular decompression. surgery was without complication and the patient tolerated it well. she was extubated and transferred to the sicu for close neurological monitoring and systolic blood pressure control less than 140. postoperative head ct demostrated moderate pneumocephalus, no hemorrhage. overnight into she required nicardipine for sbp control. she was started on oral metoprolol and by the afternoon on she no longer required iv bp agents. her bp control was liberalized and she was transfered to the regular floor. on she was neurologically stable but still complained of significant nausea. her medications were adjusted and she was encouraged to take po and ambulate. she continued to do well and she was discharged home on . medications on admission: dexilant 30 mg every am ranitidine 150 mg at bedtime tegretol 200 mg one pill twice daily and 1.5 pills at bedtime equaling 700 mg daily discharge medications: 1. acetaminophen 325-650 mg po q6h:prn pain 2. carbamazepine 300 mg po hs 3. carbamazepine 200 mg po bid 4. dexlansoprazole *nf* 30 mg oral qd reason for ordering: wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. pt take the multiphase delay release 5. docusate sodium 100 mg po bid rx *docusate sodium 100 mg 1 capsule(s) by mouth twice a day disp #*60 capsule refills:*0 6. metoprolol tartrate 25 mg po bid hold sbp <100, hr<60 7. multivitamins 1 tab po daily 8. oxycodone (immediate release) 5-10 mg po q4h:prn headache rx *oxycodone 5 mg tablet(s) by mouth every four (4) hours disp #*60 tablet refills:*0 9. ranitidine 150 mg po hs 10. senna 2 tab po hs:prn constipation 11. prednisone 10 mg po qd duration: 24 hours begin on tapered dose - down rx *prednisone 5 mg 2 tablet(s) by mouth once daily on and 1 tablet on disp #*3 tablet refills:*0 12. prednisone 5 mg po qd duration: 24 hours begin , then discontinue tapered dose - down discharge disposition: home discharge diagnosis: trigeminal neuralgia 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. ?????? your wound was closed with non-dissolvable sutures then 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. ?????? 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 were on a medication such as coumadin (warfarin), or plavix (clopidogrel), or aspirin, prior to your injury, you may safely resume taking this only when cleared by the dr . ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. followup instructions: follow-up appointment instructions ??????please return to the office in 10 days(from your date of surgery) for removal of your sutures and 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 4 weeks with a mri brain with and without contrast. Procedure: Decompression of trigeminal nerve root Diagnoses: Obstructive sleep apnea (adult)(pediatric) Esophageal reflux Unspecified essential hypertension Asthma, unspecified type, unspecified Diaphragmatic hernia without mention of obstruction or gangrene Trigeminal neuralgia |
allergies: demerol / codeine attending: chief complaint: altered mental status major surgical or invasive procedure: chest tube placement intubation history of present illness: mrs. is a 75 year old woman with a history of afib s/p ablation,htn,dm, spinal stenosis, with recent hospitalization for osteomyelitis who presents with altered mental status and worsening tremor. she had been discharged from following hospitalization from presumed sepsis and hypotension on to rehab. on the evening of a moonlighter was called for increasing agitation. it is unclear at what point she received 0.5mg of ativan. the patient was confused (oriented x1) with a question of increasing tremor and possibly slurred speech and was transferred to for concern of seizures v. sepsis with ams. . in ed tachy to 110s, sbp 110s and required a 0.7l fluid bolus with resolution of bp to 130s, but remained tachy to low 100s. a ct ab/pelvis revealed a fluid collection on her left flank. no pe was noted. she continued to receive vanc/flagyl and got a dose of zosyn, with admission for further work up. . ros was negative for chest pain, syncope or presyncope, myalgias, joint pains, cough, hemoptysis, black stools or red stools. patient did not have any other complaints. she reported that her tremor has been present since she was in her 20s, related to a medication effect. . this am on the floor she was intermittently oriented to place and month but sometimes thinking she was stranded without her car and needing help. she did complain of anxiety once, calling for help, and was verbally calmed down then noted to be tachycardic to the 140s. cardiology was consulted, with carotid massage x 2 performed, with return to normal sinus rythm. son notes that her speech is significantly more garbled in the last two to three days than previously. she began to have difficulty speaking status post extubation during the previous icu stay, but her speech has become progressively worse. he confirms that the patient has had a baseline tremor, thought to be due to a medication effect 20 years ago. by the time the son visited the patient in the late morning, her tremor had improved, though it did intermittently worsen when the patient became more anxious. son also noted that pt had intermittently stared off into space and been less responsive for a few minutes, then would return to conversation. past medical history: past medical history: atrial fibrillation s/p ablation, not on coumadin iron-deficiency anemia gastritis per egd, insulin-dependent diabetes mellitus c/b neuropathy, retinopathy lumbar stenosis, s/p l5-s1 laminectomy (age 40) hypertension hyperlipidemia djd tremor steatohepatitis depression past surgical history: cataract surgery carpal tunnel release bilaterally tonsillectomy appendectomy cholecystectomy social history: patient currently lives in a house in , mass. she lives with her husband. she is now retired but formerly worked in medical records at hospital. she denies etoh, tobacco, and other drugs. mrs. reports attempting to maintain a diabetic diet, but admits to not being as good about it as she should be. she reports exercising by doing chores around the house. family history: diabetes ii physical exam: on admission vs - 97.5 (98.8 rectally), 120/60, 110, 24, 100 % 2l gen: tremor worse with movement. heent: sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. cv: s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: decreased bs, worse on l. abd: soft, ntnd. no hsm or tenderness. ext: + edema b/l, pitting. skin: midline surgical scar on back. at the bottom of scar, small opening, small amount of bleeding when instpected with q-tip, no tracking noted. neuro: cnii-xii intact. strength diffusly . sensation intact. she is awake, alert, oriented to self only. responds to questions and some long term memory intact. patient able to recal 1 object at 5 minutes. difficulty with finger to nose b/l. changes at discharge: 1+ bilateral foot edema, trace bilateral lower extremity edema, alert and oriented x 3, answering questions appropriately pertinent results: ============ radiology ============ ct torso 1. no pulmonary embolus or acute aortic abnormality. 2. 2.2 x 2.0 cm fluid and air collection in the subcutaneous tissues of the left lateral abdominal wall that could reflect post-operative seroma, but abscess cannot be excluded. 3. no evidence large fluid collection surrounding spinal fixation hardware in the lumbar spine, although artifact obscures fine detail and evaluation is suboptimal. 4. cirrhotic liver with ascites. 5. bilateral pleural effusions, moderate on the left and small on the right with adjacent atelectasis. 6. atherosclerotic disease. ct head impression: limited study due to patient motion. within this limitation, no acute intracranial abnormalities identified. repeat study several rounded areas of hypodensity are seen within the left frontal region seen on axial images only that are likely areas of volume averaging, however, peripheral areas of infarction cannot be entirely excluded, and if of clinical concern, a repeat examination or mr can be performed. no evidence of hemorrhage. mr impression: 1. no definite acute infarction. 2. mild-to-moderate dilatation of the lateral ventricles, with features as described above and slightly out of proportion to the prominence of the cerebral sulci; while this can relate to volume loss, associated communicating hydrocephalus/nph cannot be completely excluded. to correlate clinically ============ neurology ============ eeg this is a normal routine eeg in the waking and drowsy states. note is made by technician of intermittent left leg shaking without obvious epileptiform discharges or eeg correlate seen during that time. due to technical difficulties, video was unavailable for review. no focal, lateralized, or epileptiform features were noted during this recording. note is made of a tachycardia of 108 bpm in a single ekg channel. 24 hour eeg this 24 hour video eeg telemetry capture no electrographic seizures. there were no clear focal or lateralizing epileptiform features. the background showed a slightly disorganized alpha theta rhythm which would be normal for advanced age. =========== cytology ============ pleural fluids negative for malignant cells. ============ cardiology ============ stress test no anginal symptoms or ischemic st segment changes to pharmacologic stress. appropriate blood pressure response with flat heart rate response to persantine infusion. nuclear report sent separately. tte the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal half of the inferior wall and mid-inferior septum and inferolateral walls. the remaining segments contract normally (lvef = 50 %). the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. compared with the prior study (images reviewed) of , regional left ventricular systolic function is now improved. the estimated pulmonary artery systolic pressure is now higher. =========== micro =========== 7:38 pm mrsa screen: no mrsa isolated. urine culture: yeast. 10,000-100,000 organisms/ml ============== labs ============== admission labs 06:00pm blood wbc-8.5 rbc-3.35* hgb-9.3* hct-30.2* mcv-90 mch-27.9 mchc-30.9* rdw-18.7* plt ct-366 06:00pm blood neuts-83.5* lymphs-9.4* monos-6.4 eos-0.5 baso-0.2 06:00pm blood pt-16.0* ptt-31.4 inr(pt)-1.4* 06:00pm blood glucose-109* urean-13 creat-1.2* na-145 k-3.7 cl-108 hco3-29 angap-12 06:00pm blood alt-20 ast-32 ck(cpk)-54 totbili-0.5 06:00pm blood ck-mb-notdone ctropnt-0.04* 06:00pm blood ck-mb-notdone ctropnt-0.04* 06:00pm blood albumin-3.1* calcium-8.3* mg-1.3* discharge labs: wbc-7.2 rbc-3.59* hgb-10.6* hct-33.2* mcv-93 mch-29.4 mchc-31.8 rdw-18.0* plt ct-324 glucose-179* urean-17 creat-1.1 na-141 k-4.3 cl-99 hco3-33* angap-13 calcium-8.9 phos-3.7 mg-1.8 brief hospital course: 75 year old woman with a history of afib s/p ablation, htn, dm, spinal stenosis, with recent hospitalization for osteomyelitis who presents with altered mental status and worsening tremor. she had been discharged from following hospitalization from presumed sepsis and hypotension on to rehab. on the evening of a moonlighter was called for increasing agitation. it is unclear at what point she received 0.5mg of ativan. the patient was confused (oriented x1) with a question of increasing tremor and possibly slurred speech and was transferred to for concern of seizures v. sepsis with ams. on the day of admission, patient was transferred to the micu for an episode of unresponsiveness on the floor. the patient rapidly improved in regards to her mental status upon admission to the micu. ct head and mri were negative, and neuro felt this event was likely toxic/metabolic in nature. she was called out to the floor where an eeg was performed and negative. she underwent diagnosistc thoracentesis which was transudative in nature on . post-thoracentesis cxr detected a left hemidiaphagm and repeat film several hours later was performed while the patient was having another episode of shaking. she became unresponsive and was noted to have shallow breathing. the xray technicians at the patient's side were unable to palpate a pulse so cpr was initiated and a code was called. code team immediately noted that patient was in a fib, and cpr was stopped. patient at this time was awake but delirious. her oxygen saturation began to plummet and decreased breath sounds were noted on the left side. cxr revealed a large hydrothorax, and patient was transferred back to the micu. a chest tube was placed and blood tinged sanguinous fluid returned. patient was intubated for airway protection. patient remained in the micu from through . while in the micu she was extubated on . she required pressors from through . her hypotension was felt to be due to hypovolemia secondary to dramatic chest tube fluid output. chest tube drained between 2 and 4 l per day of ascitic fluid from presumed hepatic hydrothorax. cardiac enzymes were slightly elevated, but consistent with her level of renal dysfunction and was felt not to have acs. she had several ttes which showed improving systolic function from ef 35 to 50%. the patient required 2 untis of prbc transfusion in the unit and multiple albumin bags for resuscitation. thoracic surgery was consulted on for assistance on hydrothorax management, and they advised no surgical intervention. instead the chest tube was placed to waterseal on and diuresis was initiated with lasix drip per thoracic surgery recommendations. a diaphragmatic defect was not felt to be responsible. the patient was able to maintain her pressures, and she tolerated diuresis with these maneuvers. her course in the micu was also complicated by intermittent episodes of sinus tachycardia to has high as 140s bpm which responded transiently to carotid massage. her sinus tach was felt to be due to shifts and anxiety. she was transferred out of the micu on . no clear cause for her change in mental status was found while in the micu. a repeat eeg was again negative, and neurology once again felt that this was likely multifactorial toxic/metabolic insults in the setting of acute on chronic renal failure, liver disease, chf, dm and hypoxia from chronic pleural effusions. back on the medical floor, she continued to improve. # altered mental status: her altered mental status was likely related to medication side effects or hepatic encephalopathy. her elavil was decreased for possible anticholinergic side effects. if her mental status worsens, suggest changing patient over to nortripytline and checking levels. # tachycardia: her sinus tachycardia improved after adding metoprolol back to her medication regimen. # anemia: she had a hematocrit drop while in the micu without clear source and was guaiac negative. after 2 units prbcs on , her hematocrit was stable. # osteomyelitis: patient is on long term vanco/metronidazole since previous hospitalization for l2 osteo and is followed by id as an outpatient. she is to continue vancomycin until and flagyl until . # mild systolic congestive heart failure: she was diuresed as above. patient's most recent ef 50%. # nash cirrhosis: she was seen by hepatology during this admission. she had a low meld. patient was started on aldactone and diuresed as above. she is to follow-up with the liver center as an outpatient. # inverted nipple noted on exam: patient will need follow up with pcp for this issue. # dm: she was continued on an insulin sliding scale. # communication: daughter , son , full code medications on admission: per last d/c sum: acetaminophen 325 mg prn q6 amitriptyline 75mg qhs bisacodyl 10 mg dailr prn docusate sodium 100 mg prn ferrous sulfate 325 mg (65 mg iron) daily furosemide 40 mg daily heparin sc 5,000 units tid lidocaine 5 %(700 mg/patch) daily prn megestrol 40 mg tid metoprolol tartrate 25 mg metronidazole 500 mg q8 miconazole nitrate 2 % powder pantoprazole 40 mg daily sennosides prn simvastatin 40 mg daily trifluoperazine 2 mg daily vancomycin 500 mg iv q 24h insulin ss 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. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 3. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 4. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): 12 hours on and 12 hours off. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for sbp<100, hr<60 . 6. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day): hold for > 4 bm per day . 7. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for skin irritation. 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 10. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours): continue until . 11. vancomycin 750 mg recon soln sig: one (1) dose intravenous once a day: until . 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). 14. trifluoperazine 2 mg tablet sig: one (1) tablet po daily (daily). 15. spironolactone 100 mg tablet sig: one (1) tablet po daily (daily): hold for sbp<100 . 16. furosemide 10 mg/ml solution sig: sixty (60) milligrams injection (2 times a day). 17. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 18. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever or pain: do not exceed 2grams daily. 19. lantus 100 unit/ml solution sig: ten (10) units subcutaneous at bedtime. 20. insulin please continue humalog insulin sliding scale as attached. 21. heparin (porcine) 5,000 unit/ml syringe sig: 5000 (5000) units injection three times a day. 22. fluconazole 200 mg tablet sig: one (1) tablet po once a day: last day . discharge disposition: extended care facility: - discharge diagnosis: altered mental status urinary tract infection hydrothorax osteomyelitis cirrhosis discharge condition: level of consciousness:alert and interactive (but intermittent as patient may wx and wane) activity status:ambulatory - requires assistance or aid (walker or cane) mental status:confused - sometimes (waxes and wanes but alert and oriented currently) questionable hospitalization delirium discharge instructions: you were admitted to the hospital for confusion. during your hospital stay, you had 2 episodes of decreased responsiveness prompting stays in the intensive care unit. we suspect your first episode was from medications causing sedation and that your second episode was from difficulty breathing because you had fluid accumulating around your left lung. you improved after draining the fluid with a cathether and taking medications to clear the fluid from your body. you were stable to be discharged to a rehab facility to work on regaining your strength. please follow-up with your pcp . . the following changes were made to your medications: decreased elavil from 75mg to 25mg as it may have worsened your confusion increased lasix to 60mg iv twice a day. this will be tapered to meet your goal ins and outs increased vancomycin to 750mg for therapeutic level decreased metoprolol from 25mg to 12.5mg started fluconazole 200 mg daily for fungus in your urine for 14 days (last day ) started lactulose 30mg tid and aldactone to help control your liver cirrhosis. started full dose aspirin for your atrial fibrillation stopped megace followup instructions: please follow-up with your pcp . . you can call to schedule an appointment. please follow-up with dr. in the liver center. you will be called about appointment scheduling but if you do not hear from them, please call (. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Thoracentesis Percutaneous abdominal drainage Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Anemia, unspecified Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Toxic encephalopathy Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Atrial fibrillation Other chronic pulmonary heart diseases Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Pulmonary collapse Dysthymic disorder Acute respiratory failure Other specified cardiac dysrhythmias Morbid obesity Other ascites Hypoxemia Hepatic encephalopathy Hypovolemia Hyperosmolality and/or hypernatremia Acute osteomyelitis, other specified sites Acute on chronic systolic heart failure Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Other chronic nonalcoholic liver disease Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use Essential and other specified forms of tremor Other specified forms of effusion, except tuberculous Other signs and symptoms in breast Unspecified psychotropic agent causing adverse effects in therapeutic use |
allergies: demerol / codeine attending: chief complaint: hypotension/hypoxia major surgical or invasive procedure: intubation history of present illness: ms. is a 75 year old woman with diabetes, hypertension, atrial fibrillation, history of c. diff, and vertebral osteomyelitis who presented with hypotension and hypoxia. she was recently discharged on following surgery for her osteomyelitis. she had been at rehab when she had an episode of hypotension and hypoxia (low 80's). she was initially seen at an osh. she was given metoprolol 50mg po, lasix 80mg iv and noted to be hypotensive. a cta of the chest was negative for pe, but had bilateral pleural effusions. she was placed on dopamine. she did not receive ivf. she was transferred to for further management. . in the ed, initial vs were: 96.1 80/palp 90 14 95% on nrb. right groin line was placed. she received zosyn in the ed. she was on vancomycin and flagyl for osteomyelitis and c. diff. originally, she was transferred to the ccu out of concern for cardiogenic shock. she was diuresed, but then stopped making urine. her clinical picture was thought to be more representative of sepsis. she was given fluids and transferred to the micu. . in the micu, she was briefly on levophed until 8am this morning. of note, she was intubated during an mri on . her sbp has been maintained in the 100-110s today. she is currently on room air. her uop has improved. fena is 0.1%. she is currently receiving ivfs. an ultrasound revealed cirrhotic liver. a paracentesis removed 2 l. blood, urine, peritoneal cultures cxs are pending. she is currently on vanc/zosyn and flagyl for history of c. diff. . patient was having episodes of constipation. now with two bowel movements today. no complaints of pain, shortness of breath, or nausea. she states she is feeling much better. past medical history: past medical history: atrial fibrillation s/p ablation, not on coumadin iron-deficiency anemia gastritis per egd, insulin-dependent diabetes mellitus c/b neuropathy, retinopathy lumbar stenosis, s/p l5-s1 laminectomy (age 40) hypertension hyperlipidemia djd tremor steatohepatitis depression past surgical history: cataract surgery carpal tunnel release bilaterally tonsillectomy appendectomy cholecystectomy social history: patient currently lives in a house in , mass. she lives with her husband. she is now retired but formerly worked in medical records at hospital. she denies etoh, tobacco, and other drugs. mrs. reports attempting to maintain a diabetic diet, but admits to not being as good about it as she should be. she reports exercising by doing chores around the house. family history: diabetes ii physical exam: general: tired heent: no icterus cardiac: rr lung: crackles at bases abdomen: +bs, bruise on right lower quadrant, right groin line without erythema, left sided bandage that is clean and dry ext: 2+ le edema of feet, 1+ of half way up calf neuro: oriented to name, year, month, hospital, had difficulty naming months backward and asked, "if i can't do this, do i have to get another mri?" pertinent results: admission labs: wbc 16.6 / hct 33.3 / plt 491 na 144 / k 3.9 / cl 109 / co2 22 / bun 26 / cr 1.3 / bg 220 bnp discharge labs: wbc 10.9 / hct 27.1 / plt 540 na 143 / k 3.3 / cl 111 / co2 26 / bun 17 / cr 1.2 / bg 103 microbiology: blood cx negative urine cx yeast urine cx yeast peritoneal fluid culture - negative urine cx yeast studies: echo ()- the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal septum, anterior and inferior walls. there is a small apical left ventricular aneurysm with apical akinesis. the remaining segments contract normally (lvef = 45 %). the estimated cardiac index is normal (>=2.5l/min/m2). no masses or thrombi are seen in the left ventricle. right ventricular chamber size is normal with focal hypokinesis of the apical free wall. 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. physiologic mitral regurgitation is seen (within normal limits). there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w cad (distal lad distribution). compared with the prior study (images reviewed) of , basal septal and anterior function are improved, but apical dysfunction is now identified. mild pulmonary artery systolic hypertension is now identified. abdominal u/s- impression: shrunken nodular liver with diffuse ascites consistent with the provided history of cirrhosis. the main portal vein is patent. a small echogenic nodule abutting the capsule is visualized, incompletely characterized on this study. this lesion may be better evaluated with multiphasic ct or an mri of the abdomen if clinically indicated mri l spine 1. postsurgical changes with fluid collections related to the surgical hardware in the dorsal soft tissues, which may be postoperative seromas. underlying infection would be difficult to entirely exclude. corrleate clinically and with labs. 2. fluid collection in the left aspect of the retroperitoneum also may be postsurgical in nature, although underlying infection in this location would also be difficult to exclude. recommendations: postcontrast mri of the lumbar spine would probably not be helpful given the degree of susceptibility artifact in the region of the surgical hardware. ct of this region may be helpful to better assess the surgical hardware and any enhancement. cxr - left lower lobe sizable atelectasis and pleural effusion. no acute pulmonary infiltrates. cardiomegaly as before. echo ()- the left atrium is elongated. the right atrial pressure is indeterminate. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate regional left ventricular systolic dysfunction with hypokinesis of the inferior wall and the distal half of the anterior septum and anterior walls, and the apex. the remaining segments contract normally (lvef = 35 %). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , left ventricular systolic dyfunction is more extensive and suggests multivessel cad (or myocarditis). the severity of mitral regurgitation is also increased. brief hospital course: 1. hypoxia: patient came in with drastically increased oxygen requirement. she was admitted to the ccu and then the micu with concerns for cardiogenic shock and sepsis. she was managed there initially with diuresis but then fluid administration given possibility of sepsis. she was briefly intubated. upon extubation, patient did very well. she continued to sat well on room air while here. she was found to have a left sided pleural effusion on chest x-ray and was on 2l nc (satting 97% on discharge). we checked room air sats also and patient was satting 96% on ra. given stable condition and good saturation on room air, we did not pursue a thoracentesis. she denied any symptoms of shortness of breath or dyspnea on exertion. 2. questionable sepsis: given that patient had elevated lactate and wbc, sepsis was a possibility. she was on pressors briefly while in the unit but was quickly weaned off. upon transfer to the floor, blood pressures normalized. zosyn was added to her prior regimen of vancomycin and flagyl. cultures did not grow anything so zosyn was discontinued shortly thereafter. patient remained hemodynamically stable during her hospitalization. there were no acute episodes of hypoxia or hypotension. lactate went from 2.4 to 1.2. she remained afebrile and her wbc trended down (was 10.9 on discharge- down from 16.6 on admission). 3. acute kidney injury- patient presented with creatinine of 1.7 and stopped responding to diuresis in the ccu. concern for sepsis arose given elevated lactate and hypotension. patient was most likely secondary to ischemic atn, as was thought to be the case during previous admission. fluid status was initially unclear though. she demonstrated signs of fluid overload on exam (3+ lle pitting edema, elevated jvp) but labs represented more of a pre-renal etiology (urine sodium < 10, hypernatremia, elevated creatinine). this was all complicated by her cirrhosis. we initially did not diurese or give the patient fluids. her creatinine improved daily. we considered giving her albumin or blood but were concerned of causing fluid overload in her lungs. we started her on lasix 20mg iv daily and she responded very well. creatinine was 1.2 on discharge. patient sent out with lasix 40mg po daily. 4. acute on chronic systolic congestive heart failure- patient had echo on admission given concern for cardiogenic shock. during previous admission, echo showed ef of 35-40% with new anterior and anteroseptal left ventricular systolic dysfunction with subtle inferior wall hypokinesis. echo on this visit showed improved ef of 45% and basal septal and anterior function. however, it showed new apical dysfunction. patient reported being very anxious and upset during hypoxic and hypotensive episode. she reports the symptoms occuring shortly after this anxious episode. given new apical akinesis and correlation with anxiety, there is a possibility that this is stress-induced cardiomyopathy. symptoms improved while here. repeat echo on revealed "moderate regional left ventricular systolic dysfunction with hypokinesis of the inferior wall and the distal half of the anterior septum and anterior walls, and the apex. the remaining segments contract normally (lvef = 35 %). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , left ventricular systolic dyfunction is more extensive and suggests multivessel cad (or myocarditis). the severity of mitral regurgitation is also increased." 5. cirrhosis- an ultrasound on revealed cirrhotic liver with no portal vein thrombosis. patient has history of steatohepatitis. lfts were within normal limits. she underwent a paracentesis during which two liters of fluid was removed. blood, urine, peritoneal cultures did not show any sbp or signs of active infection. 6. nutrition- patient had poor po intake on admission. she claimed it was due to the food and once she was discharged, her appetite was improved. she was initially on a soft (dysphagia) and nectar prethickened liquids diet. speech and swallow recommended a video study after which she was advanced to a ground and pureed (dysphagia) diet with supervision. in addition, patient was started on megace 40mg tid for appetite stimulation. she responded well and had much improved po intake by discharge. patient counseled on importance of nutrition, especially relating to her recovery. 7. osteomyelitis- no active issues while here. patient continued on vanc and flagyl. given elevated vanc troughs, patient discharged on vanc 500mg iv q24hr- last dose . she was continued on flagyl 500mg po q8hr for history of c.diff- last dose . 8. type 2 diabetes mellitus, controlled but with complications - continued on nph and sliding scale with good control of her sugars. 9. atrial fibrillation: patient rate controlled with metoprolol. metoprolol was initally held given concern of sepsis. as patient became more hemodynamically stable, metoprolol was resumed at home dose of 25mg po bid. 10. benign hypertension: see above. resumed metoprolol once patient was hemodynamically stable. 11. guaiac positive stools- patient found to have guaiac positive stools on admission. no active signs of bleeding (brown stool). she was started on pantoprazole 40mg po daily while here, which is to be continued on discharge. in addition, we ask that the patient gets a colonoscopy as an outpatient 12. iron deficiency anemia - chronic. hematocrit near baseline. patient continued on home iron supplementation. hematocrit remained stable while here. denied any fatigue or dizziness. fen: diabetic/heart healthy diet. ground and pureed (dysphagia) with supervision. ppx: dvt prophylaxis with heparin sc tid. bowel regimen- senna and docusate. ppi- pantoprazole 40mg q12 hr. code: full code communication: patient & is hcp, son : medications on admission: insulin sc (per insulin flowsheet) lidocaine 5% patch 1 ptch td daily; prn pain acetaminophen 325-650 mg po/ng q6h:prn pain/fever metronidazole (flagyl) 500 mg iv q8h miconazole powder 2% 1 appl tp amitriptyline 75 mg po hs aspirin 81 mg po/ng daily piperacillin-tazobactam 2.25 g iv q6h bisacodyl 10 mg po/pr daily:prn constipation senna 1 tab po bid:prn constipation simvastatin 40 mg po/ng daily docusate sodium (liquid) 100 mg po bid ferrous sulfate 325 mg po/ng daily trifluoperazine hcl 2 mg po daily heparin 5000 unit sc tid vancomycin 1250 mg iv q 24h 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 tablet sig: one (1) tablet po twice a day as needed for constipation. 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) inj injection tid (3 times a day). 4. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 6. megestrol 40 mg tablet sig: one (1) tablet po tid (3 times a day). 7. trifluoperazine 2 mg tablet sig: one (1) tablet po daily (daily). 8. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 9. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 10. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily; prn () as needed for pain: to affected area. leave on for 12 hours then remove . 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 12. amitriptyline 25 mg tablet sig: three (3) tablet po hs (at bedtime). 13. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain/fever. 14. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 15. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 16. vancomycin 500 mg iv q 24h start: in am 17. insulin fixed and sliding scale please follow attached scale 18. flagyl 500 mg tablet sig: one (1) tablet po every eight (8) hours. discharge disposition: extended care facility: - discharge diagnosis: primary: lumbar osteomyelitis, acute kidney injury secondary: hypertension, diabetes mellitus discharge condition: good. vital signs stable. discharge instructions: you were admitted to the hospital after having a hypotensive and hypoxic event while at rehab. while here, you recovered well. you were monitored closely and you improved daily. your oxygen requirement decreased, blood pressures normalized and kidney function improved. you denied any back pain. upon discharge, you were stable and comfortable. the following changes were made to your medications: 1. please start taking lasix 40mg by mouth daily 2. please start taking megace 40mg by mouth three times a day 3. please start taking pantoprazole 40mg by mouth daily weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: provider: , md phone: date/time: 11:30 please follow-up with your cardiologist, dr. . you should make an earlier appointment with him but you currently have an appointment on at 1:45pm. you can contact him at . he should discuss your echo results with you and possibility of outpatient stress test. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Percutaneous abdominal drainage Diagnoses: Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Unspecified septicemia Severe sepsis Atrial fibrillation Unspecified osteomyelitis, other specified sites Polyneuropathy in diabetes Other and unspecified hyperlipidemia Acute respiratory failure Long-term (current) use of insulin Septic shock Intestinal infection due to Clostridium difficile Iron deficiency anemia, unspecified Other ascites Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Background diabetic retinopathy Diabetes with neurological manifestations, type II or unspecified type, uncontrolled Benign essential hypertension Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled |
allergies: demerol / codeine attending: chief complaint: back pain major surgical or invasive procedure: laminectomy, fusion l2-l4 partial vertebrectomy, fusion l2-l3. history of present illness: 75 year-old female with atrial fibrillation s/p ablation, insulin-dependent diabetes mellitus, hypertension, spinal stenosis admitted to ortho spine for lumbar osteomyelitis, discitis, and phlegmon. prior to admission patient was being treated with iv antibotics per recommendation of ortho spine. given persistent pain and concern for worsening infection, she was taken to or this hospital course. she is currently post-op day 2 for laminectomy, fusion l2-l4 and post-op day 4 for partial vertebrectomy, fusion l2-l3. post-op course was complicated by hypotension requiring pressors; pressors were weaned and she was transferred out of sicu to cc6 on . while there she became overnight to rr of 30. she improved slightly in the morning but continued to have elevated rr. she remained hemodynamically stable. she was found to be in (creatinine 1.4, baseline 0.7) and oliguric so she was transferred to medicine for further management. . prior to transfer, urine lytes showed pre-renal picture so patient was continued on iv fluids. she received 11l of iv fluids but only put out 661ml. cxr showed low lung volumes possibly due to increased abdominal pressure so she was given a suppository (no bm since ). patient reports that she "feels good" at this time. past medical history: past medical history: atrial fibrillation s/p ablation, not on coumadin iron-deficiency anemia gastritis per egd, insulin-dependent diabetes mellitus c/b neuropathy, retinopathy lumbar stenosis, s/p l5-s1 laminectomy (age 40) hypertension hyperlipidemia djd tremor steatohepatitis depression past surgical history: cataract surgery carpal tunnel release bilaterally tonsillectomy appendectomy cholecystectomy social history: patient currently lives in a house in , mass. she lives with her husband. she is now retired but formerly worked in medical records at hospital. she denies etoh, tobacco, and other drugs. mrs. reports attempting to maintain a diabetic diet, but admits to not being as good about it as she should be. she reports exercising by doing chores around the house. family history: diabetes ii physical exam: general: woman in mild distress. anasarca heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . jvp is not elevated lungs: ctab, good air movement biaterally. abdomen: nabs. soft, nt, nd. no hsm extremities: proximal dependent edema noted but mild. no distal edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout. + reflexes, equal bl. normal coordination. gait assessment deferred psych: listens and responds to questions appropriately, pleasant pertinent results: 03:40pm blood wbc-8.5 rbc-4.38 hgb-10.9* hct-35.8* mcv-82# mch-25.0* mchc-30.5* rdw-18.3* plt ct-342 08:51pm blood wbc-17.4*# rbc-3.55* hgb-9.3* hct-29.0* mcv-82 mch-26.3* mchc-32.2 rdw-18.2* plt ct-377 03:03am blood wbc-12.5* rbc-3.15* hgb-8.2* hct-26.0* mcv-83 mch-25.9* mchc-31.4 rdw-18.3* plt ct-290 09:30am blood wbc-15.7* rbc-3.10* hgb-8.0* hct-25.6* mcv-83 mch-25.8* mchc-31.1 rdw-18.5* plt ct-237 12:25pm blood hct-25.5* 07:01pm blood wbc-13.6* rbc-3.16* hgb-8.8* hct-26.2* mcv-83 mch-27.9 mchc-33.6 rdw-17.7* plt ct-197 02:22am blood wbc-18.8* rbc-3.55* hgb-10.2* hct-30.4* mcv-86 mch-28.8 mchc-33.6 rdw-17.3* plt ct-245 03:27am blood wbc-11.0 rbc-3.16* hgb-9.0* hct-26.9* mcv-85 mch-28.5 mchc-33.4 rdw-17.7* plt ct-196 09:05am blood wbc-11.2* rbc-3.31* hgb-9.3* hct-27.6* mcv-84 mch-28.0 mchc-33.5 rdw-17.9* plt ct-231 05:10pm blood wbc-11.2* rbc-3.60* hgb-10.0* hct-31.4* mcv-87 mch-27.7 mchc-31.7 rdw-17.7* plt ct-261 05:10am blood wbc-12.9* rbc-3.49* hgb-10.0* hct-30.4* mcv-87 mch-28.7 mchc-32.9 rdw-17.6* plt ct-246 07:30am blood wbc-9.5 rbc-3.67* hgb-10.5* hct-32.3* mcv-88 mch-28.5 mchc-32.4 rdw-17.6* plt ct-274 09:10am blood wbc-12.8* rbc-4.07* hgb-11.2* hct-35.1* mcv-86 mch-27.6 mchc-32.0 rdw-17.7* plt ct-362 09:59am blood pt-20.2* ptt-33.6 inr(pt)-1.9* 05:10pm blood pt-19.4* ptt-34.1 inr(pt)-1.8* 05:10am blood pt-17.8* ptt-33.8 inr(pt)-1.6* 07:30am blood pt-19.0* ptt-32.4 inr(pt)-1.7* 09:10am blood pt-18.9* ptt-32.3 inr(pt)-1.7* 09:10am blood plt ct-362 03:40pm blood esr-30* 03:40pm blood glucose-182* urean-8 creat-0.7 na-142 k-4.7 cl-103 hco3-31 angap-13 08:51pm blood glucose-177* urean-6 creat-0.5 na-140 k-4.2 cl-109* hco3-27 angap-8 03:03am blood glucose-258* urean-8 creat-0.7 na-138 k-4.6 cl-105 hco3-26 angap-12 03:00pm blood glucose-231* urean-13 creat-1.2* na-137 k-4.8 cl-106 hco3-24 angap-12 02:22am blood glucose-189* urean-17 creat-1.3* na-137 k-4.3 cl-108 hco3-21* angap-12 01:44pm blood glucose-180* urean-20 creat-1.4* na-136 k-4.2 cl-107 hco3-22 angap-11 03:27am blood glucose-197* urean-23* creat-1.4* na-136 k-4.1 cl-108 hco3-20* angap-12 09:05am blood glucose-139* urean-22* creat-1.4* na-138 k-3.9 cl-109* hco3-23 angap-10 05:10pm blood glucose-143* urean-23* creat-1.4* na-140 k-4.1 cl-110* hco3-23 angap-11 05:10am blood glucose-151* urean-25* creat-1.3* na-138 k-4.0 cl-108 hco3-21* angap-13 07:30am blood glucose-141* urean-23* creat-1.3* na-140 k-3.5 cl-109* hco3-22 angap-13 09:10am blood glucose-204* urean-21* creat-1.2* na-140 k-3.5 cl-109* hco3-19* angap-16 09:05am blood ck(cpk)-71 05:10pm blood alt-15 ast-17 ld(ldh)-178 ck(cpk)-56 alkphos-114 totbili-0.9 09:05am blood ck-mb-2 ctropnt-0.02* 05:10pm blood ck-mb-notdone ctropnt-0.02* 08:51pm blood calcium-7.9* phos-4.4 mg-1.1* 09:10am blood calcium-8.2* phos-3.2 mg-1.5* 01:44pm blood caltibc-131* ferritn-234* trf-101* 03:40pm blood crp-1.4 06:59pm blood vanco-22.6* 05:43am blood vanco-19.6 09:05am blood vanco-25.4* 09:10am blood vanco-26.0* 05:37pm blood type-art po2-88 pco2-32* ph-7.41 caltco2-21 base xs--2 05:25pm blood glucose-160* lactate-1.3 na-135 k-3.6 cl-101 10:45am blood glucose-191* lactate-2.1* na-130* k-4.5 cl-105 11:37am blood glucose-198* lactate-2.9* na-132* k-4.4 cl-102 10:21pm blood lactate-2.2* 05:37pm blood lactate-1.0 05:25pm blood freeca-1.10* 11:37am blood freeca-0.98* l-spine films (intra-operative)- lumbar anterior spine fusion l1 through l4, seven portable intraoperative views of the lumbar spine: six lateral, one ap. films dated at 16:15 p.m. presented now for official interpretation. successive lateral views show background osteopenia, degenerative change, and multilevel listhesis. for the purposes of the this report, there is grade i anterolisthesis at l4/5. there is sclerosis at l2 which raises the question of osteomyelitis. views show steps during placement of a vertical side bar and screws into the presumptive l2 and l3 vertebral bodies and an intervertebral fusion device at l2-3, with apparent partial vertebrectomy of the infeiror l2 vertebral body. the superior screw is positioned near the superior endplate of l2, although its exact position is difficult to confirm due to lumbar lordosis on the ap view. hardware is otherwise in nominal alignment. dense aortic calcification and surgical clips are noted. impression: intraoperative radiographs demonstrating posterior fusion from l2 through l4. there is also grade 2 anterolisthesis of l4 with respect to l5, unchanged to prior radiograph. for further details, please consult the operative report. chest x-ray ()- impression: persistent left lower lobe collapse with left-sided pleural effusion. renal u/s ()- impression: 1. no hydronephrosis of the kidneys. 2. a small to moderate amount of ascites is identified. clinical correlation is advised to determine the etiology of the ascites. 3. the visualized portion of the liver has a mildly nodular outline, which may indicate cirrhosis or other chronic liver disease. correlation with history and serum liver function tests is advised. abdominal x-ray ()- impression: no obstruction or ileus seen. echo ()- the left atrium is normal in size. the estimated right atrial pressure is 0-5 mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate regional left ventricular systolic dysfunction with basal to mid anteroseptum akinesis, anterior hypokinesis, and mid to distal inferior hypokinesis. overall left ventricular systolic function is moderately depressed (lvef= 35-40 %). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , the anterior and anteroseptal left ventricular systolic dysfunction is new. subtle inferior wall hypokinesis can be appreciated in the prior study, but is worsened in the current study. brief hospital course: 75 year old female with severe spinal stenosis and chronic low back pain who had two prior hospital admissions as well as long term iv abx for concern for vertebral osteomyelitis with a suspected source being a previous steroid injection. at rehab the patient seemed to be clinically improving until she developed worsening back pain with an mri performed that was concerning for worsening of her osteomyeleitis of the lumbar spine. on pt was admitted to the orthopaedic spine service for progression of infection despite abx management and with a partial vertebrectomy of l2 and l3, fusion l2-l3, instrumentation l2-l3 (rod and screw in place), autograft bone morphogenic protein allograft, and interbody spacer performed. intraoperatively, the pt had signs of osteomyelitis at l2 and l3. on , a total laminectomy of l2/l3/l4, fusion l2-l4, segmental instrumentation of l2-l4, and implantation of autograft was performed. or cultures had 1+ poly on gram stain of tissue and cx are ngsf. on the pt was noted to be hypotensive with decreased urine output in the pacu. pressors were started and the patient was admitted to the sicu for closer monitoring. while in the sicu patient was weaned off pressors and was found to have cr of 1.4 with continued low urine output. medicine was consulted on and she was transferred to the medicine service for further evaluation of her kidney function. floor course: #. acute kidney injury/oliguria- creatinine on transfer was 1.4 (baseline is 0.7). patient was given iv fluids prior to transfer due to concern for pre-renal etiology (urine sodium < 10, recent hypotension). another concern was ischemic atn. urine was evaluated under the microscope but showed now signs of atn at that time. she continued to have minimal uop (661ml in 24 hrs). renal u/s showed no hydronephrosis and urine culture was negative. her fluids were discontinued given positive fluid balance and she was given lasix 20mg iv x 1 in the evening. she responded well overnight and continued to do so throughout her stay. her creatinine trended down (was 1.2 on discharge). patient was discharged on lasix 40mg po daily. we ask that her physician this dose while at rehab. #. tachypnea- patient found to be tachypneic after procedure up to 36. she was down to mid to high 20's on transfer to medicine and required 2l nc o2 but satted well. she was breathing in a manner she has not done before (open mouth, no signs of gasping for air). an abg was done and did not show any signs of respiratory compromise (ph of 7.41, pco2 32, po2 88). repeat chest x-ray showed low lung volumes with possible left sided effusion. another concern was intra-operative mi with resulting new wall-motion abnormality leading to poor forward flow. cardiac enzymes were negative x 2. echo performed on showed decreased systolic function compared to previous study. patient was weaned off oxygen and did very well on ra. she continued to diurese well on lasix. she was discharged on lasix 40mg po daily given her cardiac dysfunction. patient has follow-up with her cardiologist, dr. on at 1:45pm. we ask that he evalutes patients cardiac function at this visit. upon discharge, she was no longer tachypenic (rr- 16) and was satting comfortably well on room air. #. lumbar osteomyelitis- see above for more details. patient continued on vancomycin iv but given supratherapeutic levels, her dose was decreased intially to 750mg q12hr then to 1250mg q24hr. her wbc count trended down after procedure and patient remained afebrile while on the floor. ortho spine followed and patient did not show any signs of neurologic compromise. cultures did not grow any microorganisms. upon discharge, patient remains afebrile and comfortable. #. atrial fibrillation- patient is rate-controlled on atenolol 100mg daily. given recent acute kidney injury, we switched her to metoprolol tartrate (atenolol cleared by kidney). we noted that the patient was not anticoagulated with coumadin despite her history of atrial fibrillation. we discussed this with her pcp who says she has never been anticoagulated and he referred us to her outpatient cardiologist. we ask that dr. evaluate her anticoagulation options, if she requires it, when he sees her on at 1:40pm. she was discharged with metoprolol tartrate 50mg po bid. # uti- patient's ua and culture did not show any signs of infections. patient's cipro was discontinued. she remained afebrile while here. #. htn- patient was continued on home bp medications except her enalapril was held given her . enalapril was held on discharge given that creatinine was not at baseline. we ask that her outpatient physicians consider resuming her ace-i once creatinine is stable. # iron deficiency anemia- patient received 5u prbcs prior to transfer to medicine. patient continued on iron supplementation. hct on transfer 31.4 and increased to 35.1 on discharge. she did not require any additional transfusions while here. # c. diff- continued on metronidazole 500mg iv q8hr for duration of course of vancomycin (plus an additional 5 days) #. iddm- patient continued on nph 14u qhs with regular insulin sliding scale with good control of her sugars. #. hyperlipidemia- patient continued home simvastatin 40mg daily fen: mechanical soft; nectar prethickened liquids soft solids. meds whole with nectar or puree. 1:1 supervision. ppx: -dvt ppx with heparin sc tid -ranitidine for gi, senna/colace for bowel -pain management with tylenol access: piv's medications on admission: nph 14 units qhs regular ssi ciprofloxacin 200 mg iv q12h (-) hydromorphone (dilaudid) 1 mg iv q4h:prn pain acetaminophen 1000 mg po/ng q6h vancomycin 1000 mg iv q 12h (-) miconazole 2% cream 1 appl tp lorazepam 0.5 mg po/ng tid lidocaine 5% patch 1 ptch td daily ferrous sulfate 325 mg po/ng daily atenolol 100 mg po daily glucagon 1 mg im q15min:prn hypoglycemia protocol dextrose 50% 12.5 gm iv prn hypoglycemia protocol metronidazole (flagyl) 500 mg iv q8h (-) senna 2 tab po/ng :prn consitpation oxycodone (immediate release) 5-15 mg po/ng q4h:prn pain simvastatin 40 mg po/ng daily ranitidine 150 mg po bid enalapril maleate 20 mg po daily trifluoperazine hcl 2 mg po daily amitriptyline 25 mg po hs discharge medications: 1. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). 2. trifluoperazine 2 mg tablet sig: one (1) tablet po daily (daily). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for consitpation. 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 9. miconazole nitrate 2 % cream sig: one (1) appl topical (2 times a day). 10. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours). 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for anxiety. 12. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 13. phenol 1.4 % aerosol, spray sig: one (1) spray mucous membrane q6h (every 6 hours) as needed for sore throat. 14. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 15. nph insulin human recomb 100 unit/ml suspension sig: fourteen (14) units subcutaneous at bedtime. 16. insulin- sliding scale continue insulin sliding scale per attached document 17. vancomycin vancomycin 1250mg iv q24hr x 8 weeks 18. flagyl flagyl 500mg iv q8hr for duration of vancomycin treatment plus an additional 5 days 19. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 20. heparin (porcine) 5,000 unit/ml solution sig: one (1) inj injection tid (3 times a day). 21. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: - discharge diagnosis: primary: osteomyelitis, acute kidney injury secondary: diabetes mellitus, hypertension discharge condition: good. vital signs stable. mental status clear and at baseline. discharge instructions: you were admitted to the hospital to undergo back surgery for your spine infection. you tolerated the procedure well and seem to be improving daily. you were found to have low urine output after your procedure. this improved each day and your kidney function seems to be returning to normal. the following changes were made to your medications: 1. please take vancomycin 1250mg iv every 24 hours 2. please start taking lasix 40mg by mouth daily 3. please stop taking your atenolol 4. please start taking metoprolol tartrate 50mg by mouth twice a day 5. please stop taking your enalapril until your kidney function returns to its baseline. your physicians should check your vancomycin level periodically and re-dose the medication as needed. followup instructions: provider: , md phone: date/time: 11:30 provider: , md phone: date/time: 11:30 please follow-up with your cardiologist, dr. , on , at 1:45pm. you can contact him at . Procedure: Venous catheterization, not elsewhere classified Lumbar and lumbosacral fusion of the anterior column, posterior technique Other exploration and decompression of spinal canal Local excision of lesion or tissue of bone, other bones Lumbar and lumbosacral fusion of the anterior column, anterior technique Other partial ostectomy, other bones Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Fusion or refusion of 2-3 vertebrae Insertion of recombinant bone morphogenetic protein Diagnoses: Other iatrogenic hypotension Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Toxic encephalopathy Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Long-term (current) use of insulin Intestinal infection due to Clostridium difficile Intraspinal abscess Acute osteomyelitis, other specified sites Other and unspecified disc disorder, lumbar region Lumbosacral spondylosis without myelopathy Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Oliguria and anuria Infection following other infusion, injection, transfusion, or vaccination Psoas muscle abscess Degeneration of lumbar or lumbosacral intervertebral disc |
allergies: augmentin / cipro / keflex / insulins attending: chief complaint: non-healing r foot ulcers and severe hammer 2nd toe major surgical or invasive procedure: transmetatarsal amputation of the right foot and tendo achilles lengthening of right lower extremity history of present illness: 76 y/o m with diabetes, hypertension, hyperlipidemia with non-healing diabetic r foot ulcer admitted for r tma and tendo-achilles lengthening. pt has history of a r third metatarsal head resection in and additional debridement in . pt underwent clindamycin therapy from until his present admission without improvement. past medical history: chronic systolic chf atrial fibrillation cad diabetes type ii (allergy to insulin) on oral medications chb s/p ppm ( , ) left tma in social history: married, lives with wife. retired police officer. quit smoking 40 years ago (5 pack-year history), drinks wine occasionally family history: n/c physical exam: general: awake, cooperative, nad. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no nuchal rigidity respiratory: ctab, no wheezes/rhonchi/rales - coarse upper airway sounds cardiovascular: rrr abdomen: soft, nt/nd, + bs extremities: no c/c/e bilaterally. right foot is post-op without any noted discharge or blood on skin: no rashes or lesions noted. pertinent results: ct scan of the right ankle and distal lower leg with contrast. indication: 76-year-old man status post right transmetatarsal amputation with poor healing and wound drainage. persistent fevers. technique: ct scan of the right lower leg and ankle was performed with intravenous contrast. images were acquired in the axial plane. coronal and sagittal reformats were created and reviewed. no comparisons. findings: post-surgical changes of the mid foot are seen following transmetatarsal amputation. at the distal aspect of the foot, there is a large rim-enhancing fluid collection that represents either postoperative seroma or abscess. there is extensive rim enhancement and reticular edema of the residual mid foot as well. evaluation of the underlying osseous structures is suboptimal but no definite evidence of frank erosion is seen apart from the post-surgical changes following previous osteotomy. osseous alignment is preserved. there is lucency at the medial aspect of the talar dome that could reflect overlying osteochondral abnormality. there is edema along the medial aspect of the ankle. dense atherosclerotic vascular calcification is seen. within limits of technique, the tendons are grossly intact. no additional loculated fluid collection is identified. impression: 1. large loculated, rim-enhancing fluid collection in the foot adjacent to the metatarsal amputation sites. the possibility of infection must be excluded. 2. no definite evidence of underlying osseous abnormality to suggest osteomyelitis, although evaluation is severely limited by the previous post- surgical changes in this area. 12:30pm blood wbc-8.4 rbc-3.47* hgb-10.6* hct-32.5* mcv-94 mch-30.6 mchc-32.7 rdw-13.9 plt ct-560* 12:30pm blood plt ct-560* 05:00am blood glucose-112* urean-10 creat-0.9 na-140 k-3.8 cl-107 hco3-26 angap-11 05:00am blood calcium-8.0* phos-3.1 mg-1.8 08:41pm urine color-yellow appear-clear sp -1.021 urine blood-tr nitrite-neg protein-neg glucose-neg ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg urine rbc-* wbc-0-2 bacteri-few yeast-none epi-<1 transe-0-2 9:06 pm swab source: tma drainage. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): escherichia coli. sparse growth. staphylococcus, coagulase negative. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r fecal culture (final ): no salmonella or shigella found. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. fecal culture - r/o vibrio (final ): no vibrio found. fecal culture - r/o yersinia (final ): no yersinia found. fecal culture - r/o e.coli 0157:h7 (final ): no e.coli 0157:h7 found. cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). brief hospital course: pt admitted for non-healing diabetic r foot ulcer iv antibiotics pre-op'd ep consulted to interrogate pacer pre-op podiatry: name of procedure: tendo achilles lengthening of right lower extremity. vascular: name of procedure: transmetatarsal amputation of the right foot. pt extubated in the transfered to the pacu in stable condition. once recovered from anesthesia. pt transfered to the floor in stable condition. ep reconsulted interrogated pacer post op pt experienced frank melena with drop of bp to 90 from 140, transfered to the cvicu. gi consulted. 2units of , pt tranfused 2 units of rbc's. egd performed, saw duodenal ulcer with active bleeding. injected with epi and clipped. complete resolution of bleeding. protonix iv bid. serial hct followed. id coinsulted for persistant fevers.recommended broad spectrum ab with blood cx's. vanco, aztreonam and flagyl started. pt also. pain medications held confused post operatie period. pt still confused, mental status changes. neurology consulted. no folcal signs of acute stroke seen.. low dose serequel given. no haldol. pain meds held to minimum. pt confusion improved. diet advanced. pt delined. pt consult obtained pt did require some lasix for systolic / chronic chf. improved wit lasix. pt still febrile. ct scan of foot obtained. showed fluid. lateral incision opened. old hematoma expressed, cx's taken. vanco decreased to 750 . bedside swaalow exam done medications on admission: meds: coumadin 2.5, toprol xl 100, digoxin 250, lisinopril 40, hctz 12.5, metformin 1000, glyburide 5, lovastatin discharge medications: 1. digoxin 250 mcg tablet sig: one (1) tablet po daily (daily). 2. metformin 1,000 mg tablet sig: one (1) tablet po once a day. 3. glyburide 5 mg tablet sig: one (1) tablet po daily (daily). 4. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 5. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed. 6. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed. 8. lovastatin 10 mg tablet sig: one (1) tablet po once a day. 9. toprol xl 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 11. aztreonam 1 gram recon soln sig: one (1) recon soln injection q8h (every 8 hours) for 10 days: dc on . 12. vancomycin 500 mg recon soln sig: 1.5 750 mg intravenous twice a day for 10 days: moniter creatinine and trough. 13. coumadin patient was on coumadin for afib. please hold for now. pt had gi bleed. also need further surgery. discharge disposition: extended care facility: health care center discharge diagnosis: diabetic foot ulcers pmh: dm type 2 cad chf (ef unknown) afib p pacemaker htn hyperlipidemia discharge condition: stable discharge instructions: discharge instructions following transmetatarsal amputation this information is designed as a guideline to assist you in a speedy recovery from your surgery. please follow these guidelines unless your physician has specifically instructed you otherwise. please call our office nurse if you have any questions. dial 911 if you have any medical emergency. activity: there are restrictions on activity. on the side of your amputation you are non weight bearing until cleared by your surgeon. you should keep this amputation site elevated when ever possible. you may use the other leg to assist in transferring and pivots. but try not to exert to much pressure on the amputation site when transferring and or pivoting. please keep knee immobilizer on at all times to help keep the amputation site straight. no driving until cleared by your surgeon. please call us immediately for any of the following problems: redness in or drainage from your leg wound(s) . watch for signs and symptoms of infection. these are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. if you experience any of these or bleeding at the incision site, call the doctor. exercise: limit strenuous activity for 6 weeks. do not drive a car unless cleared by your surgeon. try to keep leg elevated when able. bathing/showering: you may shower immediately upon coming home. no bathing. a dressing may cover you??????re amputation site and this should be left in place for three (3) days. remove it after this time and wash your incision(s) gently with soap and water. you will have sutures, which are usually removed in 4 weeks. this will be done by the surgeon on your follow-up appointment. wound care: sutures / staples may be removed before discharge. if they are not, an appointment will be made for you to return for staple removal. when the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. these will stay on about a week and you may shower with them on. if these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. medications: unless told otherwise you should resume taking all of the medications you were taking before surgery. you will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (check with your physician if you have fluid restrictions.) if you feel that you are constipated, do not strain at the toilet. you may use over the counter metamucil or milk of magnesia. appetite suppression may occur; this will improve with time. eat small balanced meals throughout the day. cautions: no smoking! we know you've heard this before, but it really is an important step to your recovery. smoking causes narrowing of your blood vessels which in turn decreases circulation. if you smoke you will need to stop as soon as possible. ask your nurse or doctor for information on smoking cessation. avoid pressure to your amputation site. no strenuous activity for 6 weeks after surgery. diet : there are no special restrictions on your diet postoperatively. poor appetite is expected for several weeks and small, frequent meals may be preferred. for people with vascular problems we would recommend a cholesterol lowering diet: follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and ldl (low density lipoprotein-the bad cholesterol). exercise will increase your hdl (high density lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. you may be self-referred or get a referral from your doctor. if you are overweight, you need to think about starting a weight management program. your health and its improvement depend on it. we know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. if interested you can may be self-referred or can get a referral from your doctor. if you have diabetes and would like additional guidance, you may request a referral from your doctor. follow-up appointment: be sure to keep your medical appointments. the key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. don't let them go untreated! please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. this should be scheduled on the calendar for seven to fourteen days after discharge. normal office hours are 8:30-5:30 monday through friday. please feel free to call the office with any other concerns or questions that might arise. patient was on coumadin for afib. please hold for now. pt had gi bleed. also need further surgery. followup instructions: provider: , md phone: date/time: 2:00 fax weekly cbc / bmp/ vanco trough / esr / crp to dr . while on antibiotics. Procedure: Venous catheterization, not elsewhere classified Amputation through foot Endoscopic control of gastric or duodenal bleeding Transfusion of packed cells Transfusion of other serum Other change in muscle or tendon length Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Other and unspecified hyperlipidemia Heart valve replaced by other means Cardiac pacemaker in situ Acute systolic heart failure Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Ulcer of heel and midfoot Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Other hammer toe (acquired) |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status, abdominal pain. major surgical or invasive procedure: right ij line placement and removal picc line placement and removal intubation with mechanical ventilation blood and platelet transfusion history of present illness: this patient is a -year-old woman, chinese-speaking only (specific dialect of a small region), also with baseline dementia, who presents via ems with chief complaint of several days abdominal pain and worsening mental status at home. she lives alone, and her daughter had been caring for her for the last 2 weeks when she started to have more weakness. eventually could no longer get out of bed, then stopped eating and became fore unresponsive. her family called ems. ems found the patient to be hypotensive and started her on dopamine en route to ed. in the ed, her initial vitals were notable for temperature of 30.6 degrees celsius. hematocrit was 21.7 (from baseline in mid 30s in ), with platelets of 34 (from baseline 200-300 in ), and white count of 8.0. diff on white count showed 81 polys and 3 bands. ua was positive. inr was 1.8 with lactate of 3.4. labs otherwise notable for hypernatremia to 163 with creatinine of 1.4 from baseline 0.7 to 0.8. trauma surgery was consulted in ed given concern of ischemic bowel. patient then underwent ctap that showed rll pna versus aspiration with bilateral effusion. although there was severe celiac, sma, and stenosis there was no complete occlusion and no evidence of bowel ischemia. there was nonspecific anal and rectal wall thickening. as for interventions, patient was given vancomycin and zosyn for presumed urosepsis. she was resuscitated with three liters normal saline, 4u prbcs, and 6u platelets. she was given 10 mg vitamin k for the elevated inr. patient was persistently hypotensive to the 80s and a right ij was placed. she was started on norepinephrine and intubated for airway protection given concern of altered mental status and aspiration on ct scan. vitals at time of admission are bp 123/67, hr 62, rr 16, sat 100% on assist control ventilation, fio2 100%, vt 450 with peep of 5 and rr 20. in the intensive care unit, exam notable for cold distal extremities. patient sedated and therefore ros could not be gathered. past medical history: --baseline dementia --blind and hard of hearing --l2 vertebral fracture and back pain --s/p cerebral infarcts in mca territory --hypertension --hypercholesterolemia --atrial fibrillation, not on coumadin --elevated glucose --constipation --hemorrhoids --ef >55% per echo social history: lives alone with help from her daughter in . no history of smoking, etoh, or illicit drug use. per daughter, 2 weeks ago patient started eating less (patient had been living independently), and daughter has been since coming to her house on a daily basis to help with all adls and aidls. family history: non-contributory. physical exam: physical exam at admission: vitals: t: 91, bp: 98/54 p: 64 vent settings: assist control (volume targeted), tidal volume: 450 cc, respiratory rate: 16, peep: 5 cm/h2o, fio2: 50% general: intubated, sedated heent: right eye opaque, nonreactive to light (baseline as per daughter), left eye reactive to light. neck: no lad lungs: clear anteriorly cardiovascular: irregularly irregular, s1, s2, no murmurs. abdomen: soft, nontender, nondistended. gu: foley in place extremities: cold distal extremities; dp pulses could not be appreciated; pertinent results: labs at admission: 09:40am blood wbc-4.6 rbc-1.81* hgb-3.6* hct-13.3* mcv-74* mch-20.0* mchc-27.2* rdw-22.0* plt ct-17* 10:12am blood neuts-81* bands-3 lymphs-12* monos-3 eos-0 baso-0 atyps-1* metas-0 myelos-0 nrbc-5* 09:40am blood pt-24.3* ptt-53.3* inr(pt)-2.3* 10:12am blood glucose-133* urean-82* creat-1.4* na-163* k-4.3 cl-135* hco3-16* angap-16 10:12am blood alt-20 ast-28 totbili-0.6 10:12am blood albumin-2.1* calcium-8.4 phos-5.5*# mg-2.6 serial cardiac enzymes: 23:56 0.16 09:40 0.23 07:27 0.22 19:26 0.17 14:23 0.12 09:40 0.09 labs wbc rbc hgb hct mcv mch mchc rdw plt ct 6.31 4.93 11.9* 40.0 81* 24.1* 29.8* 26.1* 153 glucose urean creat na k cl hco3 angap 79 31* 0.7 152* 3.5 120* 19* 17 b12 1515 tsh 3.1 alb 1.8 electrocardiogram (): atrial fibrillation. precordial t wave inversions in leads v1-v3 are suggestive of myocardial ischemia. compared to the previous tracing t wave changes are new. q-t interval is now prolonged. electrocardiogram (): atrial fibrillation. compared to the previous tracing t wave changes in the precordial leads are similar. the q-t interval is similarly prolonged. imaging data: ct head (): impression: no change from 12 hours prior. isodense left frontal subdural collection measuring up to 8 mm is again compatible with subacute to chronic subdural hematoma. no hyperdense component to suggest superimposed acute hemorrhage. also again noted are left posterior temporal/parietal encephalomalacia reflecting chronic infarct, changes secondary to chronic small vessel ischemic disease, mild atrophy and ethmoid mucosal sinus disease. the study and the report were reviewed by the staff radiologist. transthoracic echocardiogram (): the left atrium is mildly dilated. the right atrial pressure is indeterminate. left ventricular wall thicknesses and cavity size are normal. there is mild global left ventricular hypokinesis (lvef = 40-45 %). the estimated cardiac index is normal (>=2.5l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure(pcwp>18mmhg). right ventricular chamber size is normal with mild global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are moderately thickened. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is no pericardial effusion. impression: normal biventricular cavity sizes with mild global biventricular hypokinesis c/w diffuse process (toxin, metabolic, etc.). pulmonary artery hypertension. moderate mitral regurgitation. moderate tricuspid regurgitation. compared with the prior study (images reviewed) of , biventricular hypokinesis is now present and the severity of mitral regurgitation and tricuspid regurgitation have increased. ctap (): 1. bilateral pleural effusions, left more than right. left lower lobe atelectasis. right lower lobe pneumonia or aspiration. 1.3cm focal ground-glass opacity in the periphery of the right upper lobe is nonspecific and may be related to the right lower lobe process. follow-up ct to demonstrate resolution is suggested. 2. cardiomegaly, severely atherosclerotic aorta and iliac vessels with intramural thrombus. apparent linear densities in the thoracic aorta likely represent contrast mixing with unopacified blood. there is no definite evidence of aortic dissection. 3. no evidence of bowel obstruction or bowel wall thickening to suggest bowel ischemia. the celiac axis, sma and appear patent, however, stenosis at the proximal portion of these vessels may be severe (please note that this study is not dedicated for evaluation of intra-abdominal arteries). 4. mild thickening of the anal and rectal wall with mild presacral edema is nonspecific. please clinically correlate. 5. 7-mm hypodense lesion in the neck of the pancreas. followup mri can be obtained for further evaluation if clinically warranted. 6. new t7 vertebral body compression fracture and progression of l2 vertebral body fracture. brief hospital course: in summary this is a -year-old woman presenting with abdominal pain, worsening mental status, found to be hypothermic and hypotensive in ed, initially intubated on pressors and treated empirically for urosepsis/aspiration pneumonia. # hypotension/pna/uti: consider in differential diagnosis sepsis (urinary source, pneumonia, gi source), hypovolemia, bleeding (gi source given guaiac positive stool), cardiogenic (given elevated biomarkers and ekg changes). patient with positive ua and abdominal pain with evidence of possible aspiration pneumonia on ctap; thus infection seemed most likely to be the cause for her hypotension. she had a 6 day course of cefepime and flagyl. vanco was initially given as stopped on day 4 since sputum cx was negative. abx were stopped when pt removed her picc and not restarted due to change in goals of care. her resp status improved. # hypothermia: likely from underlying infection. other considerations include environmental exposure, hypothyroid (myxedema) or adrenal insufficiency. her cortisol level was normal (25.7 at admission). tsh was wnl. her hypothermia improved with treatment of the urinary tract infection. # abdominal pain: consider in differential diagnosis cystitis, mesenteric ischemia, infectious colitis. patient underwent ctap in ed that showed severe atherosclerotic disease in the celiac, sma, and although no definite complete occlusion. there was mild rectal and anal wall thickening that was nonspecific, without evidence of bowel ischemia. of note, lipase and transaminases were normal. trauma surgery was consulted initially for concern of bowel ischemia. however, given the above ct findings, they felt that surgical intervention was not indicated. the patient's lactate improved with treatment of her infections, anemia, and hypovolemia. # respiratory status: she was intubated in the emergency room for airway protection in the setting of altered mental status and evidence of aspiration on ct. there was also concern of pulmonary edema because of all the blood products that she had received. when she improved hemodynamically and her infection was treated, she was extubated without complication on the first hospital day. she was then diuresed. # ekg changes, positive tropinin: likely demand ischemia in the setting of sepsis and profound anemia. the ekgs were reviewed by the cardiology fellow, who recommended trending the troponin and no intervention. # altered mental status: this was thought to be multifactorial. pt had a subacute subdural hematoma, which may have been causing her subacute decline at home. then once she was extubated she was very unresponsive and only moving her right arm. after several days she appeared to be able to move both hands and legs, but favored the right. she was newly nonverbal and it was unclear do to the language barrier if she could follow commands. it is likely that she had either a cva vs hypoperfusion brain injuries in the setting of her hypotension. pt was seen by neurosurgery and her head ct was repeated while in er without sig change in bleed. # anemia, thromobcytopenia, and elevated inr: pt appeared to have dic (secondary to sepsis or profound hypothermia), and may have an underlying myelodysplastic process. hematology evaluated the pt in the icu. in addition to the blood products given in the er (rbc x 4, plts x 7), she was given 1 more unit of plts. her anemia appeared to be a combination of likely gi losses since stool was guaiac positive and hemolysis. pt had some schistocytes on the peripheral smear. pt was tx with vitamin k. gi was consulted, but since no more bleeding occurred the pt was not scoped. . # hypernatremia, acute kidney injury: her hypernatremia was likely related to dehydration and decreased po intake in the setting of hypotonic insensible losses the hypernatremia was initially corrected. her acute renal failure was likely prerenal, it corrected with ivf and tx of uti. her sodium then rose again once her ivf were stopped in the setting of becoming comfort measures and the pt removed her picc line. another piv was not placed. # vertebral compression fractures: ctap at admission showed new t7 vertebral body compression fracture and progression of l2 vertebral body fracture. this may have been contributing to the abdominal pain with which she presented. # goals of care: on a family meeting with daughter and grandson was held with an interpreter. due to her multiorgan failure and general malnutrition (alb 1.8) pt has a very poor prognosis. especially due to her poor mental status state. the goals were changed to dnr/dni with comfort measures. the next day she removed her picc, and did not want to have a piv placed, so ivf were stopped. pt also removed her doboff after her icu stay. over the next 2 days her level of alertness appeared to increase, with more purposeful movements of both arms. however, she was still nonverbal, and not following any commands. palliative care were also consulted. she was transferred to hospice care. # communication: patient's daughter ()is the hcp, , and the grandson (speaks english (). medications on admission: --docusate 100 mg --ranitidine 150 mg --aggrenox 25-200 mg --lisinopril 20 mg qday --bisacodyl 5 mg --simvastatin 20 mg qday --caltrate 600-400 mg --amlodipine 10 mg qday discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 2. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 3. oxycodone 5 mg/5 ml solution sig: 2-4 mg po q1h (every hour) as needed for pain: hold for resp rate<10. 4. olanzapine 5 mg tablet, rapid dissolve sig: 0.5 tablet, rapid dissolve po tid (3 times a day) as needed for agitation. discharge disposition: extended care facility: hospice and palliative care discharge diagnosis: septic shock aspriation pneumonia subdural hematoma hypernatremia gastrointestinal bleed dissemintated intravascular coagulopathy hemolytic anemia acute renal failure demand ischemia urinary tract infection malnutrition discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: you were admitted with low blood pressure. you were found to have multiorgan failure. you had a pneumonia, bladder infection, mild heart attack, bleed from your intestine, and an abnormal sodium. also you were found to have a bleed in your brain. you will be going to a hospice facilty due to your severe illness. your medications have changed. please see the attached list. followup instructions: see your hospice doctor 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 Diagnoses: Thrombocytopenia, unspecified Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Acute posthemorrhagic anemia Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Acute myocardial infarction of other anterior wall, initial episode of care Other persistent mental disorders due to conditions classified elsewhere Acute respiratory failure Defibrination syndrome Pneumonitis due to inhalation of food or vomitus Septic shock Do not resuscitate status Metabolic encephalopathy Hyperosmolality and/or hypernatremia Subdural hemorrhage Chronic vascular insufficiency of intestine Celiac artery compression syndrome Fecal impaction |
allergies: atorvastatin / clarithromycin / biaxin / gemfibrozil / influenza virus vaccine attending: chief complaint: angina/ doe major surgical or invasive procedure: s/p endoscopic cauterization of angiotasia in the lesser curvature of the stomach by gastroenterology history of present illness: very nice 78 year old female with an extensive past medical history which includes peripheral disease requiring several interventions and surgeries, coronary artery disease requiring multiple interventions and status post cabg in and aortic stenosis which has been followed by serial echocardiograms. she has recently noted chest pain with dyspnea on exertion. past medical history: pmh: cad w/ coronary artery bypass graft in , chronic anemia, gib due to asa/avm?, as, h/o hemolytic anemia, homocystinemia, carotid stenosis, pvd with r fem- bypass and l angio with stent psh: triple bypass with three stents in place, right proximal sfa to below knee popliteal artery with left svg , left sfa and above-knee popliteal angioplasty with stenting, left mid sfa angioplasty , l cea with graft social history: neg drinker neg smoker family history: n/c physical exam: pulse: resp: o2 sat: b/p right: left: height: 117 weight:62" general: skin: dry intact heent: perrla eomi neck: supple full rom well healed l cea incison chest: lungs clear bilaterally well healed sternotomy incision heart: rrr irregular murmur :loud blowing systolic murmur abdomen: soft non-distended non-tender bowel sounds + well healed midline abdm incision extremities: warm , well-perfused edema-none varicosities: none . well healed bilat svg harvest site incisions neuro: grossly intact a&ox3, mae, follows commands pulses: femoral right: 2+ left: cath site dp right: 2+ left: 2+ pt : 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit right: loud radiated murmur left: loud radiated murmur pertinent results: 07:15am blood wbc-5.5 rbc-3.65* hgb-10.4* hct-33.5* mcv-92 mch-28.5 mchc-31.0 rdw-18.4* plt ct-120* 07:15am blood glucose-127* urean-45* creat-1.5* na-142 k-5.4* cl-110* hco3-23 angap-14 01:26am blood pt-12.7 ptt-28.1 inr(pt)-1.1 brief hospital course: ms. was admitted on for an aortic valve replacement and coronary artery bypass grafting. this procedure was cancelled after general anesthesia induction due to upper gi bleed prior to start of surgery. gi consulted in the or for evaluation. an angiotasia was discovered in the lesser curvature of the stomach and was endoscopically cauterized. she was transferred to the intensive care unit. successive hematocrits were stable and no further follow-up was recommended by the gastrointestinal service. dr. cleared her for discharge with a plan to have her hematocrit checked weekly for the next two weeks, and then if they are stable plan to perform the aortic valve replacement and coronary artery bypass grafting on . medications on admission: norvasc 10mg tablet daily calcitonin 200 units nasal spray daily plavix 75mg tablet daily (ld ) cyanocobalamin 1000mcg sq bimonthly digoxin 125 mcg tablet daily procrit 40,000 units weekly tricor 145mg tablet daily novolog insulin 70/30 30 units isosorbide dinitrate 10mg tablet toprol xl 50mg tablet daily nitroglycerin 0.4 mg tablet prn chest pain pantoprazole 40mg tablet zocor 40mg tablet daily sucralfate 1gm tablet qid aspirin 81mg tablet daily ferrous sulfate 325mg tablet daily multivitamin 1 tablet daily vitamin c/vitamin e/copper/zinc oxide/lutein (preservision) one tablet daily discharge medications: 1. outpatient lab work lab work:**hematocrit check weekly x 2 weeks at the same time as weekly blood draws. please have results sent to cardiac surgery office fax ( phone (. attn: . 2. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 4. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). disp:*30 tablet sustained release 24 hr(s)* refills:*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. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 9. insulin nph & regular human 100 unit/ml (70-30) suspension sig: thirty (30) units subcutaneous twice a day. disp:*qs units* refills:*2* discharge disposition: home discharge diagnosis: -status post endoscopic cauterization of angiotasia in the lesser curvature of the stomach by gastroenterology -preop redo sternotomy avr/cabg discharge condition: good discharge instructions: lab work:**hematocrit check weekly x 2 weeks at the same time as weekly blood draws. please have results sent to cardiac surgery office fax ( attn: . if hematocrit is stable, you will undergo an aortic valve replacement and coronary artery bypass grafting on . do not take your plavix or digoxin. followup instructions: lab work:**hematocrit check weekly x 2 weeks do not take your plavix or digoxin. scheduled appointments: provider: lab phone: date/time: 9:30 provider: lab phone: date/time: 10:15 provider: , md phone: date/time: 11:00 Procedure: Endoscopic control of gastric or duodenal bleeding Diagnoses: Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Aortocoronary bypass status Aortic valve disorders Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Other and unspecified angina pectoris Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Acquired hemolytic anemia, unspecified Surgical or other procedure not carried out because of contraindication Angiodysplasia of stomach and duodenum with hemorrhage |
history of present illness: the patient underwent arteriogram which demonstrated no inflow disease but diffuse sfa disease. the patient was admitted for elective revascularization. past medical history: hypertension. coronary artery disease status post coronary artery bypass grafting in . she had a limited ................... to the circumflex right coronary artery and obtuse marginal. type 2 diabetes times eight years. history of neuropathy secondary to diabetes. chronic anemia with history of colon bleed. negative colonoscopy. aortic stenosis. allergies: no known drug allergies. medications on admission: ferrous sulfate, folic acid 1 mg q.d., lanoxin 0.25 mg q.d., altace 10 mg q.d., toprol xl 50 mg q.d., tri-chlor 160 mg q.d., lipitor 10 mg q.d., glyburide 3 mg q.d., glucophage 850 mg b.i.d., epogen q.week, fosamax 35 mg q.week, vitamin c, vitamin e, ecotrin 81 mg. physical examination: vital signs: blood pressure 144/70, pulse 60. general: the patient was alert and cooperative white female with some anxiety. heent: left upper lid mole. the remaining exam was unremarkable. there was a question of carotid bruits bilaterally versus transmitted murmur. chest: clear to auscultation. heart: regular rhythm, with a 3-4/6 systolic ejection murmur throughout the pericardium. abdomen: liver edge was one fingerbreadth below the costal margin. spleen nonpalpable. extremities: the patient had no pulses palpable bilaterally. hospital course: the patient was admitted to the preoperative holding area on . he underwent a femoral to popliteal bypass with nonreversed saphenous vein, angioscopy and valve lysis. the patient tolerated the procedure well. she had a palpable dorsalis pedis and triphasic posterior tibial at the end of the procedure. she was transferred to the pacu in stable condition. postoperative hematocrit was 29.9, bun 27, creatinine 0.9, potassium 4.2. she continued to do well from a hemodynamic standpoint and was transferred to the vicu for continued monitoring. on postoperative day #1, nitroglycerin was weaned off. her hematocrit remained at 27.0. she was converted to percocet for analgesic control. preoperative medications were instituted. diet was advanced as tolerated. fluids were hep-locked. hematocrit was at baseline. perioperative kefzol was continued until all lines were discontinued. the patient remained in the vicu. on postoperative day #2, t-max was 101.4??????, white count 11.1, hematocrit 25.8, platelet count 93. bun and creatinine remained stable. pulse exam remained unchanged. incisions were clean, dry, and intact. she was transfused 1 u packed red blood cells. lines were discontinued, and she was transferred to the regular nursing floor. posttransfusion hematocrit was 29.4. her t-max was 100.4??????, and then defervesced to 99.3??????. incentive spirometry and ambulation was encouraged. kefzol was discontinued. the patient was seen by physical therapy who felt that she would be safe for discharge to home with family support. her remaining hospital stay was unremarkable. she was discharged in stable condition. wounds were clean, dry, and intact. she had a functioning graft. she is to follow-up with dr. as directed. she should continue on her preoperative medications, in addition to percocet tab q.4-6 hours p.r.n. pain. discharge diagnosis: 1. calf claudication status post left femoral to popliteal bypass with nonreversed saphenous vein graft, angioscopy and valve lysis. 2. aortic stenosis, stable. 3. coronary artery disease, stable. 4. diabetes type 2, controlled. 5. chronic anemia with blood loss anemia, transfused. , m.d. dictated by: medquist36 Procedure: Other (peripheral) vascular shunt or bypass Diagnoses: Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Unspecified essential hypertension Iron deficiency anemia secondary to blood loss (chronic) Atrial fibrillation Aortic valve disorders Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with rest pain |
allergies: atorvastatin / clarithromycin / biaxin / gemfibrozil / influenza virus vaccine / morphine / percocet attending: chief complaint: aortic stenosis major surgical or invasive procedure: redo sternotomy, aortic valve replacement (21mm porcine) history of present illness: this 79 year old female with an extensive past medical history including coronary artery disease requiring multiple interventions including coronary artery grafting in . she has known aortic stenosis which has been followed by serial echocardiograms. she has recently noted chest pain with dyspnea on exertion. she was recently admitted in for redo-operation which was cancelled due to upper gi bleed. she subsequently underwent endoscopic cauterization of angiotasia in the lesser curvature of the stomach. of note, she was recently hospitalized at the for anemia and shortness of breath, where she required several units of prbc's. at this time, she has no further evidence of gi bleed is admitted for redo-operation. past medical history: s/p coronary artery bypass grafting peripheral disease s/p gastric hemorrhage and cauterization insulin dependent diabetes mellitus diastolic heart failure hypertension hyperlipidemiaq abdominal aortic aneurysm s/p right total hip replacement h/o hemolytic anemia s/p left carotid artery endarterectomy paroxysmal atrial fibrillation chronic renal insufficiency social history: denies etoh use nonsmoker family history: noncontributory physical exam: admission: pulse: 69 resp: 18 o2 sat: 100% bp 156/68 general: pleasant, elderly female in no acute distress skin: dry intact - well healed sternotomy heent: perrla eomi neck: supple full rom well healed l cea incison chest: lungs clear bilaterally well healed sternotomy incision heart: rrr irregular murmur :loud blowing systolic murmur abdomen: soft non-distended non-tender bowel sounds + well healed midline abdm incision extremities: warm , well-perfused edema-none varicosities: none . well healed bilat svg harvest site incisions bilaterally. she has remaining gsv in her left lower extremity that appears to be 4-5mm in diameter. neuro: grossly intact a&ox3, mae, follows commands pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit right: loud radiated murmur left: loud radiated murmur pertinent results: 12:45am blood wbc-8.8 rbc-3.39* hgb-10.0* hct-29.4* mcv-87 mch-29.6 mchc-34.1 rdw-17.9* plt ct-135* 01:10pm blood wbc-15.7*# rbc-2.50*# hgb-7.2*# hct-22.2*# mcv-89 mch-29.0 mchc-32.6 rdw-18.7* plt ct-107* 02:50pm blood pt-14.4* ptt-35.3* inr(pt)-1.2* 01:10pm blood pt-15.6* ptt-35.4* inr(pt)-1.3* 12:45am blood glucose-57* urean-66* creat-1.6* na-136 k-4.2 cl-99 hco3-26 angap-15 03:02am blood glucose-162* urean-36* creat-1.4* na-139 k-5.9* cl-110* hco3-22 angap-13 echocardiography report , portable tte (complete) done at 10:20:00 am final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 79 f hgt (in): 63 bp (mm hg): 109/39 wgt (lb): 132 hr (bpm): 88 bsa (m2): 1.62 m2 indication: pericardial effusion. tamponade. s/p avr icd-9 codes: 402.90, 423.3, 423.9, v42.2, 424.0, 424.2 test information date/time: at 10:20 interpret md: , md test type: portable tte (complete) son: , rdcs doppler: full doppler and color doppler test location: west sicu/ctic/vicu contrast: none tech quality: suboptimal tape #: 2009w080-0:00 machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: *5.3 cm <= 4.0 cm left atrium - four chamber length: *5.9 cm <= 5.2 cm left atrium - peak pulm vein s: 0.6 m/s left atrium - peak pulm vein d: 0.5 m/s right atrium - four chamber length: *6.5 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: 4.2 cm <= 5.6 cm left ventricle - ejection fraction: 60% >= 55% left ventricle - lateral peak e': *0.08 m/s > 0.08 m/s left ventricle - septal peak e': *0.04 m/s > 0.08 m/s left ventricle - ratio e/e': *23 < 15 aorta - sinus level: 2.9 cm <= 3.6 cm aorta - ascending: *3.6 cm <= 3.4 cm aortic valve - peak velocity: *2.9 m/sec <= 2.0 m/sec aortic valve - peak gradient: *36 mm hg < 20 mm hg aortic valve - lvot diam: 1.9 cm mitral valve - e wave: 1.4 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 1.75 mitral valve - e wave deceleration time: 174 ms 140-250 ms tr gradient (+ ra = pasp): 20 to 22 mm hg <= 25 mm hg pulmonic valve - peak velocity: 0.9 m/sec <= 1.5 m/sec findings left atrium: moderate la enlargement. right atrium/interatrial septum: moderately dilated ra. left ventricle: mild symmetric lvh. normal lv cavity size. overall normal lvef (>55%). tdi e/e' >15, suggesting pcwp>18mmhg. no resting lvot gradient. right ventricle: normal rv wall thickness. dilated rv cavity. rv function depressed. paradoxic septal motion consistent with conduction abnormality/ventricular pacing. paradoxic septal motion consistent with prior cardiac surgery. aorta: normal aortic diameter at the sinus level. focal calcifications in aortic root. mildly dilated ascending aorta. focal calcifications in ascending aorta. aortic valve: bioprosthetic aortic valve prosthesis (avr). increased avr gradient. trace ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. moderate mitral annular calcification. mild thickening of mitral valve chordae. calcified tips of papillary muscles. no ms. mild (1+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. normal tricuspid valve supporting structures. no ts. moderate tr. pulmonic valve/pulmonary artery: pulmonic valve not well seen. no ps. normal main pa. no doppler evidence for pda pericardium: no pericardial effusion. general comments: suboptimal image quality - poor echo windows. conclusions the left atrium is moderately dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef 60%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular cavity is dilated with depressed free wall contractility. the ascending aorta is mildly dilated. a bioprosthetic aortic valve prosthesis is present. the transaortic gradient is higher than expected for this type of prosthesis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is no tricuspid stenosis. moderate tricuspid regurgitation is seen. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the aortic valve has been replaced; mitral regurgitation is reduced. electronically signed by , md, interpreting physician 12:26 ?????? caregroup is. all rights reserved. brief hospital course: as a same day admission on the patient underwent redo sternotomy with a 21 mm porcine aortic valve replacement. cross clamp time was 47 minutes, total bypass time 68 minutes. see operative note for details. she weaned from bypass on propofol and neosynephrine infusions in stable condition. she was extubated the evening of surgery and remained stable. she was started on nitroglycerin for hypertension and weaned from the drip on post operative day #1. post operatively, the patient developed acute tubular nephrosis with a peak creatinine of 1.9 (baseline 1.3.) the patient's lasix dose was decreased and her creatinine was slowly decreasing at the time of discharge to 1.6. she is to have her bun and creatinine checked in 1 week after discharge. her potassium was also peaked at 7.0 post operatively. the patient was given lasix, kayexalate, d50 and insulin to treat the hyperkalemia. at the time of discharge, potassium was stable at 4.2. on postoperative day 2, pt went into rapid atrial fibrillation (with a history of afib.) she was started on an amiodarone gtt, transitioned to be amiodarone and her beta blocker was increased. her blood pressure was 80-90's systolically and increased after 1 unit of red blood cells for a hematocrit of 25, allowing further increase in beta blocker dose. at the time of discharge, she was in a rate controlled afib. she is not to receive any coumadin (only asa 81) due to history of gi bleed. chest tubes and pacing wires were removed per cardiac surgery protocol. insulin was started at half her home dose on post operative day # 4 with good blood sugar control. she was transferred to the floor and continued to work with physical therapy. she was noted to have a right upper extremity phlebitis, likely from an amiodarone infiltrated iv. she was started on a 5 day course of keflex. on post operative day # 5 her renal function continued to improve, potassium was stable, she was ambulating in the halls with assistance and her incisions were healing well. it was felt that she was safe for transfer to rehab at this time. medications on admission: norvasc 10mg tablet daily calcitonin 200 units nasal spray daily cyanocobalamin 1000mcg sq bimonthly procrit 40,000 units weekly novolog insulin 70/30 25 units imdur 30mg daily lopressor 25mg tid nitroglycerin 0.4 mg tablet prn chest pain pantoprazole 40mg tablet zocor 40mg tablet daily aspirin 81mg tablet daily ferrous sulfate 325mg tablet daily multivitamin 1 tablet daily preservision daily discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 7 days. disp:*7 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation for 30 days. disp:*60 capsule(s)* refills:*0* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*100 tablet, delayed release (e.c.)(s)* refills:*2* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever/pain. 5. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 6. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 7. amiodarone 200 mg tablet sig: two (2) tablet po every twelve (12) hours for 7 days. 8. amiodarone 200 mg tablet sig: two (2) tablet po once a day for 7 days. 9. amiodarone 200 mg tablet sig: one (1) tablet po once a day for 14 days: further dosing to be adjusted by cardiologist. 10. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 12. hydromorphone 2 mg tablet sig: one (1) tablet po every hours as needed for pain for 10 doses. 13. insulin nph & novolog 100 unit/ml (70-30) suspension sig: one (1) 10 units subcutaneous once a day: q am. increase to home dose of 20 units q am as po intake increases. 14. insulin nph & novolog 100 unit/ml (70-30) suspension sig: one (1) 15 units subcutaneous once a day: q pm. increase dose to 30 units q pm as po intake increases. 15. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for (r)forearm phlebitis for 5 days. 16. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). discharge disposition: extended care facility: - discharge diagnosis: aortic stenosis s/p coronary artery bypass grafting peripheral disease s/p gastric hemorrhage noninsulin dependent diabetes mellitus diastolic heart failure hypertension hyperlipidemiaq abdominal aortic aneurysm s/p right total hip replacement h/o hemolytic anemia s/p left carotid artery endarterectomy paroxysmal atrial fibrillation chronic renal insufficiency 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 () dr. in weeks () dr. in 2 weeks pt is to have k, bun/crea, cbc drawn in 1 week after discharge Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Acute kidney failure with lesion of tubular necrosis 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 Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Aortic valve disorders Peripheral vascular disease, unspecified Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Abdominal aneurysm without mention of rupture Other vascular complications of medical care, not elsewhere classified Phlebitis and thrombophlebitis of upper extremities, unspecified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: stemi c/b vfib arrest major surgical or invasive procedure: cardiac catheterization history of present illness: 89 y.o male with dm, ?chf/cad, moderate mr, hld reports that since lifting a heavy item into a dumster last wednedsay (2 days prior to admission) had midepigastric soreness like pain which never went away. it was made worse with laying on his left side. not worse with activity. today he vomited once and took a full strength asa and presented to . new afib and inferior lateral ste. . 1 min of arrival and 40 min of sxs, by report patient had a vfib arrest. not on monitor at the time. cpr initiated, debrillator placed and rhythm changed into afib with rvr without intervention. patient does not recall events but apparently had 1-3 minutes of chest compressions. wife notes that there was a lot of commotion and he was unconscious for a short perior of time. . prior to tranfer he was given lidocaine bolus, lidocaine gtt at 1mg/min. he was started on integrilin bolus 11.2mg /wt based (guess fo 60kg). bolus heparin 4000 u. plavix 600mg given in cath lab here at . . in cath lab, noted to have a totally occluded mid rca, thrombectomy with improved flow and bms placed. was given diltiazem 1mg centrally after procedure when had a "wide complex tachycardia" and af broke. right groin sheath was pulled. pain free now. other coronaries with mild disease. did right heart cath at end and pa pressure 30. pa diastolic <15, ra pressures nl. . on the floor, he states that his nausea did not completely go away but is much improved. his nausea resolved while in ccu and then returned with bilious vomiting after taking metoprolol and atorvastatin. . he initially stated that he did not have chest pain and then after vomiting, developed mild pleuritic cp around the left 5th rib. . on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, hypertension 2. cardiac history: - cabg: - percutaneous coronary interventions: - pacing/icd: 3. other past medical history: chf in peripheral neuropathy s/p ccy right hernia repair osteopenia hypothyroidism bph social history: walks 2-3 times/week for about 45 min. less now due to joint discomfort and neuropathy. uses . - tobacco history: denies - etoh: denies family history: *mother - hypertension *father - emphysema and lung cancer *sisters (3) - 1. breast cancer and thyroid nodule excision 2. oral/pharyngeal cancer 3. unknown thyroid problem *cousins - one with unknown thryoid problems. physical exam: admission physical examination: vs: 97, 103, 124/87, 20, 98/ra general: nad. pleasant. mood, affect appropriate. hoh heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. dry mucous membranes. neck: supple with jvp of 9 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. tachycardic, 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. right femoral site with clear dressing, dry and intact, no bruit or hematoma. extremities: no edema. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: 2+ dp 2+ pt 2+ left: 2+ dp 2+ pt 2+ . discharge physical exam: vs: 97.8, 64, 101/52, 22, 95%ra, 74.4kg general: nad. pleasant. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. dry mucous membranes. neck: supple with jvp at level of sternal angle. cardiac: pmi located in 5th intercostal space, midclavicular line. regular rate, regular rhythm normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: rales at bases bilaterally abdomen: soft, ntnd. no hsm or tenderness. right femoral site with clear dressing, dry and intact, no bruit or hematoma. extremities: trace edema in ble??????s. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: 2+ dp 2+ pt 2+ left: 2+ dp 2+ pt 2+ pertinent results: admission labs: . 08:47pm blood wbc-7.0# rbc-4.16* hgb-13.0* hct-38.5*# mcv-93 mch-31.3 mchc-33.8 rdw-13.9 plt ct-105* 08:47pm blood pt-12.5 ptt-42.2* inr(pt)-1.1 08:47pm blood plt ct-105* 08:47pm blood glucose-167* urean-24* creat-0.9 na-140 k-4.1 cl-106 hco3-26 angap-12 08:47pm blood alt-35 ast-162* ld(ldh)-420* ck(cpk)-1320* alkphos-93 totbili-1.2 08:47pm blood ck-mb-250* mb indx-18.9* ctropnt-2.42* 08:47pm blood calcium-9.6 phos-3.0 mg-1.8 cholest-159 08:47pm blood %hba1c-5.5 eag-111 08:47pm blood triglyc-69 hdl-53 chol/hd-3.0 ldlcalc-92 08:47pm blood tsh-1.2 08:47pm blood free t4-1.3 05:23pm blood type-art po2-264* pco2-37 ph-7.40 caltco2-24 base xs-0 intubat-not intuba 05:23pm blood k-3.9 05:23pm blood hgb-12.6* calchct-38 o2 sat-99 . pertinent labs: . 08:47pm blood alt-35 ast-162* ld(ldh)-420* ck(cpk)-1320* alkphos-93 totbili-1.2 08:47pm blood ck-mb-250* mb indx-18.9* ctropnt-2.42* 03:17am blood ck-mb-216* mb indx-15.8* ctropnt-4.50* 08:47pm blood %hba1c-5.5 eag-111 08:47pm blood triglyc-69 hdl-53 chol/hd-3.0 ldlcalc-92 08:47pm blood tsh-1.2 08:47pm blood free t4-1.3 . discharge labs: . 05:48am blood wbc-4.2 rbc-3.65* hgb-11.6* hct-33.7* mcv-93 mch-31.7 mchc-34.3 rdw-13.7 plt ct-104* 05:48am blood plt ct-104* 05:48am blood glucose-102* urean-22* creat-1.0 na-141 k-4.1 cl-109* hco3-27 angap-9 05:48am blood calcium-9.5 phos-3.4 mg-1.9 . micro/path: . blood culture x 2 : ngtd urine culuture : no growth mrsa screening : negative . imaging/studies: . c.cath : 1. two vessel coronary artery disease. 2. st elevation myocardial infarction with occlusion of the mid rca. 3. successful export thrombectomy and pci of the mid rca with bms (see ptca comments). 4. continue aspirin and plavix. 5. post-mi care in the ccu. . cxr portable : findings: no rib fractures identified and there is no pneumothorax. the heart is mildly increased in size and there is volume loss at both bases but there is no overt pulmonary edema. compared to the prior study from there is improved aeration in the left lower lobe and the heart size is mildly increased. . tte : lvef: 30% the left atrium is normal in size.. left ventricular wall thicknesses and cavity size are normal. lv systolic function appears depressed (ejection fraction 30 percent) secondary to extensive severe inferior posterior and lateral wall hypokinesis/akinesis; the posterior wall is dyskinetic. the right ventricular free wall thickness is normal. right ventricular chamber size is normal. with severe global free wall hypokinesis. the aortic valve leaflets are moderately thickened. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. . cxr portable : findings: there is a new left-sided picc line with tip in the left axilla. this abnormal position was called to dr. by dr. at 11:55 a.m. on , the overall appearance of the lungs is not substantially changed compared to the film from the prior day. there is no pneumothorax. brief hospital course: 89 yo male with chf/cad, moderate mr, and hld presents with inferior/lateral stemi who coded for vfib arrest in the osh ed, rec'd chest compressions, and vfib resolved s/p export thrombectomy and bms to mid rca admitted to the ccu for hypotension following the procedure. . active diagnoses: . # cad/stemi/vfib arrest c resuscitation: mr. presented to an osh ed 2 days following development of epigastric pain after a period of exertion. per report he suffered from a vfib arrest, had chest compressions, and reverted to afib with rvr on monitor. he was given a lidocaine bolus and started on lidocaine, heparin, and integrillin drips, given an asa and transferred to for further evaluation and treatment. he was taken to the cath lab where he received a loading dose of plavix and found was noted to have 2 vessel disease with a thrombotically occluded rca and a 60% diffusely occluded lad. he had export thrombectomy and bms to rca. he was given dilt in the cath lab for a wide complex tachycardia which broke. he was transferred to the ccu with hypotension and required gentle dopamine pressor support and iv fluid boluses to maintain a map >50 which was weaned and discontinued after 2 days. he was monitored on telemetry and evidence of ectopy ceased 72 hours following cath. he had a tte which showed lvef 30% secondary to extensive severe inferior posterior and lateral wall hypokinesis/akinesis and rv with free wall hypokinesis. he was started on 2.5mg lisinopril daily (should be given in the morning), 12.5mg metoprolol succinate (which should be given in the evening), 80mg atorvastatin daily, and continued on plavix 75mg and asa 325mg. we would consider adding spironolactone as a part of his chf regimen but defer this until later assessment of recovery of lv/rv function by tte in weeks. . # afib with rvr: pt with new afib, likely related to the peri-infarct period. chads score 3. on aspirin and plavix and has history of recent falls without intracranial hemorrhage. we deferred initiation of coumadin anti-coagulation in favor of monitoring for resolution of afib following the peri-infarct period. . chronic diagnoses: . # hld: stable. continued on atorvastatin 890mg po daily . # bph: stable. we held his tamsulosin given his relative hypotension but continued his home finasteride. he did not have issues with urinary obstruction during his hospitalization. . # hypothyroidism: per report, not on synthroid, thyroid studies wnl??????s. this should be followed as an outpatient. . transitional issues: . # he is relatively hypotensive with blood pressure ranges of 70's-100's/40's-50's. unclear if this is new for him and related to decreased cardiac output from his mi. he denies symptoms such as light-headedness, chest pain, shortness of breath, or orthostatic symptoms even while at these pressures and was able to walk with physical therapy without significant issues. . # he could likely benefit from some fine-tuning of his chf regimen as an outpatient but this must be balances against his relative hypotension and his advanced age. this may require repeat tte in weeks to assess recovery of his lvef and myocardial function. . # he was full code during this admission . # he was discharged to rehab for continue working on his strength and physical conditioning. medications on admission: asa 81 mg daily finasteride 5mg qhs mvi daily tamsulosin 0.8 mg daily caltro 600mg with meals ibuprofen 200mg daily omega 3 fatty acid- fish oil 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:*0* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 5. calcium carbonate 600 mg (1,500 mg) tablet sig: one (1) tablet po twice a day. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*0* 7. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 8. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 9. metoprolol succinate 25 mg tablet extended release 24 hr sig: 0.5 tablet extended release 24 hr po daily (daily). 10. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 11. multivitamin tablet sig: one (1) tablet po once a day. 12. omega 3-6-9 fatty acids 400-400-200 mg capsule sig: one (1) capsule po once a day. discharge disposition: extended care facility: northeast - discharge diagnosis: primary: -st elevation myocardial infarction s/p cath and stent -hypotension requiring pressors . secondary: -hyperlipidemia -benign prostatic hyperplasia -arthritis 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. you were admitted to for evaluation and treatment of a heart attack. your course was complicated by an abnormal heart rhythm and cardiac arrest. you were successfully resuscitated. a cardiac catheterization was performed which showed multi-vessel disease with acute blockage of one of the arteries of your heart which cause your heart attack. the blockage was removed and a bare metal stent was placed to keep the vessel open. . your blood pressure were a little low during this admission but you did not have significant symptoms and were able to walk with the nurses and physical therapy without significant difficutly. . weigh yourself every morning, md if weight goes up more than 3 lbs. . the following changes have been made to your medications: - stop tamsulosin as this can lower your blood pressure - stop ibuprofen as this can increase your risk of bleeding when getting aspirin and plavix - start metoprolol succinate 12.5mg by mouth once daily (take this at night) - start lisinopril 2.5mg by mouth once daily (take this in the morning) - start plavix 75mg by mouth once daily (do not stop taking this medication unless told by a cardiologist) - start atorvastatin 80mg by mouth once daily - change aspirin to 325mg by mouth once daily . please follow-up with the appointments below. followup instructions: department: internal medicine when: monday at 1 pm with: , md building: (, ma) campus: off campus best parking: free parking on site department: adult specialties when: tuesday at 2:00 pm with: , md building: (, ma) campus: off campus best parking: free parking on site department: adult specialties when: wednesday at 12:15 pm with: , dpm building: (, ma) campus: off campus best parking: free parking on site Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization 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 Central venous catheter placement with guidance Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Cardiogenic shock Acute myocardial infarction of inferolateral wall, initial episode of care Chronic diastolic heart failure Disorder of bone and cartilage, unspecified Chronic total occlusion of coronary artery |
allergies: erythromycin base / zithromax attending: addendum: mr. on bal grew haemophilus species not influenzae and completed a 7 day course of levofloxacin for possible pneumonia. discharge disposition: home md Procedure: Closed [endoscopic] biopsy of bronchus Other repair and plastic operations on trachea Other repair and plastic operations on bronchus Diagnoses: Esophageal reflux Pure hypercholesterolemia Personal history of tobacco use Pulmonary collapse Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria Other diseases of trachea and bronchus Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Other acute postoperative pain |
allergies: erythromycin base / zithromax attending: chief complaint: tracheobronchomalacia. major surgical or invasive procedure: right thoracotomy and tracheobronchoplasty bronchoscopy with bronchoalveolar lavage. history of present illness: mr. is a 67-year-old gentleman who has had a cough and recurrent infections. he is noted to have severe diffuse tracheobronchomalacia. he felt better with a tracheobronchialized stent in place. we discussed the risks of the operation including failure to ameliorate symptoms, worsening breathing or frank respiratory failure, pneumonia, injury to the intrathoracic structures such as the thoracic duct, airway, lungs, heart, aorta, other vessels, recurrent laryngeal nerve, esophagus, or other structures. we also discussed the possibility of recurrence, reoperation, gastroesophageal reflux worsening. mr. understood all of these risks and wished to proceed. social history: married with two adult sons. is a retired lawyer/business man. quit smoking 25 years ago and had been a 40-50ppy smoker. smokes one cigar a week. drinks one alcoholic beverage per night. has had recent international travel. had a negative ppd 2 weeks prior to visit. family history: non-contributory physical exam: vs: t 96.8 hr: 68 sr bp 118/70 sats: 95% ra general: 67 year-old male in no apparent distress heent: normocephalic mucus membranes mosit neck: supple no lymphadenopathy card: rrr normal s1,s2 no murmur/gallop or rub resp: clear breath sounds bilataerally gi: benign extre: warm no edema incison: right thoracotomy site clean no erythema margins well approximated skin: upper mid back with raised blisters neuro: non-focal pertinent results: wbc-7.3 rbc-3.84* hgb-11.9* hct-36.0* plt ct-212 wbc-15.7*# rbc-4.51* hgb-13.9* hct-41.4 plt ct-269 glucose-108* urean-11 creat-1.0 na-138 k-4.1 cl-99 hco3-31 glucose-126* urean-21* creat-0.9 na-138 k-4.2 cl-108 hco3-22 glucose-160* urean-24* creat-1.0 na-142 k-4.0 cl-107 hco3-23 calcium-8.6 phos-3.5 mg-2.0 ck(cpk)-2404* ck(cpk)-3578* ck(cpk)-2970* ck(cpk)-1029* ck-mb-36* mb indx-1.2 ctropnt-<0.01 ck-mb-15* mb indx-1.5 ctropnt-<0.01 bronchoalveolar lavage from rll. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs. respiratory culture (final ): >100,000 organisms/ml. commensal respiratory flora. haemophilus species not influenzae. 10,000-100,000 organisms/ml.. cxr: : very mild interstitial abnormalities probably edema. heart size is normal. tiny right pleural effusion layers posteriorly and there is a small component of pleural fluid in the upper aspect of one of the major fissures, probably the left. mediastinum has an unremarkable postoperative appearance aside from thickening of the posterior wall of the trachea, seen best on the lateral view. no pneumothorax. : there has been interval removal of the right-sided chest tube. there is an increased amount of right subcutaneous emphysema. no pneumothorax is identified. given the increased subcutaneous emphysema, continued followup is recommended. there is subsegmental atelectasis in the left lower lobe and right mid lung with some fluid in the right fissure. : lateral aspect of the right lower chest is excluded from the examination. the other right pleural surfaces are normal; previous right apical pneumothorax has cleared, pneumomediastinum is less pronounced and subcutaneous emphysema in the right chest wall and neck, probably unchanged. bibasilar atelectasis has nearly cleared. left lung is clear. heart size normal. no mediastinal widening. right midline drain in place. brief hospital course: mr. was admitted on for right thoracotomy and tracheobronchoplasty bronchoscopy with bronchoalveolar lavage. he was extubated in the operating room. he tolerated the procedure was transferred to the sicu overnight for respiratory monitoring. respiratory: aggressive pulmonary toilets, mucolytic nebs were administered. oxgenation 95% 4l via nasal cannula. over the course of his hospitalization the oxygen was titrated off with oxygen saturation 97% ra. chest-tube: right chest tube was removed on pod3. he was followed by serial chest films see reports above. cardiac: he remain in sinus rhythm and hemodynamically stable thoughtout his hospital course. gi: no issues nutrition: he was seen by speech and swallow which showed large reflexive coughing when sips of thin liquid followed regular solids consistent with likely aspiration. recommend a po diet of nectar thick liquids and soft solids for meals on . over the next few days his reflexive coughing improved he was re-evaluated by speech 0n he tolerated thin liquids and regular consistency solids without concern for aspiration. renal: renal function stable with good urine output. his cpks were monitor throughout and trending down. foley was removed he voided. id: his bal on grew gnr/gpc and he completed a 7 day course of levofloxacin. pain: bupvacaine/dilaudid epidural managed by the acute pain service was titrated to good pain control. on the epidural was removed he converted to po pain medication with good control. neuro: no issues dispositon: he was discharged to home on . he will follow-up with dr. and dr. as an outpatient. medications on admission: benzonate 100 mg tid prn. mucinex 1200 mg discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): while taking narcotics. 2. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*70 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: tracheobronchomalacia. discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: call dr. office if experience with any questions or concerns. -rash on back: wash with mild soap water, pat dry. apply hydrocortisone cream to raised areas only -monitor incision for signs of infection: incrased redness or drainage -take pain medications as needed. -you may take aleve or motrin prn for pain with food and water. -take stool softners while taking narcotics. -no driving while taking narcotics -you may shower. no tub bathing or swimming for 4 weeks followup instructions: follow-up with dr. at 10:00am in the chest disease center building i follow-up with dr. at 10:30am same place chest x-ray 9:30 am in the clinical center radiology. Procedure: Closed [endoscopic] biopsy of bronchus Other repair and plastic operations on trachea Other repair and plastic operations on bronchus Diagnoses: Esophageal reflux Pure hypercholesterolemia Personal history of tobacco use Pulmonary collapse Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria Other diseases of trachea and bronchus Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Other acute postoperative pain |
allergies: no known allergies / adverse drug reactions attending: chief complaint: hypoxia major surgical or invasive procedure: s/p tracheostomy tube history of present illness: ms. is a 39 year old female who sustained a large left sided mca stroke on thought secondary to a carotid dissection, seizure disorder who was sent in from rehab due to hypoxia. she was noted to be in respiratory distress in the morning and her sat was found to be 57%. her t-tube was suctioned and washed out with normal saline with improvement of her o2 sats to 93% ra. she typically has her tube capped during the day and has humidified air overnight. . of note she was recently admitted for t-tube placement on . she tolerated the procedure well and was transferred to rehab. . in the ed, initial vs were: t 95.3 p 125 bp 116/75 r 28 o2 sat 100 4l. . on the floor, she was seen by ip and her t-tube was switched out for a tracheostomy tube. she was noted to have another significant mucous plug which was suctioned out. she was unable to verbalize how she was doing however she denied any pain or discomfort. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - l mca cva ppresented with aphasia and r sided weakness, thought to due to cva secondary to thrombosis and embolism from concurrent l carotid dissection. thrombectomy attempted and "partially successful" but then developed edema and midline shift with progressive neurological deterioration in the face of hypertonic saline and mannitol. therefore family elected to pursue l hemicraniotomy and partial l temporal lobectomy. has persistent hemiplegia and aphasia but responds appropriately to questions. - possible hypertension - possible seizure at the time of carotid dissction - hap with gnr complicating icu course 12/. she completed a 10-day course of zosyn. - chronic headaches after head injury (hit in head by student in special ed class she was teaching) - s/p right carpal tunnel release - s/p hysterectomy 3 years ago social history: currently resides rehab macu. former special ed teacher. two children. no etoh, smoking, family history: sister also with stroke in 30's though etiology unknown. sister also w/ dvt and headaches. father with stroke in his 60's. physical exam: vitals: t: 100.2 bp: 132/74 p: 121 r: 18 o2: 99% 40% tracheostomy general: alert, answering yes or no questions, actively coughing heent: sclera anicteric, mmm neck: supple, jvp not elevated, no lad trach: patent, no erythema or swelling 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, has a peg in place gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: no movement of right side, strength 0/5 on right side, right facial droop, left sided strength 4/5, responding with appropriate left hand guestures to questions pertinent results: chest x-ray : impression: tracheostomy tube not visualized. no acute cardiopulmonary abnormality. . chest x-ray : findings: in comparison with the study of , the tracheostomy tube is now in place. low lung volumes may account for much of the apparent prominence of the transverse diameter of the heart. no vascular congestion or acute focal pneumonia. . 09:40am blood wbc-15.6*# rbc-4.04* hgb-12.0 hct-34.4* mcv-85 mch-29.7 mchc-34.9 rdw-13.7 plt ct-421# 03:35am blood wbc-5.9# rbc-3.16* hgb-9.3* hct-26.6* mcv-84 mch-29.5 mchc-35.0 rdw-13.5 plt ct-317 09:40am blood glucose-127* urean-12 creat-0.5 na-139 k-4.1 cl-102 hco3-24 angap-17 03:35am blood glucose-102* urean-13 creat-0.4 na-139 k-3.9 cl-104 hco3-27 angap-12 09:52am blood lactate-2.7* brief hospital course: ms. is a 39 year old female who sustained a large left sided mca stroke on thought secondary to a carotid dissection, seizure disorder who was sent in from rehab due to hypoxia most likley due to mucous plug. . #. hypoxia: most likley due to mucous plug. according to her husband her tube was not being capped during the day however according to nursing at rehab she was always capped during the day. ip saw her when she arrived and switched her t-tube to a tracheostomy which she tolerated well. she was noted to have mucous occluding her t-tube. she should continue to have her trach suctioned and given humidified air overnight . #. tachycardia: appears to be sinus tachycardia on ekg. underlying cause of tachycardia include respiratory distress vs. albuterol use vs. pain. her tachycardia resolved the following day. . #. cva: she has a baseline expressive aphasia, dense hemiplegia on her right side, and ability to communicate with yes or no guestures in an appropriate manner. she was continued on aspirin 81mg and simvastatin. . #. seizure: she is currenlty well controlled on her home regimen. she was continued keppra. . #. hypertension: currenlty well controlled on current regimen. she was continued metoprolol 25mg . . #. agitiation: she has a history of agitation which she responds well to haldol. she was continued on haldol 1mg prn medications on admission: 1. aspirin 81 mg tablet : one (1) tablet po once a day. 2. bisacodyl 10 mg suppository : one (1) suppository rectal at bedtime as needed for constipation. 3. methylphenidate 2.5 mg tablet, chewable : one (1) tablet, chewable po twice a day. 4. metoprolol tartrate 25 mg tablet : one (1) tablet po twice a day. 5. omeprazole 20 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po twice a day. 6. simethicone 80 mg tablet, chewable : one (1) tablet, chewable po four times a day as needed for indigestion. 7. acetaminophen 325 mg tablet : 1-2 tablets po four times a day as needed for pain. 8. morphine concentrate 20 mg/ml solution : ml po q4 hrs: prn as needed for pain. 9. lidocaine (pf) 10 mg/ml (1 %) solution : four (4) ml injection q1h (every hour) as needed for pain. 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : 1-2 puffs inhalation q6h (every 6 hours) as needed for dyspnea/wheezing. 11. haloperidol 1 mg tablet : one (1) tablet po bid (2 times a day) as needed for agitation. 12. lactulose 10 gram/15 ml syrup : fifteen (15) ml po qid (4 times a day) as needed for constipation. 13. levetiracetam 100 mg/ml solution : seven y (750) mg po bid (2 times a day). 14. simvastatin 40 mg tablet : one (1) tablet po daily (daily). 15. docusate sodium 50 mg/5 ml liquid : one hundred (100) mg po bid (2 times a day). 16. senna 8.6 mg tablet : 1-2 tablets po bid (2 times a day) as needed for constipation. 17. milk of magnesia 400 mg/5 ml suspension : thirty (30) ml po once a day as needed for constipation. 18. t-tube flushes keep open to humidified air. flush with 3 ml ns and suction back 19. mucinex 1,200 mg tab, multiphasic release 12 hr : one (1) tab, multiphasic release 12 hr po twice a day. tab, multiphasic release 12 hr(s) 20. omeprazole 20 mg capsule, delayed release(e.c.) : two (2) capsule, delayed release(e.c.) po q 12h (every 12 hours) as needed for gerd. 21. guaifenesin 100 mg/5 ml syrup : fifteen (15) ml po bid (2 times a day). discharge medications: 1. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 2. bisacodyl 10 mg suppository : one (1) suppository rectal hs (at bedtime) as needed for constipation. 3. methylphenidate 5 mg tablet : 0.5 tablet po bid (2 times a day). 4. metoprolol tartrate 25 mg tablet : one (1) tablet po bid (2 times a day). 5. simethicone 80 mg tablet, chewable : one (1) tablet, chewable po qid (4 times a day) as needed for indigestion. 6. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for pain. 7. haloperidol 0.5 mg tablet : two (2) tablet po bid (2 times a day) as needed for agitation. 8. lactulose 10 gram/15 ml syrup : fifteen (15) ml po q6h (every 6 hours) as needed for constipation. 9. levetiracetam 100 mg/ml solution : seven y (750) mg po bid (2 times a day). 10. simvastatin 40 mg tablet : one (1) tablet po daily (daily). 11. docusate sodium 50 mg/5 ml liquid : one (1) po bid (2 times a day). 12. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 13. magnesium hydroxide 400 mg/5 ml suspension : thirty (30) ml po q12h (every 12 hours) as needed for constipation. 14. guaifenesin 100 mg/5 ml syrup : fifteen (15) ml po bid (2 times a day). 15. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation q2h (every 2 hours) as needed for sob/wheezing. 16. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 17. mucinex 1,200 mg tablet, er multiphase 12 hr : one (1) tablet, er multiphase 12 hr po bid (2 times a day). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnosis hypoxia to mucous plug discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , you were admitted into the icu because you were noted to have low oxygen saturation. this was most likley due to a blockage in your t-tube. you were seen by the interventional pulmonology who switched out your t-tube for a tracheostomy tube. you tolerated the procedure well and it was felt that you safe to return to rehab. there were no changes to your medications. it was a pleasure taking care of you. we wish you a speedy recovery. followup instructions: please follow up with dr. in 2 weeks. please call ( to make a follow up appointment. md Procedure: Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Bronchoscopy through artificial stoma Replacement of tracheostomy tube Removal of intraluminal foreign body from trachea and bronchus without incision Diagnoses: Unspecified essential hypertension Other pulmonary insufficiency, not elsewhere classified Other convulsions Other specified cardiac dysrhythmias Other late effects of cerebrovascular disease Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Mechanical complication due to other implant and internal device, not elsewhere classified Other and unspecified special symptoms or syndromes, not elsewhere classified Late effects of cerebrovascular disease, aphasia Other late effects of cerebrovascular disease, facial weakness Attention to gastrostomy Edema of larynx Dysphagia, oropharyngeal phase Foreign body in main bronchus Other abnormal granulation tissue Other late effects of cerebrovascular disease, dysphagia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: respiratory distress major surgical or invasive procedure: bronchoscopy history of present illness: 39yof s/p left cranioplasty and temporal lobectomy on for decompression after left mca dissection and infarct, s/p tracheostomy for subglottic tracheal stenosis followed by ip who initially presented to for pain at the tracheostomy site, transferred for concern for dislodged tracheostomy, being admitted to the micu for further evaluation and management. . past medical history significant for a left mca dissection and large left mca territory infarct with residual expressive aphasia and hemiplegia. she underwent a bronchoscopy by ip at the time for residual dysphagia which showed subglottig stenosis above the stoma, and a t-tube was placed. however, the t-tube was subsequently removed due to severe mucus plugging and a #6 cuffed portex tracheostomy tube was placed. she had been tolerating a passe-muir valve, but has been unable to tolerate capping for prolonged periods. she is being evaluated for a possible button vs cannulation of the tracheostomy as an outpatient, and is scheduled to see interventional pulmonology on for this evaluation. per family, she has not been using her passe-muir valve at home very much, and has been only requiring humidified oxygen at night to sleep. . currently, per family report and ed report, the patient has had increasing pain at the site of the tracheostomy tube since yesterday with mild erythema at the site of the tracheostomy but without swelling, drainage, or fevers. per family, she was short of breath since the onset of her pain but has not been wheezing, and there was a question of whether the dyspnea was related to her anxiety about the tracheostomy. she has a chronic cough which has increased in frequency but she has not had increased sputum and has not had yellow or green sputum. the family was concerned as the tracheotomy tube appeared slightly displaced, and the patient was having discomfort at the site, and transported her to . . in the ed, initla vs were: 97.8 124/88 61 24 100% on 10l trach mask. the patient was not noted to be in respiratory distress at that time and was breathing comfortably. she was given nebs and suctioned small amount of white sputum. cxr at osh showed no displacement of the tracheotomy tube. her family requested transfer to , as she is followed by ip here, and she was transferred to for further management. . in the ed, initial vs: 97.8 73 133/80 16 99% ra for respiratory distress and wheezing, the patient was given 1 albuterol neb on arrival, and morphine 4mg iv for pain at the tracheostomy site. subsequently she had no respiratory symptoms and the trach was suctioned without difficulty. the osh images were uploaded and ip was consulted, who felt the tracheostomy tube was not displaced and recommended no further imaging studies and recommended discharge with outpatient f/u on wednesday. however, the ed physicians recommended further monitoring in-house, and following rediscussion with interventional pulmonology, empirical antimicrobials were initiated and patient admitted for monitoring of the pain at the trach site. the patient was given keflex 500mg po and vancomycin 1gm iv and 1l ns. she developed red man syndrome during vancomycin infusion, no wheezing or airway involvement, and was given benadryl 50mg iv. she was admitted to micu for pulmonary toilet given her frequent suctioning requirement for regular, non-purulent mucus (q2-3 hr per ed report). on transfer, vs were: afebrile 105 124/78 99% on humidified o2 10l which was increased given the patient's significant anxiety. . on arrival to the micu, the patient was comfortable and with adequate sao2 on high flow humidified air and denied shortness of breath on limited history while communicating with the use of hand signals. she did acknowledge pain at the tracheostomy site but denied pain at any other site. past medical history: - ich - s/p peg, tracheostomy, switched to t-tube for tracheostenosis but subsequently reversed to tracheostomy on for respiratory distress - s/p right carpal tunnel release - s/p hysterectomy 3 years ago - htn - seizures - migraines - gerd - hap with gnr complicating icu course - s/p endometrial ablation under general anesthesia social history: - tobacco: denies any history of tobacco use. - etoh: denies. - illicit drugs: denies. expressive aphasia and hemplegic but able to communicate with yes and no signs and pictures. currently resides at home with husband and children. former special ed teacher. family history: sister also with stroke in 30's though etiology unknown. sister also w/ dvt and headaches. father with stroke in his 60's. physical exam: admission exam: vs: 98.8 68 127/73 22 100% high flow trach mask gen: pleasant, alert, interactive, comfortable, nad heent: pupils equal and round, eomi, sclera anicteric, mmm, op without lesions, tracheostomy in place with high flow mask. cv: rrr, normal s1 and s2, no m/r/g resp: cta b/l with good air movement throughout, no wheezes or rhonchi abd: +b/s, soft, nt/nd, no masses or hepatosplenomegaly ext: no c/c/e, increased warmth and mild erythema and fullness of lle compared to rle, 2+ dp pulses b/l skin: no rashes/no jaundice/no splinters neuro: alert, interactive, uses yes and no hand signals and follows basic commands but comprehension difficult to assess given expressive aphasia. moving all extremities. pertinent results: 04:57am blood wbc-6.7 rbc-4.06* hgb-11.1* hct-33.5* mcv-82 mch-27.2 mchc-33.1 rdw-14.2 plt ct-288 07:40pm blood wbc-10.0 rbc-4.55# hgb-12.1 hct-36.5 mcv-80*# mch-26.5*# mchc-33.0 rdw-14.2 plt ct-372 08:44am blood glucose-91 urean-13 creat-0.4 na-139 k-4.1 cl-107 hco3-22 angap-14 07:40pm blood glucose-99 urean-14 creat-0.5 na-139 k-4.8 cl-105 hco3-20* angap-19 brief hospital course: 39yof s/p left cranioplasty and temporal lobectomy on for decompression after left mca dissection and infarct, s/p tracheostomy for subglottic tracheal stenosis followed by ip who initially presented to for pain at the tracheostomy site, transferred for concern for dislodged tracheostomy, being admitted to the micu for management of acute tracheobronchitis or tracheal tube site infection and intermittent respiratory distress. #. tracheostomy tube placement: pt was transferred to with concern for malpositioning of her tracheotomy tube. the patient's osh cxr was uploaded and reviewed by interventional pulmonology and the ed. the patient's tracheostomy tube was able to be suctioned without difficulty and the placement was not felt to be dislodged based on imaging and clinical assessment. pt was noted during her hospitalization to be very wheezy, she was thus given albuterol nebulizers, pulmonary toilet. she was discharged with follow-up with interventional pulmonary. she was also recommended to use her albuterol inhaler more frequently. #. pain at tracheostomy site: she was also noted to have at the tracheostomy site which was likely due to mild irritation. as a cellulitis process could not be ruled out she was discharged on a regimen of bactrim and keflex. oxycodone was also prescribed prn for pain control. #. h/o ich: recently evaluated by neurosurgery in with documented slow improvement of mental status, speech, and motor skills. she was continued on her home regimen of levetiracetam. #. htn: she was continued on metoprolol, hydralazine per home regimen. #. dyslipidemia: she was continued on simvastatin per home regimen. #. depression: continued citalopram per home regimen. #. psych: continued home methylphenidate and haldol medications on admission: - albuterol sulfate neb q6h prn sob - levetiracetam 100 mg/ml solution: 7.5 ml - metoprolol tartrate 25 mg tid - hydralazine 25 mg q6h prn sbp>160. - methylphenidate 5 mg - haloperidol 1 mg po bid - citalopram 10 mg daily - omeprazole 20 mg (e.c.) q 12h - simvastatin 40 mg daily - acetaminophen 325 mg tablet: 1-2 tablets q6h prn pain - oxycodone-acetaminophen 5-325 mg tablet: 1-2 tablets q4h prn pain - docusate sodium 100 mg - senna 8.6 mg tablet daily - bisacodyl 5 mg (e.c.): two tablets daily - simethicone 80 mg q6h - sc heparin 5,000 units tid discharge medications: 1. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 10 days: last dose . disp:*40 capsule(s)* refills:*0* 2. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po bid (2 times a day) for 10 days. disp:*20 tablet(s)* refills:*0* 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 4. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 6. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 7. levetiracetam 100 mg/ml solution sig: seven y (750) mg po bid (2 times a day). 8. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 9. methylphenidate 5 mg tablet sig: one (1) tablet po bid (2 times a day). 10. haloperidol 1 mg tablet sig: one (1) tablet po twice a day. 11. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every four (4) hours as needed for dyspnea: please take your nebs every hours for the first 4 days, then take your nebs as you usually do. 12. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 13. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 14. senna 8.6 mg tablet sig: one (1) tablet po once a day as needed for constipation. 15. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 16. hydralazine 25 mg tablet sig: one (1) tablet po every six (6) hours as needed for high blood pressure. 17. oxycodone 5 mg capsule sig: one (1) capsule po every hours as needed for pain: cause drowsiness. disp:*30 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: cellulitis around tracheostomy site discharge condition: mental status: clear and coherent but expressive aphasia. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you presented to the hospital with pain at your tracheostomy site and concern for the placement of the tracheostomy tube. you had a chest xray which did not show concerns for displacement of your tracheostomy tube, and the interventional pulmonary specialist evaluated you and performed a bronchoscopy which did not show any concerning findings. you were started on antibiotics for a possible skin infection around your tracheostomy tube. you had shortness of breath initially on presentation to the emergency room but this improved with pain control and your oxygen saturations were excellent throughout your hospital stay. just before leaving the hospital yesterday you had another episode of difficulty breathing, we think this is from your wheezing and the pain at your trach site. you were observed overnight and had no other issues. the following changes were made to your home medications: - start keflex 500mg every 6 hours for 7 days, to end . - start bactrim ds tablet twice daily, to end . - metoprolol was decreased to twice daily for lower blood pressures. - you should increase your albuterol nebulizer treatments to every four hours for the next 4 days, after that you can take as much as you did before - you can take oxycodone 5mg every 4-6 hours as needed for your neck pain at the trach site. if you do not have any pain you do not have to take this medication. this medication causes sedation. as we discussed it does not appear that you were taking the subcutaneous heparin injections (to prevent blood clots) that was on your medication list, so this has been removed from you med list. please follow up with your primary physician and neurologist/neurosurgeon about your blood pressure medications. followup instructions: you will be contact to follow up at the interventional pulmonary clinic within the next 10 days. if you do not receive a phone call from them, please call ( to schedule an appointment to be seen within the next 7-10 days. we have emailed the surgeon who placed your peg tube about removing it, as it was unable to be done while inpatient. they should be in contact with you about this, but if you do not hear from them, please call ( to follow up. alternatively, dr. in interventional pulmonology may choose to do this at your next visit with him. you have the following appointments scheduled: department: neurology when: monday at 4:30 pm with: , md building: sc clinical ctr campus: east best parking: garage department: west clinic when: tuesday at 9:00 am with: , md building: de building ( complex) campus: west best parking: garage md Procedure: Bronchoscopy through artificial stoma Diagnoses: Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Late effects of cerebrovascular disease, aphasia Infection of tracheostomy Cellulitis and abscess of neck Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: right sided weakness and language disturbance major surgical or invasive procedure: 1. percutaneous tracheostomy with a bronchoscopy. 2. percutaneous endoscopic gastrostomy. 3. left-sided craniotomy for decompression. 4. hemicraniectomy. 5. temporal lobectomy. 6. duraplasty. history of present illness: 39 year old female with h/o headaches and possible hypertension presents with right arm weakness and inability to communicate. she was last seen normal yesterday at 11:00pm when she went to bed. she usually wakes up at 5:30am in the morning to walk the dog. she usually walks the dog in her pajamas. her husband did not hear her get up this morning and is not sure whether she actually did walk the dog. at 5:41, she shook her husband to awaken him and could not say any words. she was still in her pajamas at that time. she was able to walk with his support, then had a one-minute episode of generalized shaking. she was initially brought to , where she received lorazepam 2mg, phenytoin, and solumedrol 125mg. ct showed an asymmetrical dense left mca sign, and the patient was transferred to for further management. ros: she started a new medication a few weeks ago for headaches. she developed green discharge from the eyes when this medication was started; this has now resolved. 2-3x over the last month she has had a sensation that objects around her were moving. 2x over the last month she has choked on her food. at baseline she has decreased strength in her right hand from her carpal tunnel syndrome. she has been limping for 2 days. she frequently moves around to prevent her headaches. she occasionally has constipation, for which she takes miralax. she has not had any blood in her stool or urine. denies recent problems with fever, vision, hearing, cough, vomiting, weakness, or paresthesias. past medical history: - chronic headaches after being hit on the head by a child in a special education class she was teaching 3-5 years ago. - s/p right carpal tunnel release - s/p hysterectomy 3 years ago - question of hypertension. family denies this and reports sometimes her blood pressure goes low, but the patient is on cardizem and reports sometimes the doctors put on medications without a clearly known reason. - no prior seizures, stroke, intracranial hemorrhage, or recent surgeries social history: works as a special education teacher. husband, daughter, and sister at bedside. denies etoh, smoking, illicits. family history: sister had a stroke at age 33; she does not know the cause of this. sister has also had a dvt and headaches. dad had a stroke at age 62. physical exam: initial t 98.6, hr 98, bp 130/80, rr 16, o2sat 98% 4l gen: lying in bed, nad heent: normocephalic, atraumatic. mucous membranes moist. neck: supple 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 skin: no rash ext: no edema neurologic examination: mental status: general: stuporous. with sternal rub arouses for less than a minute, then closes eyes again. speech/language: moans with some unintelligible sounds that may be attempts at words. does not follow simple commands. . cranial nerves: ii: pupils equally round and reactive to light, 4 to 2 mm bilaterally. ignores $20 in right visual field. iii, iv, vi: near complete eye movement to the right but does not bury sclera. extraocular movements otherwise intact without nystagmus. v1-3: patient unable to state whether facial sensation is intact. vii: right lower facial droop with showing the teeth. viii: hearing grossly intact; turns to voice. ix & x: not tested. : not tested. xii: not tested. . motor: normal bulk bilaterally. tone normal. no observed myoclonus or tremor. able to bend right arm antigravity at elbow but cannot lift upper arm off bed. when the arm is held up, it falls back to the bed. able to hold left arm, right leg, and left leg antigravity for 10 seconds. . deep tendon reflexes: biceps: tric: brachial: patellar: achilles toes: right 2 2 2 3 2 downgoing left 2 2 2 3 2 downgoing positive crossed adductors. . sensation: withdraws to noxious in all extremities. . coordination: finger-nose-finger normal on the left. . gait: not tested. discharge exam t 97.4 p 88 bp 113/66 r 18 spo2 100% gen: lying in bed, alert but not verbal pertinent results: ct perfusion: 1. thrombus within the distal left m1 segment with poor filling of left anterior temporal branches. the focal moderate stenosis of the left internal carotid artery origin, with no other evidence of vascular atherosclerosis, may represent a dissection or intramural hematoma and may be a source of this thrombus. 2. ct perfusion reveals a very small region of relatively preserved cbv and cbf with in the most posterior/superior region of the prolonged mtt which may represent a small area of ischemic penumbra. however, the vast majority of the prolonged mtt is matched. cta 1. thrombus within the distal left m1 segment with poor filling of left anterior temporal branches. the focal moderate stenosis of the left internal carotid artery origin, with no other evidence of vascular atherosclerosis, may represent a dissection or intramural hematoma and may be a source of this thrombus. 2. ct perfusion reveals a very small region of relatively preserved cbv and cbf with in the most posterior/superior region of the prolonged mtt which may represent a small area of ischemic penumbra. however, the vast majority of the prolonged mtt is matched. mr 1. interval expected evolution of the patient's large left mca territory infarct, which spares the vast majority of the basal ganglia and thalamus. the anterior and posterior portions of the infarct extend medially into the aca territories. this could be secondary to interval emboli to these regions with/without a component of watershed ischemia. 2. faint regions of susceptibility artifact within the infarct concerning for early/petechial hemorrhage. follow up with non-contrast ct head. tte impression: mild pulmonary artery systolic hypertension. normal biventricular cavity sizes with preserved global and regional biventricular systolic function. no definite cardiac source of embolism identified. if clinically indicated, a tee would be better able to define a potential atrial septal defect/patent foramen ovale. cxr findings: as compared to the previous radiograph, the extent of air in the abdomen has minimally decreased. also decreased is the pre-existing relatively extensive right pleural effusion. improved ventilation of the left lung base. normal size of the cardiac silhouette. no newly appeared focal parenchymal opacities. post-surgical ct findings: the patient is status post left frontotemporal craniectomy. there has been interval resolution of post-operative pneumocephalus. a large left parenchymal hypodensity in the middle and anterior cerebral artery distribution is unchanged compared to most recent studies. foci of hyperdensity within this region likely representing foci of hemorrhagic conversion are also unchanged compared to prior. there has been interval improvement in the rightward shift of normally-midline structures, with improvement in effacement of the left lateral ventricle and the basilar cisterns. there is no evidence of new hemorrhage or infarct. brief hospital course: 39 yr hispanic female right handed presents with sudden onset of global aphasia and right side weakness and possible seizure. patient was intially treated at osh with ativan and solumedrol. patient had ct of head that showed a hyperdense left mca concerning for an occlusion of the left mca. there were no early signs of ischemia on that ct brain. the patient was transferred to . nihss at ed was initially 15 and then decreased to 12. cta brain showed a left mca distal m1 occlusion. cta neck was concerning for a left proximal ica dissection. ct perfusion showed a small area of mismatch in the superior division of the left mca. neuro: being out of the window for iv tpa, patient was taken to angio suite and underwent a thrombectomy with the merci device. after multiple passes with the merci clot retriever, the left superior division of the mca was partially opened up. vasospasm of the left superior division was noted, which seemed to respond to nitroglycerin. during the angio it was confirmed that patient had a left carotid dissection. patient was admitted to the neuroicu w. q1hr neuro checks. follow up head ct has demonstrated increased edema with 8 mm of midline shift but no bleed. since there was no intracranial hemorrhage, on patient was restarted on aspirin. however given her increased edema and potential increase in icp, neurosurgery was consulted. patient was placed on iv mannitol. later on a central line was placed. at 4:20pm on patient's pupils became dilated and fixed at 6 mm, with minimal gag, minimal oculocephalic and minimal corneals. patient was given 3% hypertonic saline and hyperventilated. ct demonstrated increase in shift to the right. patient was given 30 ml of 23.4% ns. extensive discussion was held with family (including her husband and two daughters) about goals of care and poor prognosis. the family requested that left hemicraniectomy be performed to save her life. they understood that left hemicraniectomy would not improve her function or reverse her deficits. patient underwent left hemicraniectomy and partial left temporal lobectomy. for the carotid dissection a follow up carotid u/s was done which demonstrated l ica < 40% stenosis; r ica 0% stenosis. stroke was thought to be secondary to thrombus that embolized from the dissection. for secondary protection, simvastatin 40 mg was started for an ldl of 161. a1c was 5.5. tsh was 0.60. patient also had noted generalized shaking while at lgh. she was loaded with phenytoin. a routine eeg was performed which demonstrated encephalopathy. no subsequent sz activity was noted during her hospitalization. phenytoin levels remained stable. patient was maintained on fosphenytoin 100mg iv q8h for seizure prophylaxis and was kept on seizure, fall, and aspiration precautions. cardiovascular: - patient initially kept at sbp goal 140-180 (must keep sbp<185 dbp<105. her bp goal was eventually lowered. transthoracic echo demonstrated an lvef >55%;mild pulmonary artery systolic hypertension, but no source of emboli. pulmonary: - intubated prior to ir procedure gastrointestinal / abdomen / nutrition: - difficulty with ng tube placement. resume feeds per post op care. renal: - patient's i's and o's were monitored with foley. endocrine: - patient was kept on an riss, goal fs<150 infectious disease: - patient has continued to trend upward on wbc count. low grade fever at point of herniation going into or. finished 10-day course of zosyn. afebrile >72 hours, no leukocytosis. id fellow signed off. prophylaxis: dvt: boots, famotidine communication: (, ( code status: full medications on admission: cardizem cd 120mg po daily amitriptyline 10mg po qhs gabapentin 300mg po bid ibuprofen 800mg po tid prn pain excedrin migraine 250-250-65mg q4-6h prn headache miralax prn constipation discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. white petrolatum-mineral oil 56.8-42.5 % ointment sig: one (1) appl ophthalmic prn (as needed) as needed for dry eyes. 6. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed) as needed for dry eyes. 7. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po q8h (every 8 hours) as needed for constipation. 8. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 9. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) treatment inhalation q6h (every 6 hours) as needed for wheezing. 11. levetiracetam 250 mg tablet sig: three (3) tablet po bid (2 times a day). 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: left sided mca stroke left ica dissection gram - rods pneumonia discharge condition: activity status: bedbound. alert but non-verbal discharge instructions: you were admitted to the neurology service at after you had onset of right-sided weakness and difficulty speaking. we attempted interventional thrombectomy and it was discovered there was an ica dissection. after the procedure you developed swelling and required a temporal lobectomy and hemicraniotomy by neurosurgery. you did not regain speech, and were unable to follow commands on discharge. you will be sent to rehab and will follow-up with neurosurgery and neurology. medications started 1. aspirin 325 mg daily 2. simvistatin 3. senna/colace 4. famotidine 5. keppra 750 mg 6. bisacodyl, lactulose 7. metoprolol 25 mg po tid followup instructions: the patient will need to follow up with at in weeks. a follow-up appointment will be arranged. the patient will need followup with neurosurgery in weeks. an appointment will be arranged. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Arteriography of femoral and other lower extremity arteries Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries Temporary tracheostomy Other repair of cerebral meninges Operations on two or more extraocular muscles involving temporary detachment from globe, one or both eyes Lobectomy of brain Other craniectomy Incision of vessel, intracranial vessels Diagnoses: Pneumonia due to other gram-negative bacteria Unspecified essential hypertension Other convulsions Occlusion and stenosis of carotid artery without mention of cerebral infarction Compression of brain Acute respiratory failure Dissection of carotid artery Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Cerebral edema Headache Other specified complications of procedures not elsewhere classified Cerebral embolism with cerebral infarction Encephalopathy, unspecified Aphasia Other alteration of consciousness Other conditions of brain Late effects of other accidents Facial weakness Other musculoskeletal symptoms referable to limbs Family history of stroke (cerebrovascular) Homonymous bilateral field defects Late effect of injury to blood vessel of head, neck, and extremities |
allergies: no known allergies / adverse drug reactions attending: addendum: mrs. had hypoglycemia last evening and was symptomatic and did not feel up to going home. her discharge was post-poned and she had no further episodes and was discharged to home on . discharge disposition: home with service facility: md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery Open heart valvuloplasty of mitral valve without replacement Other repair of heart and pericardium Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Chronic kidney disease, unspecified Acute respiratory failure Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Old myocardial infarction Chronic diastolic heart failure Aneurysm of heart (wall) |
allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea, s/p intubation major surgical or invasive procedure: mvr (28mm ring), laa lig, pericar clsr w core matrix history of present illness: this is a 58 year old lady with a history of dm, htn, tobacco abuse, dchf, renal artery stenosis status post recent ccu hospitalization for imi, and w/u for mvr this week who presented to an osh with respiratory distress requiring intubation secondary to pulmonary edema. . ms. was recently transferred to for managment of an inferior myocardial infarction. cardiac catheterization revealed total occlusion of rca and 60% occlusion of om1, no interventions were made. an echo confirmed presence of severe mitral regurgitaion with a basal inferior left ventrical aneurysm. cardiac surgery was consulted at the time and the patient was tentatively scheduled for mitral valve repair on with dr. . she had already obtained dental clearance with 5 teeth extracted and carotic ultrasound and cardiac mri were performed prior to discharge. she was determined not to be a candidate for cabg. . she had been doing well since her discharge without episodes of cp or chest tightness or shortness of breath per her husband's report. she had been compliant with her medications and diet control. this morning, she and her husband went to a . within 20 to 30 minutes she noted acute sob after walking to the bathroom. ems was called, sbps were in the 200s w/ o2 sats in the 70s off oxygen. she was given nitro, 40 of iv lasix started on bipap and transferred to where she was intubated for respiratory distress. a cxr was consistent with pulmonary edema. ecg on admission demonstrated aterolateral peaked t waves and inferior twi. concerned for acs, she was started on heparin and nitro gtt and given aspirin. a bedside echo demonstrated basal inferior akinesis with an aneurysmal segment but otherwise normal wall motion with severe mr and mild ai. cardiac enzymes were cycled and normal. a bnp was in the 626. the patient's husband requested transfer to as her cardiac care is handled here. on arrival to , she was intubated and sedated. cardiac surgery was reconsulted for coronary revascularization. past medical history: 1. cardiac risk factors: diabetes, hypertension, tobacco abuse 2. cardiac history: - diastolic heart failure - hypertension since childhood per pt (does not know readings) - hx of stroke with right sided facial weakness at age 15. symptoms resolved in 3 months. no residual. -percutaneous coronary interventions: none 3. other past medical history: -possible copd -left ras social history: patient lives with a large family. does not work. immigrated from . married with very involved daughters (2) and several sons. met her husband at age 19. -tobacco history: up to 2 packs a day for >30 years -etoh: none -illicit drugs: none family history: non contribatory physical exam: vs: 96.6 56 124/70 82 14 100% on ps 15/5 vt 550 and fi02 of 60%general: 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 not elevated cardiac: difficult to hear heart sounds over rhoncherous breath sounds on exam, rr, normal s1, s2. grade iii/vi holosystolic murmur, best heard at apex. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored. rhoncherous right > left. abdomen: soft, ntnd. + bs extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ dp 2+ pt 2+ left: carotid 2+ dp 2+ pt 2+ pertinent results: ecg sinus rhythm. left atrial abnormality. left ventricular hypertrophy. slightly prolonged q-t interval. compared to the previous tracing of the findings are similar. . chest xray findings: as compared to the previous radiograph, there is no relevant change. the patient has been intubated. the tip of the tube projects 4 cm above the carina. there are bilateral parenchymal opacities highly suggestive of pulmonary edema. the patient has received a nasogastric tube, the tip of the tube is not visualized but the course is normal. no pleural effusions. borderline size of the cardiac silhouette. . 04:40am blood wbc-7.3 rbc-2.74* hgb-8.6* hct-24.9* mcv-91 mch-31.3 mchc-34.4 rdw-13.8 plt ct-492*# 10:06pm blood wbc-7.4 rbc-3.09* hgb-9.6* hct-27.8* mcv-90 mch-31.1 mchc-34.6 rdw-14.9 plt ct-250 04:40am blood glucose-66* urean-60* creat-2.2* na-135 k-4.1 cl-98 hco3-25 angap-16 10:06pm blood glucose-49* urean-36* creat-1.4* na-132* k-3.6 cl-95* hco3-25 angap-16 04:25am blood wbc-9.0 rbc-2.89* hgb-8.7* hct-26.2* mcv-91 mch-30.0 mchc-33.1 rdw-13.9 plt ct-618* 04:35am blood urean-51* creat-1.9* na-139 k-3.8 cl-101 04:35am blood pt-14.7* inr(pt)-1.3* 04:25am blood pt-13.9* inr(pt)-1.2* brief hospital course: on ms. was taken to the operating room and underwent a mitral valve repair with 28-mm physio ii ring annuloplasty model #5200, serial #.. please see operative report for further details. 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 on no inotropic or vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. she did have some post operative atn with a peak creatinine of 2.5 (baseline 1.4) creatinine was decreasing at the time of discharge and was 1.9 on post operative day 8. she was found to be in a second degree heart block and amiodarone which was started for atrial fibrillation was stopped. she was alternating between sinus brady 40-60's and atrial fibrillation 110-115 and ep service was consulted. they recommended stopping the amiodarone, converting lopressor 12.5 tid to toprol xl 25 daily and anticoagulation with coumadin. coumadin was started with inr goal of .5. vna is to draw inr and call results into clinic for further dosing instructions. she was scheduled for a 1 month follow up with ep. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 8 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged home with services in good condition with appropriate follow up instructions medications on admission: active medication list as of : medications - prescription amlodipine - 10 mg tablet - 1 tablet(s) by mouth once a day atorvastatin - (prescribed by other provider) - 80 mg tablet - one tablet(s) by mouth daily chlorthalidone - 25 mg tablet - 1 tablet(s) by mouth daily (daily) clopidogrel - (prescribed by other provider) - 75 mg tablet - one tablet(s) by mouth daily furosemide - 20 mg tablet - 1 tablet(s) by mouth once a day insulin glargine - 100 unit/ml (3 ml) insulin pen - 35 insulin(s) once a day insulin lispro - 100 unit/ml insulin pen - 0-12 insulin(s) four times a day insulin lispro - (prescribed by other provider) - 100 unit/ml solution - subcutaneous per sliding scale isosorbide mononitrate - 30 mg tablet extended release 24 hr - 2 tablet(s) by mouth daily (daily) labetalol - 200 mg tablet - 1 tablet(s) by mouth twice a day lisinopril - (prescribed by other provider) - 20 mg tablet - one tablet(s) by mouth daily metoprolol succinate - 25 mg tablet extended release 24 hr - 1 tablet(s) by mouth once a day medications - otc aspirin - 325 mg tablet - 1 tablet(s) by mouth daily (daily) blood sugar diagnostic - strip - 1 strip(s) four times a day blood-glucose meter - kit - 1 kit(s) four times a day one touch ultra docusate sodium - 100 mg capsule - 1 capsule(s) by mouth twice a day as needed for constipation insulin needles (disposable) - 31 gauge x " needle - 1 needle(s) four times a day lancets - misc - 1 misc(s) four times a day senna - 8.6 mg capsule - 1 capsule(s) by mouth twice a day as needed for constipation discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 2. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for temperature >38.0. disp:*40 tablet(s)* refills:*0* 3. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. atorvastatin 80 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. 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* 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 8. toprol xl 25 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:*0* 9. insulin glargine 100 unit/ml cartridge sig: twenty five (25) units subcutaneous q am. disp:*qs 1 month units* refills:*0* 10. insulin glargine 100 unit/ml cartridge sig: twelve (12) units subcutaneous q pm. disp:*qs 1 month units* refills:*0* 11. furosemide 40 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 12. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 5 days. disp:*5 tablet, er particles/crystals(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: postoperative diagnoses: 1. severe mitral regurgitation. 2. coronary artery disease. 3. status post previous inferior inferobasal myocardial infarction. 4. small inferobasalar aneurysm secondary to previous myocardial infarction. 5. severe hypertension. discharge condition: discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage 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: provider: , md phone: date/time: 3:45 provider: follow up: , in 1 month date/time: thurs at 10:20 am provider: , md phone: date/time: 2:00 please call your pcp and schedule an appointment for 2-3 weeks name: , w. location: /east address: , e/cc-6, , phone: come in to 6 for a wound check, this is scheduled for at 10:30 hrs coumadin started for afib - goal inr 2-2.5 patient given 5 mg coumadin on with inr 1.3 first draw with results to be called to clinic vna to draw k, bun, crea in 3 days and call results into cardiac surgery office at Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery Open heart valvuloplasty of mitral valve without replacement Other repair of heart and pericardium Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Chronic kidney disease, unspecified Acute respiratory failure Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Old myocardial infarction Chronic diastolic heart failure Aneurysm of heart (wall) |
allergies: no known allergies / adverse drug reactions attending: chief complaint: syncope major surgical or invasive procedure: cardiac catheterization with no intervention history of present illness: 58 year old female with history of dm, htn, tobacco abuse, and h/o chf who presented to osh on with 2 days of nonproductive cough and worsening sob. . family reports that patient started to complain of sob a week prior to presentation. on , she became unconscious shortly after coming out of the shower. ems was called, and on arrival patient was responsive but gradually became unresponsive en route to the ed. she was given 40mg iv lasix by ems. . on presentation to osh she was in respiratory distress with hr in the 140s, sbp > 200 and afebrile. she was started on a nitro gtt, and intubated. cxr showed pulmonary edema. ekg initially showed sinnus tachycardia, left atrial enlargement, and inferior apical st abnormalities. subsequent ekg showed sinus thythm with nonspecific st abdnormalities and t-wave inversions. initial troponins were elevated at 0.26. she was given asa, lipitor, metoprolol, and started on heparin gtt. she was transferred to the icu and aggressively diuresed. respiratory status improved and she was extubated on 1/. . echocardiogram done at osh hospital showed thickened aortic valve without stenosis, mild ai, and thickened mitral valve leaflets with severe mr. she was also noted to have concentric lvh with normal chamber dementions, normal rv, and small pericardial effusion without tamponade phyiology. ef was 70%. she was treated briefly with antibiotics for leukocytosis, but these were discontinued when no source was found. nitro gtt was stopped on and she was transferred for further evaluation. . upon arrival to she was taken to the cath lab where she was noted to have total occlusion of the distal rca with l>r collaterals, was also 60% stenosis of the om2(lcx), otherwise no significant cad. hemodynamic measurements were notable for ra pressure 14, rv 55/8(16), pcw 33, pa 55/32 (44), lv 147/12, lvedp 27, ao 147/80. she was transferred to the ccu with stable vital signs. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: past medical history: 1. cardiac risk factors: diabetes, hypertension, tobacco abuse 2. cardiac history: - diastolic heart failure - hypertension since childhood per pt (does not know readings) - hx of stroke with right sided facial weakness at age 15. symptoms resolved in 3 months. no residual. -percutaneous coronary interventions: none 3. other past medical history: -possible copd social history: patient lives with a large family. does not work. immigrated from . married with very involved daughters. - history: up to 2 packs a day for >30 years -etoh: none -illicit drugs: none physical exam: on admission: vs: t=98 bp=165/75 hr=85 rr=16 o2 sat=95% nc (2l) general: lying in bed, drowsy, nad 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 cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. grade iii/vi holosystolic , best heard at apex. no thrills, lifts. no s3 or s4. lungs: anterior exam moving air appropriately, 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. right cath site c/d/i. 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+ . : gen: alert, oriented, nad heent: supple, jvd 7 cm cv: rrr, soft systolic at apex, no thrills, lifts. no s3 or s4 resp: crackles bibasilar, faint this am abd: soft, active bs, nt extr: no peripheral edema neuro: a/o, no focal defects extremeties: right groin with no ecchymosis or tenderness pulses: right: dp 1+ pt 1+ left: dp 1+ pt 1+ skin: intact pertinent results: on admission: 02:33pm blood wbc-12.7* rbc-3.92* hgb-11.4* hct-34.5* mcv-88 mch-29.1 mchc-33.1 rdw-13.8 plt ct-277 02:33pm blood glucose-159* urean-22* creat-1.4* na-134 k-4.2 cl-103 hco3-24 angap-11 04:00am blood ck(cpk)-599* 02:33pm blood alt-36 ast-33 ld(ldh)-318* ck(cpk)-874* alkphos-112* totbili-0.7 04:00am blood ck-mb-5 ctropnt-0.19* 02:33pm blood ck-mb-7 ctropnt-0.19* 02:33pm blood albumin-3.1* calcium-8.6 phos-3.7 mg-1.7 cholest-180 02:33pm blood %hba1c-13.7* eag-346* . on discharge: 06:50am blood wbc-8.1 rbc-3.31* hgb-9.8* hct-28.5* mcv-86 mch-29.6 mchc-34.3 rdw-14.1 plt ct-283 06:50am blood glucose-148* urean-28* creat-1.6* na-136 k-3.7 cl-99 hco3-32 angap-9 . echo : 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. left ventricular chamber size is normal. there is inferobasal thinning/aneurysm. the remaining segments contract normally. no intraventricular thrombus is seen. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen. a central jet of mild (1+) aortic regurgitation is seen. the mitral valve leaflets are normal. there is no systolic prolapse or mass/vegetation seen. severe (4+) mitral regurgitation is seen. the tricuspid valve leaflets are normal. no vegetation or mass is seen. there is no pericardial effusion. impression: severe mitral regurgitation with normal mitral valve morphology. inferior left ventricular aneurysm. mild aortic regurgitation without discrete vegetation. simple atheroma in the descending thoracic aorta. . : cardiac catheterization: comments: 1. coronary angiography in this right-dominant system demonstrated one-vessel disease. the lmca had no angiographically apparent disease. the lad was a large wrap-around vessel supplying most of the inferior wall and had no angiographically apparent disease. the lcx had a 60% stenosis in its second obtuse marginal branch. the rca had a distal total occlusion with left-to-right collaterals. 2. resting hemodynamics revealed moderately elevated right-sided filling pressures and severely elevated left-sided filling pressures, with an rvedp of 16 mm hg and a pcwp of 33 mm hg. there was moderate pulmonary arterial systolic hypertension, with a pasp of 55 mm hg. the cardiac index was depressed at 1.8 l/min/m2. there was mild systemic arterial hypertension. there was no gradient upon pullback of the catheter from the left ventricle to the aorta. final diagnosis: 1. one-vessel and vessel coronary artery disease. 3. severe elevation of left sided filling pressures consistent with severe mitral regurgitation. . renal ultrasound : preliminary report !! pfi !! 1. abnormal arterial parvus tardus waveforms involving the left kidney with slightly elevated flow velocities in the proximal main left renal artery suggestive of underlying renal artery stenosis. this can be confirmed with a cta or mra. . carotid ultrasound and cardiac mri final report pending. brief hospital course: # nstemi: found at outside hospital to have elevated cardiac enzymes. initial ck 112, trop-i 0.26 -> 0.89. today, ck: 874 mb: 7 trop-t: 0.19. ekg showed st-elevations in inferior leads, consistent with imi. on catherization today here found to have total occlusion of rca and 60% occlusion of om1, no intervention. hemodynamical measurements were consistent with borderline cardiogenic shock. pt was started on asa, beta blocker and atorvastatin and lisinopril was continued. aggressive blood pressure control was started. she has remained chest pain free during hospital stay. . # severe mr: confirmed on echo and cardiac mr. was concerning for papillary muscle dysfunction resulting in mitral regurgitation from the ischemic event. indeed, tee here showed severe mr inferior lv aneurysm. cardiac surgery was consulted and pt is tentatively scheduled for mv repair or replacement on with dr. . five teeth were removed on with no complications. pt will see dr. next week. please note that carotid ultrasound and final cardiac mr reports are pending. # acute on chronic diastolic chf: patient has a history of chf and reports one episode of prior exacerbation. on admission to osh patient had respiratory distress requiring intubation, attributed to pulmonary edema. echocardiogram there showed lvef of 70%, thus her chf is likely diastolic in nature. her severe mr is also likely contributing factor to poor forward flow. she was aggresively diuresed with marked improvement in respiratory function. currently, she has few crackles on lung exam, without edema in the lower extremities. cxr is consistent with underlying copd (likely from smoking) and mild bilat pleural effusion. she was started on furosemide 20 mg daily on discharge and instructed on daily weights and a low sodium diet. . # diabetes: a1c 13. only on metformin at home, but blood glucose at osh was >500. pt reports poorly controlled blood sugars at home. seen by endocrinologist from clinic and started on lantus 35 units in am with humalog sliding scale. blood sugars on discharge were 120-140. extensive teaching was done regarding diabetic diet, insulin injections and blood sugar control. she will follow up with the clinic for further monitoring in the next 2 weeks. . # hypertension: patient has been hypertensive to the 180s since arriving at the ccu. interestingly, she reports high blood pressure since childhood with a possible stroke at age 15 that resulted in left sided facial droop. this was in . symptoms resolved in about 3 months and there were no other sequalae. during this hospital stay, she was started on amlodipine, imdur, labetolol, and chlorthalidone in addition to home lisinopril with sbp 100-130 at discharge. she feels slightly dizzy but her gait is steady and she is not orthostatic. a renal ultrasound was performed that showed left sided renal artery stenosis, unable to be quanitified. she will need cta or mra as outpatient to further characterize. . # chronic renal failure: no baseline cr measurement in our system. compared to osh records, cr of 1.4 today is improved from prior. potentially pre-renal from being ill and or chf exacerbation. her creatinine at discharge was 1.6 after receiving gadolinium and in setting of decreased po's. she should have chem 7 checked on . . # leukocytosis: patient had an elevated leukocytosis up to 20 at osh which has resolved. she was treated with antibiotics for pneumonia. currently, she is afebrile, no cough or sputum production. . # anemia: hct 28 on discharge. no baseline value to compare in our system, thought admissioned measurement at osh was ~40. post cath but without obvious signs of bleeding. decreasing hct thought secondary to phlebotomy and decreased po intake. iron studies should be sent as an outpatient. medications on admission: lisinopril 40 mg daily metformin 850mg discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 4. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. metoprolol succinate 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:*2* 6. chlorthalidone 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. blood glucose monitoring kit sig: one (1) kit miscellaneous four times a day: one touch ultra. disp:*1 kit* refills:*2* 8. lancets,ultra thin misc sig: one (1) lancet miscellaneous four times a day. disp:*150 lancets* refills:*2* 9. insulin glargine 100 unit/ml (3 ml) insulin pen sig: thirty five (35) units subcutaneous once a day. disp:*1 box* refills:*2* 10. insulin lispro 100 unit/ml insulin pen sig: 0-12 units subcutaneous four times a day. disp:*1 box* refills:*2* 11. insulin pen needle 31 x needle sig: one (1) needle miscellaneous four times a day. disp:*150 needles* refills:*2* 12. one touch test strip sig: one (1) strip miscellaneous four times a day. disp:*150 strips* refills:*2* 13. metformin 500 mg tablet sig: one (1) tablet po twice a day. 14. labetalol 200 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 15. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: two (2) tablet sustained release 24 hr po daily (daily). disp:*60 tablet sustained release 24 hr(s)* refills:*2* 16. furosemide 20 mg tablet sig: one (1) tablet po once a day. 17. outpatient lab work please check chem-7 and cbc on friday with results to dr. / at 6 discharge disposition: home with service facility: discharge diagnosis: severe mitral regurgitation non st elevation myocardial infarction uncontrolled diabetes mellitus acute on chronic diastolic congestive heart failure hypertension left sided renal artery stenosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you passed out after a shower and was found to have a heart attack. the heart attack affected the muscles around your mitral valve so your valve is not working properly. you will see dr. next week to discusss a mitral valve repair or replacement. in the meantime, we added some new medicines to control your blood pressure and started you on insulin to control your blood sugars. you were seen by an endocrinologist from the who recommended that you check your blood sugars four times a day with a short acting insulin, humalog, taken 15 minutes before each meal. in addition, you will take a long acting insulin before breakfast every day. because of your mitral valve function, you have had some excess fluid in your lungs. we started you on furosemide (lasix) to prevent the fluid from building up. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . we made the following changes in your medicines: 1. start taking glargine (lantus) insulin every day to control your blood sugars 2. start taking humalog (lispro) insulin four times a day before meals according to a sliding scale 3. start taking labetelol to lower your blood pressure 4. start taking imdur to lower your blood pressure 5. start taking aspirin 325 mg every day to prevent another heart attack 6. start taking atorvastatin to lower your cholesterol 7. start taking metoprolol to lower your heart rate and help your heart recover from the heart attack 8. start taking chlorthalidone to lower your blood pressure 9. start taking amlodipine to lower your blood pressure 10. continue taking metformin and lisinopril as before. 11. check your blood sugar four times a day, before meals and at bedtime. followup instructions: department: when: friday at 3:45 pm with: , md building: sc clinical ctr campus: east best parking: garage department: cardiac services when: wednesday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: cardiac surgery when: wednesday at 1:30 pm with: , md building: lm campus: west best parking: garage diabetes center phone: address: , ma provider: , md date/time: thursday at 2:00pm md, Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnostic ultrasound of heart Extraction of other tooth Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Tobacco use disorder Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Acute on chronic diastolic heart failure Atherosclerosis of renal artery Cardiogenic shock Long-term (current) use of insulin Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Diastolic heart failure, unspecified Dental caries, unspecified Chronic total occlusion of coronary artery Chronic periodontitis, unspecified Cracked tooth |
allergies: no known allergies / adverse drug reactions attending: chief complaint: elective admission for stent/coiling of l mca aneurysm major surgical or invasive procedure: : cerebral angiogram with stent assisted coiling of the l mca aneurysm history of present illness: 52f with incidental finding of l mca aneurysm (5mm) and r mca aneurysm (1mm). past medical history: 1. hiv: on truvada and lexiva, last cd4 count 868; acquired from blood transfusion; diagnosed ~8 years ago 2. sickle cell anemia social history: works in childcare. smokes 1 ppd x30 years. no etoh or illict drug use. family history: dad passed away from stroke at age 56. mom is healthy. sister had a ruptured aneurysm. physical exam: pre-angio: awake, alert, oriented x3, mae full motor. upon discharge:vss af she is awake alert oriented with perrl bilaterlly, non focal neuros exam. her distal pulses are full and her groin sites are benign. she is tolerating po and voiding freely. pertinent results: head ct : findings: imaging degraded by metallic star artifact from the aneurysm coil pack. allowing for this limitation, there is no evidence of hemorrhage, edema, mass, mass effect, or infarction. the ventricles and sulci are normal in size and configuration. the basal cisterns appear patent and there is preservation of -white matter differentiation. no fracture is identified. the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. no facial or other extracranial soft tissue abnormality is seen. impression: no evidence of acute intracranial process brief hospital course: 52f who was admitted for an elective stent assisted coiling of the l mca aneurysm. patient was given plavix 600mg po x1 prior to the case. left femoral access was acheived for aline monitoring. stent placement and coiling was acheived without complication. post-angio she was transferred to the icu for monitoring. the left sheath remained in place. she was started on a heparin drip at 700 cc/hr for a ptt goal of 60-80. a post angiogram head ct was completed and was normal. she advanced in her diet and her pain controlled. her groin sites remained intact and the left groin microsheath was removed. she was discharged to home on. patient was discharged on asa and plavix for one month. medications on admission: truvada 200/300mg 1 tab daily, colace, flexeril 10mg , oxycodone prn, folic acid 1mg daily, flovent 2 puffs , wellbutrin 150mg , flonase daily, prilosec daily discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 2. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po daily (daily). 3. bupropion hcl 150 mg tablet extended release sig: one (1) tablet extended release po bid (2 times a day). 4. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily): please do not take your omeprazole while on plavix . capsule, delayed release(e.c.)(s) 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) for 30 days. disp:*30 tablet(s)* refills:*0* 8. pepcid 40 mg tablet sig: one (1) tablet po twice a day: please use pepcid in place of your omeprazole while on plavix. . disp:*60 tablet(s)* refills:*2* 9. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po q6h (every 6 hours) as needed for headache. disp:*40 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: left mca aneurysm right mca aneurysm discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: angiogram with embolization and stent placement medications: ?????? take aspirin 325mg (enteric coated) once daily for one month. ?????? take plavix (clopidogrel) 75mg once daily for one month. ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort. what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs. ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? after 1 week, you may resume sexual activity. ?????? after 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? no driving until you are no longer taking pain medications what to report to office: ?????? changes in vision (loss of vision, blurring, double vision, half vision) ?????? slurring of speech or difficulty finding correct words to use ?????? severe headache or worsening headache not controlled by pain medication ?????? a sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? 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 6 months with a mri/mra ( protocol). please call to make this apointment. Procedure: Arteriography of femoral and other lower extremity arteries Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Esophageal reflux Tobacco use disorder Asthma, unspecified type, unspecified Cerebral aneurysm, nonruptured Asymptomatic human immunodeficiency virus [HIV] infection status Sickle-cell disease, unspecified |
allergies: aspirin / cefuroxime axetil attending: chief complaint: unresponsiveness major surgical or invasive procedure: intubation history of present illness: pt is a 32-yo woman with h/o ivda recently started on methadone, who is admitted after being found unresponsive. the pt was found unresponsive of unknown duration at her group home, lying supine in bed. she had reportedly last been seen normal at ~1500 this afternoon, approx 1-2 hours prior to being found unresponsive. reportedly, she had started on methadone on monday, with an increase in her dose from 45mg to 50mg yesterday. she also had been vomiting for the past few days. she was initiated on ventilation by bls until ems arrived. she was noted by ems to have pinpoint pupils, so she received narcan 2mg im + 2mg iv, without significant effect except for a slight increase in pupillary diameter. she was then intubated by rapid sequence intubation and transported to center. . at center, she was noted to be pale, cool, and dry, smelling of foul urine, with coffee-grounds from her ngt and thick brown secretions from her ett. gcs was 3 and she was thought to have decorticate posturing and possibly intermittent seizing, without change to ativan 2mg iv x2 and fosphenytoin. head ct showed diffuse cerebral edema with loss of white- matter c/w anoxic brain injury, so she received decadron 10mg iv x1. abg was 7.28/48.4/361.9, and cxr showed bilateral lower lobe atelectasis and mild pulmonary vascular congestion. wbc was elevated at 33.9 as well, so she received levofloxacin 750mg iv x1 and was ordered for vancomycin 1gram iv x1. she also received protonix 40mg iv x1 and a 500cc ns ivf bolus. urine tox was only positive for methadone. she was transferred to ed for further evaluation. . in the ed, vs - bp 123/82, hr 76, r 18, sao2 100% ra. she remained intubated but was awake, moving her eyes and arms purposefully, so she was sedated with midazolam and fentanyl gtts. ecg and cxr were unremarkable, and nchct showed no ich or infarct. she is being admitted to the micu for further care. . on arrival to the micu, she was noted to desaturate while being suctioned... past medical history: ivdu depression social history: homeless, boyfriend. hx of ivdu currently in clinic family history: nc physical exam: intubated, following commands, moving purposefully nc/at, perrl/eomi, sclera anicteric supple, no lad lungs cta bilat, no r/rh/wh heart rrr, nl s1-s2, no mrg abd +bs, soft/nt/nd, obese extrem wwp no c/c/e diffuse scabs reflecting excoriations. pertinent results: labs on admission: 09:50pm blood wbc-22.6* rbc-5.19 hgb-12.3 hct-41.1 mcv-79* mch-23.7* mchc-30.0* rdw-15.9* plt ct-391 09:50pm blood neuts-93.9* lymphs-3.7* monos-1.0* eos-1.2 baso-0.1 09:50pm blood pt-14.9* ptt-29.5 inr(pt)-1.3* 09:50pm blood glucose-110* urean-13 creat-0.9 na-140 k-4.2 cl-99 hco3-26 angap-19 09:50pm blood alt-91* ast-181* alkphos-129* totbili-0.4 02:53am blood ck-mb-11* mb indx-1.6 ctropnt-<0.01 02:53am blood albumin-3.8 calcium-8.6 phos-2.7 mg-1.9 02:53am blood osmolal-285 09:50pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 09:55pm blood lactate-4.0* . labs on discharge: 06:40am blood wbc-13.3* rbc-4.25 hgb-10.2* hct-32.9* mcv-77* mch-24.0* mchc-31.0 rdw-16.5* plt ct-415 06:40am blood neuts-67.3 lymphs-27.3 monos-3.4 eos-1.3 baso-0.6 06:40am blood pt-14.2* ptt-33.6 inr(pt)-1.2* 06:40am blood glucose-71 urean-6 creat-0.7 na-140 k-4.1 cl-104 hco3-26 angap-14 02:53am blood alt-81* ast-147* ld(ldh)-766* ck(cpk)-684* alkphos-108* totbili-0.3 06:40am blood calcium-9.0 phos-2.7 mg-1.8 . microbiology: blood cultures ( - 20): no growth pending . images: ct head: no acute hemorrhage. no midline shift. no cerebral edema appreciated . cxr (): et tube and orogastric tube in standard location. retrocardiac opacification may be atelectasis or pneumonitis from infection or aspiration and follow up chest radiograph is recommended. . cxr (): 1. endotracheal tube terminates at least 1.3 cm above the carina, should be withdrawn 3cm. no pneumothorax. 2. slightly worse mild bibasilar atelectasis. . cxr (): bibasilar linear atelectasis brief hospital course: assessment / plan: 32-yo woman with h/o ivda recently started on methadone, found unresponsive at her group home and intubated, also thought to have anoxic brain injury with decorticate posturing and/or seizures, elevated wbc, coffee-ground emesis, and thick secretions. . #. unresponsiveness: pt found unresponsive at home, thought to be due to overdose, possibly combination of increased dose of methadone with other ingestions although history very unclear. did not respond initially to narcan, and neuro exams previously concerning per osh records, including decorticate posturing, question of intermittent seizures, and reportedly head ct c/w anoxic brain injury. at extubation patient is responsive and purposeful without sedation. repeat nchct here without concerning findings. tox screen positive only for methadone. no concerning deficits on neurologic exam. psych evaluated patient and felt there was no concern for suicide attempt. . #. coffee-ground emesis: reported at osh. likely secondary to injury to lateral tongue during intubation. hct remained stable during hospitalization and no further coffee-ground emesis was identified. . #. leukocytosis: thought to be secondary to acute stress response. initially started on vancomycin, levofloxacin, and flagyl. these were discontinued when transfered to general medicine floor. patient remained afebrile and leukocytosis trended down. . #. transaminitis: very mild transaminitis during hospitalization. unclear if this is secondary to recent acute illness, med effect, or more chronic process such as a viral hepatitis. transaminases trending down prior to discharge. these will need to be followed as an outpatient after discharge. further, testing for hepatitis should be performed. asymptomatic at time of discharge. medications on admission: paxil 20mg daily methadone per clinic dosing discharge medications: 1. paxil 20 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: primary: unresponsiveness nos depression insomnia hx of drug abuse 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 caring for you while you were admitted with unresponsiveness. you were initially intubated to support your breathing. it is unclear what led to this episode of unresponsiveness. it may have been secondary to your recent increase in methadone dosing. we will contact your methadone clinic regarding a lower methadone dose. . please contact your primary care physician . () regarding a follow up appointment in the next two weeks. further, return to your methadone clinic on monday for continued care. . no changes were made to your medications regimen. your methadone clnic should decrease your methadone dose, given concern that this may have contributed to your medication regimen. . again, it was a pleasure participating in your care. followup instructions: please contact your primary care physician . () regarding a follow up appointment in the next two weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Other convulsions Depressive disorder, not elsewhere classified Opioid type dependence, continuous Acute respiratory failure Cerebral edema Accidental cut, puncture, perforation or hemorrhage during other specified medical care Altered mental status Hematemesis Home accidents Poisoning by methadone Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Poisoning by analgesics, antipyretics, and antirheumatics, undetermined whether accidentally or purposely inflicted Open wound of tongue and floor of mouth, without mention of complication |
allergies: lisinopril attending: chief complaint: chief complaint: melena, hematemesis, acute renal failure reason for micu transfer: massive gi bleed, hypoxic resp failure major surgical or invasive procedure: endoscopy with banding of bleeding vessels history of present illness: mr. is a 65 yo m with h/o etoh cirrhosis, pud and ?chf one year ago in setting of afib (on coumadin) who is transferred to from for hematemesis and melena. he initially presented to lgh on c/o two days of melena progressing to bright red hematemesis this morning. on arrival to lgh his hct was 23, inr 8.9, and sbp was 60. he received 2 units rbc, 4 units ffp, 10 units vitamin k, and octreotide. had egd at lgh which showed large nonbleeding esophageal varices, gastric fundus obscured by blood clot. no intervention was performed. after egd he was hypoxic and was intubated with fentanyl/versed for airway protection; sats improved s/p intubation. he was medflighted to for further care including . paralyzed with pancuronium during transport. . on arrival to ed, the patient was noted to have significant ascites. ngt was placed, no active bleeding. labs notable for hct 30.2, inr 2.3, lactate 1.7, cr 4.1, trop 0.03, abg 7.39/40/304/25. patient received another 1 unit rbc, started octreotide and pantoprazole (bolus + gtt) and ceftriaxone. continued sedation with fent/midaz. his maps were stable in 70s while in ed, but minimal uop (80cc). he was seen by hepatology in ed who recommended deferring egd until tomorrow, erythromycin to clear blood from stomach, maintaining maps ~70 to balance prevention of portal hypertensive bleeding with end-organ perfusion (given high cr). has 4 pivs (16g, 18g, 20g, 22g). vent settings on transfer: fio2 50%, tv 478, rate 18, peep 5. vitals prior to transfer: 96/65 71 18 100%. . on arrival to the micu, vitals were: 72 115/70 (map 79) 14 100%. pt was intubated and sedated. he had massive tense ascites. a repeat endoscopy at demonstrated grade iii varices in lower third of esophagus, three of which were banded. patient's last transfusion was on the 20th and his hct has been stable around 39. the patient's course was complicated by atn thought to be secondary to hypovolemia in the setting of ugib. renal team evaluated in micu and determined there were muddy casts on ua. the patient was started on hd on after temporary line was placed. while in the micu, the team was able to wean the patient from the ventilator and was extubated on . with regard to cirrhosis, patient underwent a paracentesis in micu where 4.5l were removed. saag of 2.2, protein of 1.4, sterile fluid. finally, the patient had two episodes of r arm, shoulder, leg shakiness for a few minutes in the micu. these episodes resolved spontaneously. he was given 1mg iv ativan, q4h prn agitation to cover for alcohol withdrawal. an eeg was slow, encephalopathic, l hemisphere with sharp waves in arrhythmic waves, might have been pre-seizure activity, focus still active! an mri demonstrated global cerebral atrophy, but no evidence of acute intracranial abnormality such as hemorrhage, infarct or mass. an unclear lesion at the superior-anterior aspect of the clivus was noted which could be related to the sphenoid sinus, although a lytic lesion in the clivus was not entirely excluded. a repeat eeg on had normalized. neurology signed off of the patient. past medical history: -etoh cirrhosis -possible chf, ef unknown -afib, on coumadin -pud social history: significant etoh abuse, currently has 3 hard liquor drinks daily, previous history of 6 beers/day. denies history of withdrawal or dts. lives in upstate , in ma for the summer. lives with fiance. in touch with family including son. denies current tobacco use, quit 20 years ago, 15 years x 3 cigs/day. family history: -m:deceased, old age -f:deceased, cancer, cad physical exam: physical exam on admission vitals: 72 115/70 (map 79) 14 100% general: intubated, sedated heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: irregularly irregular, s1 s2, no r/m/g lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: massive tense ascites with +fluid wave. +caput medusa. +bs. reducible hernia in right groin. cannot palpate liver/spleen edge. gu: foley in place, draining dark yellow urine ext: 2+ pitting pedal and presacral edema. warm, well-perfused. no clubbing/cyanosis. neuro: intubated, sedated phyiscal exam on discharge vs: t 98.3 bp 102/59 hr 76 rr 20 o2 96 on ra general: nad, comfortable appearing, heent: sclera anicteric, mmm neck: supple without nad, cardiac: iregular without m/r/g noted, in afib on monitor lungs: lung fields clear b/l abdomen: large abdomen. no ttp, rebound, or guarding. +caput medusa. +bs. cannot palpate liver/spleen edge. ext: 2+ pitting pedal, warm, well-perfused. no clubbing/cyanosis. neuro: aox3. no asterixis. problem with reciting months backwards pertinent results: labs on admission 12:20pm blood wbc-10.0 rbc-3.37* hgb-9.8* hct-30.2* mcv-90 mch-28.9 mchc-32.3 rdw-17.5* plt ct-184 12:20pm blood pt-24.5* ptt-43.2* inr(pt)-2.3* 12:20pm blood glucose-87 urean-54* creat-4.1* na-139 k-4.2 cl-104 hco3-22 angap-17 12:20pm blood alt-17 ast-27 alkphos-123 totbili-1.6* 12:20pm blood albumin-3.2* labs on discharge 05:16am blood wbc-10.4 rbc-3.14* hgb-9.1* hct-28.6* mcv-91 mch-28.8 mchc-31.6 rdw-19.6* plt ct-103* 05:16am blood plt ct-103* 05:16am blood glucose-87 urean-23* creat-3.7* na-128* k-3.6 cl-94* hco3-27 angap-11 05:16am blood alt-23 ast-74* alkphos-151* totbili-3.9* 05:16am blood albumin-2.8* calcium-7.6* phos-2.3* mg-1.7 egd - found grade 3 esophageal varices s/p 3 bands. te the left atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). 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 but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion . ruq u/s 1. patent, hepatopetal main portal vein. 2. large volume ascites. 3. cholelithiasis. . mri: 1. global cerebral atrophy, but no evidence of acute intracranial abnormality such as hemorrhage, infarct or mass. dedicated seizure protocol mri can be considered if clinically indicated. 2. unclear lesion at the superior-anterior aspect of the clivus which could be related to the sphenoid sinus, although a lytic lesion in the clivus is not entirely excluded . ct can be considered for further characterization. . eeg: impression: this telemetry captured no pushbutton activations. the background was slow with bursts of generalized slowing throughout. this indicates a widespread encephalopathy. there were several left occipital sharp waves on the isolated recording just after midnight on the 21st, but these did not appear again later in the longer eeg monitoring. there were no definitely epileptiform features, and there were no electrographic seizures. the slow background indicates encephalopathy, but the slowing was not as profound (and without typical "triphasic" waves) as seen typically in hepatic encephalopathy. this raises the possibility of a contribution from medications. brief hospital course: hospital course: this is a 65 yo m with h/o etoh cirrhosis, pud and ?chf one year ago in setting of afib (on coumadin) who presents with ugib and hypotension. . acute issues # ugib: the patient p/w h/o etoh cirrhosis and pud, egd at osh showed nonbleeding esophageal varices and gastric outlet obscured by blood clot. ddx included variceal bleed vs. peptic ulcer vs. oozing in setting of supratherapeutic inr (9). his varices were not banded because not certain they were etiology of bleed, and would need to avoid re-scoping after banding. at he was continued on ppi gtt and octreotide gtt, ceftriaxone q24hrs, erythrmoycin. his ng tube was clamped. he was continued on levophed which was ultimately discontinued. he was initially transfused 2 units of prbc and 1 unit ffp with an additional unit of prbc on hd3. a ruq ultrasound revealed evidence of large volume ascites and cirrhosis. a repeat upper endoscopy revealed 4 cords of grade iii varices at the lower third of the esophagus and middle third of the esophagus (ligation). the likely source of the bleeding was felt to be from esophageal varices. there were no gastric varices noted. some bleeding may have been from portal gastropathy. 3 bands were successfully placed. he was continued on an octreotide gtt for 72 hours, ppi. two large volume paracenteses were performed draining near 5l rescpectively were performed with albumin 50g iv. once vitals signs were stable and hematocrits remained unchanged, the patient was moved to the floor. on the floor, no additional episodes of bleeding occurred. the patient was maintained on a ppi. an outpatient egd has been scheduled for for a repeat egd. . # : likely secondary to hypovolemia from gi bleed. hepatorenal syndrome was also considered given tense ascites; elevated inr. renal was consulted and recommended in the setting of oliguria and volume overload, initiation of hd. he was started on hd and tolerated this well. he was still oliguric upon transfer to the floor. while on the floor, a tunneled line was placed and the patient was started on hemodialysis. urine output remained around 150ml/day. hemodialysis was continued per the renal team, and will be continued after discharge. . #hepatic encephalopathy: upon arrival to the floor, the patient was found to have asterixis and diminished ability to perform attention-related tasks. he was started on lactulose 30ml tid-qid. his dose was reduced as his stool output reached about 1l/day and he was having difficulty maintaining k. his dose was changed to 15ml tid, which brought his stools to about daily. rifaximin was added. upon discharge asterixis had resolved and patient was able to complete attention-related tasks. . # hypotension: likely hypovolemia in setting of gi bleed. creatinine elevation likely represents poor end-organ perfusion, although lactates have been reassuring thus far. per liver, goal map ~70 to balance risk of re-opening portal hypertensive bleed with maintaining good end-organ perfusion. the patient was taken off diuretics, calcium channel blockers, and metoprolol. initially on the floor his pressures were in the 100s systolic, but stable. once his his pressures rose to the 130-140s systolic, propranolol was started for ugib prophylaxis. . # hypoxic respiratory failure: pt became hypoxic at osh after egd, intubated for airway protection. have aspirated blood in setting of hematemesis. also has significant r atalectasis elevated hemidiaphragm: likely tense ascites is causing elevated transpleural pressures. after initiation of hd and large volume paracentesis, his respiratory status significantly improved. he was extubated on hd 6. he completed a course of aspiration pna treatment with ceftriaxone. while on the floor he had occassional episodes of wheezing which were treated with nebs. his respiratory status significantly improved over the course of hospitalization. . # elevated troponin: troponin 0.03 in ed, likely demand ischemia related to blood loss, also elevated in setting of renal failure. . # ua: pt with many bacteria, 6 wbcs, trace leuk esterase on ua. he completed a course of ceftriaxone. he had no complaints of dysuria, frequency, or hematuria during his hospital stay. . chronic issues: # ?chf: pt reportedly has h/o chf diagnosed one year ago in setting of afib. his ef is unknown. pertinent because would affect whether is feasible. a tte demonstrated mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). . # afib: nn coumadin upon arrival to the hospital, inr supratherapeutic to 9, improved over the course of the hospitalization. he is being discharged off of coumadin giving his risk of rebleeding. he will have a repeat egd in one week to evaluate esophageal varices. of note, his heart rate has been controlled while on the floor with propranolol, remaining in the 50-80s. # etoh cirrhosis: actively drinking 6 beers/day, last drink was day before admission. has ascites on exam and demonstrated on ruq u/s. . transitional issues: -patient will be started on outpatient hemodialysis. a ppd was negative. -patient requires u/s mapping of upper extremity and initiate vein preservation protocol of non-dominant hand. -patient has an outpatient egd scheduled at in hepatology in . medications on admission: preadmission medications listed are correct and complete. information was obtained from pcp. 1. amlodipine 5 mg po daily 2. warfarin 2.5 mg po daily16 3. digoxin 0.125 mg po daily 4. furosemide 60 mg po daily 5. magnesium oxide 400 mg po once duration: 1 doses 6. metoprolol succinate xl 200 mg po daily 7. omeprazole 20 mg po daily 8. multivitamins 1 tab po daily discharge medications: 1. rifaximin 550 mg po bid 2. propranolol 20 mg po bid hold for systolic <95, thanks! 3. pantoprazole 40 mg po q12h can transition pantoprazole to po dosing at next scheduled administration. thanks! 4. nephrocaps 1 cap po daily 5. acetaminophen 500 mg po q6h:prn pain 6. lactulose 30 ml po bid discharge disposition: extended care facility: discharge diagnosis: esophageal varcies alcoholic liver disease acute kidney injury discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , it was a pleasure taking care of you at . you were admitted to the hospital with gi bleed from esophageal varicies and also found to have kidney failure. the varices were banded and the bleeding has stopped. we started you on hemodialysis for your kidney failure which will be continued following this hospitalization until a kidney doctor decides it is safe to stop. the following changes have been made to your medications: -stop your coumadin (warfarin) until you see the liver doctors -stop your metoprolol -stop your amlodipine -stop your digoxin -stop your lasix -start nephrocaps, 1 cap daily -start lactulose 15ml three to four times per day, adjust to bowel movements per day -start propranolol 20mg twice daily -start rifaximin 550mg twice daily please see below for follow up appointments that have been made on your behalf. followup instructions: department: hemodialysis when: saturday at 7:30 am department: gi-west procedural center when: friday at noon with: , md building: building ( complex) campus: west best parking: garage md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Hemodialysis Venous catheterization for renal dialysis Percutaneous abdominal drainage Endoscopic excision or destruction of lesion or tissue of esophagus Diagnoses: Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Alcoholic cirrhosis of liver Portal hypertension Atrial fibrillation Personal history of tobacco use Pulmonary collapse Acute respiratory failure Other shock without mention of trauma Other ascites Anticoagulants causing adverse effects in therapeutic use Esophageal varices in diseases classified elsewhere, with bleeding Hepatic encephalopathy Other specified disorders of stomach and duodenum Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction Chronic diastolic heart failure Other and unspecified alcohol dependence, continuous Venous (peripheral) insufficiency, unspecified Personal history of peptic ulcer disease Other acute and subacute forms of ischemic heart disease, other |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: wound infection/hematoma major surgical or invasive procedure: drainage of hematoma history of present illness: 52yom with hep c and h/o ivda, pod#11 s/p right ilioprofunda bypass with dacron tube graft after found to have occluded right fem-ak popliteal bypass, now presents from hypotensive (sbp 80s) with erythematous wound and 2.2x1.8x4.0cm fluid collection within right groin incision per ct scan. reportedly, feeling well although noted groin incision progressively "red" over past 2-3 days. he denies tenderness or drainage from wound, fever/chills, nausea/vomiting, numbness/tingling of extremities, or difficulty walking. on presentation to osh, found to be afebrile but hypotensive with sbp 80s, with erythematous staple line, without dopplerable right lower extremity pulse, and reportedly with cr 5.1. he was given 3l ivf, vancomycin and levofloxacin, and underwent ct lower extremity prior to being transferred to for further evaluation and . past medical history: past medical history: hepatitis c, h/o cva , h/o adrenal insufficiency, h/o ivda, h/o tobacco use past surgical history: h/o fem-ak popliteal bypass, right iliofemoral and profunda endarterectomy with dacron patch angioplasty (), angiogram () - occluded fem-ak at proximal portion with reconstitution of flow at r profunda femoris artery distally, s/p right ilioprofunda bypass with dacron tube graft () social history: divorced lives with mother and x-wife house current tobacco use former iv drug abuse, not at present- heroin family history: noncontributory physical exam: physical exam neuro/psych: oriented x3, affect normal, nad. neck: no masses, trachea midline. nodes: no clavicular/cervical adenopathy. skin: no atypical lesions. heart: regular rate and rhythm. lungs: clear, normal respiratory effort. gastrointestinal: non distended, no masses. rectal: abnormal: guaiac positive. extremities: no rle edema, no lle edema, no varicosities. pulse exam (p=palpation, d=dopplerable, n=none) rle dp: n. pt: d. lle dp: d. pt: d. description of wound: right groin staple line intact; wound with increased warmth, erythematous and tender with no drainage expressible pertinent results: 02:15am plt count-129*# 02:15am wbc-6.0 rbc-3.90* hgb-12.5* hct-36.7* mcv-94 mch-32.1* mchc-34.1 rdw-13.9 02:15am alt(sgpt)-240* ast(sgot)-191* ld(ldh)-172 alk phos-72 amylase-102* tot bili-0.5 02:15am glucose-115* urea n-33* creat-3.7*# sodium-133 potassium-4.4 chloride-101 total co2-21* anion gap-15 brief hospital course: in the ed, patient was hypotensive after 2 l fluid bolus and was subsequently started on levophed and admitted to the sicu. cipro, flagyl, and vancomycin were started. staples were removed from the groin site and the wound was packed with significant serous drainage noted. echocardiogram showed normal ventricular function and was negative for effusion and vegetation. on hospital day 2, levophed was weaned off.creatinine declined to 1.0. blood cultures were positive for gpc in clusters. wound culture grew mrsa. on hospital day 3, patient remained hemodynamically stable and was subsequently transferred out of the sicu to the floor. a wound-vac was placed over the right groin site. metoprolol 25 mg was added for hypertension with improvement. the day of discharge, vac was removed for transfer and wound was found to be granulating well. patient was ambulating and tolerating a regular diet. pain was well-controlled. patient is to be discharged on 2 weeks oral bactrim/cipro/flagyl. medications on admission: lisinopril 10 mg daily, escitalopram 10 mg daily, colace 100 mg ,simvastatin 10 mg daily, asa 81 mg daily, plavix 75 mg daily discharge medications: 1. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 14 days. disp:*28 tablet(s)* refills:*0* 2. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 5. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 14 days. disp:*42 tablet(s)* refills:*0* 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). 8. bactrim ds 800-160 mg tablet sig: one (1) tablet po twice a day for 14 days. disp:*28 tablet(s)* refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 10. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). tablet(s) 11. percocet 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*20 tablet(s)* refills:*0* 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: wound infection discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted for a wound infection of your left groin with presumed sepsis. the wound was incised and drained and you were started on antibiotics. the wound culture suggested you were infected with methicillin-resistant staph aureus (mrsa). we started you on metoprolol 25 mg orally twice a day for of your blood pressure. 1) you should continue the antibiotics by mouth for 2 weeks. 2) a nurse will come to your home to change the dressing for the wound vac. you should get daily wet-to-dry dressing changes until the woundvac arrives. please call your doctor or go to the emergency department if: *you experience new chest pain, pressure, squeezing or tightness. *you develop new or worsening cough, shortness of breath, or wheeze. *you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience an unusual discharge. *your pain is not improving within 12 hours or is not under control within 24 hours. *your pain worsens or changes location. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *you develop any concerning symptoms. general discharge instructions: please resume all regular home medications, unless specifically advised not to take a particular medication. please take any new medications as prescribed. please take the prescribed analgesic medications as needed. you may not drive or heavy machinery while taking narcotic analgesic medications. you may also take acetaminophen (tylenol) as directed, but do not exceed 4000 mg in one day. please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. please also follow-up with your primary care physician. incision care: *please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until cleared by your surgeon. *keep your groin incision clean and dry after woundvac dressing placement. followup instructions: dr. in 2 weeks. call ( to schedule an appointment. follow-up with your primary care doctor of your blood pressure. Procedure: Venous catheterization, not elsewhere classified Application of pressure dressing Diagnoses: Other postoperative infection Chronic hepatitis C without mention of hepatic coma Severe sepsis Hematoma 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 Septic shock Methicillin resistant Staphylococcus aureus septicemia |
allergies: no known allergies / adverse drug reactions attending: addendum: discharged to center for recuperative stay; expected stay to be <30 days discharge disposition: extended care facility: healthcare center - md, Procedure: Cholecystectomy Partial hepatectomy Diagnoses: Pure hypercholesterolemia Malignant neoplasm of liver, secondary Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Depressive disorder, not elsewhere classified Atrial flutter Osteoarthrosis, unspecified whether generalized or localized, site unspecified Personal history of malignant neoplasm of large intestine Other constipation Examination of participant in clinical trial Other alteration of consciousness |
allergies: no known allergies / adverse drug reactions attending: chief complaint: metastatic colon ca to liver major surgical or invasive procedure: segment 6 resection, cholecystectomy, intraoperative ultrasound, skin punch biopsy times 2 (research). history of present illness: per dr. operative note as follows: 89-year-old male who underwent a sigmoid colectomy for a t2 n0 m0 adenocarcinoma of the colon on . he has had followup ct scans of the abdomen. on , it demonstrated a 2.1 x 2.2 cm hypoattenuating mass and some smaller nodules in segment 6 concerning for metastatic disease. there is a ? segment 3 nodule. a pet ct on , demonstrated fdg avid right lobe lesion in segment 6 measuring 2.7 x 2.5 cm. no other fdg avid activity was noted. he underwent a thorough cardiac evaluation and was found to be a suitable candidate for hepatic resection. he has provided informed consent and is now brought to the operating room for segment 6 resection and intraoperative ultrasound. he is also part of a research protocol and has consented to skin punch biopsy. past medical history: 1. paroxysmal atrial fibrillation on amiodarone 2. hypertension 3. question of cad 4. hypothyroidism 5. hypercholesterolemia 6. osteoarthritis 7. hemorrhoids 8. history of gastrointestinal ulcers 9. falls 10. cervical spinal stenosis 11. pneumonia past surgical history: 1. status post removal of prostate adenoma x2 2. status post left cataract removal - 3. status post right cataract removal - 4. status post appendectomy 5. status post turp social history: lives at home with his wife in . son speaks and very involved. walks with a cane because his legs are weak. he attends a day program five days per week. they moved to the united states from in . family history: the patient's father had prostate cancer and hypertension. he died at age 80. his mother had "spine problems" and a stroke. she died at age 75. pertinent results: 05:15am blood wbc-8.9 rbc-4.09* hgb-12.4* hct-36.9* mcv-90 mch-30.4 mchc-33.6 rdw-13.0 plt ct-201 05:15am blood wbc-8.9 rbc-4.09* hgb-12.4* hct-36.9* mcv-90 mch-30.4 mchc-33.6 rdw-13.0 plt ct-201 05:45am blood pt-12.7 ptt-27.1 inr(pt)-1.1 05:45am blood glucose-89 urean-14 creat-1.2 na-135 k-4.1 cl-100 hco3-27 angap-12 05:45am blood alt-76* ast-29 alkphos-72 totbili-0.5 11:25am blood alt-280* ast-324* alkphos-61 totbili-1.4 05:45am blood calcium-8.7 phos-3.6 mg-1.9 05:15am blood caltibc-170* ferritn-1602* trf-131* brief hospital course: on , he underwent segment 6 resection, cholecystectomy, intraoperative ultrasound, skin punch biopsy times 2 for metastatic colon cancer to the liver. surgeon was dr. . please refer to operative note for further details. postop, he experienced afib with rvr. on , he was transferred to the sicu on for management of afib. he also had low grade fevers. on , he was bradycardic. lopressor was decreased. cardiac enzymes were drawn and were negative x3. he had brief episodes of hypotension with sbp of 70 when sleeping. cardiology was consulted. amiodarone drip was started and converted to oral amiodarone. lopressor (oral) was stopped. he was transferred out of the sicu to the med- unit once rate controlled. he was on tele and had intermittent doses of iv lopressor for tachycardia with rates of 120s. hctz was resumed and diuresed with decreased edema. cardiology was in favor of anticoagulation given afib and new right heart failure. however, the patient refused coumadin. his son was contact and was contacting pcp to discuss risk vs benefit. he remained in a sinus rhythm. dr. was contact on and recommended decreasing amiodarone to 200mg per day given current sr with hr in 70s, and if heart rates increased at rest (60-70s), low dose beta blocker could be resumed. lisinopril 5mg daily was recommended. this was ordered. a f/u appt with dr. should be scheduled in weeks. per report of wife, patient experienced a fall (unwitnessed by staff) without injury the day after surgery when he insisted to get oob without waiting for assist. no injury was sustained. wife reported that he was confused. per interpreter, patient was alert and oriented. geriatrics was consulted early in hospital stay as patient was confused with some hallucinations. recommendations were to adjust pain medications and resume prozac. low dose risperdol was prescribed at hs for confusion/interrupted sleep (sundowning) with improved mental status. his wife was present on most days and the russian interpreter was used to assist communication. diet was slowly advanced and tolerated. iv meds were switched to oral meds. iv dilaudid was switched to low dose oxycodone (2.5mg doses).he was passing flatus and having bowel movements. he was assisted to get oob. pt evaluated and recommended rehab for deconditioning. the patient was ambulating with a cane. the incision remained intact with staples and was without redness/bleeding/drainage. staples will be removed in f/u with dr. . overall, he did well from the standpoint of the liver resection. lfts initially increased then trended down. pathology report was to be reviewed in follow up with the patient and family. vital signs were stable at time of discharge. medications on admission: aspirin 81', brimonidine0.15% eyedrops,tums 600", fluoxetine 20', hctz 12.5', levothyroxine 50', lisinopril 20', metoprolol 6.25", psyllium 1', simethicone 180"', simvastatin 10' discharge medications: 1. brimonidine 0.15 % drops sig: one (1) drop ophthalmic q8h (every 8 hours): both eyes. 2. fluoxetine 10 mg capsule sig: two (2) capsule po daily (daily). 3. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 4. levothyroxine 25 mcg tablet sig: two (2) tablet po daily (daily): except on sunday7. 5. risperidone 0.5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po qhs (once a day (at bedtime)): give at 8pm. 6. tylenol 650mg po prn q 6 hours for pain. not to exceed more than 2000mg/day 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 10. amiodarone 200 mg tablet sig: one (1) tablet po once a day. 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. calcium 600 + d(3) 600 mg(1,500mg) -400 unit tablet sig: one (1) tablet po twice a day. 13. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily): hold for sbp <110. discharge disposition: extended care facility: healthcare center - discharge diagnosis: metastatic colon ca to liver afib discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: please call dr. office if you have any of the following: fever, chills, nausea, vomiting, inability to eat or drink, jaundice, incision redness/bleeding/drainage you may shower no heavy lifting/straining followup instructions: provider: , md, phd: date/time: 9:00 provider: , md phone: date/time: 11:20 provider: , md phone: date/time: 10:00 provider: schedule follow up appointment dr. at (cardiologist) in weeks md, Procedure: Cholecystectomy Partial hepatectomy Diagnoses: Pure hypercholesterolemia Malignant neoplasm of liver, secondary Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Depressive disorder, not elsewhere classified Atrial flutter Osteoarthrosis, unspecified whether generalized or localized, site unspecified Personal history of malignant neoplasm of large intestine Other constipation Examination of participant in clinical trial Other alteration of consciousness |
allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p motor vehicle crash major surgical or invasive procedure: none history of present illness: 20yo m s/p mvc, unrestrained, resulting in ejection from car, intubated in field for gcs 3. the mechanism of the crash is not known at the time. he was apparently noted to have some arm twitching activity, and per report, his pupils were not reactive. he was paralyzed with rocuronium at the field and had been given ativan in the ed. it is not known if any drugs or alcohol were involved. became hypertensive and bradycardic in ed, given mannitol. past medical history: adhd per family social history: social etoh, positive for smoking family history: non-contributory physical exam: upon arrival to trauma bay: vs: hr 40, bp 180s systolic gen: intubated, sedated with propofol, rigors throughout his extremities. multiple lacerations noted. heent: intubated, left temporal scalp laceration. hard c-collar in place. cv: slow, regular, no murmurs resp: clear anteriorly abd: soft ext: multiple lacerations, left wrist is particularly affected neuro: pupils are reactive 2.5-1.5mm bilaterally, no corneals, rn positive gag/cough. vor not performed. spontaneous extensor posturing of his upper extremities, as well as to nailbed pressure. lower extremities withdraw to babinski testing and nailbed pressure.. reflexes are symmetric and hyporeflexic throughout. toe is upgoing on the left. pertinent results: 09:02pm wbc-11.6* rbc-4.35* hgb-14.5 hct-41.8 mcv-96 mch-33.3* mchc-34.7 rdw-12.2 09:02pm glucose-83 urea n-12 creat-1.0 sodium-136 potassium-3.7 ct chest/abd/pelvis (prelim read): non-displaced fracture through r posterior 10th rib. small amount of dense fluid in the pelvis. bibasial dense opacities likely aspiration. ct head w/o contrast (prelim read): 1. tiny foci of hemorrhage in the left basal ganglia, lt subependymal and corpus callosum (ant genu) concerning for . 2. fracture of the left lamina paprycea. ?? fx left orbital floor - dedicated ct facial bones advised. 3. no skull fracture. b/l subgaleal hematoma. ct c-spine (prelim read): left c7 superior facet fracture. no alignment abnormalities. cxr (prelim read): appropriately positioned et and ng tubes. no acute intrathoracic process. ct head: decreased conspicuity of one white matter hyperdense focus with two persistent additional hyperdense foci, suggestive of diffuse axonal injury. ct max/face: left orbital fracture. disruption of the medial wall of the left maxillary sinus with near-complete opacification of the left maxillary sinus. 10/29 l forearm/elbow: transverse fracture of the proximal shaft of the left ulna, with slight medial displacement of the distal fracture fragment. cxr: new rll opacification concerning for aspiration. brief hospital course: mr. was admitted to ticu for monitoring & continued care. neurosurgery was consulted for the punctate brain hemorrhage and surgical intervention not warranted. repeat ct head consistent with persistent . his neuro exam was followed closely and continued to improve, moving all extremities and following commands intermittently. orthopedic spine was consulted for the left c7 superior facet fracture; he was placed in a hard cervical collar which will remain in place for at least 8 weeks. plastics was consulted for the facial fractures which were also managed non operatively. he was initially recommended for unasyn and placed on sinus precautions. ophthalmology consulted for assessing for globe entrapment and no acute issues were identified. he was seen by orthopedics for the left ulnar fracture which was placed in a splint, he will return to clinic in 2 weeks for more xrays and assessment for the need for operative repair at that time. during his icu stay he was noted with fever to 103.7 and was pan-cultured. his cxr showed new rll opacity; bronch was performed which showed thick, purulent sputum (r>>l), bal sent. empiric antibiotic coverage for aspiration pneumonia was started with vanc/zosyn/cipro. he received 500cc ns bolus x2 given for low urinary output and tachycardia with good response he remained stable and was subsequently extubated. as he showed significant improvement he was transferred to the regular nursing unit for ongoing care. once on the surgical he continued to progress. he was seen by occupational therapy and deemed appropriate for home with 24 hour supervision given his head injury. his iv antibiotics were changed to po levaquin. at time of discharge he was ambulating independently and tolerating a regular diet. he and his family were provided instructions on his necessary follow up appointments and his medications were reviewed in depth. he was discharged to home with his family. medications on admission: none discharge medications: 1. tylenol extra strength 500 mg tablet sig: two (2) tablet po every six (6) hours as needed for pain. 2. levaquin 750 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* 3. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 4. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 5. senna 8.6 mg tablet sig: 1-2 tablets po twice a day as needed for constipation. 6. trazodone 100 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. disp:*30 tablet(s)* refills:*1* 7. zyprexa zydis 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po twice a day as needed for agitation. disp:*60 tablet, rapid dissolve(s)* refills:*0* discharge disposition: home discharge diagnosis: s/p motor vehicle crash injuries: closed head injury bilateral subgaleal hematomas left c7 superior facet fracture right post 10th rib fracture aspiration right femoral hematoma left orbital floor fracture fracture of the left lamina paprycea maxillary sinus medial wall fracture left ulnar fracture discharge condition: level of consciousness: alert and interactive. impulsive due to brain injury. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital after a motor vehicle crash where you sustained multiple injuries which include a small closed brain injury with some bleeding beneath the scalp; fracture of the bones in your face and around your eye called the orbital bone; a fracture of the lower arm bone called the ulnar and a spine bone fracture in the cervical bones that are located in your neck - there was no injury to your spinal cord itself. because of this injury you are required to wear a hard neck (cervical) collar for at least 8-12 weeks. you will then follow up with the orthopedic spine doctor for more xrays after that time period. you were seen by the occupational therapist and being recommended to follow up with the cognitive neurologist after discharge for your head injury. followup instructions: follow up in cognitive clinic with dr. in 1 week. call for an appointment. follow up in clinic with dr. in 2 weeks for reassessment of your ulnar fracture. call for an appointment. follow up in clinic with dr. for your facial fractures in 2 weeks. call for an appointment. follow up in orthopedic spine with dr. clinic in 4 weeks. call for an appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Closed [endoscopic] biopsy of bronchus Diagnoses: Open wound of scalp, without mention of complication Pneumonitis due to inhalation of food or vomitus Closed fracture of one rib Closed fracture of seventh cervical vertebra Closed fracture of orbital floor (blow-out) Motor vehicle traffic accident of unspecified nature injuring driver of motor vehicle other than motorcycle Closed fracture of unspecified part of ulna (alone) Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration |
allergies: keflex / avelox / nifedipine / pulmicort / doxycycline attending: chief complaint: sob major surgical or invasive procedure: corevalve aortic valve replacement via ileofemoral approach history of present illness: this 74 year old woman has severe aortic stenosis with nyha class iii symptoms of chf. she describes exertional dyspnea after walking blocks or if she talks for an extended period of time. this improves when she stops to rest. she denies any chest pain or dizziness. she also has pulmonary hypertension which is secondary to hepatopulmonary syndrome r/t liver cirrhosis. she has been treated with sildenafil for several years, with subsequent pa systolic of 50. she is also on home oxygen 2l per nasal cannula continuously. she states that she has been on the oxygen for close to 20 years. she has esophageal varices grade 1 and was cleared for procedure by gastroenterology. she was seen by liver service and was deemed to be childs a with espophageal varices and prohibitive for surgical avr. she was referred for corevalve/tavr trial. she has met all inclusion criteria, with no exclusion criteria. she is here for elective tavr. she reports recent episode of bronchitis for which she was treated with 3 weeks of antibiotics and steroids (last dose 1/16) with improvement. . corevalve was successfully placed today in the or using an ileofemoral approach. she is currently intubated and sedated, stable. of note, pacemaker appearing to be firing inappropriately despite hr of 70s. also only seeing pacemaker spikes, not capturing, no qrs complexes. . unable to obtain review of systems since the patient is intubated. acknowledges some mild back pain, but no other pain. past medical history: 1. severe aortic stenosis 2. hepatic cirrhosis prior etoh use - esophageal varices- s/p bleed required tx -grade 1 varices - pulmonary hypertension hepatopulmonary syndrome 3. pulmonary nodules by chest ct stable since 4. arthritis of spine and hips 5. s/p basal cell cancer excision of lip 6. s/p hemorrhoidectomy hemorrhoid surgery social history: married and lives with her husband in , . worked as a secretary, now retired. has 6 children. tobacco: never smoked. etoh: no etoh x 22 years family history: father had emphysema. mother has alzheimer's and is 96 physical exam: admission physical exam: general: intubated and sedated, opens eyes spontaneously, responsive, appropriate. height: 63 inches weight: 73.8 kg skin: color pink, skin warm and dry. no decubiti. heent: normocephalic, anicteric, conjunctiva pink. oropharynx moist. partial dentition lower. neck: supple, trachea midline. chest: no obvious deformities/scarring. ctabl scatterred rhonchi. heart: rrr. no m/r/g abdomen: soft,nontender, nondistended. +bs. femoral venous sheath in place. extremities: no lower extremity edema at present. neuro: alert and oriented, responsive. perrla, eomi. cn ii-xii grossly intact, tone power, reflexes coordination sensation intact in all four extremities. pulses: palpable peripheral pulses. 2+ carotid/femoral/dp/pt bilaterally. . discharge physical exam: vitals: tm/tc: 98.6 hr:93 bp:110/61 rr:18 02 sat: 98 (ra) weight: 68.9 kg (yest 70.3kg) ) tele: sinus rythm general: pleasant, oob adlib, in no acute distress heent: perrla, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, jvp non elevated chest: ctabl no wheezes, no rales, no rhonchi cv: s1 s2 normal in quality and intensity rrr no murmurs rubs or gallops abd: soft, non-tender, non-distended, bs normoactive. no rebound/guarding, neg hsm. neg sign. bm yesterday. lower abdominal echymosis stable. ext: wwp, no edema. dps, pts 2+. bilateral groin sites clean and dry. no erythema. no palpable hematomas. neuro: cns ii-xii intact. 5/5 strength in u/l extremities. oob ad lib, gait steady. denies pain, showered yesterdy. skin: no rash psych: calm, pleasant, asking questions approp. pertinent results: admission labs: 12:40pm blood wbc-4.5 rbc-4.02* hgb-12.9 hct-37.0 mcv-92 mch-32.0 mchc-34.9 rdw-13.8 plt ct-83* 12:40pm blood pt-12.4 ptt-30.1 inr(pt)-1.1 12:40pm blood glucose-87 urean-21* creat-0.7 na-142 k-3.9 cl-106 hco3-29 angap-11 12:40pm blood albumin-3.5 12:40pm blood alt-27 ast-40 ck(cpk)-169 alkphos-117* totbili-0.9 12:40pm blood ck-mb-3 probnp-136 12:40pm blood %hba1c-6.1* eag-128* 12:40pm blood hemoglobin, free-4.6 . discharge labs: 06:10am blood wbc-4.2 rbc-3.24* hgb-10.5* hct-29.7* mcv-92 mch-32.3* mchc-35.3* rdw-15.5 plt ct-115* 06:10am blood glucose-153* urean-7 creat-0.8 na-137 k-3.7 cl-102 hco3-26 angap-13 06:10am blood alt-24 ast-43* ck(cpk)-60 alkphos-68 totbili-2.1* 06:10am blood ck-mb-2 probnp-156 06:10am blood albumin-3.6 mg-2.0 . chest x-ray (): the lung volumes are normal. borderline size of the cardiac silhouette and mild tortuosity of the thoracic aorta. there is a moderate enlargement of the right pulmonary artery, already documented on a ct examination from and since then unchanged. no acute changes. no pleural effusions. no pulmonary edema. . echo (): the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. an aortic corevalve prosthesis is present and appears well-seated. the aortic gradient was not assessed. mild (1+) aortic regurgitation is seen. trivial mitral regurgitation is seen. mild (1+) mitral regurgitation is seen. compared with the prior study (images reviewed) of , a corevalve is now in place. . chest x-ray (): as compared to the previous radiograph, a right internal jugular catheter has been inserted. inspiration is improved as compared to the pre-interventional radiograph. there is no evidence of pulmonary edema. known enlargement of the right hilus. normal size of the cardiac silhouette. no pleural effusions. . echo (): the left atrium is normal in size. the estimated right atrial pressure is 5-10 mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the right ventricular cavity is mildly dilated with borderline normal free wall function. an aortic corevalve prosthesis is present. the aortic valve prosthesis appears well seated, with normal transvalvular gradients. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normally functioning aortic corevalve with mild aortic regurgitation. preserved left ventricular function. moderate-severe tricuspid regurgitation with severe pulmonary artery systolic hypertension. compared with the post aortic corevalve implantation study dated , the corevalve continues to be well seated. transaortic gradients (not assessed on the prior study) are normal. . abdominal x-ray (): supine views of the abdomen demonstrate multiple air-filled loops of small and large bowel. a single loop of jejunum in the mid-abdomen is slightly dilated due to mild localized ileus. no evidence of obstruction. calcified splenic artery aneurysm is seen in the left upper quadrant. brief hospital course: 74 yo f with h/o severe as with nyha class iii chf admitted for corevalve/tavr. . #aortic stenosis s/p corevalve/tavr: procedure completed successfully without complication. post operatively she was monitored in the ccu for 48 hours, after which her pacer wires were pulled (she had no pacer requirement). she had one episode of chest pain post-operatively without ekg changes or enzyme leak. otherwise, her course was uncomplicated. she underwent tte which showed successful placement of corevalve. patient discharged on asa and plavix to complete 3 month course. . #rhythm: sinus throughout, without rhythm disturbance. pacer not required. . #hepatic cirrhosis: she has cirrhosis by both an abdominal ct scan and mri with esophageal varices. she has not had bleeding recently. she has a meld score = 10 and appears to be childs- class a prohibitive for surgery per liver service. was not active during this hospitalization. she was restarted on her home diuretics with good uop when she was stabilized. . #pulmonary hypertension secondary to hepatopulmonary syndrome: she has apparently responded to sildenafil 60 mg daily with a reduction in her pulmonary pressures from over 100 mmhg systolic to 65 mmhg systolic. this has appeared stable over the past several years. she was maintained on her home sildenafil and her home o2 requirement of 2l nc. medications on admission: furosemide - 40 mg tablet (noncompliant leg cramps) ipratropium bromide - 0.2 mg/ml (0.02 %) solution qid levalbuterol hcl dosage uncertain levalbuterol tartrate - 45 mcg/actuation hfa aerosol prn potassium chloride - 20 meq tablet, er sildenafil - 20 mg tid spironolactone - 50 mg tablet zolpidem - 10 mg tab qhs prn codeine-guaifenesin - 100 mg-10 mg/5 ml liquid q 4hrs multivitamin - daily discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. sildenafil 20 mg tablet sig: one (1) tablet po tid (3 times a day). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. spironolactone 25 mg tablet sig: two (2) tablet po bid (2 times a day). 5. codeine-guaifenesin 10-100 mg/5 ml syrup sig: five (5) ml po q4h (every 4 hours) as needed for cough. 6. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 7. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime) as needed for insomnia. 8. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*2* 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 10. multivitamin tablet sig: one (1) tablet po once a day. 11. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po twice a day: while taking furosemide. discharge disposition: home with service facility: vna of and southern nh discharge diagnosis: 1. aortic stenosis s/p corevalve transcatheter aortic valve replacement 2. pulmonary hypertension 3. hepatic cirrhosis 4. esophageal varices discharge condition: alert and oriented x 3, calm, receptive, asking questions appropriately and verbalizing good understanding of instructions and plan. ambulatory with assist for supervision. mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mrs. , you were admitted on for and elective transcatheter aortic valve replacement with the corevalve device to treat your severe symptomatic aortic stenosis. your procedure was successful and your postoperative course was without complications. you are now ready for discharge. your discharge instructions include: 1.weigh yourself every morning, md if weight goes up more than 3 lbs. 2. shower daily with antibacterial soap 3. keep groin sites clean and dry, no powders or lotions. 5. no lifting > 10 lbs your medications will remain the same as those prior to your procedure with the following additions: 1. clopidrogel 75mg - take one tablet daily 2. aspirin 81mg - take one tablet daily 3. acetaminophen 325mg - take 1-2 tablets every 6 hours if needed for pain. 4. famotidine 20mg - take 1 tablet twice a day while on aspirin and clopidrogel. followup instructions: follow up appt with dr :20pm. follow up with dr in weeks. (pcp) follow up with dr in weeks. (pulmonologist) Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Aortography Arteriography of other intra-abdominal arteries Endovascular replacement of aortic valve Diagnoses: Anemia of other chronic disease Congestive heart failure, unspecified Alcoholic cirrhosis of liver Other and unspecified alcohol dependence, in remission Acute on chronic diastolic heart failure Hematoma complicating a procedure Aortic valve disorders Other chronic pulmonary heart diseases Other specified cardiac dysrhythmias Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other complications due to other internal prosthetic device, implant, and graft Diseases of tricuspid valve Lumbosacral spondylosis without myelopathy Other dependence on machines, supplemental oxygen Esophageal varices without mention of bleeding Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx Solitary pulmonary nodule Arthropathy, unspecified, pelvic region and thigh Precordial pain Hepatopulmonary syndrome |
allergies: erythromycin base attending: chief complaint: osh transfer for mssa bacteremia and surgical evaluation major surgical or invasive procedure: 1. arthrotomy right knee with anterior synovectomy. 2. arthrocentesis right shoulder. 1. resection of medial half of right clavicle, sternoclavicular joint and partial resection of manubrium. 2. debridement of subcutaneous tissue and chest wall muscle. 1. debridement of right chest wound, skin, muscle and bone. 2. exploration of right chest open wound. 3. right latissimus flap reconstruction of right chest wound. 4. right chest local advancement flap closure. history of present illness: mr. is a 54m with pmh etoh abuse and htn who initially presented to with chest pain, knee pain, shoulder pain, fever and several months of polyuria, polydipsia, and 30 lb weight loss found to be in dka. there he was started on an insulin drip and given ivf. he had arthrocentesis of his knee and ac joint which revealed gpcs and had blood cultures positive for mssa. he also was noted to have indurated erythema over anterior chest wall-cellulitis and had ct which revealed hazy infiltration and edema around pectoralis, scm and anterior mediastinum. he was treated with vanco/clinda for his infection and surgery was consulted for concern for necrotizing fasciitis although no crepitus or gas seen on ct. surgery there preferred that he be trasnferred to tertiary care center for further eval so he was transferred to . . upon admission, he became hypercarbic and somnolent requiring intubation after receiving ativan per ciwa and pain medications. abg 7.14/79.7/316 prior to intubation and 7.29/46/100+ on 100% after. other vss without hypotension or tachycardia. past medical history: hypertension gerd cortisone shot 2 weeks ago r knee s/p ccy social history: (per records) drinks at least one 6 pack per day, sometimes more. quit smoking 20 years ago, but used to smoke 2 ppd. has one cat. denied h/o drug abuse. family history: (per records) father - prostate ca, brother - dm, one grandparent with prostate ca physical exam: on admission general: intubated, answering yes/no questions, awake, alert heent: sclera anicteric, mmm, oropharynx with + thrush neck: supple, jvp not elevated, no lad chest: anterior chest wall erythema and induration with limited rom r shoulder. no crepitus lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place. no penile ulcers or lesions ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema r knee: + effusion. no erythema or ttp pertinent results: ============ radiology ============ ct chest 1. severe progressive right anterior chest wall infection involving at least the pectoralis major muscle in its entirety and probable subcutaneous tissue to the cervicothoracic junction. 2. large phlegmon with a stable prevascular component is enlarging superiorly at the base of the neck anterior to the thyroid gland inferior to the phlegmon, likely mediastinitis has progressed. 3. new small bilateral pleural effusion probably attributable to interval development of bibasilar atelectasis. . ct chest impression: no evidence of fluid collection or abscess or other signs of soft tissue infection. post-surgical changes from prior right anterior chest wall resection are stable. . ct neck 1. marked asymmetric enlargement of the right-sided pectoralis, sternocleidomastoid and strap muscles with effacement of fat planes and surrounding fat stranding and mildly heterogeneous enhancement is concerning for infection with pyomyositis. mildly heterogeneous enhancement, especially within the right strap muscles can represent edema versus early myonecrosis. 2. widening of the sternoclavicular joints and apparent erosive changes, particularly involving the dorsal aspect of the sternum, is suspicious for septic arthritis; there may also be a component of chronic degenerative change. 3. mild short-term increase in abnormal soft tissue-attenuation collection extending into the inferior neck and surrounding the thyroid gland. there is no peripheral enhancement; however, in this setting, this is highly suspicious for infectious phlegmon. 4. endotracheal tube is only 1 cm above the carina. repositioning is recommended. deviation of the trachea to the left is likely from mass effect of markedly edematous right neck musculature. . tee the left atrium and right atrium are normal in cavity size. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch and descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no echocardiographic evidence of endocarditis. . radiology report in-111 white blood cell study study date of , s. in-111 white blood cell study clip # reason: osteo multiple sites of mrsa s/p r shoulder resection r knee washout w/persistent fevers eval for infected pocket final report radiopharmaceutical data: 327.0 uci in-111 wbcs (); history: 54 year old male with multifocal mrsa infection, status post right knee washout and right sternoclavicular resection. interpretation: following the injection of autologous white blood cells labeled with in-111, images of the whole body were obtained at 24 hours. these images show marked increased tracer activity about the right knee. additionally, there is a somewhat linear, horizontally oriented region of increased uptake in the right chest anteriorly, just inferior to the expected location of the clavicle. the above findings are consistent with infectious process involving the right knee and right anterior chest wall. impression: positive in-111 wbc scan demonstrating increased uptake in the right knee and right anterior chest wall compatible with infection in these locations. discussed with . , m. , m.d. approved: mon 3:55 pm . provisional findings impression: jekh tue 1:43 pm pfi: left picc tip at the cavoatrial junction. final report history: 54-year-old male with left arm picc. study: pa, lateral and oblique chest radiographs. comparison: . findings: the heart and mediastinal contours appear normal. the hila are normal appearing bilaterally. the lungs are clear of masses or consolidations. surgical clips project over the lower aspect of the right lung. there is no large pleural effusion or pneumothorax. previously described left picc tip is best seen on oblique views and appears to be at the cavoatrial junction. the osseous structures are grossly intact. impression: left picc tip at the cavoatrial junction. the study and the report were reviewed by the staff radiologist. dr. dr. approved: tue 2:14 pm . ============== micro ============== . osh blood culture - mssa x2 bottles . mrsa screen (final ): no mrsa isolated. . 1:15 pm tissue pecturalis muscle right. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram positive cocci. in pairs and clusters. tissue (final ): staph aureus coag +. moderate 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------------- 0.5 s trimethoprim/sulfa---- <=0.5 s anaerobic culture (final ): no anaerobes isolated. . 1:50 pm tissue right manubrium. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (final ): staph aureus coag +. sparse growth. sensitivities performed on culture # , . anaerobic culture (final ): no anaerobes isolated. . 1:00 pm tissue right knee synoruin. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. tissue (final ): staph aureus coag +. sparse growth. staph aureus coag +. rare growth second type. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | staph aureus coag + | | clindamycin-----------<=0.25 s <=0.25 s erythromycin----------<=0.25 s <=0.25 s gentamicin------------ <=0.5 s <=0.5 s levofloxacin----------<=0.12 s <=0.12 s oxacillin------------- 0.5 s <=0.25 s trimethoprim/sulfa---- <=0.5 s <=0.5 s anaerobic culture (final ): no anaerobes isolated. ============= labs ============= wbc rbc hgb hct mcv mch mchc rdw plt ct 15:57 13.6* 4.09* 12.5* 37.8* 93 30.6 33.1 13.6 228 5.7 2.69* 7.9* 25.1* 93 29.5 31.6 15.3 548* . glucose urean creat na k cl hco3 angap lipemic specimen 15:57 304*1 15 0.6 140 4.3 107 23 14 125*1 9 0.6 139 4.2 106 27 10 . alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 15:12 2781 . crp 03:00 162.6*1 04:10 174.8*1 09:50 31.2*1 source: line-picc . esr 03:00 70* 04:10 78* 09:50 121* source: line-picc . vanco 06:44 23.6* source: line-picc; vancomycin @ trough brief hospital course: # anterior wall cellulitis/mediastinitis: patient has anterior chest cellulitis with e/o mediastinal involvement and edema of neck strap muscles and underwent debridement and removal of clavicle, manubrium, and pectoralis muscle on . blood cultured remained negative at , but grew mssa at osh. patient was initially managed on nafcillin, cefepime and clindamycin, but narrowed to nafcillin and clindamycin prior to transfer from the micu to the surgical floor. patient was extubated on and tolerated well. intraoperative cultures from abscess cavities and bone returned positive for mssa, suggestive of osteomyelitis. the wound was inspected daily and dressing changes continued. patient was taken to the or on with the plastic surgery service. a right latissimus flap reconstruction of right chest wound and right chest local advancement flap closure was performed. patient tolerated the operation well. the flap was monitored closely and remained viable. at the most medial tip of the flap there a small, dark area of ischemia that did not change over time. the right posterior latissimus area remained flat and intact and all drains remained productive with serous output. . # septic knee/sc joint: pt had complained of r knee pain after steroid injection and had mssa from joint fluid as well as ? purulence from r sternocalvicular joint per d/c summary. underwent joint washout on . followed along by orthopedics. physical therapy continued to work with patient for range of motion and ambulation. . # hypercarbic respiratory failure: patient with episode of hypercarbia day prior to transfer am in setting of somnolence, likely from receiving ativan for etoh withdrawal and narcotics for pain. also have undiagnosed sleep apnea given wife??????s reports of gasping arousals and snoring. also concern that neck muscle edema resulting in airway obstruction although was never reportedly stridorous. repeat abg without hypercarbia. extubated on after no procedures were felt necessary. . #. mssa bacteremia: patient with mssa bacteremia and mssa r knee tap consistent with septic arthritis. also with area of cellulitis anterior chest so it was unclear which came first and if separate processes. possible etiology is introduction of bacteria into joint space when had steroid injection resulting in mssa bacteremia. tee negative for endocarditis. patient was initially managed with nafcillin and clindamycin for toxin inhibition. his clindamycin was discontinued after 5 days, and he was then maintained on nafcillin. he then continued to have high fevers, and possibly a rash, and, given concern that nafcillin was the cause of his persistent fevers, his nafcillin was discontinued. his rash-- present only on his flanks-- resolved quite quickly (in less than 12 hours) but his fevers continued despite a normal leukocyte count. he was febrile for days, and ultimately, after an extensive work-up, his fevers were felt maybe to be secondary to his famotidine. however, patient was treated with vancomycin iv for the remainder of his stay which he tolerated well. the id service will follow him as an outpatient for a total of 6 weeks of iv antibiotic therapy. a picc line was inserted to left upper extremity for this purpose. . # dka: pt initially presented to osh with dka now with blood sugars 100s-200s. sugars well controlled on nph. consulted for recommendations. he has maintained normoglycemic on current regimen of lantus and insulin sliding scale. . #. etoh abuse: mvi, thiamine, folic acid. no signs of withdrawal and no therapy indicated. . # thrush: treated with fluconazole 100 mg iv x1. hiv test negative at osh. medications on admission: omeprazole discharge medications: 1. vancomycin 500 mg recon soln sig: 1250 mg recon solns intravenous q 8h (every 8 hours) for last doses weeks: goal trough 15-20. disp:*207 recon soln(s)* refills:*0* 2. famotidine 20 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) as needed for constipation. disp:*60 capsule(s)* refills:*0* 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*0* 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 6. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 7. multivitamin tablet sig: one (1) tablet po daily (daily). tablet(s) 8. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. disp:*35 syringes* refills:*1* 9. lantus 100 unit/ml solution sig: twenty six (26) units subcutaneous at bedtime. disp:*1000 units* refills:*2* 10. insulin syringe 1 ml 29 x 1 syringe sig: one (1) miscellaneous four times a day. disp:*100 syringes* refills:*2* 11. lancets misc sig: one (1) miscellaneous four times a day: use to check your blood suger four times per day (before meals and at bedtime). disp:*100 lancets* refills:*2* 12. hydromorphone 4 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 13. humalog 100 unit/ml solution sig: per sliding scale subcutaneous 4 times/day (before meals and at bedtime). disp:*1000 units* refills:*2* 14. one touch test strip sig: one (1) in four times a day. disp:*100 strips* refills:*2* 15. outpatient lab work weekly cbc with diff, bun, cr, vancomycin trough, esr, crp. all laboratory results should be faxed to infectious disease r.ns. at (. all questions regarding outpatient antibiotics should be directed to the infectious disease r.ns. discharge disposition: home with service facility: , discharge diagnosis: diabetic ketoacidosis mediastinitis mssa sepsis right knee infection discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted on for debridement of a chest wall infection and chest wall reconstructionreconstruction. please follow these discharge instructions. . personal care: 1. leave your posterior chest dressings in place until your follow up appointment with dr. . if they get wet underneath then you may remove them and leave open to air. 2. clean around the drain site(s), where the tubing exits the skin, with hydrogen peroxide. 3. strip drain tubing, empty bulb(s), and record output(s) times per day. 4. a written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. you may shower daily. no baths until instructed to do so by dr. . . activity: 1. you may resume your regular diet. 2. do not lift anything heavier than 5 pounds or engage in strenuous activity until instructed by dr. . . medications: 1. resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. you may take your prescribed pain medication for moderate to severe pain. you may switch to tylenol or extra strength tylenol for mild pain as directed on the packaging. please note that percocet and vicodin have tylenol as an active ingredient so do not take these meds with additional tylenol. 4. take prescription pain medications for pain not relieved by tylenol. 5. your antibiotic (vancomycin) will be given iv as prescribed. 6. take colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. you may use a different over-the-counter stool softerner if you wish. 7. do not drive or operate heavy machinery while taking any narcotic pain medication. you may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . call the office immediately if you have any of the following: 1. signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. a large amount of bleeding from the incision(s) or drain(s). 3. fever greater than 101.5 of 4. severe pain not relieved by your medication. . return to the er if: * if you are vomiting and cannot keep in fluids or your medications. * if you have shaking chills, fever greater than 101.5 (f) degrees or 38 (c) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * any serious change in your symptoms, or any new symptoms that concern you. . drain discharge instructions you are being discharged with drains in place. drain care is a clean procedure. wash your hands thoroughly with soap and warm water before performing drain care. perform drainage care twice a day. try to empty the drain at the same time each day. pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. record the amount of drainage fluid on the record sheet. reestablish drain suctiondressing change: followup instructions: please follow up in the plastic surgery clinic on friday (). call for an appointment. . please follow up with your pcp for help with management for your diabetes. . please follow up with infectious diseases provider: , md phone: date/time: 11:10 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Attachment of pedicle or flap graft to other sites Arthrocentesis Other excision of joint, other specified sites Other partial ostectomy, scapula, clavicle, and thorax [ribs and sternum] Synovectomy, knee Diagnoses: Esophageal reflux Cellulitis and abscess of trunk Unspecified essential hypertension Unspecified osteomyelitis, other specified sites Methicillin susceptible Staphylococcus aureus septicemia Sepsis Candidiasis of mouth Alcohol abuse, unspecified 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 Other complications due to other vascular device, implant, and graft Dermatitis due to drugs and medicines taken internally Pain in joint, shoulder region Mediastinitis Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Unspecified drug or medicinal substance causing adverse effects in therapeutic use Pyogenic arthritis, lower leg Acute venous embolism and thrombosis of superficial veins of upper extremity Antacids and antigastric secretion drugs causing adverse effects in therapeutic use |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p stemi, cardiac arrest major surgical or invasive procedure: intubation (already intubated when presented from outside hospital) swan-ganz catheter tandem heart placement with ecmo device percutaneous coronary intervention s/p drug eluting stent to left anterior descending coronary artery history of present illness: 76f with h/o htn was transferred from for cabg evaluation after cardiac cath showed 95% lm disease and 99% lad stenosis with the cath procedure complicated by vt x2 s/p cardioversion and afib s/p cardioversion. per report, patient syncopized at home after a trip to bathroom, witnessed by daughter. was unresponsive for 20-30 seconds and patient soon became alert and vomitted. she was complaining of chest pain radiating to abdomen. daughter called ems, and patient was brought to ed. . on arrival to osh ed at 7:25am, ekg showed st elevations in i, avl, v1-v2, st depressions in ii, iii, avf, v3-v6. patient was given aspirin, heparin, plavix and lasix 20mg iv, and was taken to cath lab emergently. patient arrived at the cath lab at 8:12am with cardiogenic shock and chf with ongoing chest pain. dopamine was started right away, with levophed added at about 10am. iabp was placed as well. immediate right heart cath showed pcwp of 44mmhg. patient was intubated during the cath procedure for respiratory distress. lhc demonstrated high grade distal 95% stenosis in lm at trifurcation with lad, lcx and ramus branch with timi 1 flow into lad and lcx. 99% stenosis was noted in proximal lad. ptca with 2.5mm balloon sequentially into lad adn lcx was performed with restoration of timi 4 flow and moderate residual stenosis in lm. the cardiac cath was complicated by vt x 2 s/p cardioversion to sinus rhythm. at that time, decision was made for emergent transfer to for cabg. electrical conversion of atrial fibrillation to a normal sinus rhythm was achieved. . of note, the labs drawn at 7:43am showed k of 2.7. . upon arrival to , patient was hypothermic to 80sf, on dopamine 20, she was unresponsive on no sedation, and brain stem reflexes were minimal with very sluggish pupillary response. bleeding was noted around ett, so she was bronch'd. her labs were notable for ck of 8807, ck-mb and troponin > assay. lactate rose to 8.2. after endotracheal bleeding slowed down, decision was made to transfer patient to ccu for initiation of arctic sun cooling protocol, but prior to transfer patient woke up as her temp came up. since she continued to have some neurological deficits, she was started on arctic sun at 10:30pm. furthermore, prior to transfer to ccu, ett was noted to be leaky, and on repeat bronch, the ett was found to be above the cord. it was re-positioned by dr. prior to transfer. . unable to obtain ros. past medical history: 1. cardiac risk factors: hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: poba to lad on (see cath report below) -pacing/icd: none 3. other past medical history: - benign left breast lump - osa - arthritis social history: patient worked in custodial service at . -tobacco history: none -etoh: rare -illicit drugs: none family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission exam: general: intubated, minimally responsive patient. neck: supple with jvp of 14cm lying recumbent. cardiac: pmi located in 5th intercostal space, midclavicular line. rr. cardiac sounds obscured by iabp. no thrills, lifts. lungs: anterolateral rales. abdomen: soft, nt. mildly distended. no hsm or tenderness. unable to auscultate abdominial bruits with iabp. extremities: no c/c/e. femoral lines in place on r, iabp on l. skin: no stasis dermatitis, ulcers, scars, or xanthomas. neuro: plantar flexion bilaterally. handgrip bilaterally. able to sluggishly open/close eyes to command. pulses: right: carotid 2+ dp 1+ pt 1+ left: carotid 2+ dp 1+ pt 1+ pertinent results: admission labs: 12:10pm blood wbc-14.7* rbc-4.49 hgb-13.0 hct-40.7 mcv-91 mch-29.1 mchc-32.0 rdw-13.0 plt ct-228 12:10pm blood neuts-83* bands-2 lymphs-8* monos-5 eos-1 baso-0 atyps-0 metas-1* myelos-0 12:10pm blood pt-12.5 ptt-78.8* inr(pt)-1.1 12:10pm blood glucose-463* urean-20 creat-1.2* na-132* k-3.6 cl-101 hco3-18* angap-17 12:10pm blood alt-362* ast-1564* ld(ldh)-2630* alkphos-58 amylase-180* totbili-0.7 12:10pm blood lipase-50 12:52pm blood ck-mb-greater th ctropnt-greater th 12:10pm blood albumin-3.5 calcium-7.4* phos-5.3* mg-2.7* 12:17pm blood type-art po2-100 pco2-57* ph-7.10* caltco2-19* base xs--12 12:17pm blood lactate-3.5* . labs on morning of death: 04:59am blood wbc-13.0* rbc-2.86* hgb-8.4* hct-26.7* mcv-93 mch-29.4 mchc-31.5 rdw-23.5* plt ct-214 04:59am blood pt-14.2* ptt-71.2* inr(pt)-1.2* 04:59am blood alt-732* ast-239* alkphos-115* totbili-1.3 04:59am blood mg-2.3 04:59am blood glucose-213* urean-127* creat-4.8* na-132* k-3.6 cl-95* hco3-18* angap-23* . microbiology: sputum cultures , , , , , , grew pan-sensitive klebsiella pneumoniae. urine culture : pan-sensitive e. coli . echocardiogram (tte) : the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate to severe regional left ventricular systolic dysfunction with severe hypokinesis of the septum and anterior walls, distal half of the lateral wall and apex. the remaining segments contract well (lvef 30%). no left ventricular thrombus is seen, but images are suboptimal to fully exclude. right ventricular chamber size is normal with focal hypokinesis of the apical free wall. the aortic valve leaflets are mildly thickened (?#). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a fat pad. impression: mild symmetric left ventricular hypertrophy with extensive regional systolic dysfunction c/w multivessel cad (proximal lad and lcx distribution). right ventricular apical dysfunction. mild mitral regurgitation. mild aortic regurgitation. . cardiac catheterization : 1. two vessel and left main coronary artery disease. 2. successful placement of tandem heart mechanical support device. 3. successful removal of the iabp. . cardiac catheterization : 1. two vessel coronary artery disease. 2. successful pci of the lmcx, lad and lcx. 3. successful placement of iabp. 4. elevated left and right sided filling pressures. 5. normal cardiac index. . ct chest/abdomen/pelvis : 1. uniform enhancement of the pancreas without evidence for necrosis however there is development of small fluid collections anterior to the body and at the tail of the pancreas, which may represent early developing pancreatic pseudocyst. no definite evidence for abscess. 2. bilateral pleural effusions and adjacent atelectasis have improved. however, bilateral ground glass opacities and right middle lobe opacities have worsened. findings may be due to ards or worsening pneumonia. 3. dilation of the cbd may reflect papillary stenosis. 4. heterogeneous enhancement to the liver likely reflects contrast timing. no focal lesions are identified. brief hospital course: 76 year old female with history of hypertension who presented from outside hospital s/p anterolateral stemi and vf/vt arrest. after prolonged hospitalization, the decision was made to focus care on comfort, and the patient expired on . # s/p anterolateral stemi, s/p vf/vt, pea arrest. cardiac catheterization at outside hospital revealed distal lmca 95% stenosis; proximal lad 99% stenosis (hazy lesion), mid lad tubular 50% stenosis. lcx and rca angiography showed minor luminal irregularities. proximal lad stenosis s/p ptca with resultant timi grade 3 flow. patient was at very high risk for lmca intervention and was to have cabg once her neurological status could be better assessed. she was transferred to intubated with an intraaortic balloon pump in place. she was placed on the arctic sun induced hypothermia protocol for 12 hours, decreased from the normal cooling duration because the patient was noted to by hypothermic on her own on presentation to the outside hospital. the patient had a pea arrest the afternoon after rewarming, was resuscitated with chest compressions, epinephrine, and atropine. she was in cardiogenic shock and required the placement of a tandem heart support device, later with addition of ecmo to ensure perfusion. the patient survived the initial cardiac event and was subsequently weaned off ecmo and tamdem heart. multiple discussions were had with cardiac surgery, and it was mutually decided that the patient was unlikely to survive cabg. therefore, the decision was made to undergo high-risk pci. the patient underwent cardiac catheterization on and had a des x1 (to lmca via lcx and ptca of proximal lad). she has remained chest pain free with no further evidence of ischemia. on , the patient had another pea arrest, was again resuscitated with chest compressions and acls algorithm including atropine. the patient was found to be profoundly acidemic and was corrected with bicarb pushes and gtt. the etiology is unclear but it is suspected to be secondary to her ventilatory mechanics. at that time the patient was requiring multiple pressors. on , a family meeting was held, the decision was made to focus further care on comfort, withdrawing pressors and mechanical ventillation. the patient developed progressive bradycardia and hypotension and died with her family at her bedside. # cardiogenic shock: the patient presented with dopamine and iabp for hemodynamic support. she was in cardiogenic shock on arrival to with cool extremities and pulmonary edema. a tte showed an lvef 35% with antero-apical hypokinesis. the patient also had elevated pcwp and elevated pulmonary pressures, presumably from lv volume overload. diuresis was started at which time the patient became hypotensive. the patient underwent a pea arrest with 2 minutes of cpr and appeared to be in worsening cardiogenic shock. a tandemheart was placed in the catheterization laboratory and the iabp was removed. however, the night after placement the tandemheart, the la catheter moved and became misplaced in ra. this created a large shunt with significant hypoxemic respiratory distress. an in-line ecmo was attached to the tandemheart system. the patient had the devices for 2-days after which a trial off the assist device was tried. her co remained stable and the devices were removed in the or. the patient had an intermittent pressor requirement throughout her course. she was on phenylephrine for blood pressure support. midodrine was added. after her pea arrest the patient was on a total of 5 pressors which were able to be weaned to only norepinephrine after 24 hours. on , a family meeting was held, the patient was made comfort measures only, with pressor and ventillatory support withdrawn. she died with her family at the bedside. # septic shock ... as determined by low systemic vascular resistance - treated for klebsiella pneumonia, though this was not clearly the source of her septic shock ; meropenem/vanc/cipro for ventilator-associated coverage - slowly weaned pressors - made cmo and died on # hypoxemic respiratory failure patient had significant pulmonary edema during initial part of hospitalization in the setting of decreased cardiac function, requiring high peep. she diuresed well while on ecmo and tandem heart with oxygenated blood directly to renal arteries. she was treated empirically for ventilator-associated pneumonia with broad-spectrum antibiotics, though sputum cultures grew only pan-sensitive klebsiella, which was subsequently felt to be only a colonizer. after patient's neurologic status significantly improved, family agreed to bedside tracheostomy performed by thoracic surgery on , at which point peep was decreased to 8, fio2 of 40%. peep was slowly weaned down to 6 over the next week. after second pea arrest during fourth week of hospitalization, patient was again fluid overloaded in the setting of worsening renal failure, and fio2 requirement fluctuated. on , a family meeting was held, and the patient was made cmo. a morphine drip was started, vasopressors and mechanical ventillation were withdrawn, and the patient died with her family at her bedside. # pancreatitis during second week of hospitalization, patient was noted to have distended abdomen and was grimacing to palpation. lipase was elevated and trended upwards, peaking at 417 before trending back downwards. amiodarone was temporarily stopped because of rare side effect of pancreatitis. pain was treated with fentanyl boluses, and tube feeds were stopped until clinical resolution of pancreatitis. ct abdomen showed peri-pancreatic fluid collections, possible early pseudocyst, noted to be stable on subsequent imaging, not thought to be source of infection. gastroenterology was consulted and followed along with patient briefly. # anemia hematocrit drop transfused prbcs - may have been secondary to tandem heart and ecmo device no obvious sources of blood loss, though she was noted to have significant amount of blood suctioned from oropharynx and et tube, initially thought to be from posterior nasopharynx, packed by ent team for 1 day # paroxysmal atrial fibrillation patient's rhythm went into atrial fibrillation intermittently throughout hospitalization. she was loaded with intravenous amiodarone then started on po dosing and low dose beta blocker. amiodarone was discontinued for a couple of weeks because of small chance it was contributing to pancreatitis but was restarted after resolution of pancreatitis. # thrombocytopenia patient noted to have thrombocytopenia while on tandem heart and ecmo, but thrombocytopenia resolved after these devices were removed. # patient's code status was full code on admission, changed to dnr during her second week of hospitalization, reversed back to full code after her neurologic status improved and she was able to communicate effectively with family during third week of hospitalization, then once again reversed to dnr after pea arrest during fourth week of hospitalization. on , a family meeting was held, and the decision was made to change the patient's code status to comfort measures only. vasopressors and mechanical ventillation were withdrawn, and the patient died with her family at her bedside. medications on admission: hctz 25mg qd advil prn discharge medications: n/a discharge disposition: expired discharge diagnosis: primary: 1. st-elevation mi 2. cardiogenic shock 3. vt/vf/pea arrest 4. septic shock 5. hypoxemic respiratory failure 6. pancreatitis 7. atrial fibrillation discharge condition: expired discharge instructions: n/a followup instructions: n/a md, Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Coronary arteriography using two catheters Parenteral infusion of concentrated nutritional substances Left heart cardiac catheterization Insertion of endotracheal tube Fiber-optic bronchoscopy Fiber-optic bronchoscopy Laryngoscopy and other tracheoscopy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Removal of external heart assist system(s) or device(s) Insertion of implantable heart assist system Insertion of drug-eluting coronary artery stent(s) Hypothermia (systemic) incidental to open heart surgery Extracorporeal membrane oxygenation [ECMO] Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on two vessels Diagnoses: Acidosis Anemia, unspecified Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Acute myocardial infarction of anterolateral wall, initial episode of care 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 Cardiac arrest Anoxic brain damage Cardiogenic shock Septic shock Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Ventricular fibrillation Mechanical complication due to other implant and internal device, not elsewhere classified Other septicemia due to gram-negative organisms Acute systolic heart failure Accidents occurring in residential institution Acute pancreatitis Pneumonia due to Klebsiella pneumoniae Dependence on respirator, status Central nervous system complication Cardiac rhythm regulators causing adverse effects in therapeutic use |
allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath, fever, increased cough major surgical or invasive procedure: placement of central venous line r ij history of present illness: mr. is a very nice 48 yo -speaking gentleman with nsclc, chronic hbv, h/o positive ppd coming with productive cough and fever. he received his routine chemotherapy on of his cycle 6, day 1 of taxotere. he was in his prior state of health until around friday ~2-3 days ago when he noticed subjective fever, prodcutive cough with yellowish sputum and worsening shortness of breath. his wife reports noticing that he also was cold/chills starting a few days prior to the fever. he took his temperature on the day of admission and found it to be 101.4 f. he acknowledges chest pain only with cough, some difficulty urinating and occassional low leg pain which has been assoicated w/getting his chemo therapy. he denies any sick contacts, palpitations, dizziness, abdominal pain, sore throat, otalgia, joint pains or skin rashes. of note, he is chemo/radiation therapy for lung cancer and is schueduled for his next session next week. . in the ed his initial vs were: t 98.1 f, hr 128, bp 112/73 mmhg, rr 20 x', spo2 98%ra. on exam he was tachypneic, mentating well with difficult exam in the lungs with poor air movement. he had labs that showed wbc 6.5, hct 40.1, plts 281, na 136, k 4.2, cl 99, co2 24, bun 18, creat 0.9, gluc 133, lactate:2.5. blood cultures were drawn. cxr showed new rll consolidates compatible with pna and stable masses in rul and rml. throught his stay int he ed he spiked up to 103 and received tylenol and vanco and cefepime as well as a dose of hydrocort. he underwent cvl placement (rij). he initially received 4 l ns without much improvement in blood pressure and therefore was admitted to the . his vs prior to transfer are: 93 30 87/56 100.3. access: 20 g. rij . on the floor, vs were 95.6 hr 84 110/81 rr 25 97% ra. pt was not using accessory muslces, generally appeared ill but not toxic. pt's bp had returned to baseline bp after ivf and levophed was turned off. pt denied pain currently. noted he only had pain w/cough but was not currently coughing. . past medical history: chest x-ray on 4cm mass right infrahilar region ct scan right upper lobe, 3.5 x 3.3 cm, multiple mediastinal pathologically enlarged lymph nodes were noted in the right upper paratracheal area (12mm), the right lower paratracheal area (11 mm), and the subcarinal area (12 mm). thoracentesis on negative for malignanc cells single atypical cell, cannot further characterize. abundant lymphocytes and scattered mesothelial cells. repeat thoracentesis was performed, and on right vats procedure with pleural biopsy and talc pleurodesis as well as placement of a pleur-x catheter. status post 3 cycles of carboplatin,paclitaxel, bevacizumab, and anamorelin hcl/placebo as part of dfhcc 07-369. started second line erlotinib on . dose increased to 50 mg/day on . continues on therapy and will now add alimta. --continued progression will add to the alimta and tarceva. --continued progression--will begin taxotere. recent bx of lung consistent with nsclca. past medical history: 1. advanced nonsmall cell lung cancer as above. 2. history of positive ppd. per report treated with short course of inh several years ago. 3. chronic hepatitis b. on tenofovir. it reactivated with chemotherapy. 4. hyperlipidemia 5. helicobacter pylori infection social history: 30-pack-year history of smoking. quit one year ago. no recent alcohol use. denies illicits. lives with wife. speaking family history: mother died this past week. father died at age 70 with a history of hypertension. no reported family history of cancers or blood disorders. physical exam: vs: 95.6 hr 84 110/81 rr 25 97% ra general - ill appearing man but nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear, no exudate neck - supple, no thyromegaly, no jvd, no carotid bruits, no lad lungs - resp unlabored, no accessory muscle use, decreased breath sounds in upper right consistent w/known masses, also crackles at base of right, left clear heart - rrr, no mrg appreciated at this time, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding. extremities - wwp, no edema, 2+ peripheral pulses (radials, dps), no tenderness to palplation of legs although pt reports legs sore after chemo skin - no rashes or lesions neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, gait not tested. discharge exam: pertinent results: admission labs: 05:50am blood wbc-6.5 rbc-5.00 hgb-13.4* hct-40.1 mcv-80* mch-26.8* mchc-33.4 rdw-17.7* plt ct-281 03:41am blood wbc-5.7 rbc-4.39* hgb-11.8* hct-34.5* mcv-79* mch-26.9* mchc-34.2 rdw-17.7* plt ct-264 05:50am blood neuts-39* bands-2 lymphs-32 monos-26* eos-0 baso-0 atyps-1* metas-0 myelos-0 03:41am blood neuts-53 bands-0 lymphs-31 monos-15* eos-0 baso-0 atyps-1* metas-0 myelos-0 05:50am blood plt smr-normal plt ct-281 03:41am blood pt-14.3* ptt-29.6 inr(pt)-1.2* 03:41am blood plt smr-normal plt ct-264 05:50am blood gran ct-2535 05:50am blood glucose-133* urean-18 creat-0.9 na-136 k-4.2 cl-99 hco3-24 angap-17 03:41am blood glucose-124* urean-15 creat-0.9 na-140 k-3.4 cl-106 hco3-27 angap-10 05:50am blood alt-44* ast-60* ld(ldh)-484* alkphos-104 totbili-0.7 03:41am blood alt-31 ast-43* ld(ldh)-356* alkphos-84 totbili-0.4 05:50am blood albumin-3.2* 03:41am blood calcium-7.7* phos-2.0*# mg-1.9 05:50am blood cortsol-20.8* 01:04pm blood lactate-1.4 micro: pending imaging: chest (pa & lat) study date of 5:58 am frontal and lateral views of the chest: again seen is the large right upper lobe and right middle lobe masses consistent with known cancer. multiple other small nodules are also seen throughout the right lung including the right lower lobe, unchanged. an area of increased subtle density at the right lower lobe base appears slightly more prominent when compared to the recent scout radiographs of the chest ct of , even given differences in technique. there is a small right-sided pleural effusion, stable. the left lung remains clear. impression: 1. large right upper lobe and right middle lobe masses with small pulmonary nodules noted in the left lower lobe. stable small right-sided pleural effusion. 2. although comparison to the recent chest ct is difficult given differences in technique, an area of increased subtle opacity at the right lung base could potentially represent an early pneumonia. ct chest w/contrast study date of 3:47 pm ct chest: mdct imaging was performed from the thoracic inlet to the upper abdomen after the uneventful intravenous administration of contrast. sagittal and coronal reformats were prepared. comparison: chest radiograph , ct chest . findings: in the right upper lobe is a 7.6 x 7.2 x 7.6 cm mass, which has increased in size since the previous examination. there is increased ground-glass opacity in the periphery of this mass (2:17). this mass extends medially, invading into the mediastinum and causing obliteration of the right upper lobe apical bronchi, unchanged. the azygos vein is obliterated as well as the pulmonary artery supplying the right upper lobe, stable. within the right middle lobe is a 5.8 x 3.6 cm mass, increased in size since the prior examination. multiple subcentimeter size nodules within the right lower lobe are grossly stable to somewhat increased in size. a small pleural effusion on the right is larger. there remains areas of linear enhancement along the pleura concerning for pleural metastatic invasion. a 1.9 x 1.6 cm node along the right anterior mediastinum (2:20) has increased in size. subcentimeter nodules in the left lung (3:18, 29) appear stable. the thoracic aorta appears normal. the main pulmonary artery is enlarged measuring 3.6 cm, somewhat increased. however, apart from the obliteration of the right upper lobe pulmonary artery due to the mass there is no evidence for pulmonary embolus. no pericardial fluid is present. there is a small left effusion. there is fluid within the esophagus which is only somewhat distended. there is extensive soft tissue within the mediastinum (2:19) in an area of invasion. a 4-mm prevascular lymph node (2:19) is present. there is no significant axillary lymphadenopathy. limited views of the upper abdomen appear within normal limits. bone windows: again noted is a sclerotic focus within a right anterior seventh rib, unchanged since . there is slight thickening of the posterior cortex of the right clavicle, (4:4), stable since . impression: 1. increased size of right upper, and right middle lobe pulmonary masses. the right upper lobe mass invades into the mediastinum causing obliteration of the right upper lobe bronchi, and right apical pulmonary artery. 2. increased size of a right pleural effusion with pleural enhancement concerning for pleural invasion. 3. some areas of increased ground-glass opacity, particularly in the periphery of the large pulmonary masses. while this most likely is due to tumor extension, pneumonia is not entirely excluded. 4. small left effusion with stable subcentimeter left-sided pulmonary nodules. 5. enlarged main pulmonary artery, but no evidence for pulmonary embolism. brief hospital course: pt is a 48 yo -speaking gentleman with nsclc, chronic hbv, h/o positive ppd p/w pneumonia pt was admitted to the because of hypotension requiring pressors. cxr with e/o pna with rul and rll infiltrates in addition to known masses, also with fever and cough with sputum production. started cefepime, vancomycin and levofoxacin and blood cx were drawn prior to starting abx. a ct chest was done that showed worsening tumor, but no evidence of pe or clear infiltrate. symptoms were managed with tylenol and guaifenisin. hypotensive in the ed, this improved with ivf, was also briefly on norepinephrine but this was quickly weaned off. home lasix was held in setting of hypotension. dr. , his outaptient oncologist, was contact and recommended holding terceva. home tenofovir was continued. he was noted to have urinary retention and abd pain, so foley was placed and drained 700+ ml of retained urine. foley was discontinued prior to transfer to floor due to patient request.on the floor pt remained afebrile and hemodynamically stable not requiring supplemental o2.iv antibiotics were discontinued and patient remained on levoflox with plan to complete a 10 day course. on discharge pt instructed to restart tarceva as there is recent evidence that discontinuation of tarceva at time of progression can cause a flare of the cancer disease. pt is scheduled for f/u with dr . blood and sputum cxs were negative. medications on admission: viread 300 mg po daily tarceva 25 mg tab po daily dexamethasone 4 mg po bid after chemo tylenol 325 mg iophen c-nr 10 mg-100 mg/5 ml po q4-6 hrs prn clindamycin 1% gel lasix 20mg every other day (stopped taking in setting of fever, acute illness) discharge medications: 1. nebulizer nebulizer machine 2. tarceva 25 mg tablet sig: one (1) tablet po once a day. 3. levofloxacin 750 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. disp:*30 day* refills:*0* 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 8. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po daily (daily). 9. codeine-guaifenesin 10-100 mg/5 ml syrup sig: ten (10) ml po bid (2 times a day) as needed for cough. disp:*30 day* refills:*0* discharge disposition: home discharge diagnosis: pneumonia non small cell lung cancer cough discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr you were admitted with fever and cough and diagnosed with pneumonia. you were first admitted to the intensive care unit because of low blood pressure and when this stabilized you were transferred to the oncology floor. you were treated with antibiotics and will need to complete a course of oral antibiotics at home. during your hospital stay on the oncology floor you remained afebrile, oxygenating well adn not requiring supplemental oxygen. changes in medications; levofloxacin albuterol neb inh. as needed guaifenesin/codeine as needed hold lasix followup instructions: department: hematology/oncology when: tuesday at 10:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 11:00 am with: , rn building: sc clinical ctr campus: east best parking: garage department: liver center when: friday at 10:40 am with: building: lm campus: west best parking: garage Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Retention of urine, unspecified Malignant neoplasm of other parts of bronchus or lung Fever, unspecified Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Personal history of antineoplastic chemotherapy Other specified hypotension |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: increased dyspnea major surgical or invasive procedure: four vessel coronary artery bypass grafting utilizing the left internal mammary artery to left anterior descending with saphenous vein grafts to obtuse marginal, distal circumflex, and pda. history of present illness: this is a 62 year old male, who over the past month or so, has experienced greatly increased dyspnea on minimal physical exertion. he denies chest discomfort of any nature. he has a known anterior and apical perfusion defect on a recent myocardial perfusion imaging evaluation and was referred for cardiac catheterization which revealed severe three vessel coronary artery disease. given the findings, he was referred for surgical revascularization. past medical history: - esrd s/p 2 pediatric transplants ' (placed in rlq, one medial, one lateral) - h/o uric acid nephropathy and secondary focal segmental glomerular sclerosis - chronic right hydronephrosis between medial transplant kidney and bladder - chronic allograft nephropathy - medial kidney biopsied on - nephrolithiasis - tertiary hyperparathyroidism - sepsis - coronary artery disease - hyperlipidemia esrd, on lipitor - hypertension - h/o sciatica social history: pt is an immigrant from with his wife . drinks alcohol occasionally. he denies tobacco use. he is married w/two sons. one son is a family medicine physician at family history: both parents are deceased and had hx of cad. patient has a brother who is healthy. . physical exam: general: lying flat - no acute distress skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur none abdomen: soft obese non-tender bowel sounds + surgical scars right flank, midline and llq old pd cath site extremities: warm , well-perfused edema + 2 right pedal and + 1 left pedal varicosities: none neuro: grossly intact pulses: femoral right: +1 left: +1 dp right: +2 left: +2 pt : +1 left: +1 radial right: +1 left: +1 carotid bruit right: no bruit left: no bruit pertinent results: white blood cells 8.6 4.0 - 11.0 k/ul performed at west stat lab red blood cells 2.70* 4.6 - 6.2 m/ul performed at west stat lab hemoglobin 8.7* 14.0 - 18.0 g/dl performed at west stat lab hematocrit 24.4* 40 - 52 % performed at west stat lab mcv 90 82 - 98 fl performed at west stat lab mch 32.1* 27 - 32 pg performed at west stat lab mchc 35.5* 31 - 35 % performed at west stat lab rdw 15.8* 10.5 - 15.5 % performed at west stat lab basic coagulation (pt, ptt, plt, inr) platelet count 148* 150 - 440 k/ul performed at west stat lab brief hospital course: mr. was admitted and underwent coronary artery bypass grafting by dr. . for surgical details, please see operative note. stress dose steroids were given intraoperatively. following surgery, he was brought to the cvicu for invasive monitoring. within 24 hours, he awoke neurologically intact and was extubated without incident. experienced atrial fibrillation and was started on amiodaronewhich was discontinued due to an interaction between cyclosporin and amiodarone. his betablocker was increased and he converted back to a normal sinus rhythm within 24 hours. he was transferredto the stepdown unit on postoperative day two. with aggressive pulmonary toilet, nebs and incentive spirometer he titrated off oxygen with oxygen saturations of 95% ra. he was followed by renal transplant who recommended monitoring cyclosporine trough and chem 7 as outpatient. his renal function remained stable. he was seen by physical therapy for stength and conditioning. he continued to make steady progress and was cleared for discharge to home on pod# 5 by dr. . on day of discharge the upper pole of his sternal incision was noted to be erythematous without drainage. per dr. recommendation - a 7 day course of keflex was started and mr. and his wife were given explicit instructions by me and dr. to call regarding any redness, fever, chills or drainage. medications on admission: allopurinol - 100 mg tablet - 2 tablet(s) by mouth once a day cyclosporine modified - 25 mg capsule - 2 capsule(s) by mouth twice a day brand name medically necessary, no substitution - no substitution darbepoetin alfa in polysorbat - 60 mcg/ml solution - 60mcg sc q1-2weeks diltiazem hcl - 240 mg capsule,degradable cnt release - 1 capsule(s) by mouth twice a day furosemide - 80 mg tablet - 1 tablet(s) by mouth twice a day hydralazine - 50 mg tablet - 1 tablet(s) by mouth three a day isosorbide mononitrate - 30 mg tablet sustained release 24 hr - 1 tablet(s) by mouth once a day lisinopril - 10 mg tablet - 1 (one) tablet(s) by mouth once a day metolazone - 2.5 mg tablet - 1 tablet(s) by mouth twice a day metoprolol succinate - 200 mg tablet sustained release 24 hr - 1 (one) tablet(s) by mouth once a day mycophenolate mofetil - 500 mg tablet - 1 tablet(s) by mouth twice a day brand name medically necessary no substitution prednisone - 1 mg tablet - 4 tablet(s) by mouth once a day simvastatin - (prescribed by other provider) - 40 mg tablet - 1 tablet(s) by mouth qpm medications - otc aspirin - (otc) - 81 mg tablet - 1 (one) tablet(s) by mouth once a day multivitamin - (update) - tablet - 1 tablet(s) by mouth once a day discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. cyclosporine modified 25 mg capsule sig: two (2) capsule po q12h (every 12 hours). 3. cephalexin 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 6 days. disp:*21 tablet(s)* refills:*0* 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. prednisone 1 mg tablet sig: four (4) tablet po every other day (every other day). 6. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po bid (2 times a day). tablet(s) 7. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. allopurinol 100 mg tablet sig: two (2) tablet po daily (daily). 9. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 10. lasix 80 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 11. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 12. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: coronary artery disease, s/p cabg end stage renal disease hypertension dyslipidemia discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with incisions: sternal - healing well, mild erythema at upper pole. no drainage leg left - healing well, no erythema or drainage. 2+ lower extremity 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: you are scheduled for the following appointments surgeon: dr. on @ 230 pm cardiologist: dr. on @ 940 am labs: cyclosporin, chemistry - in lab in for transplant service on thrusday 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: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Central venous catheter placement with guidance Diagnoses: Acidosis Anemia in chronic kidney disease Coronary atherosclerosis of native coronary artery Hyposmolality and/or hyponatremia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Chronic kidney disease, unspecified Other and unspecified angina pectoris Kidney replaced by transplant Other hyperparathyroidism |
allergies: penicillins / sulfa (sulfonamide antibiotics) / codeine / erythromycin base / clindamycin / carbamazepine / furadantin / tetracycline / actonel / fosamax attending: chief complaint: chest pain major surgical or invasive procedure: s/p off-pump cabg x 2 (left interal mammary artery to left anterior descending, lesser saphenous vein graft to obtuse marginal) history of present illness: mrs. is 77 yo female with history of coronary artery disease s/p bare metal stent to lcx , des to lad , hypertension, hyperlipidemia, transient ischemic attack/?cerebral vascular accident, pulmonary embolism s/p ivc filter (>30 years ago) who was transfered from with chest pain. patient reports her cp woke her up from sleep last night and described it as substernal/epigastric, pressure-like, radiating to bilateral chest and accompanied by mild shortness of breath. the pain was worse with ambulation, accompanied by palpitaions on ambulation and similar to her pain in the past when she had the stents placed. she initially thought it was gas pains and took milanta and ranitidine with mild relief. she then took 2 sln with little relief and went back to sleep. woke up this am with the cp and decided to go to the hospital. she was taken to where an ekg was reportedly normal and 1st set of ce's was negative. she was given sln without improvement of her cp then started on heparin and nitro gtt's with some relief. she was transferred to for surgical evaluation. past medical history: dyslipidemia hypertension coronary artery disease s/p bms to lcx , des to lad hypothyroidism gerd tia/?cva pulmonary embolism 30 years ago s/p ivc filter chronic bronchitis (pt reports no history of smoking, no known lung disease) chronic back pain s/p l5-s1 laminectomy epistaxis hx of fungal esophagitis rx w/ diflucan osteoarthritis osteoporosis headaches hearing loss s/p rectocele repair s/p hysterectomy s/p tonsillectomy s/p esophageal dilatation s/p l knee arthroscopy s/p r abdominal hernia repair social history: the patient is originally from bavaria in . patient lives alone in , independently manages finances and grocery shopping. she is widowed and has six children, all living in proximity. retired seamstress. no tobacco use current or past. no alcohol use. no ivdu. family history: significant for hypercoagulability. there is no family history of premature coronary artery disease or sudden death. mother died of a pulmonary embolism, father died of a pneumothorax. physical exam: pulse:58 resp:16 o2 sat:100/ra b/p right:130/49 left:110/52 height:5'4" weight:154 lbs general:awake alert oriented skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur 2/6 systolic ejection murmur no radiation noted. abdomen: soft non-distended non-tender + bowel sounds extremities: warm , well-perfused 2+ pitting edema; bilateral varicosities. 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: very soft bruit left: no pertinent results: cardiac cath: lmca: hazy distal 40-50% lad: ostial 75%; heavily calcified mid lad proximal to stent to 30% in-stent restenosis mid lad with diffuse 30-40% beyond the stent: tortuous very high diagonal with mild proximal plaquing; slightly slow flow consistent with microvascular dysfunction in the lad proper and d1 lcx: patent proximal cx and patent stent in mid cx; small om1, modest om2, large tortuous om2, small om4; mid cx 40% after om4; modest tortuous lpl; slightly slow flow consistent with microvascular dysfunction rca: mild diffuse plaquing throughout to 30%; tortuous modest am1 and am2; tortuous rpda, rpl1 and rpl2 with slightly slow flow consistent with microvascular dysfunction vein mapping: grayscale and color doppler son with measurements was performed of the right and left lower extremity for venous mapping. ultrasound demonstrates a right lesser saphenous vein within the calf region measuring 0.19-0.25 cm. the left saphenous vein measures 0.19-0.30 cm and also visualized in the calf region. the greater saphenous veins were not identified bilaterally. carotid u/s: findings are consistent with less than 40% stenosis bilaterally. pft's: spirometry 8:09 am pre drug post drug actual pred %pred actual %pred %chg fvc 3.05 2.67 114 fev1 2.38 1.84 129 mmf 2.46 2.08 118 fev1/fvc 78 69 113 lung volumes 8:09 am pre drug post drug actual pred %pred actual %pred tlc 5.48 4.66 118 frc 3.15 2.78 113 rv 2.61 2.00 131 vc 2.90 2.67 109 ic 2.33 1.89 124 erv 0.54 0.78 69 rv/tlc 48 43 111 he mix time 2.38 pre-op 04:30pm blood wbc-3.6* rbc-3.48* hgb-11.1* hct-31.5* mcv-91 mch-31.9 mchc-35.3* rdw-13.1 plt ct-223 06:13pm blood wbc-6.0 rbc-2.13* hgb-6.9* hct-19.9* mcv-93 mch-32.2* mchc-34.5 rdw-13.0 plt ct-132* 05:43am blood wbc-4.9 rbc-2.94* hgb-9.3* hct-25.5* mcv-87 mch-31.7 mchc-36.6* rdw-14.2 plt ct-151 04:30pm blood pt-13.0 ptt-74.9* inr(pt)-1.1 04:30pm blood pt-17.0* ptt-34.4 inr(pt)-1.5* 06:13pm blood pt-16.7* ptt-50.3* inr(pt)-1.5* 10:21pm blood pt-14.9* ptt-34.3 inr(pt)-1.3* 04:30pm blood glucose-89 urean-16 creat-0.9 na-141 k-3.8 cl-107 hco3-25 angap-13 05:43am blood glucose-100 urean-15 creat-0.8 na-136 k-4.4 cl-102 hco3-29 angap-9 02:50pm blood alt-16 ast-23 ck(cpk)-39 alkphos-33* totbili-0.4 dirbili-0.1 indbili-0.3 03:57am blood calcium-8.1* phos-2.2* mg-2.0 02:50pm blood %hba1c-5.4 eag-108 06:20am blood triglyc-93 hdl-58 chol/hd-2.6 ldlcalc-74 discharge 05:43am blood wbc-4.9 rbc-2.94* hgb-9.3* hct-25.5* mcv-87 mch-31.7 mchc-36.6* rdw-14.2 plt ct-151 05:43am blood glucose-100 urean-15 creat-0.8 na-136 k-4.4 cl-102 hco3-29 angap-9 echocardiography report echocardiographic measurements results measurements normal range left atrium - long axis dimension: 3.8 cm <= 4.0 cm left atrium - four chamber length: *6.0 cm <= 5.2 cm left atrium - peak pulm vein s: 0.8 m/s left atrium - peak pulm vein d: 0.5 m/s left atrium - peak pulm vein a: 0.3 m/s < 0.4 m/s right atrium - four chamber length: *5.6 cm <= 5.0 cm left ventricle - septal wall thickness: 0.9 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.8 cm <= 5.6 cm left ventricle - systolic dimension: 2.7 cm left ventricle - fractional shortening: 0.44 >= 0.29 left ventricle - ejection fraction: 60% to 65% >= 55% left ventricle - stroke volume: 79 ml/beat left ventricle - cardiac output: 4.76 l/min left ventricle - cardiac index: 2.71 >= 2.0 l/min/m2 left ventricle - lateral peak e': *0.08 m/s > 0.08 m/s left ventricle - septal peak e': *0.08 m/s > 0.08 m/s left ventricle - ratio e/e': 11 < 15 aorta - sinus level: 2.9 cm <= 3.6 cm aorta - ascending: 2.9 cm <= 3.4 cm aorta - arch: 2.8 cm <= 3.0 cm aortic valve - peak velocity: *2.2 m/sec <= 2.0 m/sec aortic valve - peak gradient: *20 mm hg < 20 mm hg aortic valve - mean gradient: 11 mm hg aortic valve - lvot vti: 28 aortic valve - lvot diam: 1.9 cm aortic valve - valve area: *1.5 cm2 >= 3.0 cm2 aortic valve - pressure half time: 580 ms mitral valve - e wave: 0.9 m/sec mitral valve - a wave: 0.7 m/sec mitral valve - e/a ratio: 1.29 mitral valve - e wave deceleration time: 198 ms 140-250 ms tr gradient (+ ra = pasp): *38 mm hg <= 25 mm hg findings left atrium: dilated la. right atrium/interatrial septum: mildly dilated ra. left ventricle: normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). no resting lvot gradient. no vsd. right ventricle: normal rv chamber size and free wall motion. aorta: normal diameter of aorta at the sinus, ascending and arch levels. focal calcifications in aortic root. aortic valve: mildly thickened aortic valve leaflets (3). no as. filamentous strands on the aortic leaflets c/with lambl's excresences (normal variant). mitral valve: mildly thickened mitral valve leaflets. physiologic mr (within normal limits). normal lv inflow pattern for age. tricuspid valve: mildly thickened tricuspid valve leaflets. mild tr. pulmonic valve/pulmonary artery: pulmonic valve not visualized. no ps. physiologic pr. pericardium: no pericardial effusion. conclusions the left atrium is dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). the tricuspid valve leaflets are mildly thickened. there is no pericardial effusion. impression: normal regional and global biventricular systolic function. no pathologic valvular abnormalities. brief hospital course: mrs. was transferred from outside hospital with chest pain at rest. she was treated with medical management and had no ekg changes and negative cardiac enzymes. she underwent cardiac cath on which showed left main and ostial lad disease. she underwent surgical work-up which included, pulmonary function test, carotid u/s and vein mapping. patient had acute onset 10/10 chest pain on and settled following iv morphine and was started on eptifibatide infusion and nitro infusion. patient went to operating room on for urgent off-pump coronary artery bypass grafting. please see operative report for surgical details. in summary she had: off pump coronary bypass x2 with left internal mamary to left anterior descending artery, and saphenous vein graft to obtuse marginal artery. she tolerated the operation and following surgery she was transferred to the cvicu for invasive monitoring in stable condition. within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. on post-op day one she was started on beta-blockers and diuresed towards pre-op weight. later on this day she was transferred to the step-down floor for further care. chest tubes and epicardial pacing wires were removed per protocol. she was seen and worked with physical therapy for strength and mobility. on post-op day three she had episodes of atrial fibrillation and received amiodarone and beta-blockers were titrated up. she was eventually started on coumadin with a goal inr of .5, plavix was discontinued once coumadin was started. on pod#5 she was ambulating with assistance, tolerating a full oral diet and her incisions were healing well. she was discharged to rehabilitation at health care in on pod# 5. all follow up appointments were advised. medications on admission: --metoprolol 50 mg orally twice daily --aspirin 325 mg daily --lisinopril 10 mg daily --simvastatin 80 mg daily --sublingual nitroglycerin 0.4 mg prn chest pain/pressure --ranitidine 300mg daily --plavix 75 mg daily --spiriva inhaler once daily prn --levothyroxine 50 mcg daily --colace 100 mg daily --vitamin d 1000 units daily --mvi --ascorbic acid 10mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 3. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 4. ascorbic acid 250 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 6. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 7. ranitidine hcl 150 mg tablet sig: two (2) tablet po daily (daily). 8. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 11. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 12. furosemide 40 mg tablet sig: one (1) tablet po once a day for 2 weeks. 13. potassium chloride 10 meq tablet extended release sig: one (1) tablet extended release po once a day for 2 weeks. 14. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): take two 200mg tablets twice daily x 5 days. then one 200mg tablet twice daily. finally, one 200mg table once daily until stopped by cardiologist. 15. warfarin 1 mg tablet sig: one (1) tablet po once a day: please adjust dose for goal inr. indication: atrial fibrillation goal inr 2-2.5 first draw , then qmon, wed, fri. 16. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 17. warfarin 5 mg tablet sig: one (1) tablet po once (once) for 1 doses. discharge disposition: extended care facility: health care center - discharge diagnosis: coronary artery disease s/p off-pump coronary artery bypass graft x 2 past medical history: dyslipidemia hypertension s/p bms to lcx , des to lad hypothyroidism gerd tia/?cva pulmonary embolism 30 years ago s/p ivc filter chronic bronchitis (pt reports no history of smoking, no known lung disease) chronic back pain s/p l5-s1 laminectomy epistaxis hx of fungal esophagitis rx w/ diflucan osteoarthritis osteoporosis headaches hearing loss s/p rectocele repair s/p hysterectomy s/p tonsillectomy s/p esophageal dilatation s/p l knee arthroscopy s/p r abdominal hernia repair discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage lesser saph site on left lower extremity clean/dry/intact with staples in place 1+ edema 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: surgeon: dr. # on at 1:45pm cardiologist: dr on at 1:00pm please call to schedule the following: 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** labs: pt/inr for coumadin ?????? indication: atrial fibrillation goal inr 2-2.5 first draw , then qmon, wed, fri md Procedure: Single internal mammary-coronary artery bypass Other and unspecified coronary arteriography (Aorto)coronary bypass of one coronary artery Other operations on nervous system Intravascular pressure measurement of coronary arteries Diagnoses: Other chronic pain Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified pleural effusion Unspecified essential hypertension Acute posthemorrhagic anemia Unspecified acquired hypothyroidism Atrial fibrillation Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Osteoporosis, unspecified Personal history of venous thrombosis and embolism Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Backache, unspecified |
allergies: codeine / penicillins attending: chief complaint: acetominophen toxicity major surgical or invasive procedure: picc line placement history of present illness: this is a 40 yo female with long h/o depression initially admitted to micu from osh for eval for liver transplant for likely acute tylenol toxicity possibly suicide attempt and now transferred to the liver service with improving liver enzymes and mental status. patient was admitted to hospital on for worsening depressive symptoms, auditory hallucinations, and altered mental status. she was found to have an initial transaminitis of ast 1700 and alt 1614 with t.bili 3.3 (direct 2.7). during her 24 hrs at , she progressively worsened such that prior to transfer, her ast was 5495, and alt 5039 with t.bili of 3.4. her inr was 2.4 prior to transfer. her creatinine was also elevated initailly at 2.1 but improved to 1.5 prior to transfer. at the osh, her ct abdomen showed moderate fatty infiltration of the liver, and abdominal us showed s/p cholecystectomy, but no biliary dilation. there was no comment on portal vein thrombosis. a ct head was also negative. prior to transfer to , the patient had been intubated due to worsening mental status. there is no other documentation regarding that event. her vitals were stable prior to transfer. she was transferred on a propofol gtt. she had also received a nac infusion while at for concern of acute acetaminophen induced hepatic injury, though her acetaminophen level was low at the osh. she may have ingested large quantities of tylenol ? days prior to presentation - per notes, her mother states that she had emailed her ex-husband stating she planned to od on tylenol and left a suicide note. patient arrived at on and was extubated within 24 hours of arrival to micu. patient found by transplant team not to need liver transplant as labs have improved. patient was continued on nac (inr on transfer is 1.8) and has been receiving increasing lactulose (without bowel movements) for encephalopathy. she also has acute renal failure, likely atn from tylenol, and has been followed by the renal team. patient with ngt - she has had sips but otherwise not eating. mental status is currently somnolent. on arrival to the floor, she is sleeping and appears comfortable. she is not able to answer any questions. all history was obtained from the medical records from the osh and the patient's husband and daughter. past medical history: 1) depression 2) s/p appendectomy 3) s/p cholecytstectomy 4) s/p d&c 5) acute bronchitis -> pna in 6) chronic r-sided chest pain with ? findings on imaging (per husband - images were done as part of pna work-up) social history: patient lives with her husband of ~2 years. she is unemployed. she smokes ppd and denied alcohol or drug use. has two sisters and , brother . (father , mother () are also involved in her life. daughter from her previous marriage lives in . family history: - father with etoh cirrhosis - both living physical exam: vitals - t: 97.4 bp: 127/73 hr: 101 rr: 22 02 sat: 99% on ra general: sleeping in bed. opens eyes very briefly in response to name, non-verbal at this time. follows some commands, although very weak/somnolent. nad. heent: ngt in place. conjunctival hemorrhages (obtained during transfer from osh) obscure sclera bilaterally; skin does not appear overtly jaundiced. cardiac: tachycardic but regular, no murmur/rub/gallop lung: cta bilaterally although exam compromised by somnolence (cannot breathe deeply, difficult to position) abdomen: soft, ? ttp worst over ruq and epigastric regions, + nabs ext: 2+ dp pulses bilaterally. trace non-pitting pedal edema. neuro: cannot assess sensation, strength at this time. derm: some ecchymoses around eyelids (per husband, related to taping her eyelids shut during transport from osh) pertinent results: labs on admission: 10:16pm fibrinoge-202 10:16pm pt-37.3* ptt-35.6* inr(pt)-3.9* 10:16pm plt count-98* 10:16pm neuts-93.5* bands-0 lymphs-4.6* monos-1.1* eos-0.3 basos-0.5 10:16pm wbc-12.5* rbc-4.28 hgb-12.9 hct-37.9 mcv-89 mch-30.2 mchc-34.1 rdw-13.9 10:16pm hcv ab-negative 10:16pm acetmnphn-neg 10:16pm hbsag-negative hbs ab-negative hav ab-negative igm hbc-negative igm hav-negative 10:16pm osmolal-292 10:16pm albumin-3.4 calcium-7.1* phosphate-2.8 magnesium-2.7* 10:16pm alt(sgpt)-7683* ast(sgot)-8243* ld(ldh)-8510* alk phos-122* tot bili-4.0* 10:16pm estgfr-using this 10:16pm glucose-155* urea n-30* creat-1.6* sodium-131* potassium-4.2 chloride-100 total co2-13* anion gap-22* 10:21pm d-dimer-greater th 11:14pm lactate-4.9* 11:14pm type-art po2-360* pco2-26* ph-7.38 total co2-16* base xs--7 11:17pm fdp-80-160* labs on discharge: : wbc-9.4 hb-10.3 hct-30.9 plt-228 : na-137 k-4.0 cl-103 hco3-25 bun-17 cr-0.7 glu-100 : ca-9.1 mg-1.8 phos-3.5 : alt-113 ast-80 tb-2.6 ap-139 alb-3.6 ldh-177 : ptt-30.1 inr-1.0 ================ imaging: ======== echocardiogram : the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: mild pulmonary artery systolic hypertension. normal biventricular cavity sizes with preserved global and regional biventricular systolic function. ======== portable cxr : impression: ap chest reviewed in the absence of prior chest radiographs: very low lung volumes exaggerate heart size which is probably normal, and produce or reflect atelectatic crowding at the lung bases. the upper lungs are grossly clear. there is no pleural effusion or evidence of central adenopathy. tip of the endotracheal tube is at the level of the lower margin of the clavicles, no less than 15mm from the carina, probably 2 cm below optimal placement. ======== abdominal us with doppler : comparison: none. abdominal ultrasound: the liver is diffusely echogenic. there are no focal hepatic lesions. the right and left kidneys measure 10.7 cm and 11.9 cm in length, respectively. there is no hydronephrosis. a right parapelvic cyst measures 2.4cm x 2.3cm x 1.8cm. the head of the pancreas is unremarkable. the body and tail are not well seen due to bowel gas. there is no intrahepatic ductal dilation. the patient is status post cholecystectomy. the common duct measures 9 mm, normal in the setting of cholecystectomy. the spleen is normal in size. the aorta is not well seen due to bowel gas. doppler examination: the main, right and left portal veins are patent, with appropriate waveforms and anterograde, hepatopetal flow. the common hepatic artery is patent, with appropriate waveforms. the right, middle and left hepatic veins are patent, with appropriate waveforms as well as the superior mesenteric vein and inferior vena cava. impression: 1. echogenic liver consistent with fatty infiltration. other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. right parapelvic renal cyst. 3. normal liver doppler examination. ======== ecg : sinus tachycardia, rate 103. low r wave voltage in leads v4-v6. poor r wave progression. mild non-specific st-t wave changes in ii, iii, avf and v4-v6. these changes are non-specific and non-diagnostic. no previous tracing available for comparison. brief hospital course: the following issues were addressed at this admission: 1. acute hepatotoxicity. believed secondary to acetominophen overdose. level at outside hospital was > 6, but patient likely did not present for 1-3 days post-ingestion (patient states she is unable to remember the exact circumstances surrounding overdose, and husband reports that she seemed very tired/ill about 2 days prior to admission). she was initially transferred to the micu for possible emergent transplantation. she was evaluated by the transplant team here. however, with nac and supportive therapy, lfts began to trend down and her mental status slowly improved. at the time of transfer to the floor on hospital day 3, she was still somnolent and not responding verbally to questions. she continued to receive nac until inr dropped below 1.5. lfts, bilirubin, inr have trended down steadily. inr has now normalized, while lfts, bilirubin are approaching normal. she is expected to recover normal liver function. 2. acute renal failure. believed secondary to atn (muddy brown casts, fena of 0.3) which is a known complication of acetominophen toxicity. creatinine peaked at 3.3 and then trended down slowly to (presumed) baseline of 0.7-0.8 by the time of discharge. 3. electrolyte wasting. the patient was noted to become hypokalemic and hypophosphatemic several days into this admission, requiring maximum supplementation of 180 meq of potassium and packets of neutra-phos daily. the potassium wasting was suspected to be secondary to a renal tubular defect (though patient was not acidotic at that time), given levels in the urine > 50 meq/l when serum values would indicate that < 5 meq/l would be expected. she was started on amiloride at 2.5 mg daily and increased to 5 mg daily, which reduced the urinary potassium wasting and helped to stabilize serum k values at ~4. she will be continued on this medication at discharge with a plan to follow up with the nephrology team for further outpatient management. the low phosphate may have been partially secondary to wasting in the urine but is also common in hepatic regeneration given increased physiologic demand. her phos level stabilized without the need for supplementation prior to discharge (though patient has been encouraged to drink 1 cup of skim milk with meals to help supplement). finally, magnesium levels were noted to drop several days after the k wasting began. she continued to require grams of supplementation daily until , when levels remained in the normal range without supplementation. amiloride was stopped on and potassium levels remained stable in the normal range. she will require follow up of her electrolytes at her outpatient renal follow up appointment. 4. depression. after regaining full consciousness, the patient acknowledged that she has been struggling with depression for some time. she states that she is "terrified" that she tried to hurt herself in this way. after much negotiation, the patient's husband brought in a note that she had written, stating that voices were telling her that it was time to die. in addition, her mother reported that she had sent an email to her ex-husband threatening acetominophen overdose several days prior to admission; her current husband denied knowledge of this event. she was followed by psychiatry and social work throughout this admission, and maintained off all psych meds (including home xanax and seroquel). she is future-oriented and expresses interest in inpatient psychiatric therapy. she has generally received good social support from her family (sisters, daughter, husband, ) throughout this stay, and states that much healing has taken place between her family members. of note, during her time on the floor, she was placed under 1:1 observation by a sitter for her own safety. several mornings prior to discharge, the patient told the team that she had been verbally abused by three consecutive night sitters (stating that they had made comments such as "if i were your daughter, i would never forgive you" and "if i were your husband, i would never let you leave the house again." this incident was reported to the sitter coordinator and is under investigation. however, there is suspicion that the patient either fabricated these accusations or perhaps hallucinated (she had reported hallucinations at the time of admission to the osh, and could possibly have depression with psychotic features or other psychiatric disorder), as these were three independent staff members and this is unexpected behavior from staff, who are generally well-trained. these issues require further investigation by her future psychiatry team. on the day of her discharge, her psychiatry team determined that she was no longer actively suicidal and cancelled her section 12 and requirement for 1:1 sitter. at the patient's request, she was discharged later that same evening with the understanding that she will be referred to an outpatient program or personal psychiatrist. medications on admission: 1) seroquel 300 mg qhs 2) xanax 1 mg q8h prn 3) valerian root for insomnia (per husband) 4) melatonin for insomnia (per husband) discharge medications: 1. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia: please attempt to wean off of this medication within 2 weeks. disp:*7 tablet(s)* refills:*0* 2. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 1x/week (fr) for 4 weeks. disp:*4 capsule(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*0* 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: - acute hepatotoxicity secondary to acetominophen overdose - acute tubular necrosis secondary to acetominophen overdose - renal tubular defect (exact pathophysiology uncertain; no acidosis) resulting in electrolyte wasting presumed secondary to acetominophen overdose - depression - hypokalemia - hypomagnesemia - hypophosphatemia secondary: - anxiety discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: you were transferred to with liver toxicity related to acetominophen (tylenol) overdose. you were initially admitted to the icu and evaluated by the transplant team for possible liver transplantation. however, with appropriate supportive care, your liver function recovered. you were also noted to have kidney failure upon arrival to . you were evaluated by the renal team, who felt that your kidney failure was related to the acetominophen overdose. you were noted to pass large amounts of electrolytes in your urine, which was felt also to be related to the kidney injury by the acetominophen. your electrolytes were closely monitored and you received appropriate supplementation. because of concern that your overdose was intentional, you were followed closely by the psychiatry team during your stay. they initially recommended transfer to an inpatient psychiatric facility where you would therapy to address issues of underlying depression and mental health problems. today the psychiatry team met with you and felt as you were not longer endorseing suicidal thoughts, it would be safe to be discharged home with a half day program to be arranged tomorrow. you will be contact by the psychiatric case manager tomorrow to arrange this. please call and ask for dr. or dr. if you do not hear from someone tomorrow. we have made the following changes to your medication regimen: - stop taking xanax (you will be treated for anxiety according to recommendations from your inpatient pscyhiatry team) - stop taking seroquel (you will be treated for depression according to recommendations from your inpatient pscyhiatry team) - take as needed ambien (zolpidem) for insomnia. you should try to wean yourself off of this medication within two weeks, as it may become habit-forming and is not intended for long-term use. please keep your follow up appointments as outlined below. followup instructions: you have a follow up appointment scheduled with your primary care physician . on at 1:30pm. please call if you need to reschedule: (. liver: you have a follow up appointment scheduled with dr. at 3:20pm on at the liver center. please call if you have questions or need to reschedule. renal: you will need to follow up with the kidney doctors who treated while in the hospital. someone from their department will be contacting you to arrange an appointment with dr. or one of her colleagues. their office number is ( Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other endoscopy of small intestine Diagnoses: Acute kidney failure with lesion of tubular necrosis Hypopotassemia Dysthymic disorder Acute respiratory failure Disorders of phosphorus metabolism Other acquired absence of organ Other constipation Other encephalopathy Poisoning by aromatic analgesics, not elsewhere classified Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics Other and unspecified coagulation defects Gastroesophageal laceration-hemorrhage syndrome Disorders of magnesium metabolism Hepatitis, unspecified Mixed acid-base balance disorder Other specified gastritis, with hemorrhage |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath and substernal chest pain major surgical or invasive procedure: cardiac catheterization history of present illness: 57yo female former smoker with a history of htn, hyperlipidemia, rheumatoid arthritis, copd/asthma, hep c admitted to hospital on with a presumed copd exacerbation and transferred to cath lab with presumed nstemi s/p cath admitted to ccu for post-cath retroperitoneal bleed. per patient she has been having progressively worsening asthma symptoms including shortness of breath (worse at night and with lying flat) over the last 2-3 years. she saw dr. last year and he diagnosed her with asthma/copd with possible concomittant restrictive physiology. she has been using her nebulizers at home but has not been taking her other medications including statin and anti-hypertensives. over the last few weeks her shortness of breath has been worsening. she denies worsening orthopnea, pnd, and lower extremity edema, but has had each of these symptoms off and on for the last few years. she went to see her pcp about ten days ago and he put her on prednisone for a presumed copd exacerbation. per the patient this did not help. . last night at about 4pm she experienced acute severe sob at rest associated with 8/10 substernal chest pain and a feeling like she was going to die. she tried using her nebulizers but she did not feel better so she called ems who took her to hospital. there, she was treated for an asthma attack with albuterol nebs and cpap. abg was 7.23/59/395 on cpap. she then received iv solumedrol. she was monitored overnight in the icu where her respiratory status improved very quickly. however, her troponin i climbed from 0.06 on admission to 2.63 on the third set with cks flat but ckmbs rising to mid-20s. she was subsequently diagnosed with an nstemi and treated with aspirin, plavix load, heparin drip. vital signs prior to transfer to cath lab afebrile, bp 107/76 hr 80s rr 16-22 o2 sat 100% on 2l. . in cath lab patient underwent left heart catheterization during which they found no occluded coronaries but anterior wall hypokinesis with preserved ef (50%) on lv gram. attempted access through right side but unable to get adequate access so cath was finished through the left side. patient was then noted to be hypotensive. she recevied pressors, 2 units prbcs, and ivf in the cath lab. vascular surgery was consulted after pt was found to have traumatic stick of right circumflex branch of femoral artery. underwent vascular coiling with good effect angiographically post-procedure. on left side, pressure was applied in cath lab for 45min and left with fem stop in place. right side stopped oozing and now transferred to ccu with femoral pressure holder. . on arrival to ccu patient was breathing comfortably with no complaints of chest pain, palpitations, shortness of breath, orthopnea, leg pain, back pain, nausea. she denied any numbness/tingling/weakness. she was on neosynephrine and initally hypotensive but responded to ivf bolus. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: +dyslipidemia, +hypertension 2. other past medical history: hep c s/p treatment in (unknown med) rheumatoid arthritis s/p humira treatment for 6 months in copd/asthma depression nephrolithiasis social history: lives with her daughter in . -tobacco history: 15 years of ppd smoking quit in -etoh: none -illicit drugs: none family history: father died of lung cancer. mother with . physical exam: vs: t=96.7 bp=105/79 hr=77 rr=16 o2 sat= 97% on ra general: wdwn f in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. neck: supple with jvp three cm above clavicle with patient lying flat. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. sm heard best at apex radiating to axilla. 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. fem stop in place on left. right sided hematoma. no right sided femoral bruit. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: labs @ hospital: wbc-7.3, hgb-11.9, hct- 33.1, plat-236, inr- 1.0, bun-13, cr-0.9 , k- 3.5. abg: 7.42/36/120.1 on 3.5 l nc ck: 81->163->176 ck-mb: 2.4->21.8->25.2 troponin i: 0.06->2.31->2.63 cholesterol panel: tgs 47, chol 236, ldl 171, hdl 56 labs @ on admission: 04:10pm hct-27.2*# 06:15pm wbc-18.4* rbc-3.88* hgb-11.4*# hct-34.0* mcv-88 mch-29.5 mchc-33.6 rdw-15.3 06:15pm plt count-278 06:15pm ck(cpk)-106 06:15pm urea n-12 creat-0.6 sodium-139 potassium-4.7 chloride-112* total co2-17* anion gap-15 09:46pm hct-36.6 04:04am blood wbc-15.7* rbc-3.40* hgb-10.0* hct-29.6* mcv-87 mch-29.4 mchc-33.8 rdw-15.9* plt ct-239 07:55am blood hct-29.0* 12:13pm blood hct-29.6* 04:04am blood ck(cpk)-74 04:04am blood ck-mb-notdone ctropnt-0.28* probnp-7255* 04:04am blood triglyc-164* hdl-30 chol/hd-5.5 ldlcalc-101 cardiac catheterization: 1. coronary angiography in this right dominant system revealed no angiographically apparent coronary artery disease. the lmca was widely patent. the lad and lcx were without disease. the rca had no evidence of stenosis. 2. left ventriculography revealed anterolateral wall akinesis-dyskinesis with preserved contractile function of other walls. the lvef was 54%. final diagnosis: 1. coronary arteries are normal. 2. anterolateral wall dyskinesis. echo: the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with hypokinesis of the mid anterior septum and anterior walls. the remaining segments contract normally (lvef = 50 %). the estimated cardiac index is normal (>=2.5l/min/m2). 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. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen.the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: mild regional left ventricular systolic dysfunction in an atypical/non-coronary distribution suggesting focal myocarditis or variant of takotsubo cardiomyopathy. increased pcwp. mild aortic regurgitation. ct abdomen/pelvis: impression: moderate right retroperitoneal hematoma, with high attenuation material pooling in the pelvic portion of this collection most consistent with extravasated contrast not yet resorbed. multiple high- attenuation foci in the right groin are compatible with closure device/coils. brief hospital course: 57 year old female with history of copd, dyslipidemia, transferred from outside hospital with nstemi s/p cardiac cath complicated by retroperitoneal bleed s/p coil admitted to ccu for monitoring. . # retroperitoneal bleed: nicking of circumflex femoral artery on right side during cardiac cath procedure. now s/p placement of 3 coils. vascular team aware of patient. s/p hypotension intraoperatively with use of pressors, 2 units prbc and ivf. hematocrit has been stable on day after cath. ct abdomen showed stable retroperitoneal bleed. will hold aspirin and plavix for the time being. received 2 units of packed red blood cells in the cath lab, hematocrit stabiilzed and continued to improve during hospitalization. patient was discharged with stable hematocrit of 27.5. . # coronaries: patient was transferred from hospital with nstemi now s/p cardiac cath that showed no native coronary disease. echo showed mild regional left ventricular systolic dysfunction with hypokinesis of the mid anterior septum and anterior walls in an atypical/non-coronary distribution suggesting focal myocarditis or variant of takotsubo cardiomyopathy. etiology of chest pain, enzyme leak and wall motion abnormality still unclear - possibly lysed clot vs. takotsubo vs. focal myocarditis. aspirin and plavix were held given recent bleed. ace inhibitor and beta blocker were started as well as high dose statin given likelihood of atypical takotsubo cardiomyopathy as the leading diagnosis. . # pump: patient has no history of systolic or diastolic dysfunction but now is nstemi or stress-induced cardiomyopathy. bnp 7255. pt has been euvolemic. she will need a repeat tte within the next week or two to evaluate systolic function and the anterolateral hypokinesis. . # rhythm: patient has been in normal sinus rhythm while monitored on telemetry. . # copd: patient has history of copd with possible additional restrictive physiology. treated by dr. . pt had been on po steroids for ~10days prior to admission. initially this episode was attributed to copd exacerbation with acute respirtory acidosis consistent with copd, however may be chf as patient has hypokinesis of her anterior wall on lv gram. currently patient breathing comfortably on room air and lying flat clinically euvolemic. pt has been receiving nebulizer treatment with standing atrovent and albuterol as well as steroid taper. the patient will continue her steroid taper upon discharge. . # htn: on lisinopril 5 po daily. . # hyperlipidemia: patient has history of hyperlipidemia with ldl at outside hospital 170 and here 101. on lipitor 80 po daily. . # rheumatoid arthritis: currently patient is asymptomatic. . ### patient will need a repeat tte in weeks for follow up ### medications on admission: fometerol 20 mcg one vial every 4-6 hours as needed proair inhaler 90 mcg 1-2 puffs inhaled prn cymbicort 2 puffs aleve 220 mg po bid as needed for ra pain medications on transfer from osh: plavix 300 mg (taken ) then 75mg daily aspirin 325 mg daily heparin gtt at 750 u/hr lisinopril 2.5mg daily albuterol nebs solumedrol 60mg iv daily discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. prednisone 10 mg tablet sig: two (2) tablet po daily (daily) for 5 days. disp:*10 tablet(s)* refills:*0* 3. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 6. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 8. symbicort 80-4.5 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation twice a day. 9. prednisone 10 mg tablet sig: one (1) tablet po once a day for 5 days: start taking 10 mg a day after you've finished five days of 20 mg a day. disp:*5 tablet(s)* refills:*0* 10. azithromycin 500 mg tablet sig: one (1) tablet po once a day for 2 days: start tomorrow. disp:*2 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagosis: focal myocarditis or variant of takotsubo cardiomyopathy secondary diagnoses: 1. cardiac risk factors: +dyslipidemia, +hypertension 2. other past medical history: hep c s/p treatment in (unknown med) rheumatoid arthritis s/p humira treatment for 6 months in copd/asthma depression nephrolithiasis discharge condition: stable and improved discharge instructions: you were admitted to from hospital to have a cardiac catheterization done. you were initially treated at for a copd attack, and during this time, lab tests showed that your heart may have been damaged. your catheterization was complicated by a small hemorrhage near your right groin, and you were monitored in the icu for a short period of time after the procedure. you received blood transfusions and iv fluids, and did well. the catheterization did not show any blocked arteries, but did show a small amount of weakening in the pumping function in your heart. you have been started on new medication for this. you were transferred out of the icu, continued to do well, and you were discharged on in improved condition. the following changes were made to your medications: these medications have been added: lisinopril 5 mg daily for your heart function metoprolol 12.5 mg twice a day for your heart function simvastatin 80 mg daily for your heart and cholesterol montelukast 10 mg daily for your lungs aspirin 81 mg daily please continue taking your albuterol, symbicort, and prednisone as your have been before coming to the hospital. please discuss these new medication changes with dr. , your pcp, , see below. you will also see dr. , see below. you will have had another ultrasound of your heart at this point to compare to the ultrasound you had during this hospitalization. please call your physician 911 if you develop chest pain/pressue, shortness of breath, lightheadedness/dizziness, fevers, chills, or any other concerning medical symptoms. followup instructions: primary care: , w. phone: date/time: monday at 10:00am. cardiology: dr. phone: (‎ date/time: monday at 3:15pm. , upstairs from dr. Procedure: Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Arteriography of other intra-abdominal arteries Other endovascular procedures on other vessels Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Personal history of tobacco use Accidental puncture or laceration during a procedure, not elsewhere classified Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Rheumatoid arthritis Chronic obstructive asthma, unspecified Diastolic heart failure, unspecified Myocarditis, unspecified Takotsubo syndrome Accidental cut, puncture, perforation or hemorrhage during heart catheterization |
allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea major surgical or invasive procedure: thoracentesis left-sided pleural pigtail catheter placement history of present illness: 83 yo m with afib on coumadin, hypertension, hl and hypothyroidism sent in from pcp to the today for an inr elevated to 10.7. he has newly found metastatic disease with bony lesions on hip mri. planned to see oncology soon with likely biopsy, but was brought in due to inr. he has had hip and groin pain for a couple months. imaging was obtained by pcp recently showing multiple bony lesions. . in the ed inital vitals were, 98.0 100 100/75 16 94% ra. he was given 10mg po vitamin k. cxr showed large left sided pleural effusion suspicious for lung mass. bedside cardiac echo shows no pericardial effusion but large left pleural effusion. given levaquin for question of pneumonia. given a 500cc bolus for sbp 79. on transfer, sbp85 hr102 rr16 o2 95% on 4l. . on arrival to the icu, he is comfortable and feeling well. he has no complaints. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: 1. anxiety 2. depression 3. osteoarthritis 4. sciatica 5. hypothyroidism 6. hypertension 7. hypercholesterolemia 8. question of atrial fibrillation - the patient is on coumadin but is unclear why. this is managed through the hospital. social history: the patient is a widower. he moved from to be near his sons. has one son in and another in . he walks one mile daily for exercise. - tobacco: smoked 1ppd for 30 years, quit 30+ years ago. significant second hand smoke from wife - alcohol: none - illicits: none family history: sister - unknown cancer physical exam: admission physical exam general: alert, oriented, no acute distress heent: sclera anicteric, dry mucus membranes, oropharynx clear neck: supple, jvp not elevated, no lad lungs: minimal lung sounds on left, clear lungs on right cv: irregularly irregular no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ edema bilaterally skin: warm and dry discharge physical exam: breathing comfortably, no acute distress distant l lung sounds, crackles r lung patient is comfort measures only, minimal exam pertinent results: 09:15am urine color-yellow appear-hazy sp -1.025 09:15am urine blood-lg nitrite-neg protein-30 glucose-neg ketone-tr bilirub-neg urobiln-neg ph-5.5 leuks-sm 09:15am urine rbc-160* wbc-38* bacteri-none yeast-none epi-<1 03:45pm pleural wbc-575* rbc-* polys-69* lymphs-19* monos-0 eos-1* macro-11* 03:45pm pleural totprot-3.3 glucose-83 ld(ldh)-286 cholest-58 micro: blood (): ngtd 3:44 pm pleural fluid pleural fluid. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (preliminary): no growth. anaerobic culture (preliminary): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): urine (): ngtd preliminary cytology: pleural fluid adenocarcinoma cells, pending more detailed analysis. scant cells, so difficult to get special stains. studies: ecg (): atrial fibrillation with rapid ventricular response. diffuse low voltage. no previous tracing available for comparison. clinical correlation is suggested. cxr (): large left pleural effusion with left upper lobe collapse and left central adenopathy. left-sided mass is presumed. echo (): the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy. 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%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size is normal. with normal free wall contractility. the aortic valve leaflets 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. the tricuspid valve leaflets are mildly thickened. there is a trivial/physiologic pericardial effusion. ct abd/pelvis (): 1. aggressive central left upper lobe lesion that invades the left pulmonary artery, superior left pulmonary vein and occlude the left upper pulmonary bronchus. 2. extensive mediastinal lymphadenopathy. 3. multiple pleural deposits. 4. bone metastases and pathological fracture of the right eighth rib. 5. tense left pleural effusion. cxr (): in comparison with the study of , the degree of opacification in the left hemithorax has increased. however, this could relate to a redistribution of pleural fluid in the supine position, when compared to the upright pa view in the comparison study. nevertheless, there certainly does not appear to be any substantial reduction in the degree of pleural fluid. no pneumothorax is seen. cxr (): right basal atelectasis has nearly cleared and small right pleural effusion is stable. because of rightward patient rotation, it is hard to say whether there has been interval rightward mediastinal shift, but i believe there has been, suggesting an increase in the volume of the already large left pleural effusion that nearly completely collapses the left lung, and obscures extensive intrathoracic malignancy as seen on the torso ct earlier today. bleeding into the left pleural space is certainly possible. no pneumothorax. cxr (): a modest decrease in the large left pleural effusion is reflected in a slight increase in the small region of apical lung aeration and return of the trachea to the midline. small to moderate right pleural effusion is larger. no pneumothorax. cxr (): as compared to the previous radiograph, there is no relevant change. extensive left pleural effusion, occupying approximately two-thirds of the left hemithorax, with displacement of the mediastinal and cardiac structures towards the right. on the right, there is unchanged evidence of a small pleural effusion and an otherwise normal lung parenchyma. mri head w/ and w/out contrast() impression: 1. no acute intracranial abnormality. 2. no evidence of metastatic disease. 3. sequelae of chronic small vessel ischemic disease, with chronic lacunar infarct in the left centrum semiovale. ct chest w/ contrast (): impression: 1. status post left pleural pigtail catheter placement with improvement in the volume of left pleural effusion and minimally improved aeration of the left lower lobe. left lower lobe bronchus shows short segment occlusion, likely reflective of a mucus plug. 2. continued large left upper lobe mass with mass effect on the adjacent bronchus and artery; mediastinal lymphadenopathy, most prominent in the subcarinal stations. 3. new small consolidation in the anterior portion of the right lung apex may represent residual atelectasis versus a new focus of pneumonia; small right simple pleural effusion with minimal associated atelectasis. 4. ascites. 5. bone metastases as described above. cxr upright portable view of the chest demonstrates left lower lobe consolidation. diffuse opacification of the left hemithorax is not significantly changed since study obtained five hours prior. the right lung is clear without pleural effusion or pneumothorax. the hilar and mediastinal silhouettes are unremarkable. heart size is difficult to discern due to adjacent opacities. impression: persistent left lower lobe consolidation and large left pleural effusion, unchanged. brief hospital course: patient summary: ============== 83 yo m with htn, hl, hypothyroid and significant smoking history found to have a large left lung mass, as well as multiple bony lesions. admitted to the micu with hypercoaguability and hypotension. on discussion with patient, family and medical teams, pursued comfort measures only. active issues: ============== # malignancy primary lung malignancy is most likely given large lung mass on ct. also with significant smoking history. mets in r pelvis, rib and thoracic spine. thoracentesis was performed with specimens sent for cytology confirming adenocarcinoma. given his advanced disease and poor functional status, no treatment options beyond palliative care were available. elected to undergo some palliative radiation of right pelvis. patient decided that he preferred to go home with hospice and spend time with family. he was made cmo with plan to transfer back home with hospice. . # hypotension resolved. pt had hypotension upon arrival to ed w/ sbp nadir 79, very responsive to fluids. pt received 5-6l ivf w/in first 24 hours of hospital stay, complicated by pulmonary edema, worsening effusions and increased work of breathing (nasal cannula to 6l. sbp in the 120s. lactate improved. most likely etiology was poor po intake. he was transferred to the medical oncology floor on , however had recurrent hypotension and was transferred back to micu on . . # supratherapeutic inr: question secondary to poor po intake versus cirrhosis by ct abdomen. improved with vitamin k 20g total and ffp. lovenox stopped due to cmo. . # atrial fib: stopped metoprolol for cmo. stable issues ============== # anxiety/depression: continued citalopram . # hypothyroid: stopped levothyroxine for cmo . # hl: stopped simvastatin for cmo . # bph: stopped finasteride, foley remained in place transitional issues: ===================== - will need to return for chest tube replacement via ip on monday - pcp f/u - oncology f/u - one suture in l axilla --> to be taken out - f/u blood and pleural fluid cultures medications on admission: citalopram - 40 mg tablet - 1 tablet(s) by mouth daily finasteride - 5 mg tablet - 1 tablet(s) by mouth daily levothyroxine - 25 mcg tablet - 1 tablet(s) by mouth daily metoprolol tartrate - 25 mg tablet - 0.5 (one half) tablet(s) by mouth twice a day simvastatin - 40 mg tablet - 1 tablet(s) by mouth daily warfarin - 5 mg tablet - 1 tab fridays, tab other days acetaminophen - 500 mg tablet - 1000 mg by mouth three times a day calcium carbonate-vitamin d3 - 600 mg-400 unit tablet - 1 tablet(s) by mouth twice a day omega-3 fatty acids-vitamin e - (otc) - dosage uncertain discharge medications: 1. citalopram 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 2. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. disp:*20 tablet(s)* refills:*0* 3. prochlorperazine 25 mg suppository sig: one (1) rectal every twelve (12) hours as needed for nausea. disp:*10 supp* refills:*0* 4. levsin/sl 0.125 mg tablet, sublingual sig: sublingual every 4-6 hours as needed for increased secretions. disp:*10 tablets* refills:*0* 5. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po every 4-6 hours as needed for nausea. disp:*10 tablet(s)* refills:*0* 6. morphine concentrate 100 mg/5 ml (20 mg/ml) solution sig: 2-20 mg po q1hr as needed for discomfort, shortness of breath. disp:*40 ml* refills:*0* 7. acetaminophen 650 mg suppository sig: one (1) supp rectal every four (4) hours as needed for fever>101f. disp:*10 supp* refills:*0* 8. lorazepam intensol 2 mg/ml concentrate sig: 0.25-2 mg po every four (4) hours as needed for nausea/anxiety/agitation. disp:*10 ml* refills:*0* 9. hospice - admit to - oxygen via nasal cannula 3l-10l titrate as needed for comfort 10. tessalon perles 100 mg capsule sig: two (2) capsule po three times a day. disp:*180 capsule(s)* refills:*0* 11. colace 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*0* 12. senna 8.8 mg/5 ml syrup sig: one (1) po three times a day. disp:*qs qs* refills:*0* discharge disposition: extended care facility: at - discharge diagnosis: metastatic adenocarcinoma, likely lung primary 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: mr. , you were admitted to the hospital and found to have a large metastatic lung cancer. after discussions with your medical teams and your family, you elected to go home with hospice. followup instructions: you are scheduled for a chest tube to be placed by the interventional pulmonology service where: - pre-op date: wednesday , 10am phone: **if you have any questions prior to your visit, or if you have increasing symptoms of shortness of breath, please feel free to call this number primary care department: gerontology when: monday at 9:00 am with: , md building: lm campus: west best parking: garage the thoracic oncology team is also working to set up an appointment for you. Procedure: Insertion of intercostal catheter for drainage Thoracentesis Other radiotherapeutic procedure Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Acquired coagulation factor deficiency Unspecified acquired hypothyroidism Atrial fibrillation Secondary malignant neoplasm of other specified sites Personal history of tobacco use Depressive disorder, not elsewhere classified Pulmonary collapse Other and unspecified hyperlipidemia Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Anxiety state, unspecified Hypotension, unspecified Malignant neoplasm of upper lobe, bronchus or lung Long-term (current) use of anticoagulants Unspecified accident Do not resuscitate status Gross hematuria Injury to bladder and urethra, without mention of open wound into cavity Secondary malignant neoplasm of bone and bone marrow Anemia in neoplastic disease Neoplasm related pain (acute) (chronic) Other diseases of trachea and bronchus Pathologic fracture of other specified site Malignant pleural effusion |
allergies: sulfa (sulfonamide antibiotics) / vancomycin attending: chief complaint: mitral regurgitation major surgical or invasive procedure: mitral valve repair (32mm st. ) history of present illness: this 64 year old white male with no significant history, aside from arthroscopic knee surgery, sought care for several months of progressive dyspnea. he was found to be in atrial fibrillation and underwent evaluation which revealed 4+ mitral regurgitation with torn chordae and clean coronaries. he was transferred to for definitive care. past medical history: lt knee arthroscopy t&a as child social history: retired commercial pilot rare etoh use remote pipe smoker family history: noncontributory physical exam: admission: awake, alert, nad neuro: intact lungs: clear cro: af 106, gr 3/6 sem at apex ext: no cce pertinent results: 06:10am blood wbc-11.9* rbc-2.98* hgb-9.6* hct-26.9* mcv-90 mch-32.1* mchc-35.6* rdw-13.9 plt ct-113* 06:10am blood pt-17.8* inr(pt)-1.6* 07:10am blood pt-16.2* inr(pt)-1.4* 03:09am blood pt-18.4* ptt-36.5* inr(pt)-1.7* 11:58am blood pt-16.7* ptt-35.6* inr(pt)-1.5* 06:10am blood glucose-108* urean-12 creat-1.0 na-134 k-4.3 cl-96 hco3-31 angap-11 echocardiography report , tte (complete) done at 4:01:39 pm final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 64 m hgt (in): 71 bp (mm hg): 127/78 wgt (lb): 212 hr (bpm): 111 bsa (m2): 2.16 m2 indication: preoperative assessment. icd-9 codes: 427.89, 424.0, 424.2 test information date/time: at 16:01 interpret md: , md test type: tte (complete) 3d imaging. son: , rdcs doppler: full doppler and color doppler test location: west echo lab contrast: none tech quality: adequate tape #: 2009w006-0:51 machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: *6.3 cm <= 4.0 cm left atrium - four chamber length: *7.0 cm <= 5.2 cm right atrium - four chamber length: *6.4 cm <= 5.0 cm left ventricle - septal wall thickness: *1.3 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *6.0 cm <= 5.6 cm left ventricle - systolic dimension: 3.7 cm left ventricle - fractional shortening: 0.38 >= 0.29 left ventricle - ejection fraction: 60% to 65% >= 55% left ventricle - lateral peak e': 0.17 m/s > 0.08 m/s left ventricle - septal peak e': 0.10 m/s > 0.08 m/s left ventricle - ratio e/e': 13 < 15 aorta - sinus level: 3.3 cm <= 3.6 cm aorta - ascending: 3.4 cm <= 3.4 cm aorta - arch: *3.1 cm <= 3.0 cm aortic valve - peak velocity: 1.5 m/sec <= 2.0 m/sec mitral valve - e wave: 1.8 m/sec mitral valve - a wave: 0.0 m/sec mitral valve - e wave deceleration time: 157 ms 140-250 ms tr gradient (+ ra = pasp): *56 mm hg <= 25 mm hg findings multiplanar reconstructions were generated and confirmed on an independent workstation. left atrium: marked la enlargement. right atrium/interatrial septum: moderately dilated ra. no asd by 2d or color doppler. left ventricle: mild symmetric lvh with normal cavity size and regional/global systolic function (lvef>55%). no resting lvot gradient. no vsd. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. mildly dilated aortic arch. no 2d or doppler evidence of distal arch coarctation. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. moderate/severe mvp. moderate thickening of mitral valve chordae. torn mitral chordae. no ms. moderate to severe (3+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. mild tr. moderate pa systolic hypertension. pulmonic valve/pulmonary artery: no ps. pericardium: no pericardial effusion. conclusions the left atrium is markedly dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic arch 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 moderate/severe mitral valve prolapse (predominantly the posterior leaflet). there is moderate thickening of the mitral valve chordae. torn mitral chordae are present with prolapse through the mitral valve in systole. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mitral valve prolapse with moderate to severe mitral regurgitation. preserved biventricular systolic function. moderate pulmonary hypertension. electronically signed by , md, interpreting physician 16:28 brief hospital course: he was transferred to the cvicu in stable condition and heparin was begun for atrial fibrillation. dental clearance was obtained and mitral valve repair and annuloplasty with a 32mm st. saddle ring was performed on . see operative note for details. attempts at dccv prebypass resulted in vf and the institution of urgent bypass. amiodarone was administered postoperatively. a maze procedure was not undertaken due to the dilated atrium. his lvef was 25-30% after surgery by tee. he weaned from bypass on epinephrine, neosynephrine ansd propofol. he transferred back to the cvicu where milrinone was begun due to low ci with elevated svr despite adequate volume resuscitation. his index rose, epinephrine was stopped and he remained stable. he was weaned from the ventilator and extubated easily. the milrinone and neosynephrine were weaned and beta blockde was resumed with good ventricular rate control. diuretics were administered and coumadin resumed. following transfer to the floor he was ambulated, pt worked with him for strength and mobility and medications were titrated for maximum bebefit. he was discharged home having been instructed to medications, restrictions and followup care. arrangements were made for dr. to follow and manage his coumadin. medications on admission: lopressor 50mg asa 325mg/d 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. influen tr-split vac (pf) 45 mcg/0.5 ml syringe sig: one (1) ml intramuscular asdir (as directed). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). tablet, delayed release (e.c.)(s) 5. furosemide 40 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* 6. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 7 days. disp:*7 tab sust.rel. particle/crystal(s)* refills:*0* 7. warfarin 2.5 mg tablet sig: as ordered tablet po once a day: inr 2.5-3. disp:*100 tablet(s)* refills:*2* 8. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 2 tablets twice daily for 10 days then 1 tablet twice daily. disp:*120 tablet(s)* refills:*2* 9. hydromorphone 2 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for 2 weeks. disp:*50 tablet(s)* refills:*0* 10. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. 11. outpatient lab work please check inr on and results called to dr. discharge disposition: home with service facility: vna discharge diagnosis: mitral regurgitation chronic atrial fibrillation 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 the office if you have any questions or concerns dr. will follow your inr and coumadin dosing. followup instructions: dr. in 4 weeks (call heart center ) dr. (cardiology) in weeks () dr. (primary care) in 2 weeks please call to scedule appointments Procedure: Extracorporeal circulation auxiliary to open heart surgery Open heart valvuloplasty of mitral valve without replacement Operations on chordae tendineae Diagnoses: Mitral valve disorders Congestive heart failure, unspecified Atrial fibrillation Atrial flutter Long-term (current) use of anticoagulants Rupture of chordae tendineae |
allergies: aspirin / bupropion / cisplatin / hydromorphone / ibuprofen / iron / venlafaxine attending: chief complaint: headache, visual changes, witnessed seizure major surgical or invasive procedure: intubation history of present illness: the patient is a 44-yo woman with metastatic cervical cancer to lung, being treated with xrt and chemotherapy, hypertension, depression/anxiety/ptsd/panic disorder, and poly-substance abuse. she initially presented to hospital with headaches, visual changes, and a witnessed seizure, with nchct showing peri-mesencephalic sah. she was transferred to ed and evaluated by the neurosurgery consult team, and underwent cta of the head and neck that raised concern for pres. she was admitted to the neuro icu as she was intubated, sedated, and on a nicardipine gtt for bp control. since admission, brain mri done was also suggestive of pres but could not optimally assess for brain mets as this was done without contrast given the pt's acute renal failure. eeg also showed no seizure activity, and she is being maintained on keppra currently. her sedation has been weaned and she is on ativan prn for sedation. she continues on the nicardipine gtt to achieve goal sbp <140, with hydralazine standing + prn and labetalol prn as well to titrate this off. past medical history: - cervical cancer * diagnosed * found to have metastatic lung lesions , s/p right thoracoscopy with rml wedge and parietal pleural biopsy * treated with xrt, chemotherapy * last treatments with avastin and gemcitabine on - hypertension - vertigo - chronic back pain - polysubstance abuse (alcohol, heroin, cocaine, opioids) - depression, cutting behavior, prior suicide attempt - anxiety - panic disorder - ptsd social history: per son, lives in with brother, divorced, had a son & daughter (daughter is deceased, cause under investigation), receives disability, likes the beach. - tobacco: ppd x 12-13 years - alcohol: 5 / 2 weeks (previously drank heavily; son estimates 25 in one session) - illicits: remote (1 year ago); heroin, cocaine, "pain pills" family history: - positive for seizures (brother) - negative for stroke, cerebral aneurysm in first degree relative physical exam: vitals: t: 99.1 bp: 139/69 p: 78 r: 18 o2: 97 general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: 12:00pm wbc-4.6 rbc-3.97* hgb-13.0 hct-39.9 mcv-100* mch-32.8* mchc-32.6 rdw-19.0* 12:00pm pt-11.3 ptt-25.8 inr(pt)-0.9 12:00pm fibrinoge-447* 12:00pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 12:00pm glucose-126* urea n-20 creat-1.5* sodium-140 potassium-4.4 chloride-105 total co2-24 anion gap-15 01:00pm urine blood-lg nitrite-neg protein-500 glucose-tr ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg imaging: cta neck w&w/oc & recons impression: 1. hemorrhage in the quadrigeminal cistern with subtle hemorrhage in the sulci of occipital lobe. there are hypodensities in both occipital lobes in the white matter which could be suspicious for posterior reversible encephalopathy in view of patient's clinical history of hypertension. 2. ct angiography of the head demonstrates no evidence of aneurysm. subtle increased meningeal vascular structures in both occipital lobes could be secondary to hyperemia from posterior reversible encephalopathy syndrome. 3. no evidence of venous sinus thrombosis. 6:27 am ct c-spine w/o contrast impression: 1. no acute fracture of the cervical spine. 2. irregular nodule possibly cavitary in the right apex for which a chest ct is recommended. 6:27 am ct head w/o contrast impression: 1. essentially unchanged appearance of hemorrhage in the quadrigeminal cistern and sulci of the left occipital lobe. 2. hypodensities in the occipital lobe raise the possibility of pres. consider mr for further evaluation. 3. no large herniation. 9:07 pm mr head w/o contrast impression: 1. subarachnoid hemorrhage is again noted in the quadrigeminal plate cistern, along the superior vermis, and in the occipital sulci. 2. evidence of chronic blood products in the occipital horns of the lateral ventricles. 3. signal abnormalities in the subcortical white matter of the occipital, parietal, and frontal lobes, as well as in the right corona radiata, compatible with the posterior reversible encephalopathy syndrome. no evidence of acute infarction. however, subtle vasogenic edema related to small metastases is difficult to exclude in the absence of intravenous contrast. 1:46 pm ct head w/o contrast impression: 1. no acute intracranial process. previously identified subarachnoid blood in the ambient cistern is no longer seen, compatible with expected evolution of blood products. 2. development of diffuse fluid opacification of the bilateral mastoid air cells. clinical correlation is advised. 10:09 am mr head w & w/o contrast clip # impressions: 1. no evidence of intracranial metastases. no acute hemorrhage or other acute abnormality. 2. persistent opacification of bilateral mastoid air cells, which can be seen in mastoiditis. radiology report ct head w/o contrast study date of 3:48 pm impression: 1. no intracranial hemorrhage or acute intracranial abnormality. 2. persistent, although improved mastoid air cell opacification. brief hospital course: nicu course: once admitted, the patient was seen by ep for sinus bradycardia to the 20s and long qtc on ecg. these were thought to be centrally mediated, and she did not have any bradycardia for several days. her renal function was elevated since admission, with cr in the 1.8-1.9 range, but she has been maintaining good urine output and this has trended down to 1.5. her fena was 0.7% on , suggesting a pre-renal etiology, so she has received significant iv fluids. she developed a progressively worsening metabolic non-ag acidosis, as well as a primary respiratory acidosis that appears to have developed into a respiratory alkalosis, and she then had difficulty weaning from the ventilator. additionally, she had thrombocytopenia and hemolytic anemia, for which heme-onc has been consulted. her known malignancy, recent therapies with avastin and gemcitabine, and malignant hypertension, all could cause micro-angiopathic processes to account for these, as opposed to ttp. hit ab and coombs were negative and adamts13 was normal. finally, she developed a ventilator-associated pneumonia, with cxr showing a right hilar infiltrate and possible left lower lobe consolidation, and bal sample showing gprs, so she has been covered broadly with vancomycin, cefepime, and ciprofloxacin. she was transferred to the care of the micu team given the above several medical issues. . micu course: # respiratory failure: the patient was able to be extubated. speech and swallow was consulted and recommended a thin liquid, soft food diet. . # ventilator-associated pneumonia: the patient underwent an eight-day course of antibiotics. . medicine course: #. hallucinations, auditory and visual (etiology unclear) had been increasingly agitated. early psychiatric recommendations included increasing does of seroquel to 100 mg tid, which did not reduce agitation. a trial with zyprexa was proposed, but most recent recommendations, which will be followed, called for 150 mg seroquel tid with 50 mg seroquel tid prn agitation. considered adding ativan 0.5 mg as recommended if response to increased dose of seroquel, but proved unnecessary. the patient's agitation and insight significantly improved for several days. she even recognized that she has been hallucinating over the last several days. unfortunately, her delirium recurred. neurology included recommendations, based on which keppra has been discontinued. a brain mr has been ordered to help determine etiology of patient's hallucinations and delusions and demonstrated no acute changes and no evidence of intracranial metastases. head ct without contrast showed no acute changes. ua and urine culture negative. blood cultures showed no growth. lumbar puncture was unsuccesful. patient has been afebrile. daily ekgs to check qt interval. qt intervals have not exceeded 413. continued folate, thiamine, multivitamins. . # pleural effusion remained stable throught medicine course. no treatment given. . # history of recent transaminitis lfts followed, showed transaminitis to have resolved. . # acute renal failure, resolved. followed renal function, since patient had acute renal failure with anasarca in icu. creatinine has improved from that point. lasix has been discontinued. creatinine returned to baseline. . # malignant htn to anticipate eventual discharge home, anti-hypertensive regimen was simplified to labetalol 300 mg tid, which controlled patient's blood pressure well. . # sah kept bp < 160. ct scan given following quick-onset headache. no acute changes were seen, and it appears that products have mostly disappeared. . # episode of asystole on telemetry patient immediately returned to sinus rhythm. cardiology thought bradycardia might be nuerally meduated but also suggested cardio a reduction in labetalol dose to 300 mg. kept on labetolol 300 mg tid, which controlled blood pressure. patient refused to wear telemetry leads. we would consider reinstating telemetry if patient remains calm. . # history of microangiopathic hemolytic anemia, thrombocytopenia thrombocytopenia has resolved. haptoglobin was < 5, but adamts13 levels regular, no heparin antibody, pt, ptt, inr all within normal range, as was fibrinogen. hematocrit remained steady during medicine course and patient had no complaints suggestive of anemia. continued folic acid and b12. medications on admission: - atenolol 25 mg po daily - nexium 20 mg po daily - fentanyl 75 mcg td q48h - lorazepam 1 mg po qam, 2 mg po qhs prn anxiety - compazine 10 mg po q4-6 h prn nausea discharge medications: 1. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours) as needed for pain. 2. labetalol 200 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*0* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. quetiapine 100 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*0* 7. cyanocobalamin 100 mcg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: subarachnoid hemorrhage. hallucinations and delusions, etiology unclear. malignant hypertension secondary: pleural effusion acute renal failure, resolved discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ms. , it was a pleasure working with you at hospital. we treated you for some bleeding you had on your brain that may have caused you to have a seizure. we think that the bleeding has mostly resolved now. we also think that the bleeding was caused by high blood pressure, so it is very important that you take your blood pressure medications and follow up with your doctors. we have also set up an appointment with a neurologist, who may also help you prevent having more bleeding on your brain. . during your stay with us, you also developed some hallucinations and were agitated. this episode may have been caused by the bleeding in your brain or by a medication we gave you to prevent seizures or by another cause altogether. beacuse we gave you a powerful medication to control your hallucinations, we would like you to follow up with a psychiatrist to determine if you need to stay on the medication. start labetalol 300 mg three times a day start quetiapine fumarate 150 mg three times a day. start cyanocobalamin 50 mcg once daily. start thiamine 100 mg once daily. start folic acid 1 mg once daily. start pantoprazole 40 mg once daily. followup instructions: department: neurology when: monday at 1 pm with: , md building: campus: east best parking: garage . hematology/oncology appointment when: thursday, , 8:15am. name: di , address: 200 technology dr, hooksett, phone: . Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Thrombocytopenia, unspecified Unspecified pleural effusion Acute kidney failure, unspecified Subarachnoid hemorrhage Depressive disorder, not elsewhere classified Cocaine abuse, unspecified Hypopotassemia Pulmonary collapse Anxiety state, unspecified Acute respiratory failure Other specified cardiac dysrhythmias Cardiac arrest Other encephalopathy Acquired hemolytic anemia, unspecified Malignant essential hypertension Secondary malignant neoplasm of lung Ventilator associated pneumonia Alcohol abuse, continuous Personal history of malignant neoplasm of cervix uteri Delirium due to conditions classified elsewhere Opioid abuse, unspecified Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Mixed acid-base balance disorder Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Posttraumatic stress disorder Edema Facial weakness Hallucinations Panic disorder without agoraphobia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p mvc right leg and chest pain major surgical or invasive procedure: 1. irrigation debridement skin to bone right femur. 2. open reduction internal fixation with intramedullary nail right open femur fracture. history of present illness: 26 year old female who unrestrained driver in a high-speed mvc with intrusion to the dashboard noted to have open r femur fx and r rib fx's past medical history: pmh none psh none social history: smokes ppd. social alcohol drinker. denies other illicits. family history: non contributory physical exam: constitutional: uncomfortable heent: normocephalic, atraumatic trachea midline chest: clear to auscultation equal breath sound tender along right chest cardiovascular: regular rate and rhythm, normal first and second heart sounds abdominal: soft, nontender extr/back: open wound with swelling to right thigh skin: no rash pulses intact distally neuro: speech fluent psych: normal mood, normal mentation cranial nerves ii through xii grossly intact, motor in all extremities, sensory without focal deficits pertinent results: 05:00am wbc-21.2* rbc-4.83 hgb-14.2 hct-40.9 mcv-85 mch-29.5 mchc-34.8 rdw-13.7 05:00am plt count-337 05:00am pt-12.9 ptt-21.3* inr(pt)-1.1 05:00am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 05:07am glucose-247* lactate-3.3* na+-140 k+-3.6 cl--102 tco2-24 05:00am urea n-15 creat-0.9 cxr : minimally displaced rib fractures, left first through third ribs. cta chest : 1. traumatic focal dissection in the proximal descending aorta with expanding contained thrombus since . 2. no central pulmonary embolism. 3. mild pulmonary edema. 4. small bilateral pleural effusions and adjacent atelectasis. 5. stable anterior proximal left rib fractures. 6. fatty liver. mri left knee : 1. no evidence of injury to the menisci, ligaments, or tendons. 2. medial femoral condyle osseous contusion. 3. full thickness chondral fissure in the lateral tibial plateau. 4. diffuse subcutaneous soft tissue and vastus muscle edema. cta chest : 1. focal contained, post-traumatic aortic dissection in the proximal descending aorta is unchanged since previous ct dated . 2. stable fractures involving the anterior ends of first and second ribs on left side. brief hospital course: on , the patient went to the or for femur fx repair, she had low o2 sats postoperatively, requiring a non rebreather. on , the patient's c-spine was cleared and her diet was slowly advanced. logroll precautions were d/c'd and patient was started on dilaudid pca. on , the patient had an acute drop in her hct down to 23.7, she received a unit of blood and responded appropriately. she continued to have some desaturation with turning/sleeping, but she was able to be transitioned from nrb to nc. on , the patient underwent cta to rule out pe, which showed dissection of the descending aorta. cardiac surgery was consulted and recommended no surgery, but instead strict blood pressure control. on , patient was started on labetalol gtt for better hr and bp control, and this was transitioned to po lopressor and labetalol gtt was discontinued. otherwise, patient was doing well, tolerating regular diet. ortho recommended 50% weight bearing on right leg and full wt bearing on the left leg. the patient was transferred to the floor on . following transfer to the trauma floor she continued to make good progress. vascular surgery was consulted regarding her descending thoracic aortic dissection and they recommended coumadin, aspirin and keeping sbp < 140 mmhg. her coumadin was started on at 5mg followed by 7.5 mg on and . her inr on is 1.7 and she will take 5mg daily with an inr check on . dr. , her pcp will dose her coumadin starting on friday . her last cta chest was on which showed no progression of her dissection. blood pressure control was successful with lopressor and hydralazine with sbp 95-120/70 and heart rates in the 70's. she will be discharged on labetolol alone at 100 mg and the vna will follow up with blood pressure checks for the first few days. her blood sugars have been elevated since admission in the high 100-240 range. she was encouraged to follow up with dr. for further management. from an orthopedic standpoint she has done well post op. her incision is healing well and after many physical therapy visits she is able to crutch walk safely. her weight bearing status is partial (50%) on the right leg and full weight bearing on the left. her staples will be removed by the vna on . after a long recovery she was discharged home on with vna services for bp checks and coumadin teaching and monitoring. medications on admission: none discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever/pain. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 6. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 7. labetalol 100 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours): thru . disp:*4 tablet(s)* refills:*0* 9. coumadin 5 mg tablet sig: one (1) tablet po once a day: inr to determine future. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: , discharge diagnosis: s/p mvc 1. open right femur fracture 2. proximal descending thoracic aortic dissection with contained thrombus 3. left rib fractures 4. right first rib fracture discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: * you were admitted to the hospital after your car accident with multiple injuries including a broken right leg, rib fractures and a small tear in your aorta which sealed over. * your orthopedic surgery went well and your weight bearing status on the right leg is partial weight bearing with crutches. the vna will take your staples out. * your injury caused left rib fractures and the right first rib which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * you should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. if the pain medication is too sedating take half the dose and notify your physician. * pneumonia is a complication of rib fractures. in order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. this will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * you will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * symptomatic relief with ice packs or heating pads for short periods may ease the pain. * narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * do not smoke * the aortic dissection was noted on your initial ct scan. you need to have good blood pressure control and also must stay on a blood thinner called coumadin. you will need to have your blood tested frequently in the beginning of therapy but after you are regulated it should be once a month. maintain safety precautions while on coumadin so that you don't bleed. be careful with sharp objects. shave your legs with an electric razor to prevent cuts that will bleed excessively. do not use ibuprofen or any product with ibuprofen in it as it can increase your bleeding tendency. * dr. will regulate your coumadin dose. * your blood sugars have been on the high side since your admission and you should talk to your pcp about further testing for diabetes. * return to the emergency room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ), chest pain, or increased leg pain. followup instructions: call the clinic at for a follow up appointment in 4 weeks. call the vascular surgery clinic at for a follow up appointment in 4 weeks. call the acute care clinic at for a follow up appointment in weeks. dr. () wednesday at 11:45am. Procedure: Closed reduction of fracture with internal fixation, femur Diagnoses: Tobacco use disorder Urinary tract infection, site not specified Long-term (current) use of anticoagulants Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Obesity, unspecified Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Open fracture of shaft of femur Street and highway accidents Acute edema of lung, unspecified Closed fracture of four ribs Injury to thoracic aorta |
allergies: motrin / shellfish attending: addendum: at time of initial discharge, patient complained of feeling dizzy with standing. orthostatics were negative, vital signs were normal, and there were no signs of recurrent bleeding pt worked with the patient after after an additional day his symptoms improved and he was stable for discharge. discharge disposition: home with service facility: homecare md Procedure: Other endoscopy of small intestine Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Asthma, unspecified type, unspecified Percutaneous transluminal coronary angioplasty status Cocaine abuse, unspecified Blood in stool Old myocardial infarction Morbid obesity Long-term (current) use of anticoagulants Anticoagulants causing adverse effects in therapeutic use Duodenitis, without mention of hemorrhage Chronic diastolic heart failure Acute gouty arthropathy Orthostatic hypotension Other agents affecting blood constituents causing adverse effects in therapeutic use Salicylates causing adverse effects in therapeutic use |
allergies: motrin / shellfish attending: chief complaint: gib major surgical or invasive procedure: none history of present illness: 50 yo m with cad s/p multiple pci, chf, afib on coumadin, and active cocaine use presented to the ed this morning c/o 3 days of epigastric pain and melanotic stools. he was discharged from the medicine service at on . the reason for this prior admission was initially chest pain, which was thought to be non-cardiac, but his hospitalization was prolonged by severe knee pain. despite the absence of crystals on joint aspiration, he was empirically treated for gout and started on prednisone 20mg daily, allopurinol, colchicine, and pantoprazole; his ranitidine was stopped. he was discharged on a lovenox bridge for 2 doses but never received it. . per patient, the day after discharge, he developed diffuse abdominal pain and noted black stools. the consistency of the stool varied between soft to hard. denied brbpr. he also experienced some dizziness and substern chest pressure, but no chest pain similar to prior mi. he endorses using cocaine on the day prior to admission. otherwise denied alcohol or tobacco use or any ingestions. . in the ed, initial vs were: t 97.1, p 72, bp 102/76, r 22, o2 sat 100% ra. initial hct was 39.6, down slightly from his baseline in the low 40's. bun was elevated to 40s from a baseline of 10, and cr to 1.3 from a baseline of ~1.0. abd ct with po/iv contrast done as the ed staff was concerned for mesenteric ischemia given the epigastric pain in the setting of recent cocaine use--ct abd preliminary read unremarkable. ng lavage was notable for "specks" or brb which cleared after 500cc. rectal exam notable for melena. . he was given morphine 4mg iv twice for epigastric pain in addition to zofran. gi was consulted and he was given 10mg iv vit k + 2u ffp for inr 1.7. he developed a diffuse urticarial rash after receiving ffp for which he received 50mg of benadryl. during the initial 6 hours of his ed stay, he received 1l ns. immediately prior to transfer: hr= 108, bp= 132/68 and a second liter of ns was started. . on the floor, patient was slightly tachycardic and complaining of diffuse abdminal, shoulder, leg pain. he reported nausea but no vomiting. . 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. denied vomiting, diarrhea, constipation. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: - cad s/p mi x2 in setting of cocaine, bms to mid-rca - dilater cardiomyopathy with chf (lvef 15-20%) - paroxysmal atrial fibrillation on coumadin - dm-ii - dyslipidemia - hypertension - bronchitis / asthma - cocaine abuse - gout - morbid obesity - depression - obstructive sleep apnea - herniated disc, orthopedic problems of the shoulder - h/o e.coli bacteremia - h/o nephrolithiasis - s/p cholecystecomy - h/o pnas social history: had been living alone in an apartment, but now his sister and her children are staying with him. he is a former veteran in the navy and supports himself with ssdi, is single. divorced and having stress because he is paying his social security check for child support despite the children being in their 20s. reports extreme cocaine abuse with the last usage in . reports that at its peak, he was using up to $1600 worth of cocaine per day (smoked it), has been homeless in the past. reports using marijuana intermittently, but with no recent usage for the last several decades. denies any other illicit drug use, no smoking history. drinks alcohol rarely. family history: mother 78 with several heart attacks. father had psychiatric issues. one brother, six sisters; some of them with diabetes. physical exam: physical exam on arrival to vitals: t: 97.8 bp:124/80 p:111 r:21 18 o2:100% 2l nc general: obese man, lying flat in bed, in mild pain heent: sclera anicteric, pupils 2 mm, symmetric, reactive mmm, oropharynx clear neck: supple, no lad, jvp difficult to appreciate due to body habitus lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-distended, bowel sounds present. diffuse tenderness on palpation, no rebound ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. right knee intact passive range of motion. slight warmth and effusion noted. pertinent results: labs on admission: 10:25am blood wbc-13.6* rbc-4.71 hgb-13.0* hct-39.6* mcv-84 mch-27.6 mchc-32.8 rdw-14.9 plt ct-615* 07:25pm blood hct-33.7* 10:25am blood neuts-64.2 lymphs-29.2 monos-4.8 eos-0.9 baso-1.0 10:25am blood pt-19.1* ptt-24.0 inr(pt)-1.7* 10:25am blood glucose-187* urean-46* creat-1.3* na-138 k-4.4 cl-102 hco3-21* angap-19 10:25am blood alt-44* ast-26 alkphos-46 totbili-0.3 10:25am blood lipase-33 10:25am blood ctropnt-0.02* 07:25pm blood ck-mb-4 ctropnt-0.01 10:25am blood digoxin-0.5* 12:03pm blood lactate-3.6* pertinent labs: 04:42am blood wbc-10.1 rbc-3.76* hgb-10.5* hct-32.0* mcv-85 mch-27.9 mchc-32.7 rdw-14.2 plt ct-458* 10:25am blood hct-31.3* 03:21pm blood hct-31.4* 09:34pm blood hct-30.1* 03:15pm blood lactate-1.1 labs on discharge: imaging: - cxr: the cardiac silhouette is upper limits of normal. the lungs are grossly clear without focal consolidation, pleural effusions, or pulmonary edema. bony structures are intact. - ct abd/pelvis: the visualized lung bases demonstrate slight atelectasis but no masses, nodules or pleural effusions. the spleen, adrenals, pancreas, and liver appear within normal limits. patient is status post cholecystectomy with clips in the gallbladder fossa. kidneys enhance and excrete contrast symmetrically without solid masses or hydronephrosis. hypodensities in the mid pole of the left kidney (2:32) is too small to characterize but is likely a cyst. no free air or free fluid or adenopathy is present. incidental note is made of a circumaortic left renal vein but the aorta and its mesenteric branches are patent. stomach and bowel appear normal. pelvis: bowel loops appear normal including a normal visualized appendix. the bladder is normal in appearance. no free air or free fluid or adenopathy is present. bone windows: no suspicious bone lesions are present. degenerative changes are present in the lumbar spine. impression: no acute findings in the abdomen or pelvis to explain patient's symptoms. - kub: the cardiac silhouette is upper limits of normal. the lungs are grossly clear without focal consolidation, pleural effusions, or pulmonary edema. bony structures are intact. brief hospital course: 50 yo m with cad s/p multiple pci, chf, afib on coumadin, and active cocaine use, presents with 3 days of epigastric pain and melanotic stools, concerning for gi bleed. # gi bleed: patient noted to have occult positive stool, however, ng lavage only borderline positive. hct is stable at 39 though lower than baseline of mid-40s. most likely etiology of gi bleed is from medications, which includes prednisone (recently started), baseline aspirin, plavix, coumadin, and lovenox. h2-blocker was also recently stopped and patient transitioned to ppi. all of these medications would make the patient more prone to bleed. on presentation, he was slighly tachycardic with hr in the 100s, most likely from not receiving home diltiazem and metoprolol. he was started with iv pantoprazole gtt. coumadin, lovenox and plavix were held. his initial q6h hct series remained stable. gi evaluated him and did egd which showed no lesions. his bleeding stopped. his hematocrit remained stable. anticoagulation was resumed and he was observed for recurrence in the hospital. bleeding did not recur. # dilated cardiomyopathy with chf: chronic issue and patient followed closely by dr. . echocardiogram on showed moderately dilated left ventricle with severe systolic dysfunction and lvef of 15-20%. in the context of the gi bleed and fluid resuscitation, will monitor closely for signs of fluid overload. cxr on admission does not show pleural effusion or pulmonary edema and patient has good o2 sat on 2l nc, which he was able to be weaned off. he continued with metoprolol and digoxin. lisinopril, spironolactone, and furosemide were held temporarily given arf in the setting of gib; these were resumed without difficulty. # acute renal failure. on admission, cr 1.3 compared to baseline 0.9-1.1. most likely from decreased po intake leading to pre-renal process. he completed ivf from the ed. his creatinine improved. # coronary artery disease: patient has history of multiple mis in the context of cocaine abuse. he has bms to mid-rca placed here in and reported another des to lad: this was confirmed to have been done hosptial, for a 70% lad lesion, with good result. # paroxysmal atrial fibrillation. he continued to be in afib while in the icu with rate mostly in the 80s-100s. last dose of lovenox was when inr was 1.4. he was continued on digoxine and metoprolol. coumadin and lovenox were held temporarily given gib and pending egd procedure; these were resumed without incident. # dm2, and gout were stable. medications on admission: (from discharge summary): 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) puff inhalation q6h (every 6 hours) as needed for sob/wheeze. 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily 3. aspirin 325 mg tablet sig: one (1) tablet po daily 4. colchicine 0.6 mg po bid 5. digoxin 250 mcg tablet po daily 6. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn chest pain. 7. spironolactone 25 mg tablet po daily 8. simvastatin 20 mg po daily 9. furosemide 40 mg po bid 10. lisinopril 40 mg tablet po daily 11. metoprolol succinate 100 mg tablet extended release 24 hr po qd 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation every six (6) hours as needed for shortness of breath or wheezing. 14. glyburide 5 mg po bid 15. warfarin 5 mg po qd 16. allopurinol 300 mg po daily 17. prednisone 20 mg tablet po qd for 7 days ( - ) 18. oxycodone-acetaminophen 10-325 mg tablet sig: one (1) tablet po q4h (every 4 hours). 19. lovenox 150 mg 20. pantoprazole 40 mg tablet, delayed release (e.c.) po qd discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: puff inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 4. digoxin 250 mcg tablet sig: one (1) tablet po daily (daily). 5. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 6. colchicine 0.6 mg tablet sig: one (1) tablet po bid (2 times a day). 7. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). 8. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 9. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 10. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 11. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 12. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*20 tablet(s)* refills:*0* 13. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 14. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 15. glyburide 5 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home with service facility: homecare discharge diagnosis: lower gi bleeding (melena) discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: go to on to have your inr level checked. when you left it was in range at 2.2, with your daily dosing regimen of 5 mg daily department: rheumatology when: friday at 4:30 pm with: , md building: lm bldg () campus: west best parking: garage department: when: at 3:50 pm with: , md building: sc clinical ctr campus: east best parking: garage department: podiatry when: at 1 pm with: clinic (sb) building: ba ( complex) campus: west best parking: garage Procedure: Other endoscopy of small intestine Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Asthma, unspecified type, unspecified Percutaneous transluminal coronary angioplasty status Cocaine abuse, unspecified Blood in stool Old myocardial infarction Morbid obesity Long-term (current) use of anticoagulants Anticoagulants causing adverse effects in therapeutic use Duodenitis, without mention of hemorrhage Chronic diastolic heart failure Acute gouty arthropathy Orthostatic hypotension Other agents affecting blood constituents causing adverse effects in therapeutic use Salicylates causing adverse effects in therapeutic use |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall/syncope major surgical or invasive procedure: 1. aortic valve replacement with a size 19 - magna tissue valve. 2. coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal and right coronary arteries. history of present illness: 85 yo female with pmhx significant for htn, hip fracture, large submental basal cell carcinoma s/p xrt (finished ) admitted to osh with history of fall. she reports "legs giving out under her" with no associated sob, chest pain, dizziness. hx fall 1 year ago resulting in a broken hip. no loc, head ct was negative for intracranial hemmorrhage. on exam noted to have a murmur and echo revealed critical as. subsequently she underwent cardiac catherization which revealed 3 v cad. she is currently on empiric cefazolin and flagyl for xrt wound care to chin. past medical history: large thyroid nodule (seen on cxr) hiatal hernia hypertension large basal cell carcinoma below the right mandible s/p xrt x 2 cycles right hip fracture s/p right hip pin placement social history: race: caucasian last dental exam: several years ago lives with: daughter occupation: tobacco: none etoh: none family history: non-contributory physical exam: pulse:72 resp:18 o2 sat:100% ra b/p right:165/76 left: height:5'4" weight:142# general:aao x 3 in nad, pleasant skin: dry intact 1) multiple diffuse lesions on upper and lower extremites, trunk, back with excoriations and erythema surrounding 2)large erythematous warm area on left medial calf, nontender, no drainage. 3) erythema at right mandibular area and neck with large ulcerative lesion over submental area covered with dry exudate, dressed with gelfoam heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur iii/vi sem 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:1+ left:1+ pt :1+ left:1+ radial right:2+ left:2+ carotid bruit right:transmitted murmur left:transmitted pertinent results: echo: prebypass: extremely limited views on tee. unable to advance probe beyond 35 cms. no atrial septal defect is seen by 2d or color doppler. lvef=55% right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. significant aortic stenosis is present (not quantified). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. moderate (2+) mitral regurgitation is seen. there is a small pericardial effusion. dr. was notified in person of the results on at 1000am. post bypass: poor transgastric views post bypass. unable to obtain gradients post bypass. patient is av paced and receiving an infusion of phenylephrine. biventricular systolic function unchanged. bioprosthetic valve seen in the aortic position. with the limited views appears well seated and the leaflets move well. trivial aortic insufficiency present. 2+ mitral regurgitation persists. aorta is intact post decannulation. carotid u/s: 1. bilateral minimal plaque with low end, 1-39% stenosis. antegrade vertebral flow. 2. incidental sub 2-mm heterogeneous mass within the right submandibular gland. recommend further imaging to better characterize. chest ct: 1. aberrant right subclavian artery. 2. extensive coronary calcifications, moderate aortic root and valve calcifications. 3. isolated ectasia of the right pulmonary artery. 4. large hiatal hernia. 5. minimal left pleural effusion. 6. non-characteristic apical granulomas and ground-glass nodules bilaterally, non-characteristic scars, no acute inflammatory or systemic changes of the lung parenchyma. 7. 3-cm retrosternal thyroid nodule. le u/s: 1. left calf dvt of the posterior tibial veins. 2. no evidence of right leg dvt. 3. 1.5 cm right cyst. brief hospital course: as mentioned in the hpi, ms. was transferred from outside hospital following fall/syncopal episode. cath at revealed severe coronary artery disease. subsequent echo showed severe aortic stenosis. upon admission she was medically managed, including iv antibiotics for non healing chin ulcer s/p xrt which was recently completed. she underwent extensive pre-operative work-up, including chest ct, carotid and lower extremity u/s, echo and dental and vascular consults. left lower extremity ultrasound was postive for left dvt. she was treated with iv heparin pre-operatively and coumadin postoperatively which will continue for 6 months. id was consulted for her chin ulcer and she was treated with iv vanco. her mrsa swab was negative and she was transitioned to po keflex for 10days for her chin ulcer upon discharge. on she was brought to the operating room where she underwent a coronary artery bypass graft x 3 and aortic valve replacement (tissue). please see operative report for surgical details. following surgery she was transferred to the cvicu for invasive monitoring in stable condition. within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. beta-blockers and diuretics and statin therapy were initiated on post-op day one and she was diuresed towards he pre-op weight. on post-op day one she was transferred to the telemetry floor for further care. chest tubes and epicardial pacing wires were removed per protocol. she experienced post operative atrial fibrilation and was treated with po amiodarone, increased coreg and digoxin and converted to sinus rhythm. she was evaluated by physical therapy and rehab was recommended upon discharge. she was discharged to nursing and rehab on . medications on admission: medications at home: lopressor 50 mg , occ mvi meds on transfer: cefazolin im q 8 hrs, b12 100 mcg po daily, metoprolol 50 mg , flagyl 500 mg tid discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever, pain. 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 7. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day): decrease as indicated and then d/c when edema resolves. 8. keflex 500 mg capsule sig: one (1) capsule po twice a day for 10 days. 9. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itching . 10. amiodarone 200 mg tablet sig: two (2) tablet po once a day: 400mg daily for 7 days then decrease to 200mg daily. 11. warfarin 1 mg tablet sig: as directed for dvt tablet po once daily at 4 pm: goal inr 2.0-3.0 has been rec'ing 2.5 mg. 12. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). discharge disposition: extended care facility: nursing and rehab discharge diagnosis: aortic stenosis s/p aortic valve replacement coronary artery disease s/p coronary artery bypass graft x 3 past medical history: large thyroid nodule (seen on cxr) hiatal hernia hypertension large basal cell carcinoma below the right mandible s/p xrt x 2 cycles right hip fracture s/p right hip pin placement left calf dvt dx'd discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with tylenol incisions: sternal - healing well, no erythema or drainage leg right - healing well, no erythema or drainage. bilateral lower extremity 2+ edema chin wound: continue adaptic and dsd daily and prn. 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 on at 1:15pm cardiologist: dr on at 11:45am 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** labs: pt/inr for coumadin ?????? indication dvt goal inr 2.0-3.0 first draw md Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Diaphragmatic hernia without mention of obstruction or gangrene Personal history of other malignant neoplasm of skin Cellulitis and abscess of leg, except foot Personal history of irradiation, presenting hazards to health 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 Acute venous embolism and thrombosis of deep vessels of distal lower extremity Chronic ulcer of other specified sites Nontoxic uninodular goiter |
allergies: sulfa (sulfonamide antibiotics) / suprax / paxil / penicillins attending: chief complaint: altered mental status, fever, hypotension major surgical or invasive procedure: percutaneous nephrostomy tube placement history of present illness: the patient is a year old resident of rehab who presents with altered mental status. she was recently started on a course of cipro (d1 ). today had addominal pain and chills. was noted to be hypotensive to 94/62. she had urinary retention and a foley was placed. . in the ed, initial vs were: 98.3 69 113/66 18 96% ra. labs were notable for leukocytosis with bandemia, thrombocytopenia, acute renal failure and lactate of 3.8. she was given vanc and cipro. she was given only 500cc of ns for ivf due to hyponatremia. . on arrival her family states that on tuesday () she had severe flank pain and on wednesday () had pain that reminded her of menstrual cramping. last night she became acutely confused but denied pain. at baseline, she has short term memory loss but is oriented x3 and very active. her mental status represented an acute change and she was also lethargic. other notable recent past medical history is a tooth infection treated with a course of antibiotics 3 weeks ago. she was suppossed to have the tooth removed but this did not occur. she had resolution of her symptoms. . currently she denies pain, chest pain, dyspnea, abdominal pain. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, 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: niddm htn high chol dementia cataracts melanoma (completely excised) s/p hysterctomy social history: - tobacco: none - alcohol: h/o very occaisional - illicits: none family history: noncontributory physical exam: admission exam: general appearance: thin eyes / conjunctiva: perrl, ecchymoses on tongue head, ears, nose, throat: normocephalic cardiovascular: (s1: normal), (s2: normal), (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: crackles : bilat bases, no(t) wheezes : ) abdominal: soft, non-tender, bowel sounds present extremities: right lower extremity edema: absent, left lower extremity edema: absent, no(t) cyanosis, no(t) clubbing skin: warm, no(t) rash: , no(t) jaundice, many many sks neurologic: follows simple commands, responds to: verbal stimuli, movement: not assessed, tone: not assessed, cns intact discharge exam: vitals: t:96.9 bp:160/70 (140-180/70-81) p:64 (64-80) r:18 o2: 94% ra i/o: --/600+500nephro; 1130/1050++bm general: sleeping but easily rousable, oriented to self and date, year, no acute distress, speaking in full sentences heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, did not appreciate bibasilar crackles at this time, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley draining clear yellow urine; l pcn draining serosanguinous fluid. no cvat. ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: multiple sebborrheic keratoses and nevi neuro: cn 2-12 intact. tangential, spelling words frequently. perseverates and repeats important life dates. pertinent results: 12:00pm blood wbc-20.6*# rbc-3.55* hgb-10.7* hct-30.1* mcv-85 mch-30.0 mchc-35.5* rdw-13.2 plt ct-54*# 12:00pm blood neuts-88* bands-6* lymphs-3* monos-3 eos-0 baso-0 atyps-0 metas-0 myelos-0 12:00pm blood pt-14.6* ptt-29.0 inr(pt)-1.3* 12:00pm blood fibrino-918* 12:00pm blood ret aut-pnd 12:00pm blood glucose-224* urean-50* creat-2.0* na-120* k-4.9 cl-86* hco3-20* angap-19 12:00pm blood alt-19 ast-55* ld(ldh)-257* alkphos-66 totbili-0.9 12:00pm blood albumin-3.5 calcium-8.2* phos-2.9 mg-1.6 12:00pm blood hapto-pnd 12:00pm blood osmolal-pnd 12:00pm urine color-yellow appear-hazy sp -1.014 12:00pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-lg 12:00pm urine rbc-7* wbc-54* bacteri-few yeast-none epi-0 12:00pm urine casthy-4* 12:00pm urine mucous-rare 03:33pm urine hours-random creat-87 na-21 k-89 cl-20 03:33pm urine osmolal-449 11:55 am blood culture **final report ** blood culture, routine (final ): escherichia coli. final sensitivities. piperacillin/tazobactam sensitivity testing confirmed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>256 r ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- 0.5 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s aerobic bottle gram stain (final ): reported to and read back by dr. on at 0630. gram negative rod(s). anaerobic bottle gram stain (final ): gram negative rod(s). other blood and urine cultures pending. imaging: chest (portable ap) study date of 6:13 am frontal chest radiograph: there is increased perihilar indistinctness and diffuse ground-glass opacity with small bilateral pleural effusion and cardiac enlargement in keeping with congestive heart failure. retrocardiac opacity has increased and may reflect atelectasis. again seen is mild prominence in the region of the ascending aorta. attention to this area should be paid on followup chest radiographs. there is no pneumothorax. . chest (portable ap) study date of 5:07 pm frontal chest radiograph: there has been mild improvement in the degree of pulmonary edema. cardiomediastinal silhouette is stable. there is unchanged retrocardiac opacity as well as a moderate-sized left-sided pleural effusion. there is a linear lucency at the right lung apex. this may represent line, however, a pneumothorax is not excluded. recommend repeat chest radiograph. impression: 1. improving pulmonary edema. 2. left-sided pleural effusion and retrocardiac opacity. 3. lucency at the right lung apex may represent line from an overlying skin fold. recommend repeat chest radiographs. . ct abd & pelvis w/o contrast study date of 4:10 am findings: ct abdomen: lung bases demonstrate small bilateral pleural effusions with adjacent compressive atelectasis. the coronary arteries are calcified. evaluation is limited without iv contrast. the non-contrast appearance of the spleen, adrenal glands, liver, and stomach are within normal limits. a calcified gallstone is noted within the gallbladder. there is diffuse fatty atrophy of the pancreas, making it hard to fully visualize. there is diffuse calcified atherosclerotic disease of the intra-abdominal arterial vasculature. there is a small amount of ascites. the non-contrast appearance of the right kidney is within normal limits. there is mild-to-moderate hydronephrosis of the left kidney with mild surrounding fat stranding with hydroureter seen down to the level of the mid ureter. however, the ureter is not definitively seen beyond this point. a candidate distal left ureter may be seen with calcification versus multiple small obstructing stones in the distal left ureter (300b:30 and 2:64-71). ct pelvis: there is a large amount of stool within the rectum. the bladder is decompressed with a foley catheter. the uterus is absent. there is small amount of free fluid within the pelvis. intrapelvic loops of bowel are within normal limits. there is no inguinal or pelvic lymphadenopathy. bone windows: there is grade 1 anterolisthesis of l4 on l5, likely due to degenerative changes. impression: 1. limited evaluation given lack of iv contrast. mild-to-moderate hydronephrosis of the left kidney with mild surrounding fat stranding with hydroureter. the distal left ureter is not definitely seen, but may contain calcification of the ureter versus multiple small obstructing stones. alternatively, this could represent a small calcified branch artery off the internal iliac artery. 2. small amount of ascites. 3. small bilateral pleural effusions. 4. cholelithiasis. renal u.s. port study date of 12:13 am findings: the right kidney measures 12.3 cm. it is normal in appearance without hydronephrosis, stones or mass. there is a trace amount of fluid surrounding the lower pole of the right kidney, however. the left kidney measures 10.1 cm and demonstrates moderate hydronephrosis. there are no renal stones or masses. the proximal ureter is dilated; however, an obstructing cause is not seen as overlying bowel gas limits evaluation. the bladder is decompressed with a foley catheter and not well seen. impression: 1. moderate hydronephrosis of the left kidney. the obstructing cause is not identified on this study. 2. normal appearance of right kidney. trace amount of fluid surrounding the lower pole of the right kidney. 3. bilateral pleural effusions. ct head w/o contrast study date of 12:34 pm findings: there is no evidence of any intra-axial or extra-axial hemorrhage. there is good -white matter differentiation. there is disproportionate atrophy seen in the frontal lobes bilaterally. there is no evidence of large mass cerebral edema or shift of midline structures. there is some periventricular white matter hypodensities suggestive of small vessel ischemic disease. there is no evidence of any underlying fracture. mucus retention cysts are seen within the sphenoid sinuses. minimal mucosal thickening of the ethmoid air cells is noted. mastoid air cells are well pneumatized. impression: 1. no evacute intracranial process. 2. mucosal retention cysts in the sphenoid sinuses brief hospital course: yo f p/w sepsis likely uti, hyponatremia, and delirium. # urosepsis: u/a positive for pan-sensitive e coli with blood cultures growing gnrs. patient met sirs criteria. previously had flank pain concerning for pyelonephritis though u/s and ct not suggestive of active infection or any current obstruction. given l mild hydronephrosis she may have previously passed a stone. patient with persistent hypotension and elevated wbc after two days of antibiotics and it was felt infectious source not likely well controlled. on , ir placed percutaneous nephrostomy tube. patient was continued on ceftriaxone and then switched to po cipro given senstitivities showed e coli was pan sensitive. plan was to complete a 14 day course of abx (day 1 =; day 14 = ). pt improved and was able to go to floor. pt continued to recover and remain stable with improved mental status and vs. pt was discharged back to rehab with planned follow-up with urology and ir (ir placed nephrostomy tube). . # altered mental status: per family, patient with dementia at baseline, but was more altered on admission. differential diagnosis included delirium in setting of urosepsis, cipro med effect and hyponatremia. patient's mental status improved with treatment of urosepsis and treatment of hyponatremia. on floor she was very alert and pleasant, telling jokes and interacting with staff appropriately. delerium had cleared and pt had returned to baseline. . # hyponatremia: likely hypovolemic hyponatremia, may be component of siadh in setting of sepsis though low urine na. sodium acutely dropped from 128 to 120, now improved to 132 in the icu after patient received volume with ns. . # acute renal failure: likely to sepsis vs hypovolemia (pre-renal). concern for obstructive component. improved with fluid and decompression of obstruction. . # thrombocytopenia: no ttp per heme-onc. be sepsis vs med effect. dic work-up unrevealing. likely secondary to sepsis. . # anemia: as above, no evidence of ttp. be due to anemia of chronic inflammation vs renal failure. hct at recent baseline. . # dm2: held metformin while in house, iss. . # hld: continued statin, held aspirin. . planned follow-up with urology and ir: pt will be seen by urology on for follow-up and determination if additional intervention is required. per ir, regarding care of percutaneous nephrostomy tube: check site daily for signs of infection. if soiled or erythematous, change dressing and monitor. as wound heals, dressing changes can be transitioned to once per week or unless the dressing becomes soiled however site should be monitored daily for signs of infection. dressing should be changed once per week or unless the dressing becomes soiled. pt will also need to have a routine exchange of the tube every 3 months unless urology chooses to intervene (this has been scheduled for ). if a problem occurs with the tube or urology requests an earlier tube exchange or change, please call the interventional radiology clinic services number to make the necessary arrangements. as above, pt will be seen by urology on by urology for follow-up to ensure improvement and to determine if additional interventions are required. f/up remaining blood and urine cultures f/up nephrostomy tube and resolution of infection; question remains if further intervention will be needed to remove obsturction medications on admission: acetaminophen 650 q4h prn asa 81 daily kcl 10 meq daily simvastatin 20 daily atenolol 25 mg hydrochlorothiazide 25 mg daily metformin 1000mg calcium carbonate 1300 daily ciprofloxacin 250mg (received 2 doses, first dose 5/26 am) d5 normal saline @ 75 cc/hr x 13 hours, 20 min discharge medications: 1. tylenol 325 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. potassium chloride 10 meq tablet extended release sig: one (1) tablet extended release po once a day. 4. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 5. atenolol 25 mg tablet sig: one (1) tablet po twice a day. 6. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 7. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 8. calcium carbonate 500 mg calcium (1,250 mg) tablet, chewable sig: two (2) tablet, chewable po once a day. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 11. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 9 days: to complete a total of 14 days of abx. day 1 = day 14 = . disp:*9 tablet(s)* refills:*0* 12. percutaneous nephrostomy tube nephrostomy site should be checked daily for signs of infection. if soiled or erythematous, change dressing and monitor. as wound heals, dressing changes can be transitioned to once per week or if the dressing becomes soiled however site should be monitored daily for signs of infection. tube will also need to have a routine exchange of the tube every 3 months unless urology chooses to intervene. an appointment has been made for . however, if a problem occurs with the tube or urology requests an earlier tube exchange or change, please call the interventional radiology clinic services number to make the necessary arrangements. discharge disposition: extended care facility: for the aged - ltc discharge diagnosis: primary: -altered mental status, fever, hypotension due to e coli sepsis secondary to uti and nephrolithiasis -acute renal failure due to obstruction and acute infectious process secondary: hypoxia thrombocytopenia anemia hypertension discharge condition: mental status: clear and coherent but with baseline mild dementia level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you came to the hospital because you were experiencing altered mental status, fever, decreased blood pressure and were found to have and bacterial infection of your urinary track as well as a blockage of your left kidney because of stones. you were admitted to the internsive care unit where you recieved antibiotics, fluids and a tube was placed to help to decompress your left kidney and drain the urine. your symptoms improved and you were able to be moved from the intensive care unit to the regular floor. you continued to make improvements and it was felt you could be discharge back to rehab to complete your recovery there. you will have close follow-up with your regular doctor as well as urology and interventional radiology (the doctors who placed the tube to help drain your kidney). . the following changes were made to your medications: - please start taking cipro to complete your 14 day course of antibiotics (day 1 =). - please continue to take all of your other home medications as prescribed. percutaneous nephrostomy tube: your site should be checked daily for signs of infection. if soiled or erythematous, change dressing and monitor. as wound heals, dressing changes can be transitioned to once per week or unless the dressing becomes soiled however site should be monitored daily for signs of infection. you will also need to have a routine exchange of the tube every 3 months unless urology chooses to intervene. an appointment has been made for you already. however, if a problem occurs with the tube or urology requests an earlier tube exchange or change, please call the interventional radiology clinic services number to make the necessary arrangements. you will also be seen by urology on for follow-up to ensure improvement and to determine if additional interventions are required. please be sure to keep all follow-up appointments with your primary care doctor, urologist and other health care providers. . it was a pleasure taking care of you and we wish you a speedy recovery. followup instructions: please be sure to keep all follow-up appointments with your primary care doctor, urologist and other health care providers. department: surgical specialties when: wednesday at 10:00 am with: urology unit building: sc clinical ctr campus: east best parking: garage department: radiology care unit when: friday at 7:00 am building: de building ( complex) campus: west best parking: garage **nothing to eat or drink after midnight the night before** department: radiology when: friday at 8:30 am building: cc clinical center campus: west best parking: garage Procedure: Percutaneous nephrostomy without fragmentation Diagnoses: Thrombocytopenia, unspecified Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Severe sepsis Other persistent mental disorders due to conditions classified elsewhere Pulmonary collapse Iron deficiency anemia, unspecified Septicemia due to escherichia coli [E. coli] Hydronephrosis Delirium due to conditions classified elsewhere Other seborrheic keratosis |
allergies: bactrim attending: chief complaint: left-sided weakness major surgical or invasive procedure: -peg tube placement history of present illness: the patient is an 85-year-old right-handed female with a past medical history significant for hypertension, hyperlipidemia, and atrial tachycardia with a stroke resulting in transient left leg weakness in the right aca territory in who presents with an acute onset of left arm, face, and leg weakness. the patient apparently was in her usual state of health today and had fully recovered from her last stroke in 06/. the patient has been having some difficulty with osteoarthritis of her right knee and has sustained a number of falls lately. most notably, the patient had a fall last thursday secondary to this knee where she struck her lip and the left side of her face resulting in sutures about the inner part of her mouth as well as the outer lip. in addition, she may have had a slight fracture to her nose. as a result of this fall, it was decided to postpone the knee surgery while these wounds healed. today, the patient was feeling in her usual state of health until approximately 5 p.m. when she described to her daughter a sensation of dizziness, which she experienced in the bathroom. she felt like she may fall over so she slid herself on to the floor. there was no head strike and there was no loss of consciousness. the patient was currently unable to describe what occurred; however, she did call a neighbor who helped her up and placed her in the bed. afterwards, she called her daughter to inform her of what happened. at that time, the patient reported feeling well and moving all four extremities without any problem. . approximately 7 p.m. this evening, her neighbor came over and noted her to be in a normal state. by report she was able to get up, walk, and put a dvd in a dvd player. subsequently after this, she apparently told her friend that she was not feeling right and developed at around 7 p.m. the acute onset of left arm weakness and left leg weakness. her speech reportedly was not making much sense and she was noted to have a left facial droop. in addition, her eyes were fixed to the right side. based on these acute symptoms, the neighbor called ems and notified the patient's daughter and the patient was brought quickly to where she was seen as a code stroke at 7:51. the patient was evaluated by the stroke team soon after and was determined clinically to have a stroke. her nih stroke scale was 21. she had a head ct, which did not show any bleeding and a decision was made to give the patient tpa. she was given tpa at 8:32 p.m. with a 6.3 mg bolus and a 56 mg infusion subsequently. the patient did not have significant improvement over the next hour and it was decided that a cta will be done. the patient had a cta, which showed a clot in the m1 distribution and it was decided that she may be a candidate for thrombectomy. she was brought to the interventional radiology suite; however, when she got there, it was noted on the cta and ct perfusion maps that there was no obvious penumbra and the stroke attending felt that it would not give much benefit the decision was made that the risks of opening up the clot were greater than the benefits and the patient was admitted to the icu service for further management. nih stroke scale score was 21: 1a. level of consciousness: 0 1b. loc question: 2 1c. loc commands: 0 2. best gaze: 2 3. visual fields: 2 4. facial palsy: 2 5a. motor arm, left: 4 5b. motor arm, right: 0 6a. motor leg, left: 4 6b. motor leg, right: 0 7. limb ataxia: 0 8. sensory: 0 9. language: 1 10. dysarthria: 2 11. extinction and neglect: 2 time code stroke called: 19:51 (24h clock) time neurology at bedside for evaluation: 19:51 (24h clock) time (and date) the patient was last known well: 19:00 (24h clock) nih stroke scale score: 21 t-: yes time t-pa was given 20:32 (24h clock) on neuro ros (per daughter and patient), the pt denies headache, no recent change in vision. had an episode of dizziness this afternoon as described above. no recent bowel or bladder incontinence or retention. prior to above event no difficulty with gait. on general review of systems, the pt denies recent fever or chills. no night sweats or recent weight loss or gain. denies cough, shortness of breath. denies chest pain or tightness, palpitations. denies nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denies arthralgias or myalgias. denies rash. . on transfer to the cardiology service: mrs is a pleasant 85 yo female with hx htn, hld, atrial tachycardia, baseline dementia, hx aca stroke (without residual deficits) who was initially admitted to the neurology service on for large r mca stroke. during the hospitalization, whe underwent tpa with no improvement in sxs, thrombectomy was deferred given concern for risk of bleed. course has been complicated by ? vtach vs afib with abberancy on , requiring cardioverson x3 and amiodarone load. subsequent ces and echo were wnl. she then went back into afib with rvr to the 160s while intubated and getting peg on , which was controlled with esmolol during the procedure; in the pacu she apparently became hypotensive on diltiazem gtt. cardiology consult was called for management of afib; metoprolol was subsequently uptitrated and the recommendation was made to start anticoagulation with warfarin. . overnight hr became more difficult to control, requiring metoprolol iv boluses, which she was refractory to, and digoxin. she is being transferred to the cardiology for further management of afib/rvr. . . <u><b>cardiac review of systems:</b></u> (+) per hpi (-) denies chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . <u><b>other review of systems:</b></u> (+) per hpi (-) denies any exertional buttock or calf pain; prior history of deep venous thrombosis, pulmonary embolism; bleeding at the time of surgery, hemoptysis, black or red stools. . also denies fevers, chills, myalgias, joint pains; cough, wheezes; diarrhea, or recent change in bowel habits; dysuria or change in voiding habits; rashes or skin breakdown; numbness/tingling in extremities; feelings of depression or anxiety. all of the other review of systems were negative. past medical history: - right aca stroke secondary to hypoperfusion (due to an adenosine stress test) in setting of hypoplastic a1 segment of aca -osteoarthritis awaiting a right knee replacement - hyperlipidemia - hypertension - left bundle branch block - atrial tachycardia social history: "retired" homemaker, lives alone, independent in all iadls including paying bills -tob: never -etoh: no heavy use -drugs: never family history: sister with stroke at 92, sister with disease, 2 brother with cardiac disease younger than 50 (one with mi and one with angina both in 40s), 2 brothers with mi older than 50 physical exam: on admission: . vitals: t:96.7 p:78 r: 16 bp:176/52 sao2:97 general: awake, cooperative. follows some commands heent: nc/at, no scleral icterus noted, mmm, bruise an sutures on lower lip, bruise around left eye (from fall last week) neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: lungs cta bilaterally cardiac: rrr, nl. s1s2, abdomen: soft, nt/nd, normoactive bowel sounds extremities: no c/c/e bilaterally . neurologic: -mental status: alert, difficult to understand. appears to know name, in hospital. can't tell if she knows date. will follow most axial and appendicular commands, although appears to neglect left side of space (keeps raising right arm despite asked to raise left). somewhat inattentive, can't get to state dow forward. very dysarthric but speaks in full sentence. naming intact to low frequency objects. . -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. does not blink to threat on the left iii, iv, vi: right sided gaze deviation v: facial sensation intact to light touch. vii: left sided facial droop, spares forehead viii: hearing intact to voice ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. . -motor: normal bulk, increased tone in left leg. left arm, extensor postures to nox stim, otherwise flaccid. left leg mostly triple flexes, but occasionally some non-reflexive movement seen right arm, full/near full at /tricep/finger flexor, right leg, full strength, purposeful movement . -sensory: appears intact on right, withdraws to pain on left . -dtrs: tri pat ach l 2 2 2 3 2 r 2 2 2 - 2 plantar response was extensor on left, mute on right -coordination: normal fnf on right -gait: not assessed. on discharge: physical exam: unchanged other than** general: wdwn in nad. alert & oriented x3. mood, affect appropriate. no central or peripheral cyanosis; no jaundice, no palor. heent: ncat. sclera anicteric. perrl, eomi. neck: supple; no jvd. cardiac: pmi non-displaced, larger than a dime - about quarter sized. rr, normal s1, s2; no s3, s4. no m/r/g. no thrills, lifts. lungs: ctab, no adventitial sounds. respirations unlabored, no accessory muscle use. abdomen: soft, ntnd. no hsm or tenderness. no abdominial bruits. groin: no femoral bruits. extremities: no cyanosis, clubbing, or edema. sacrum: no ulcer skin: no stasis dermatitis, ulcers, scars. pulses: right: pt 2+ left: pt 2+ **neuro: cn 7 improving, with left sided facial droop improving. left sided neglect improving, with head more midline now and able to converse with people on her right. otherwise, unchanged - cn2-10 intact, 11 with deficits on left, 12 intact; hyperreflexia left ue and le, toes upgoing on left; toes down on right, normal tone and reflexes on right pertinent results: on admission: 07:55pm blood wbc-13.8* rbc-3.73* hgb-11.8* hct-34.6* mcv-93 mch-31.7 mchc-34.2 rdw-15.5 plt ct-370 07:55pm blood pt-12.7 ptt-23.6 inr(pt)-1.1 03:24am blood glucose-175* urean-21* creat-0.5 na-139 k-3.7 cl-108 hco3-22 angap-13 03:24am blood alt-12 ast-17 ck(cpk)-35 03:24am blood ck-mb-3 ctropnt-<0.01 03:24am blood calcium-8.6 phos-3.3 mg-1.8 cholest-129 03:24am blood %hba1c-5.8 eag-120 03:24am blood triglyc-62 hdl-52 chol/hd-2.5 ldlcalc-65 03:24am blood tsh-1.1 11:57pm blood type-art po2-337* pco2-27* ph-7.50* caltco2-22 base xs-0 11:57pm blood lactate-1.4 11:57pm blood o2 sat-99 11:57pm blood freeca-1.19 . on discharge: . tee : 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 symmetric left ventricular hypertrophy. overall left ventricular systolic function is normal (lvef>55%). with normal free wall contractility. the diameters of aorta at the sinus, ascending and arch levels are normal. calcified atherosclerotic plaque is seen in the left main coronary artery (clip ). there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. impression: no thrombus or spontaneous echo contrast in the la/laa. cxr no pulmonary edema. portable abdomen : impression: ng tube in adequate position. ct head w/o contrast on - extensive right mca territory infarction involving the right frontal, parietal and, temporal lobes with mildly increased edema and effacement of the right lateral ventricle compared to . a 3.4 mm leftward shift of normally midline structures is also new compared to the prior study. ct head w/o contrast on - extensive right mca territorial infarction involving the right frontal, parietal, and temporal lobes are evident on this ct study compared to the cta head and neck of , and appear increased in extent at the right frontal vertex in comparison to the mri of . the distribution of the large acute infarction is more extensive than on the dwi sequence from the mr study performed some 20 hours earlier. allowing for the "islands" of preserved brain within, there is no definite evidence of hemorrhagic conversion. tte on - left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. mr w/o contrast on - . extensive acute infarcts noted involving the right frontal, parietal, and temporal lobes with small area in the left frontal lobe and a few smaller areas in the right occipital and in the right cerebellar hemispheres cta head w/ and w/o c & recons on - 1. large right mca infarct with thrombus filling the distal right m1 segment. 2. right distal aca infarction, partially visualized, with filling defects within the pericallosal arterires bilaterally, and no evidence of penumbra in this region. this may represent the patient's known chronic infarction. atherosclerotic disease without flow limiting stenosis or occlusion. other details as above- degenerative changes in the spine with canal and foraminal narrowing . brief hospital course: 85 yo female with hx htn, hld, atrial tachycardia, baseline dementia, hx aca stroke (without residual deficits) who was initially admitted to the neurology service on for large r mca stroke, went into af-rvr, was transferred to for further management, and underwent successful tee-cardioversion. . # mca stroke: the patient was last seen normal at 7pm on , when her neighbor witnessed the onset of left arm weakness, left facial droop, and right gaze deviation. ems was called and a code stroke was called at 7:53pm. her exam was notable for a flaccid left arm with extensor posturing to stim, a left leg that triple flexes, left facial droop, right gaze deviation, left hemi-neglect. the patient had a stat ct which did not show any hemorrhage. based on the clinical picture it was determined that she had a r mca stroke and tpa was given at 8:32pm. there was no significant improvement in the patient's condition over the next hour so a cta/p was obtained. the cta showed a persistent clot in the m! segment of the right mca. based on this she was taken to the angio-suite for possible thrombectomy, however the ctp showed a near complete infarct with no obvious penumbra, and the decision was made that the risks of reperfusion injury outweighed any benefits. patient was admitted to neuro-icu with q1 hour neuro checks under . post tpa care was given. follow up head ct demonstrated extension but no definite evidence of hemorrhagic conversion. bp was kept at goal of sbp 160 - 180. pt. was transferred from the icu to the floor on . she was subsequently transferred to the cardiology service after going into af-rvr; her neurologic status improved slightly prior to discharge as detailed in the discharge pe. speech and swallow saw the patient and cleared her for the dysphagia solids and nectar liquids. . # af-rvr: patient went into atrial-tach with aberrency while undergoing peg placement and received amio 300mg iv due to concern for v-tach, then converted to sr; also received esmolol for hypertensive urgency and diltiazem gtt in the pacu, which made the patient hypotensive. she then had recurrent persistent afib with rvr and was transferred to the cardiology service for further management. pt was started on several regimens of diltiazem, metoprolol and digoxin which were unsuccessful due to hypotension (goal sbp 110-180 per neuro) and persistent tachycardia. she therefore went for tee cardioversion which was successful. she was maintained in sinus rhythm with disopyrimide and metoprolol which were continued on discharged. she was also started on warfarin therapy for stroke prophylaxis. **qtc will need to be followed with serial ekgs after discharge, with goal qtc < 500 on disopyramide.** **hr/bp will also need to be followed and metoprolol titrated accordingly.** **inr will need to be followed and warfarin titrated accordingly.** . # respiratory support: s/p intubation on while patient in atrial-tach with aberrency. she was successfully weaned from the ventilator and transferred to the floor. . # peg placement: patient failed s/s with difficulty placing ng tube early in the hospitalization. consideration for a peg was made which was placed under anesthesia by surgery on . pt then underwent a speech and swallow evaluation and diet was advanced to thickened liquids and ground solids, which she was tolerating on discharge. tube feeds were also continued due to concern for inadequate caloric intake. **pt should be re-evaluated by nutritional services at rehab.** . # anemia: work-up revealing for acd with fe:tibc of 24, but with likely concamitant iron deficiency anemia with low-normal ferritin and fe. **after discharge, may benefit from being started on fe supplementation.** . inactive issues: . # hyperglycemia, post-stroke: blood glucose well controlled on riss, requiring very little insulin. . # hypothyroidism: continued home regimen of levothyroxine sodium 100 mcg. . transitional issues: as above in **. medications on admission: -atenolol 25 mg daily -diovan 240 mg daily -simvastatin 20 mg daily -levothyroxine 100 mcg daily -mupirocin 2% nostril; never filled -triamcinolone ointment 0.1% daily to abdominal rash prn -desonide cream daily to face/body rash discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*2* 2. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 3. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 4. aspirin 81 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* 6. disopyramide 100 mg capsule sig: one (1) capsule po q8h (every 8 hours). disp:*90 capsule(s)* refills:*2* 7. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day) as needed for constipation. disp:*280 ml* refills:*2* 8. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation. disp:*60 tablet(s)* refills:*2* 9. inr check goal inr : check inr, fax results to rehab physician to titrate warfarin. : check inr, fax results to rehab physician to titrate warfarin . etc. until inr stabilizes 10. qtc check goal qtc < 500 ms : check ekg qtc -> fax results to rehab physician; disopyramide may be stopped by the physician if > 500 : check ekg qtc -> fax results to rehab physician . medications may also need to be titrated if afib recurrs. continue to check qtc until follow-up with cardiologist 11. hr & bp check goal hr 55-70. goal sbp 110-180. : check hr/bp, fax results to rehab physician; may titrate metoprolol accordingly : check hr/bp, fax results to rehab physician . continue to check hr/bp until stabilized on metoprolol regimen discharge disposition: extended care facility: hospital- discharge diagnosis: primary: -ischemic right middle cerebral artery stroke -atrial fibrillation with rapid ventricular response . secondary: -none discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: it has been a privilege to take care of you at the (). . you were hospitalized because you had a major stroke resulting from the obstruction of blood flow to the right side of your brain. you were given a medication by the neurologists to help restore blood flow and, in turn, oxygen to part of your brain affected by the stroke. you tolerated this well and over the course of the hospitalization you have regained some of the functioning that you initially lost, which is a good sign. you continue to have significant left-sided neurologic deficits that may or may not improve with time and rehabilitation. we are discharging you to a rehabilitation facility to help you exercise the left side of your body to maximize your chances of good recovery. we encourage you to take full advantage of all of their services. . your new neurologic medication regimen to prevent future strokes is: # start: warfarin 1 mg daily . during your hospitalization your heart went into an irregular fast rhythm called atrial fibrillation with rapid ventricular response. you were transferred from the neurology service to the cardiology service to have this problem addressed; on the cardiology service we treated you with medications at first, but when you continued to have this irregular rhythm, you underwent a procedure called a cardioversion with direct visualization of your heart via an esophogeal echocardiogram. you tolerated the procedure well and afterwards, your heart rhythm was regular and no longer fast. we also started you on a new medication to ensure that your heart stays in a regular rhythm. . the cardioversion and new medication are only part of your treatment. you will need to take the following medications after discharge: # start: disopyramide 100 mg every 8h # start: metoprolol 25 mg every 6h # stop: atenolol 25 mg daily # stop: diovan 240 mg daily # start: warfarin 1 mg daily; this medication will need to be adjusted by your physicians at the rehabilitation facility # start: aspirin 81 mg daily # continue: simvastatin 20 mg daily . please continue to take the rest of your medications as previously prescribed, except the following medications: # stop: triamcinolone ointment 0.1% daily # stop: desonide cream daily to face/body rash # start: senna to prevent constipation # start: colace to prevent constipation . a peg tube was placed during the hospitalization to support your nutrition while you were unable to swallow. prior to your discharge, you were evaluated by our speach and swallow service and deemed well enough to eat again and you have since been swallowing well. your peg tube is still in place, but you and your family, in conjunction with your primary care physician, make the decision in the future to remove the tube. . please attend the follow-up appointments detailed below. followup instructions: department: cardiac services when: friday at 2:00 pm with: , np building: sc clinical ctr campus: east best parking: garage department: neurology when: tuesday at 2:30 pm with: , m.d. building: campus: east best parking: garage you will also need to schedule an appointment with your pcp on discharge. md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other electric countershock of heart Other electric countershock of heart Injection or infusion of thrombolytic agent Percutaneous [endoscopic] gastrostomy [PEG] 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 Unspecified acquired hypothyroidism Atrial fibrillation Other persistent mental disorders due to conditions classified elsewhere Other and unspecified hyperlipidemia Cerebral edema Iron deficiency anemia, unspecified Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Cerebral embolism with cerebral infarction Paroxysmal supraventricular tachycardia Osteoarthrosis, localized, not specified whether primary or secondary, lower leg Hemiplegia, unspecified, affecting nondominant side Coronary vasodilators causing adverse effects in therapeutic use Dysphagia, unspecified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: fall with loss of consciousness major surgical or invasive procedure: right ear laceration repair right brow laceration repair history of present illness: history of present illness: 75 yo male with pmh htn, dm ii, etoh abuse and etoh cirrhosis, esophageal varices with gi bleed 20 yrs ago who presented with fall, while exiting a cab while intoxicated. +head strike and +loc. unclear if he syncopized or had mechanical fall. he has no recollection of the event and does not recall event. found by a neighbor lying in a pool of blood. he was transported by ems to ed. pt reports that prior to the fall he had noticed increased shortness of breath over the course of the day, most evident with exertion such as ambulating. denies experiencing any chest pain, chest pressure or palpitations. no other constitutional symptoms. he has not noticed any brbpr. stools are black, though he is on iron supplementation. . in the ed, initial vs were: t:96.8 p51 bp96/77 r12 o2 sat100ra. initial etoh level was 122. head ct showed a small 2mm l sdh and nasal bone fx. seen by neurosurg who did not feel that this required emergent intervention. inr supratherapeutic at 3.4. this was reversed with ffp and 10mg iv vitk. started on protonix gtt and octreotide gtt given guiac positive stool. hepatology was consulted and may plan for egd in am. for access has 3 18g. . on the floor, pt reports headache and nausea. on arrival he vomited about 400cc of coffee ground emesis containing bright red blood clots. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, 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: dm ii htn etoh cirrhosis, varices cad, s/p cabg ?systolic dysfunction, anti-coagulated aicd social history: works as associate athletic director at . lives with wife. - tobacco: quit 40 yrs ago - alcohol: usually drinks 2 glasses wine per night - illicits: none family history: father with cancer (unknown type) physical exam: general: alert, orientedx 3, no acute distress heent: eomi, visual field confrontation testing normal, no asd. sclera anicteric, laceration along right nasal fold with surrounding bruising, dried blood in bilateral nares,mmm, oropharynx clear. right ear laceration bandaged with mild oozing. neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: + foley gi: black guiac positive stool ext: warm, well perfused, 2+ pulses, 1+ bilateral pitting edema neuro: 4+/5 rue strength, lue strength, 5/5 strength in bilateral lower extremities, normal sensation to touch skin: r eye laceration, large laceration of r eye with exposed cartilage. pertinent results: i. labs a. admission 10:00pm blood wbc-6.9 rbc-2.60* hgb-9.1* hct-27.8* mcv-107* mch-34.9* mchc-32.6 rdw-18.1* plt ct-152 10:00pm blood neuts-73.0* lymphs-18.7 monos-6.2 eos-1.5 baso-0.6 02:46am blood fibrino-312 10:00pm blood glucose-111* urean-54* creat-2.6* na-132* k-4.5 cl-98 hco3-18* angap-21* 10:00pm blood alt-24 ast-43* ck(cpk)-86 alkphos-89 totbili-1.7* 10:00pm blood lipase-45 02:46am blood calcium-8.7 phos-3.4 mg-2.3 10:00pm blood digoxin-3.4* 10:00pm blood asa-neg ethanol-122* acetmnp-6* bnzodzp-neg barbitr-neg tricycl-neg 10:05pm blood ph-7.38 10:05pm blood glucose-104 lactate-4.6* na-139 k-4.5 cl-100 calhco3-20* 01:21am urine color-yellow appear-clear sp -1.013 01:21am urine blood-neg nitrite-neg protein-25 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 01:21am urine rbc-0-2 wbc-0-2 bacteri-mod yeast-none epi-0-2 01:21am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg c. digixon levels 07:55am blood digoxin-2.5* 01:38pm blood digoxin-3.9* 10:00pm blood digoxin-3.4* d. cardiac biomarkers 01:38pm blood ck-mb-5 ctropnt-0.03* 07:51am blood ck-mb-5 ctropnt-0.04* 02:46am blood ck-mb-5 ctropnt-0.04* probnp-4187* 10:00pm blood ctropnt-0.06* 10:00pm blood ck-mb-4 probnp-5905* ii. microbiology blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient urine urine culture-final inpatient mrsa screen mrsa screen-final inpatient iii. radiology a. head ct (admission) impression: 1. bilateral nasal bone fractures with buckling of nasal septum consistent with nasal septum fracture. 2. left extra-axial hyperdensity likely represents a small left-sided subdural hematoma with minimal mass effect. no shift of normally midline structures. 3. opacification of the ethmoid air cells as well as the sphenoid sinus. 4. opacification in the right external auditory canal may represent cerumen; however, correlate clinically for hemotympanum. b. ct c-spine: no evidence of acute fractures. multilevel degenerative changes noted. c. ct sinus/mandible/maxillofacial w/o contrast 1. bilateral nasal bone fractures and fracture of nasal septum. non displaced fracture of the anterior nasal spine. 2. fluid/mucosal thickening within the bilateral ethmoid air cells as well as within the sphenoid sinuses. d. cxr ap portable chest, findings suggest mild volume overload and central vascular congestion. no definite acute traumatic injury of the chest. e. ct head f/u 1. no significant short-term interval changes of the known bilateral subdural hemorrhage, small on the left and tiny on the right. 2. no new foci of intracranial hemorrhage. no evidence of developing hydrocephalus. note at attending review: the hyperdensity in the temporal horns could also represent normal choroid plexus. iv. cardiology echo the left atrium is moderately dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate to severe regional left ventricular systolic dysfunction with inferolateral hypokinesis and akinesis of the distal lv segments (multivessel cad). the remaining segments contract normally (lvef = 30%). no masses or thrombi are seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. a supracristal/conoseptal ventricular septal defect is identified. the right ventricular cavity is dilated with depressed free wall contractility. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is severe pulmonary artery systolic hypertension. the pulmonic valve leaflets are thickened. there is no pericardial effusion. impression: moderate to severe regional left ventricular systolic dysfunction, most c/w multivessel cad. severe pulmonary hypertension with dilated and hypokinetic rv. mild calcific aortic stenosis. brief hospital course: 75 yo male with past medical history of alcoholic cirrhosis, coronary artery disease s/p cabg, chronic systolic heart failure, atrial fibrillation s/p ablation on warfarin that presented with mechanical fall vs syncope in setting of alcohol intoxication resulting in subdural hematoma and also found to have guiac positive stool and coffee-ground emesis concerning for gi bleed. # coffee ground emesis with history of cirrhosis patient initially admitted to icu given concern for gib. the patient has a history of alcoholic cirrhosis with esophageal varices with a gi bleed approximately 20 years ago. he denied recent brbpr and has black stools at baseline in setting of iron supplementation. the primary concern was esophagitis/gastritis in setting of alcohol consumption with additional concern of variceal oozing/bleed. in addition to having a hemoccult positive stool, the patient vomited 400 cc of coffee ground emesis containing bright red blood clots on arrival to the floor and was started on protonix and octreotide gtt. he was also transfused 2 units of prbc. hepatology was consulted and felt this was more likely swallowed blood in setting of facial trauma with secondary consideration of oozing in setting of anticoagulation. they will follow as outpatient per below scheduled apt; no edg done in house. outpatient considerations are upper endoscopy in light of his coffee-ground emesis, which was deferred during hospitalization given that the patient remained hemodynamically stable without evidence of active gi hemorrhage. in the setting of facial trauma and sdh, neurosurgery would also need to comment on a safe time for the procedure. # fall the patient experienced a fall with loss of consciousness likely mechanical in the setting of intoxication. other concerns were syncope from orthostasis, arrhythmia, valvular lesion or myocardial ischemia. mi was ruled out with negative biomarkers, echo showed stable sv ejection fraction of 30 % with severe systolic dysfunction most consistent with multivessel cad, which was similar to prior echo from records. aicd was interrogated showing normal functioning device with no acute arrhythmic events. given loss of consciousness and facial trauma, his c-spine was cleared with negative ct neck and clinically. physical therapy assessed the patient and determined that the pt would be best served within a rehab facility. # subdural hematoma likely secondary to fall initial head imaging noted a small 1.5 mm hypodensity in the extra-axial space along the left cerebral hemisphere likely representing a small left-sided subdural hematoma. neurosurgery was consulted indicating no emergency intervention was indicated at this time given non-focal neuro exam and no evidence of mass effect. his coagulopathy in setting of warfarin usage was reversed with factor ix, 4 units total of ffp with subsequent inr of 1.3. serial head imaging indicates an expanding left-sided sdh and trace right frontal 2-mm subdural hematoma with no mass effect or focal neurological deficits. the patient's systolic blood pressure was kept below 140 mmhg, and he was started on keppra 500 mg po bid for 7 days for seizure prophylaxis. he will follow-up with neurosurgery in 4 weeks for a repeat head ct followed by an office visit. pt was instructed to hold coumadin but continue aspirin 81mg starting on per ns recs. his primary cardiologist was notified of this plan and agreed with holding off on anticoagulation for now. # bradycardia the patient's heart rate trending down to the 40-50s with hypotension. ekg showing ivcd and junctional rhythm concerning dig toxicity. the patient was believed to be on dig for inotropy. toxicology was consulted and recommended holding digoxin, administering. ekg findings concerning for dig toxicity showing ivcd, junctional rhythm. toxicology consulted noting routine digoxin concentration elevated to 3.9 and recommended holding digoxin, serial electrolyte checks, and administration of digibind (57 mg), avoidance of administration of calcium for treatment of hyperkalemia in setting of digoxin toxicity. the patient at the time was mentating well without any complaints. pt was discharged home with plan to hold digoxin, metoprolol, and a lower dose of lisinopril. primary cardiologist, dr. was aware and will plan to see him soon after discharge. # eye/nasal lacerations with nasal fracture and ear trauma patient had facial polytrauma on admission. plastics repaired his ear, but he deferred nasal reduction at this time, which was not performed by plastics in the setting of no airway compromise. bacitracin/xeroform/dsd was applied to his sutures twice daily along. he was given keflex 500mg po bid for 1-week after repair. patient is to arrange follow-up with plastics for wound re-eval; sutures are absorbable. # alcohol abuse the patient's initial alcohol level was 122. he has known history of alcohol abuse. there were no apparent symptoms of withdrawal during hospitalization. outpatient counseling on alcohol abuse is advised. # chronic kidney disease, stage 3 (mdrd gfr 35) per osh records, baseline cr of 1 ranging up to 1.5 in . in , cr 1.9 per osh records fluctuating between 2 and 2.2. his renal function remained stable during hospitalization. however, such a creatinine increase over 2-years would suggest uncontrolled primary process vs. secondary process. further outpatient investigation of renal issues is advised. # macrocytic anemia: his last hgb per osh records was 13.8 with admission hgb of 8.6 patient was transfused 2 units of prbc with an inappropriate elevation of hgb. differential includes chronic process with malnutrition component in setting of alcohol abuse in addition to acute blood loss from accident with potential occult gi blood loss. also direct marrow suppression from alcohol another possibility. advise outpatient cbc within 2 weeks of discharge, age appropriate cancer screening, and egd as above. # chronic systolic heart failure (last known lvef 30 % on ): the patient did not appear in heart failure during this admission. given fluid administration during micu stay and stabilization of hemodynamics, patient was placed on home bumex and was diuresed gently. renal function improved with diuresis and he was continued on home dose of bumex on discharge. # health maintenance patient was given tetanus shot during hospitalization in setting of trauma. medications on admission: lisinopril 5 mg po daily toprol 12.5 mg po daily digoxin 0.125 mg po daily kcl 20 mg po daily lipitor 80 mg po daily coumadin 2.5 mg po daily amiodarone 200 mg po daily asa 325 mg po daily insulin 70/30 (10 units qam, 4 units qpm) iron 325 mg po daily bumex 1 mg qam, qpm mvi vitamin e fish oil discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 2. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 days. disp:*4 tablet(s)* refills:*0* 3. bacitracin zinc 500 unit/g ointment sig: one (1) appl topical qid (4 times a day). disp:*5 tubes* refills:*2* 4. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain for 3 days. disp:*10 tablet(s)* refills:*0* 5. cephalexin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 2 days. disp:*6 capsule(s)* refills:*0* 6. bumetanide 2 mg tablet sig: 0.5 tablet po bid (2 times a day). 7. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 8. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 10. insulin nph & regular human 100 unit/ml (70-30) insulin pen sig: ten (10) units subcutaneous qam. 11. insulin nph & regular human 100 unit/ml (70-30) insulin pen sig: four (4) units subcutaneous qpm. 12. docusate sodium 100 mg tablet sig: one (1) tablet po twice a day as needed for constipation. disp:*60 tablet(s)* refills:*0* discharge disposition: extended care facility: of discharge diagnosis: sub-dural hematoma gastrointestinal bleed bradycardia 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: subdural hematoma (bleeding within your brain) after a fall 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. if you were on a medication such as coumadin (warfarin), or plavix (clopidogrel) prior to your injury, do not resume taking this until after neurosurgey evaluation on . if you haven been discharged on keppra (levetiracetam), you will not require blood work monitoring. call your surgeon immediately if you experience any of the following new onset of tremors or seizures. any confusion, lethargy or change in mental status. any numbness, tingling, weakness in your extremities. 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. new medications: 1. keppra for seizure prophylaxis - continue for 2 additional days as prescribed 2. lisinopril - continue with lower dose as prescribed 3. keflex for antibiotic - continue as prescribed for 2 additional days 4. aspirin 81mg - you may restart this daily medication on per neurosurgery's advice see attached list for active medications; we have discontinued many of your cardiac drugs including coumadin, metoprolol, and digoxin. you will meet with dr. per below on to discuss your cardiac medications. followup instructions: please follow up with your primary care doctor in days. dr. (): at 16:00; the visit will occur at campus within medical office 202 department: pulmonary function lab when: monday at 12:40 pm with: pulmonary function lab building: campus: east best parking: garage department: medical specialties/pulmonary when: monday at 1 pm with: , m.d. building: campus: east best parking: garage department: liver center when: wednesday at 11:40 am with: , md specialty: gastroenterology building: lm campus: west best parking: garage department: neurosurgery when: at 10:00 with: , md specialty: neurosurgery for ct scan -then, 10:45 , floor 3, with : west best parking: garage name plastic surgery - dr. phone you have been referred to plastic surgery for followup to reevaluate your nasal bone fracture (pt does not want operation) and lacerations. call the number above for an appointment within 7 days. be sure to bring your insurance, worker's comp or auto claim information. Procedure: Linear repair of laceration of eyelid or eyebrow Suture of laceration of external ear Automatic implantable cardioverter/defibrillator (AICD) check Diagnoses: Acidosis Hyperpotassemia Abnormal coagulation profile Congestive heart failure, unspecified Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Unspecified fall Open wound of forehead, without mention of complication Chronic kidney disease, Stage III (moderate) Other specified cardiac dysrhythmias Hypotension, unspecified Long-term (current) use of anticoagulants Automatic implantable cardiac defibrillator in situ Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection Hemorrhage of gastrointestinal tract, unspecified Esophageal varices in diseases classified elsewhere, without mention of bleeding Acute on chronic systolic heart failure Syncope and collapse Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use Late effects of acute poliomyelitis Closed fracture of nasal bones Acute alcoholic intoxication in alcoholism, unspecified Monoplegia of upper limb affecting unspecified side Open wound of auricle, ear, without mention of complication |
allergies: beta-blockers (beta-adrenergic blocking agts) / terazosin attending: chief complaint: shortness of breath major surgical or invasive procedure: endotracheal intubation history of present illness: 88 m admitted to with cap and atrial fibrillation with rvr on . he was treated with levaquin and then changed to ctx/azithro/flagyl and subsequently transferred to icu for hypoxia thought to be due to acute heart failure. tte showed preserved systolic function but did show moderate rv dilation so a cta chest was done which was negative for pe. remained hypoxic and placed on bipap which fell on his head causing laceration, has had 2 cth which were unrevealing for ich. has been on diltiazem gtt for rate control and vss at time of transfer wre 90s on nrb and stable bp and hr. upon arrival to the icu patient comfortable and in no acute distress, speaking in full sentences with clear sensorium. no complaints. patient then became difficult to mantain adequate oxygenation on nrb and subsequently on bipap with saturations in the 90s, patient became progressively delirious and intubation was undertaken. past medical history: atrial fibrillation atrial flutter cad s/p cabg history of pfo ulcerative colitis glaucoma hypertension bph s/p turp social history: lives at home. prior smoker quit several years ago family history: unremarkable. physical exam: general appearance: intubated, sedated eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic cardiovascular: irregular respiratory / chest: rhonchi bilaterally up to abdominal: soft, non-tender, bowel sounds present extremities: no lower extremity edema skin: warm neurologic: intubated, sedated pertinent results: labs on admission: 07:34pm blood wbc-25.3*# rbc-3.02* hgb-9.8* hct-29.7* mcv-98 mch-32.3* mchc-32.9 rdw-13.9 plt ct-308 07:34pm blood neuts-90.1* lymphs-6.8* monos-2.7 eos-0.3 baso-0.1 07:34pm blood pt-15.6* ptt-27.7 inr(pt)-1.4* 07:34pm blood glucose-125* urean-40* creat-1.0 na-150* k-3.9 cl-107 hco3-32 angap-15 07:34pm blood ck(cpk)-309 07:34pm blood ck-mb-11* mb indx-3.6 ctropnt-0.54* 03:52am blood ck-mb-5 ctropnt-0.54* 05:27pm blood ctropnt-0.45* 07:34pm blood calcium-9.4 phos-2.8 mg-2.6 08:18pm blood type- po2-57* pco2-55* ph-7.38 caltco2-34* base xs-5 comment-green top 09:09pm blood lactate-2.1* labs on discharge: micro: studies: echo (): the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. there is moderate regional left ventricular systolic dysfunction with mid- to distal anterior and anteroseptal hypokinesis. the remaining segments contract normally (lvef = 35%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. severe pulmonic regurgitation is seen. there is no pericardial effusion. impression: moderate regional left ventricular systolic dysfunction, c/w lad disease. mild to moderate mitral regurgitation. mild pulmonary hypertension. cxr (): asymmetrically distributed pulmonary edema improved substantially between and and heart size decreased. allowing for lower lung volumes, there has been no subsequent change. since 8:10 p.m. on more confluent areas of pulmonary abnormality in the axillary subsegments of the right upper lobe and right lung base posteriorly, could be pneumonia but could also be asymmetric edema and atelectasis, particularly the latter. there is no appreciable pleural effusion. et tube is in standard placement. nasogastric tube ends in the stomach. no pneumothorax. cxr (): in comparison with the study of , there is continued elevation of pulmonary venous pressure with atelectasis at the left base medially. video swallow study (): **** brief hospital course: 88 year old male with cad s/p cabg, remote smoking history, atrial fibrillation, transferred from with hypoxia after being treated for a cap . # hypoxia: initially intubated given difficulty with oxygenation. tte revealed regional akinesis and hypokinesis, as well as lvef 35%, possibly attributable to acute heart failure. he was placed on furosemide gtt but was intermittently held for hypotension. was placed on empiric antibiotics for cap. was evaluated by speech & swallow therapy, and was believed to be aspirating as well has collecting significant pharyngeal residue, to which he was insensate. this was potentially secondary to irritation of his oropharynx from his brief intubation. his hypoxia improved greatly, and it was felt that his swallow would likely recover over time. a dobhoff was placed for temporary nutrition and med administration. **** . # atrial fibrillation with rvr: placed on diltiazem gtt for rate control. amiodarone was initially held for concern for amiodarone-induced pneumonitis, but this was eventually restarted. warfarin was restarted on . dilt was switched over to po and increased to 60qd with good rate control. at dishcarge his home dose of verapamil sr was restarted. . # cad s/p cabg/chf: added lisinopril to home regimen.**** . # htn: well controlled on home regimen. medications on admission: amiodarone 200 mg daily. accupril 5 mg daily. ursodiol 300 mg t.i.d. levothyroxine 25 mcg daily. sulfadiazine 100 mg b.i.d. coumadin. verapamil sr 180 mg daily. xalatan eye drops. discharge medications: 1. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 2. metipranolol 0.3 % drops sig: one (1) drop ophthalmic qd (). 3. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 4. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm. 5. accupril 5 mg tablet sig: one (1) tablet po once a day. 6. ursodiol 300 mg capsule sig: one (1) capsule po three times a day. 7. levothyroxine 25 mcg tablet sig: one (1) tablet po once a day. 8. verapamil sr 180 mg tablet sustained release sig: one (1) tablet sustained release po twice a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: multifocal pneumonia discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - requires assistance or aid (walker or cane) discharge instructions: you were transferred to for better managment of your low oxgyen levels which had required intubation at the outside hospital. it was determined that you had a complicated pneumonia, which responded well to antibiotics. it was determined that you need tube feeds to temporarily protect your wind pipe while your swallowing is not strong. the following changes were made to your outpatient regimen: your warfarin was changed to 2mg per day. followup instructions: as needed with rehab facility md provider , md phone: date/time: 11:15 md, 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 Diagnoses: Acidosis Congestive heart failure, unspecified Unspecified essential hypertension Unspecified protein-calorie malnutrition Atrial fibrillation Acute on chronic diastolic heart failure Coronary atherosclerosis of unspecified type of vessel, native or graft Unspecified glaucoma Atrial flutter Pulmonary collapse Acute respiratory failure Hypotension, unspecified Long-term (current) use of anticoagulants Hypoxemia Ulcerative colitis, unspecified Hyperosmolality and/or hypernatremia Bacterial pneumonia, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: doe major surgical or invasive procedure: pacemaker placement history of present illness: 82 year old female with chief compliant doe over several months presenting for pacemaker placement. for the last 6mo pt would have dyspnea climbing 1 flight of stairs, or walking for a distance in her home. denies any associated cp, syncope, lh, dizziness, diaphoresis. pt's dyspnea has not progressed but constant over time. last week saw dr. (cardiology at , )pt had a holter moniter, and returned it on monday. the holter monitor found 2nd degree heart block (mobitz ii), and pt was admitted for pacemaker placement. currently pt is asymptomatic. . upon arrival to the ed, she had temperature 97.7, bp 151/43, hr 35, rr 16, sat 100% on room air. she received 243 mg aspirin (already took 81 mg at home). her heart rate was in the 40s for thr duration of her ed stay without any symptoms; her bp remained normal. . . 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. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias past medical history: - hyperlipidemia (recently self-d/c'ed atorvastatin) - rectal bleeding - scheduled for colonoscopy as outpt later this mo. social history: no hx of smoking,etoh. volunteers currently family history: father had a pacemaker. mother had gastric cancer and diabetes. physical exam: admission: vitals: 97.6, 158/99, 30, 16, 99%2l general: pleasant, nad heent: nc/at, anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: ctab, no wheezes, rales, ronchi cv: rrr, normal s1 + s2, no murmurs, rubs, gallops abdomen: +bs nt/nd, soft ext: no c/c/e, pulses 2+ neuro: aox3, cn ii-xii grossly intact, no focal deficits pertinent results: 04:06pm blood pt-12.9 ptt-25.1 inr(pt)-1.1 04:06pm blood glucose-97 urean-34* creat-1.3* na-141 k-4.6 cl-105 hco3-25 angap-16 04:06pm blood ck-mb-4 04:06pm blood ctropnt-<0.01 05:09am blood ck-mb-notdone ctropnt-<0.01 04:06pm blood ck(cpk)-101 05:09am blood ck(cpk)-73 04:06pm blood calcium-9.7 phos-3.6 mg-2.3 06:20am blood wbc-7.2 rbc-3.98* hgb-11.5* hct-34.4* mcv-87 mch-29.0 mchc-33.5 rdw-13.8 plt ct-256 05:09am blood pt-12.6 ptt-25.0 inr(pt)-1.1 06:20am blood glucose-93 urean-25* creat-0.9 na-143 k-4.4 cl-108 hco3-25 angap-14 07:15pm urine color-straw appear-clear sp -1.005 07:15pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg urine culture (final ): <10,000 organisms/ml. ecg: baseline artifact. sinus rhythm at upper limits of normal rate with 3:1 a-v block. left bundle-branch block. left axis deviation. consider inferior myocardial infarction. clinical correlation is suggested. no previous tracing available for comparison. echo: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef 70%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a fat pad. cxr 6/6/9 compared to the film from the prior day the leads are in similar location. degenerative changes are noted of the spine. the lungs are clear without infiltrate or effusion. brief hospital course: 82yof w/ hx of hl and no other cad hx who p/w doe x6mo and found on holter to be in mobitz ii. . # mobitz ii 2nd degree heart block: the patient reports doe over the last last 6 months. the patient saw her cardiologist and underwent holter monitoring. it revealed 2nd degree heart block (mobitz ii), and the patient was admitted for pacemaker placement. admission ecg showed 3:1 av block. the patient had pacer pad placed and atropine at the bedside. she underwent pacemaker placement on and received pre/post doses of vancomycin. additionally, she was continued on 3 days of keflex. she had a cxr that did not reveal ptx and pacer leads in proper position. the patient underwent echo that did not show effusion and ef of 70%. the patient tolerated the procedure and was discharged with device clinic follow-up in 1 week. # coronaries: the patient with no hx of cad. she was continued on asa 81 for primary prevention. # pump: the patient underwent echo that showed ef 70%. the paitent had no signs of chf and remained euvolemic. # hypertension: the patient with no prior history of htn. she did have several episodes of hypertension with sbp in the 150's. this could be due to pain post-procedure or undiagnosed htn. however, she did also have several measurements with sbp <120. therefore, no medication were initiated. the patient should have outpatient follow-up with her pcp. medications on admission: aspirin 81 mg daily discharge medications: 1. aspirin 81 mg tablet sig: one (1) tablet po once a day. 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 3. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 11 doses: last day . disp:*11 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: heart block, status post pacemaker placement secondary:hyperlipidemia discharge condition: stable discharge instructions: we determined that your heart was going into dangerous rhythms and you had a pacemaker placed. you tolerated the procedure well. you will need to have your pacemaker checked in device clinic on which we have scheduled. no changes were made to your medications. if you experience chest pain, shortness of breath, dizziness, passing out, fevers or chills please contact your cardiologist or come to the emergency department for evaluation. followup instructions: provider: clinic phone: date/time: 9:30 provider: , m.d. phone: date/time: 1:00 provider: , md, phd: date/time: 2:30 Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Diagnoses: Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Atrioventricular block, complete Blood in stool Other left bundle branch block |
allergies: aspirin / lisinopril / avelox attending: chief complaint: aortic stenosis major surgical or invasive procedure: avr ( . porcine) history of present illness: this 74 year old female with known aortic stenosis overthe last several months has noted increased shortness of breath with activity and occcasional palpitations. she denies any chest pain, syncope, orthopnea, but does admit to occasional pnd. previously catheterization has revealed no coronary disease and severe aortic stenosis. she was admitted now for surgery. past medical history: hypertension noninsulin dependent diabetes mellitus dyslipidemia anxiety disorder osteoporosis osteoarthritis aortic stenosis social history: lives with: husband occupation: retired shipping clerk tobacco: denies etoh: denies family history: no premature coronary disease physical exam: admission: pulse:91 resp:16 o2 sat: 97% ra b/p right: 112/60 left: 124/71 height: 60 inches weight: 180 general: nad skin: dry intact ; very slight area of pale erythema left anterior le ( pt states it has been like this for a while) heent: perrla eomi anicteric sclera;op unremarkable neck: supple full rom no jvd chest: lungs clear bilaterally heart: rrr irregular murmur- harsh 4/6 sem radiates throughout precordium to carotids abdomen: soft non-distended non-tender bowel sounds + no hsm/cva tenderness; obese extremities: warm , well-perfused edema- trace bilat. varicosities: significant bilat. neuro: grossly intact ;nonfocal exam; mae strengths pulses: femoral right: 1+ left: 2+ dp right: np left: np pt : 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit: murmur radiates to bil. carotids pertinent results: conclusions pre bypass the left atrium is moderately dilated. the left atrium is elongated. no spontaneous echo contrast is seen in the body of the left atrium. 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 size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the ascending aorta. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. mild to moderate (+) mitral regurgitation is seen. dr. was notified in person of the results in the operating room at the time of the study. post bypass there is normal biventricular systolic function. there is a bioprosthesis in the aortic position. it appears well seated. the leaflets can not be seen. no aortic regurgitation is appreciated. the maximum pressure gradient across the aortic valve is 31 mmhg with a mean pressure of 16 mmhg at a cardiac output of around 4 liters/minute. the effective orifice area of the valve is about 1.4 cm2. the mitral regurgitation is still mild to moderate. the thoracic aorta appears intact. no other changes from pre-bypass findings. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 13:55 05:15am blood wbc-7.6 rbc-3.16* hgb-9.4* hct-27.4* mcv-87 mch-29.8 mchc-34.4 rdw-14.1 plt ct-127* 10:23am blood wbc-8.3 rbc-3.03*# hgb-8.8*# hct-26.0*# mcv-86 mch-28.9 mchc-33.7 rdw-13.4 plt ct-136* 03:28am blood pt-12.1 ptt-25.4 inr(pt)-1.0 10:23am blood pt-14.2* ptt-31.4 inr(pt)-1.2* 05:15am blood glucose-149* urean-16 creat-0.8 na-138 k-4.4 cl-102 hco3-27 angap-13 02:27am blood glucose-100 urean-17 creat-0.8 na-139 k-4.5 cl-108 hco3-25 angap-11 brief hospital course: mrs. was taken to the operating room and underwent aortic valve replacement. please refer to dr operative note for further surgical details. she tolerated the procedure well and was transferred to the cvicu for further invasive monitoring. she awoke neurologically intact and was extubated postoperatively without difficulty. all lines and drains were discontinued in a timely fashion without complications. beta blockers/statin/asa and diuresis were initiated. she continued to progress and on pod# 2 she transferred to the floor for further monitoring. physical therapy was consulted for evaluation of strength and mobility. on pod#5 she was cleared by dr. for discharge to home with vna. all follow up appointments were advised. medications on admission: ocuvite ferrous sulfate 325 mg daily kcl 20meq qmwf metformin 1000 mg famotidine 40mg simvastatin 80 mg qd citalopram 40 mg qd lasix 40mg alternating with 60 mg daily glipizide 5 mg qd diovan 160 mg qd alendronate 70 mg qweek colace 100 mg daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. simvastatin 80 mg tablet sig: one (1) tablet po at bedtime. 3. famotidine 40 mg tablet sig: one (1) tablet po twice a day. 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for temperature >38.0. 5. citalopram 40 mg tablet sig: one (1) tablet po once a day. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*55 tablet(s)* refills:*0* 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 10. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). 11. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed for itching. 12. glipizide 5 mg tablet sig: one (1) tablet po daily (daily). 13. famotidine 20 mg tablet sig: two (2) tablet po bid (2 times a day). 14. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day): previous home dose 40 mg alternating with 60mg. disp:*60 tablet(s)* refills:*2* 15. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours). disp:*60 tab sust.rel. particle/crystal(s)* refills:*2* 16. alendronate 70 mg tablet sig: one (1) tablet po once a week. discharge disposition: home with service facility: vna of southeastern mass. discharge diagnosis: aortic stenosis s/p aortic valve replacement noninsulin dependent diabetes dyslipidemia hypertension degenerative joint disease s/p bilateral total knee replacements anxiety disorder s/p tonsillectomy osteoporosis discharge condition: alert and oriented x3,nonfocal ambulating independently steady gait incisional pain managed with oral analgesics incisions: sternal - healing well, no erythema or drainage discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns 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. on thursday, @ 1:00 pm () please call to schedule appointments with: primary care: dr. (in weeks cardiologist: dr. 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: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Aortic valve disorders Other and unspecified hyperlipidemia Anxiety state, unspecified Osteoporosis, unspecified Obesity, unspecified Knee joint replacement Dizziness and giddiness Varicose veins of lower extremities with inflammation |
allergies: no known allergies / adverse drug reactions attending: chief complaint: polytrauma major surgical or invasive procedure: : 1. operative treatment right hip dislocation. 2. arthrotomy hip with exploration, removal loose foreign body. 3. repair intermediate laceration right knee approximately 3 cm in length. 4. manual application of stress by surgeon for joint radiographic purposes. 5. exploratory laparotomy. history of present illness: 47m transfer from hospital after high speed mvc ~50mph. head-on motor vehicle collision reportedly intoxicated with alcohol. at osh patient initially complained of sob and bilateral chest pain and later developed worsening sob/agitation and was intubated. imaging was significant for the below injuries: left sided rib fx's: r rib fx's: 6,7 ?9 right posterior dislocated hip with femoral head fracture past medical history: none (per osh note) psh: unknown social history: unknown family history: nc physical exam: discharge physical t 98.1 p 93 bp 150/85 rr 18 o2 94 nad rrr ctab r hip incision covered, c/d/i. r knee lac covered c/d/i. ambulatory w/ touch down weight bearing on r no le edema or calf swelling pertinent results: ct torso: --peristent elevation of the left hemidiaphragm, possibly ruptured; no herniation of subdiaphragmatic contents. --progressive mediastinal widening probably due to distended veins. nevertheless torso ct finding of small hemopericardium, indicates the need to confirm aortic integrity; tee should be considered if gated cta is not feasible. --all of these findings, their clinical significance, and imaging options were discussed by telephone with dr. , surgical house officer, at 9:20am. ct pelvis: 1. the femoral head articulates appropriately with the acetabulum after reduction of the posterior hip dislocation. 2. however, femoroacetabular joint space widening remains due to multiple preliminary intra-articular fracture fragments, the largest measuring 2.5 cm with the donor site from the femoral head. 3. bilateral sclerotic anterosuperior femoral head, most likely due to avascular necrosis of unknown etiology. 4. moderate degenerative changes at femoroacetabular joints. 5. residual contrast in a distal duplicated right ureteral either due to reflux or delayed contrast excretion. brief hospital course: mr. was admitted to the tsicu following his trauma. ancef/tetanus given in er; tee was obtained given concern for missed aortic injury or tamponade - negative. he was taken to the operating room with ortho for i+d r hip, excision of osteochondral fragments and then ex-lap for concern for diaphragmatic rupture. there was no evidence of ruptured diaphragm on laparotomy. on hd2 he was extubated uneventfully and remained hemodynamically stable with mild tachycardia. he was subsequently transferred to the floor. hospital course on floor was unremarkable. was evaulated by pt who felt pt safe for discharge home. he was ambulating with touch down weight bearing on right. pt instructed to follow up in clinic in one week as well as with his pcp. the hospital metoprolol 12.5 was started for htn. medications on admission: unknown discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 2. hydromorphone 2 mg tablet sig: one (1) tablet po q3h (every 3 hours) as needed for pain. disp:*200 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: 1. blunt trauma 2. right hip dislocation with femoral neck fracture. 3. laceration right knee. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. ambulatory. touch down weight bearing with crutches on rle. discharge instructions: you were started on metoprolol 12.5 twice a day for your high blood pressure. please follow up with your pcp within one week for refills and management of this medication. touch down weight bearing on your right side on crutches. no driving while taking narcotic pain medications. stool softeners for consipation. wean yourself from narcotic pain medications. take tylenol and motrin as first line for pain. narcotics for breakthrough. followup instructions: -follow-up in clinic in one weeks. telephone # -follow-up with your pcp this week. metoprolol 12.5 mg was started in the hospital. -follow-up with dr. of ortho within two weeks. telephone #( md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnostic ultrasound of heart Exploratory laparotomy Closure of skin and subcutaneous tissue of other sites Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Closed reduction of fracture without internal fixation, femur Other arthrotomy, hip Open reduction of dislocation of hip Diagnoses: Tobacco use disorder Unspecified essential hypertension Alcohol abuse, unspecified Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Contusion of lung without mention of open wound into thorax Open wound of knee, leg [except thigh], and ankle, without mention of complication Closed fracture of eight or more ribs Closed posterior dislocation of hip Other closed transcervical fracture of neck of femur Nonspecific abnormal results of other specified function study |
Subsets and Splits