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allergies: benzodiazepines attending: chief complaint: motorcycle crash major surgical or invasive procedure: : i&d left leg with external fixator placement : orif left tibial plateau fx with vac change : i&d left leg with vac change : i&d left leg with vac change : i&d left leg with vac change : i&d left leg with vac change : i&d left leg with vac change : i&d left leg with flap coverage by plastic surgery : left leg below the knee amputation with skin coverage : i&d of stump with vac chage : washout/vac change : debridement/stsg to left bka wound defect history of present illness: 60 year old male s/p motorcycle crash at approximately 50 mph, +loc, one fatality on scene, he was helmeted. pt found over guard rail w/ open lle fracture, intubated on scene. he was taken by to the for further evaluation and care. this patient was seen in the trauma bay in the emergency department. he was seen by the trauma and vascular service. orthopedics was consulted regarding his left open tibia-fibula fracture as well as a left open foot fracture. the vascular service was involved in his care as well regarding a poorly vascularized left lower extremity. they ordered a ct angiogram that demonstrated an anterior and posterior tibial artery that was not visualized below the region of the fracture. the peroneal artery appeared to be constricted but patent down to the calcaneus. . this gentleman was hemodynamically unstable in the trauma bay. he was taken emergently to the operating room for stabilization of his tibia fracture. past medical history: gerd depression anxiety social history: no etoh/tob divorced, 3 daughters truck driver family history: nc physical exam: physical exam from vascular surgery note of : physical exam neuro/psych: abnormal: intubated, sedated. neck: no masses, trachea midline. skin: no atypical lesions. heart: abnormal: tachycardic, regular rhythm. lungs: clear, abnormal: decreased breath sounds on right. gastrointestinal: non distended, no masses, abnormal: trunk abrasions. extremities: abnormal: swelling and mottling left foot, delayed cap refill. pulse exam (p=palpation, d=dopplerable, n=none) rue radial: p. lue radial: p. rle femoral: p. dp: p. pt: p. lle femoral: p. popiteal: n. dp: n. pt: n. description of wound: proximal open tib-fib fracture, open fracture dorsum left foot, degloving injury lle with exposed muscle and extensive soft tissue involvement, significant bleeding from open wounds pertinent results: radiology: ct torso - hemopneumothorax cta le - at occluded. pt narrowed w/ reconstitution distal to fracture site. complicated open tib/fib fx ct cspine - no fx/malalignment ct head - no intracranial hemorrhage, no fractures. left femur: impression: 1. pelvic girdle is intact. 2. comminuted fracture of the proximal tibia including the tibial plateau and segmental fracture of the fibula. extensive angulation and displacement of the fx fragments and extensive soft tissue abnormalities. 3. foot (probable left -- see comment above) -- multiple fractures, not fully evaluated. ? foreign body . labs: 01:30pm plt count-196 01:30pm neuts-81.1* lymphs-16.7* monos-0.9* eos-0.8 basos-0.4 01:30pm wbc-12.7* rbc-2.96* hgb-9.3* hct-26.8* mcv-91 mch-31.4 mchc-34.6 rdw-12.6 01:30pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 01:30pm lipase-28 01:30pm glucose-138* urea n-16 creat-0.9 sodium-144 potassium-3.8 chloride-113* total co2-19* anion gap-16 01:34pm hgb-9.7* calchct-29 01:34pm lactate-3.2* na+-141 k+-3.7 cl--111 tco2-21 10:26am blood wbc-8.8 rbc-3.17* hgb-9.6* hct-29.3* mcv-92 mch-30.2 mchc-32.7 rdw-14.2 plt ct-672* 10:26am blood neuts-70.6* lymphs-22.3 monos-4.5 eos-2.0 baso-0.6 10:26am blood plt ct-672* 10:26am blood esr-129* 10:26am blood glucose-118* urean-13 creat-0.7 na-138 k-4.4 cl-105 hco3-26 angap-11 06:07am blood alt-14 ast-19 ld(ldh)-195 alkphos-82 totbili-0.3 06:15am blood lipase-62* 10:26am blood calcium-8.4 phos-5.1* mg-2.2 06:15am blood caltibc-177* vitb12-533 ferritn-985* trf-136* 06:15am blood tsh-3.9 06:15am blood cortsol-29.8* 10:26am blood crp-78.1* 05:16am blood vanco-16.3 . microbiology 8:30 am swab site: knee deep joint left knee. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final ): enterobacter asburiae. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter asburiae | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s anaerobic culture (final ): no anaerobes isolated. . 11:00 am tissue bone left leg. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. 4+ (>10 per 1000x field): gram negative rod(s). reported by phone to dr. () on at 14:56 pm. tissue (final ): enterobacter cloacae. moderate growth. burkholderia species. sparse growth. second morphology. dr. requested further workup. sensitivity testing performed by microscan. meropenem <=1 mcg/ml. chloramphenicol = 16 mcg/ml, intermediate. timentin <= 8 mcg/ml, sensitive. bacillus species; not anthracis. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter cloacae | burkholderia species | | cefepime-------------- <=1 s ceftazidime----------- <=1 s =>16 r ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s levofloxacin---------- <=1 s meropenem-------------<=0.25 s s piperacillin/tazo----- 16 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s =>2 r anaerobic culture (final ): no anaerobes isolated. . 2:29 pm swab left lateral knee. **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): this is a corrected report (). reported by phone to dr. @ 1400, . gram negative rod(s). sparse growth. burkholderia species. chloramphenicol intermediate at 16 mcg/ml. levofloxacin >=8 mcg/ml. meropenem <=1.0 mcg/ml. ertapenem susceptibility testing requested by dr. (). ertapenem = mic of > 32 mcg/ml, no interpretations sensitivity testing performed by etest susceptibility results were obtained by a procedure that has not been standardized for this organism results may not be reliable and must be interpreted with caution. timentin = resistant mic of >64 mcg/ml. previously reported as () timentin >=1.0 mcg/ml. escherichia coli. rare growth. ertapenem susceptibility testing requested by dr. (). ertapenem = sensitive mic of 0.012 mcg/ml sensitivity testing performed by etest. staphylococcus, coagulase negative. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ gram negative rod(s) | escherichia coli | | ampicillin------------ 16 i ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- 16 i <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s levofloxacin---------- r meropenem------------- s <=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=2 s <=1 s brief hospital course: mr. was involved in a motorcycle crash. he was taken by to the for an obvious open left leg fracture. he was intubated at the scene prior to transport. he was evaluated by the trauma, vascular, and orthopaedic surgery services. his ct head/cspine and torso showed hemopneumothorax and multiple rib fractures, but were otherwise negative for concurrant injury. a right sided chest tube was placed for his hemopneumothorax. a complicated open tib fib fracture of his lle was observed and stabilized and dopplerable signals were maintained in the dp on the affected side. he was taken to the or with orthopedics for external fixation of his injury. postoperatively he remained intubated and was taken to the tsicu for recovery and monitoring. in total in his perioperative course he required 16 uprbcs, 4 units ffp and 2 units platelets to maintain his hematocrit due to acute blood loss anemia. on he returned to the operating room with orthopaedics and underwent an orif left tibial plateau fx with vac change. on , , , and , he returned to the operating room and underwent an i&d with vac change to this left leg. on he returned to the operating room and underwent an i&d of his left leg with flap coverage by plastic surgery. unfortunately on he underwent a left leg below the knee amputation with skin coverage. on he returned in the operating room and underwent an i&d of stump with vac chage by plastic surgery. on he was placed on cipro for an urinary tract infection. on , mr. large open lle stump wound was finally ready for skin grafting to complete the closure of the stump. he had split-thickness skin grafts (stsg) taken from left and right thighs to cover his left lower extremity defect (total 480 cm2). mr. spent 1 more week with wound vacs in place to his stsg sites. on , the vacs were removed revealing pink, healthy stsg sites with 100% coverage/take. . throughout his stay he was also consulted on by infectious disease for help with antibiotic coverage as patient had ongoing issues with infection of his left lower extremity. please see microbiology results for specific organisms and antibiotic sensitivities. he was also seen by physical therapy to improve his strength and mobility. . the patient's care was briefly transferred to the general medicine team on for management of delirium and visual hallucinations. his delirium was in the setting of a prolonged hospital course, administration of narcotics/other pain meds, benzodiazepines and infection. his pain regimen was adjusted, his narcotics were minimized, and his antibiotic regimen was adjusted as per id recommendations. he was not given any further benzodiazepines except in the or, as it was felt these medications were likely contributing to his altered mental status. his delirium and hallucinations resolved, and the patient remained alert and oriented. of note, he did have an episode of suicidal ideation, and was seen and evaluated by psychiatry. his suicidal ideation did not persist, and psych continued to follow the patient for ongoing management of depression. after the resolution of his delirium/ hallucinations, the patient's care was transferred to the plastic surgery service. . in summary, mr. is being discharged to rehab on his 48th day of hospitalization. his hospital course has been long and difficult on many emotional and physical levels. we addressed these issues as they presented themselves during his stay with us and provided supportive care. ultimately, mr. spirit and determination are what will carry him through the rest of his recovery and rehabilitation. we wish him the best of luck! medications on admission: omeprazole, citalopram, bupropion discharge medications: . 1. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: hold if greater than 4 grams given in 24 hours . 8. gabapentin 400 mg capsule sig: one (1) capsule po bid (2 times a day). 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 10. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain : hold for sedation and rr less than 12. disp:*60 tablet(s)* refills:*0* 11. meropenem 1 gram recon soln sig: one (1) intravenous every eight (8) hours: continue to . disp:*60 * refills:*0* 12. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous q 12h (every 12 hours): continue to . disp:*40 * refills:*0* 13. olanzapine 2.5 mg tablet sig: one (1) tablet po at bedtime. discharge disposition: extended care facility: discharge diagnosis: motorcycle crash left open tibia fracture left open 2 and 3 metatarsal fracture urinary tract infection delerium wound infection discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: - wear your left lower extremity splint at all times to keep your knee immobilized. - you may do activity as tolerated and work with pt to your capacity. you should not do any range of motion activities to your left knee as it needs to remain immobile for now. you may do rom to your left hip and strengthening of your quadriceps of your left lower extremity. -continue your iv antibiotic regimen according to infectious disease recommendations. -please follow up with all the appointments listed below. -you will have daily dressing changes to your left lower extremity skin graft sites: xeroform, fluffs and kerlix. -you will have a wet to dry dressing placed to the left lateral open area on the flap area of your stump. -remember to elevate your left lower extremity at the end of the day as you will be working hard and it will likely have some swelling until it gets used to being in a dependent position. -eat, eat, eat!!! you need lots of nutrition to support your healing wounds and to build back the muscle you have lost. 'all you can eat' buffets are your friend!! -work hard at rehab and we will see you in clinic for follow up! -good luck, mr. !! followup instructions: please follow up with plastic surgery, dr. , on friday . you will need to call the office and confirm the time of the appointment: ( . dr. is located on the , , , . . infectious disease provider: flash, md phone: date/time: 11:30 . infectious disease provider: flash, md phone: date/time: 10:30 Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Arteriography of femoral and other lower extremity arteries Other local excision or destruction of lesion of joint, knee Other local excision or destruction of lesion of joint, knee Other skin graft to other sites Other skin graft to other sites Attachment of pedicle or flap graft to other sites Attachment of pedicle or flap graft to other sites Excisional debridement of wound, infection, or burn Suture of vein 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 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 Open reduction of fracture with internal fixation, tibia and fibula Nonexcisional debridement of wound, infection or burn Nonexcisional debridement of wound, infection or burn Suture of artery Open reduction of fracture with internal fixation, tarsals and metatarsals Other amputation below knee Internal fixation of bone without fracture reduction, tibia and fibula Other partial ostectomy, other bones Other partial ostectomy, tarsals and metatarsals Removal of implanted devices from bone, tibia and fibula Debridement of open fracture site, tarsals and metatarsals Debridement of open fracture site, tarsals and metatarsals Debridement of open fracture site, tarsals and metatarsals Debridement of open fracture site, tarsals and metatarsals Diagnoses: Thrombocytopenia, unspecified Esophageal reflux Other postoperative infection Urinary tract infection, site not specified Acute posthemorrhagic anemia Other opiates and related narcotics causing adverse effects in therapeutic use Pulmonary collapse Dysthymic disorder Traumatic pneumohemothorax without mention of open wound into thorax Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Closed fracture of two ribs Drug-induced delirium Delirium due to conditions classified elsewhere Concussion with loss of consciousness of unspecified duration Infection (chronic) of amputation stump Open fracture of shaft of fibula with tibia Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Open fracture of metatarsal bone(s) Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use Other motor vehicle traffic accident involving collision on the highway injuring motorcyclist Suicidal ideation Other acute postoperative pain Acute osteomyelitis, lower leg Injury to popliteal vein Injury to anterior tibial artery Other open fracture of tarsal and metatarsal bones |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: 1. coronary artery bypass grafts x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to right coronary artery and obtuse marginal arteries. 2. endoscopic harvesting of the long saphenous vein. history of present illness: 60 year old female for the past two years she has been experiencing shortness of breath and dyspnea with exertion. this occurs after walking approximately 10 minutes starts in her epigastric area and radiates up to her upper chest. it resolves with rest. she had been trying to lose weight recently and was using a treadmill and was experiencing shortness of breath and chest pain. she underwent a stress test which was abnormal. she was referred for a cardiac catheterization and was found to have coronary artery disease. she was referred to cardiac surgery for revascularization. past medical history: coronary artery disease pmh: paroxysmal atrial fibrillation, reported paf or palpitations since depression/anxiety vitamin d deficiency chronic bilateral leg/joint pain dyslipidemia frequent headaches past surgical history: tonsillectomy appendectomy social history: lives with:husband contact: (daughter) phone# occupation:skin care specialist cigarettes: smoked no yes hx: quit 6 years ago, smoked <1ppd x13-15 years other tobacco use:denies etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use:denies family history: premature coronary artery disease- mother had mi at 65, sister died at 60 with htn and ?mi physical exam: pulse:65 resp:13 o2 sat:98/ra b/p right:120/72 left:127/68 height:5'1" weight:186 lbs general: nad, aaox3 skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender extremities: warm , well-perfused edema 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: none left: none pertinent results: intra-op tee conclusions pre-bypass: no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. there is no aortic valve stenosis. trace aortic regurgitation is seen. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. dr. was notified in person of the results at time of surgery. post-bypass: the patient is a paced. the patient is on a phenylephrine infusion. biventricular function is unchanged. mitral regurgitation is unchanged. tricuspid regurgitation is moderate (2+). the aorta is intact post-decannulation. 04:17am blood wbc-9.2 rbc-2.84* hgb-8.3* hct-26.9* mcv-95 mch-29.3 mchc-31.0 rdw-13.8 plt ct-287 04:52am blood hct-26.2* 11:26pm blood hct-25.9* 04:17am blood glucose-97 urean-14 creat-0.8 na-137 k-4.3 cl-103 hco3-29 angap-9 04:52am blood urean-15 creat-0.8 02:51am blood glucose-122* urean-11 creat-0.9 na-138 k-4.4 cl-105 hco3-25 angap-12 02:52am blood glucose-118* urean-9 creat-0.5 na-135 k-4.0 cl-105 hco3-23 angap-11 brief hospital course: the patient was brought to the operating room on where the patient underwent cabg x 3 with dr. . initial attempt at endoscopic approach was aborted and converted to open cabg. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. left sided chest tube was placed for pleural effusion via endoscopic port site on post operative night before extubation. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. pod 1 or chest tubes were removed and left chest tube remained in place. she has paroxysmal atrial fibrillation which she had preoperatively but was in sinus rhtyhm at the time of discharge and was not anticoagulated. beta blocker was initiated at a low dose with sbp 90's and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. left chest tube was removed at this time and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 4 the patient was ambulating freely, she was hemodynamically stable in sinus rhythm, the wound was healing and pain was controlled with oral analgesics. the patient was discharged home with vna services in good condition with appropriate follow up instructions. medications on admission: aspirin 81 mg daily discharge medications: 1. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. disp:*60 tablet(s)* refills:*0* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain, fever. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 6. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 7 days. disp:*7 tablet, er particles/crystals(s)* refills:*0* 7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 8. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 9. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 10. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed for sob, wheezing. disp:*1 1* refills:*0* 11. hydromorphone 2 mg tablet sig: 1-2 tablets po every hours as needed for pain. disp:*30 tablet(s)* refills:*0* 12. lasix 40 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: coronary artery disease pmh: paroxysmal atrial fibrillation, reported paf or palpitations since depression/anxiety vitamin d deficiency chronic bilateral leg/joint pain dyslipidemia frequent headaches past surgical history: tonsillectomy appendectomy discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage edema- 1+ discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge followup instructions: you are scheduled for the following appointments: wound check at cardiac surgery office on at 10:15a surgeon dr. on at 1:00p cardiologist dr. on at 11:30 please call to schedule the following: primary care dr. , v. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Other incision of pleura Diagnoses: Acidosis Anemia, unspecified Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Atrial fibrillation Personal history of tobacco use Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Anxiety state, unspecified Family history of ischemic heart disease Headache Diseases of tricuspid valve Unspecified vitamin D deficiency Unspecified disorder of autonomic nervous system Pain in limb Pain in joint, site unspecified |
allergies: cipro / macrodantin attending: chief complaint: known large hepatic cyst with progressive increase in shortness of breath over the past year major surgical or invasive procedure: : laparoscopic converted to open hepatic cyst unroofing, cholecystectomy, repair of diaphragm with -tex patch; chest tube placement. : ercp history of present illness: 75-year-old female with a known large hepatic cyst who has had progressive increase in shortness of breath over the past year. in , a report documented a 12 cm septated cyst in the liver along with a 1.7 cm gallstone. a ct on demonstrated that the cyst had increased in size to 19 cm. ct on demonstrated a large cyst occupying much of the right lobe of the liver measuring 21.2 x 13.6 cm. thin septations were noted. there was elevation of the right hemidiaphragm. preoperatively the patient has a documented low pulse ox. it should be noted that preoperatively her o2 sats were noted to be approximately 86% with a po2 of 56 on room air. past medical history: hypertension, hyperlipidemia, urinary incontinence, spinal fusion, ovarian cysts, the hepatic cyst and osteoporosis. . past surgical history is significant for back surgery approximately 40 years ago. hysterectomy at age 33, appendectomy at age 33, tonsillectomy as a child. social history: married, retired bookkeeper, she has two to three glasses of wine per week socially. she has no history of smoking, iv drug use, marijuana use, blood transfusions, tattoos, or hepatitis. she has pierced ears. family history: mother who died at age 81 of a cva. father died at age 49 of heart disease physical exam: post op exam: icu intubated and sedated vs: 97.5, 74, 88/51 - 159/72, 16 100% on cmv/assist general: nad, intubated/sedated card: rrr, no murmur lungs: right diminished throughout abd: soft, non-distended, dressing c/d/i extr: no edema neuro: sedated pertinent results: immediatelypost op: wbc-16.1*# rbc-3.28* hgb-10.6*# hct-31.3*# mcv-95 mch-32.2* mchc-33.8 rdw-15.1 plt ct-182 pt-18.0* ptt-29.5 inr(pt)-1.6* glucose-105* urean-19 creat-0.8 na-142 k-4.3 cl-114* hco3-15* angap-17 alt-302* ast-506* ld(ldh)-597* alkphos-63 totbili-2.4* albumin-2.7* calcium-8.9 phos-5.1* mg-1.3* lipase-4370* lipase-122* amylase 2933 amylase-120* at discharge: wbc-7.3 rbc-3.47* hgb-11.1* hct-31.6* mcv-91 mch-32.1* mchc-35.3* rdw-15.7* plt ct-194 pt-12.1 ptt-22.6 inr(pt)-1.0 glucose-86 urean-6 creat-0.5 na-134 k-3.8 cl-98 hco3-29 angap-11 alt-45* ast-28 alkphos-115* totbili-1.0 albumin-2.9* calcium-8.5 phos-2.8 mg-1.9 alt-72* ast-48* alkphos-104 amylase-2933* totbili-0.7 brief hospital course: 75 y/o taken to the or with dr for resection of the known hepatic cyst. at the time of exploration with the laparoscope, there were dense adhesions in the abdomen that precluded additional placement of ports safely and therefore she was converted to an open cystectomy. the cyst was densely adherent and involved the diaphragm. she had a solitary gallstone. she had dense adhesions in the right upper quadrant. the cyst contained approximately 3 liters of clear fluid. during the procedure, there was a defect in the lateral-most aspect of the right diaphragm and there was an injury to a small portion of the right lower lobe of the lung with some air leak. dr. , surgery was consulted during the procedure and it was recommended that a chest tube be placed. the lung was densely adherent to the diaphragm. she tolerated the procedure, however she was not extubated, and was transferred to the sicu post operatively. the cyst pathology was benign mesothelial inclusion cyst. the patient was extubated on pod 1, the chest tube was removed on pod 3 and she remained in the sicu until pod 3 and she was transferred to 10. on pod 4 the lateral jp drain was noted to appear bilious and drain bilirubin was 11.2 (serum 0.7 same day). the following day she was sent for an ercp, the pancreatic duct was filled with contrast, the course and caliber of the duct were normal with no evidence of filling defects, masses, chronic pancreatitis or other abnormalities. cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique, extravasation of contrast was noted at the periphery of the liver, consistent with bile leak. an 8cm by 10fr cotton- plastic biliary stent was placed successfully with excellent drainage of bile and contrast. post ercp day 1 she presented with nausea and abdominal pain and amylase and lipase were noted to be significantly elevated to 2932 and 4370 respectively. she was kept npo for 2 days and then slowly advanced from clears to regular diet again. intra-op the patient received 2 units prbc's and albumin, on pod 2 she received 2 units prbcs and then 1 unit each on pod 4 and 5. her hematocrit has remained stable since the last transfusion. the patient has tolerated regular diet, and calorie counts indicate she is now getting adequate nutrition. the patient was evaluated by physical therapy. she was minimally active due to her shortness of breath prior to the surgery and will be discharged with home pt. she has been ambulating with assist. left ankle noted to be slightly swollen and a bit bruised in appearance. non-invasive studies were negative for dvt. the patient is passing flatus and on a bowel regimen. she is being sent home with the jp drain still in place. medications on admission: alendronate 70 mg 1xweek,atenolol 25',simvastatin 20', solifenacin 2 qod, advair'', calcium- vit d3, omega 3 fatty acid discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: maximum 6 tablets daily. 2. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*20 tablet(s)* refills:*0* 3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 4. simvastatin 20 mg tablet sig: one (1) tablet po at bedtime. 5. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) inhalation inhalation (2 times a day). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): take for constipation and while using narcotic pain medication. 7. solifenacin 5 mg tablet sig: one (1) tablet po every other day (every other day). 8. alendronate 70 mg tablet sig: one (1) tablet po once a week. 9. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one (1) tablet po once a day. 10. multivitamin tablet sig: one (1) tablet po once a day. 11. omega-3 fish oil oral discharge disposition: home with service facility: , discharge diagnosis: hepatic cyst and cholelithiasis diaphragmatic injury post ercp pancreatitis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane or person assist). discharge instructions: has been arranged for home pt and nursing please call dr office 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 no heavy lifting no driving if taking narcotic pain medication drain and record drain output twice daily and as needed. record output and bring copy with you to your clinic visit. call if the drainage increases significantly, changes in color or develops a foul odor. do not allow drain to hang freely as it may pull out followup instructions: md, , date/time: , 2:00 md, Procedure: Insertion of intercostal catheter for drainage Cholecystectomy Endoscopic insertion of stent (tube) into bile duct Other lysis of peritoneal adhesions Other destruction of lesion of liver Other repair of diaphragm Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Other and unspecified hyperlipidemia Iatrogenic pneumothorax Peritoneal adhesions (postoperative) (postinfection) Osteoporosis, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Chronic pancreatitis Urinary incontinence, unspecified Acute pancreatitis Acquired absence of both cervix and uterus Arthrodesis status Laparoscopic surgical procedure converted to open procedure Other specified disorders of liver |
allergies: no known allergies / adverse drug reactions attending: chief complaint: ruptured abdominal aortic aneurysm major surgical or invasive procedure: : endovascular aneurysm repair, right common femoral artery endarteretomy and patch, left common femoral artery patch : diagnostic laparoscopy history of present illness: 77f with known aaa (5.3cm in , 6.3cm in , now 8.2cm ) with recent c-diff infection treated with vanc and flagyl. she was brought to an osh on by ambulance with hypotension and bloody diarrhea. her wbc was 30 with a bandemia of 35%. a non-contrast ct abdomen was done which was concerning for a fluid collection surrounding her aneurysm with interval enlargement to 8.2cm. due to her ct findings and her hypotension, she was med flighted to for concern for acutely ruptured aaa. she was transported directly from the helipad to the angio suite/or for angiography and possible operative management. past medical history: hypertension known aaa and thoracic aortic aneurysm diverticulosis left carotid artery stenosis, left carotid endarterectomy chronic kidney disease, baseline creatinine 1.2-1.3 colonic polyp, colonic polypectomy recent c-diff infection and respiratory infection in the weeks prior to admission social history: non-contributory family history: non-contributory physical exam: on discharge: 98.8/97.7 77 136/72 20 96ra gen: nad, sitting upright in bed cv: rrr, no m/r/g, nml s1/s2 resp: clear to auscultation bilaterally abd: soft, nontender, nondistended, no masses groin: r groin c/d/i, healing well. left groin cut-down open ~1 cm, no purulence or tenderness to palpation, dry gauze applied to site, packed in wound minimally ext: warm, well-perfused, no cyanosis or edema, pulses all palpable distally, radial/ulcer palpable on right, dopplerable on left pertinent results: 05:27pm blood wbc-21.4*# rbc-4.11* hgb-10.9* hct-33.9* mcv-83 mch-26.6* mchc-32.2 rdw-15.2 plt ct-175# 12:55am blood wbc-14.3* rbc-3.79* hgb-10.2* hct-30.7* mcv-81* mch-26.9* mchc-33.2 rdw-15.7* plt ct-150 01:09am blood wbc-14.3* rbc-3.40* hgb-9.3* hct-27.7* mcv-82 mch-27.4 mchc-33.6 rdw-16.3* plt ct-132* 10:57pm blood wbc-14.5* rbc-3.45* hgb-9.7* hct-28.9* mcv-84 mch-28.2 mchc-33.6 rdw-16.5* plt ct-124* 04:40pm blood wbc-12.7* rbc-3.42* hgb-9.9* hct-28.8* mcv-84 mch-28.9 mchc-34.4 rdw-16.8* plt ct-127* 03:21pm blood wbc-13.5* hct-30.3* plt ct-143* 03:12pm blood wbc-11.9* rbc-3.54* hgb-9.8* hct-30.5* mcv-86 mch-27.6 mchc-32.0 rdw-16.7* plt ct-147* 11:46am blood wbc-11.0 rbc-3.35* hgb-9.4* hct-29.1* mcv-87 mch-28.0 mchc-32.2 rdw-17.0* plt ct-139* 06:34pm blood hct-29.5* 08:56pm blood wbc-13.7* rbc-3.32* hgb-9.3* hct-28.9* mcv-87 mch-28.1 mchc-32.3 rdw-17.4* plt ct-161 02:01am blood wbc-13.1* rbc-3.34* hgb-9.2* hct-29.1* mcv-87 mch-27.4 mchc-31.5 rdw-17.2* plt ct-166 02:33am blood wbc-14.9* rbc-3.19* hgb-8.8* hct-27.6* mcv-86 mch-27.4 mchc-31.8 rdw-17.3* plt ct-171 02:33am blood wbc-14.9* rbc-3.19* hgb-8.8* hct-27.6* mcv-86 mch-27.4 mchc-31.8 rdw-17.3* plt ct-171 02:09am blood wbc-14.0* rbc-3.28* hgb-9.1* hct-28.4* mcv-87 mch-27.7 mchc-32.0 rdw-17.3* plt ct-162 05:03am blood wbc-17.8* rbc-3.39* hgb-9.3* hct-29.6* mcv-87 mch-27.6 mchc-31.6 rdw-17.8* plt ct-156 01:48am blood wbc-10.5 rbc-2.89* hgb-8.0* hct-24.7* mcv-85 mch-27.8 mchc-32.6 rdw-18.0* plt ct-169 06:18am blood wbc-10.5 rbc-3.15* hgb-8.8* hct-26.9* mcv-85 mch-28.0 mchc-32.8 rdw-17.5* plt ct-167 02:02am blood wbc-10.5 rbc-3.32* hgb-9.5* hct-28.6* mcv-86 mch-28.5 mchc-33.2 rdw-17.3* plt ct-188 09:30pm blood hct-30.8* 03:00am blood wbc-11.3* rbc-3.47* hgb-9.6* hct-30.2* mcv-87 mch-27.7 mchc-31.8 rdw-17.3* plt ct-208 10:25am blood hct-29.4* 12:39pm blood wbc-12.4* rbc-3.61* hgb-10.2* hct-29.7* mcv-82 mch-28.4 mchc-34.5 rdw-16.8* plt ct-194 03:44am blood wbc-9.9 rbc-3.42* hgb-9.9* hct-28.5* mcv-84 mch-28.9 mchc-34.6 rdw-17.4* plt ct-224 02:12am blood wbc-8.4 rbc-3.28* hgb-9.4* hct-27.7* mcv-84 mch-28.6 mchc-33.8 rdw-17.2* plt ct-244 07:10am blood wbc-7.6 rbc-2.38* hgb-6.7* hct-20.1* mcv-84 mch-27.9 mchc-33.1 rdw-17.3* plt ct-233 05:16am blood wbc-6.3 rbc-2.93* hgb-8.6* hct-24.7* mcv-85 mch-29.4 mchc-34.8 rdw-16.0* plt ct-207 04:15am blood wbc-5.4 rbc-3.38* hgb-9.9* hct-28.3* mcv-84 mch-29.4 mchc-35.1* rdw-16.3* plt ct-188 05:24am blood wbc-6.1 rbc-3.25* hgb-9.5* hct-27.6* mcv-85 mch-29.2 mchc-34.4 rdw-16.2* plt ct-196 03:50am blood wbc-5.8 rbc-3.14* hgb-9.3* hct-27.5* mcv-88 mch-29.8 mchc-34.0 rdw-16.2* plt ct-196 05:55am blood wbc-5.8 rbc-3.56* hgb-10.4* hct-30.9* mcv-87 mch-29.2 mchc-33.7 rdw-15.8* plt ct-152 05:52am blood wbc-5.1 rbc-3.35* hgb-9.9* hct-29.2* mcv-87 mch-29.6 mchc-33.9 rdw-15.7* plt ct-143* 05:27pm blood glucose-130* urean-43* creat-2.1* na-139 k-4.8 cl-111* hco3-16* angap-17 02:58pm blood glucose-100 urean-39* creat-3.0* na-140 k-4.3 cl-105 hco3-23 angap-16 01:09am blood glucose-86 urean-39* creat-3.1* na-139 k-4.0 cl-106 hco3-21* angap-16 01:09am blood glucose-102* urean-46* creat-4.0* na-135 k-4.0 cl-103 hco3-21* angap-15 03:03am blood glucose-105* urean-42* creat-3.5* na-133 k-4.0 cl-101 hco3-21* angap-15 09:45pm blood glucose-109* urean-42* creat-3.9* na-134 k-4.4 cl-102 hco3-22 angap-14 04:23am blood glucose-120* urean-37* creat-3.4* na-137 k-4.2 cl-103 hco3-24 angap-14 03:25pm blood glucose-115* urean-30* creat-2.7* na-135 k-4.4 cl-102 hco3-23 angap-14 03:38am blood glucose-115* urean-26* creat-2.3* na-135 k-4.6 cl-103 hco3-22 angap-15 03:12pm blood glucose-110* urean-24* creat-1.9* na-133 k-4.6 cl-103 hco3-21* angap-14 10:14pm blood glucose-146* urean-61* creat-3.5* na-136 k-4.9 cl-100 hco3-25 angap-16 11:07pm blood glucose-105* urean-51* creat-3.0* na-133 k-5.2* cl-101 hco3-23 angap-14 01:48am blood glucose-102* urean-30* creat-2.2* na-139 k-4.1 cl-103 hco3-26 angap-14 07:11pm blood glucose-87 urean-58* creat-4.5*# na-134 k-4.4 cl-98 hco3-22 angap-18 03:00am blood glucose-90 urean-63* creat-4.8* na-138 k-4.4 cl-98 hco3-21* angap-23* 02:03am blood glucose-89 urean-84* creat-5.7* na-138 k-4.8 cl-100 hco3-18* angap-25* 12:39pm blood glucose-83 urean-33* creat-2.6*# na-135 k-3.6 cl-95* hco3-26 angap-18 03:44am blood glucose-72 urean-47* creat-3.6* na-137 k-3.7 cl-97 hco3-28 angap-16 02:12am blood glucose-80 urean-62* creat-5.2*# na-136 k-3.7 cl-96 hco3-23 angap-21* 04:40am blood glucose-101* urean-55* creat-3.5*# na-137 k-4.1 cl-100 hco3-29 angap-12 05:16am blood glucose-84 urean-74* creat-4.9*# na-138 k-4.3 cl-101 hco3-25 angap-16 04:15am blood glucose-73 urean-36* creat-3.1*# na-134 k-3.9 cl-97 hco3-31 angap-10 11:48am blood glucose-115* urean-51* creat-4.7*# na-135 k-4.1 cl-100 hco3-24 angap-15 05:24am blood glucose-78 urean-58* creat-5.2* na-134 k-4.3 cl-98 hco3-26 angap-14 05:21am blood glucose-81 urean-24* creat-3.4*# na-136 k-3.9 cl-101 hco3-27 angap-12 03:50am blood glucose-82 urean-30* creat-4.4* na-136 k-4.1 cl-100 hco3-25 angap-15 05:52am blood glucose-101* urean-13 creat-2.5* na-132* k-3.7 cl-95* hco3-32 angap-9 05:27pm blood alt-15 ast-29 ld(ldh)-260* ck(cpk)-214* alkphos-49 totbili-0.2 02:58pm blood ck(cpk)-126 04:48pm blood alt-13 ast-43* alkphos-67 amylase-12 totbili-2.4* 03:32pm blood alt-14 ast-28 ld(ldh)-629* alkphos-122* amylase-62 totbili-11.4* dirbili-8.1* indbili-3.3 02:03am blood alt-13 ast-23 alkphos-121* totbili-8.9* dirbili-6.3* indbili-2.6 05:00pm blood ck(cpk)-12* 05:27pm blood ck-mb-8 ctropnt-<0.01 12:55am blood ck-mb-7 ctropnt-<0.01 09:27am blood ck-mb-4 ctropnt-0.02* 02:58pm blood ck-mb-4 ctropnt-0.02* 01:09am blood ck-mb-3 ctropnt-0.02* 07:30pm blood ck-mb-2 ctropnt-0.09* 03:50am blood ck-mb-2 ctropnt-0.10* 05:00pm blood ck-mb-2 ctropnt-0.10* 05:27pm blood calcium-7.2* phos-8.2* mg-1.2* 01:09am blood albumin-2.9* calcium-7.4* phos-5.4* mg-1.9 04:10pm blood calcium-8.5 phos-5.5* mg-2.3 09:45pm blood calcium-8.5 phos-4.4 mg-2.2 03:38am blood calcium-8.2* phos-2.8 mg-2.2 02:13am blood calcium-7.4* phos-2.3* mg-2.3 02:03am blood calcium-8.2* phos-2.1* mg-2.1 02:02am blood calcium-8.2* phos-6.1*# mg-2.3 03:44am blood calcium-7.8* phos-6.3*# mg-2.0 05:16am blood calcium-7.7* phos-6.4*# mg-2.5 05:24am blood calcium-7.5* phos-6.9* mg-2.1 05:55am blood calcium-8.4 phos-3.5# mg-1.7 renal us: no detectable flow within right or left kidney with doppler son. 2. ascites. 3. a hypodense left renal lesion seen on prior ct could not be assessed with ultrasound due to limited acoustic window arterial duplex ue: 1. prior brachial artery access post evar for renal artery access. the brachial artery is patent. 2. there is occlusion of the distal radial artery (?embolic). 3. low velocity flow is noted in the ulnar artery, suggesting compromise of this vessel as well egd: erythema, friability and ulceration in the middle third of the esophagus and lower third of the esophagus, worst over the area of the aortic notch compatible with severe esophagitis medium hiatal hernia normal mucosa in the stomach prominent brunner's glands. otherwise normal egd to second part of the duodenum pill endoscopy: 1) no active bleeding site seen in the small bowel. 2) a single non-bleeding red spot vs. avm in the distal small bowel. 3) esophagitis with erosions seen in the lower esophagus. 4) suboptimal preparation of the small bowel with liquid debris. colonoscopy: diverticulosis of the whole colon worse in the sigmoid erythema and friability in the sigmoid colon (biopsy) ulceration, erythema and congestion in the colon (injection, thermal therapy) otherwise normal colonoscopy to cecum brief hospital course: 77f with known aaa (5.3cm in , 6.3cm in , now 8.2cm ) presents via from osh on with hypotension and an acutely ruptured abdominal aortic aneurysm. she was brought directly to the or where she underwent a evar and a right common femoral endarterectomy and patch and left common femoral artery artery patch. she had a long and complicated course and remained in the icu until . she was then transferred to our step down unit were she has continued to make steady progress. she is now being transferred to rehab to continue to improve her strength and mobility. 1. acute kidney injury her baseline creatnine was 1.3. post procedure her creatinine steadily rose with anuria and massive fluid overload. renal ultrasound on showed no flow to kidneys bilaterally so cvvhd was started. she has transitioned to hemodyalysis on through a tunneled hd line. she is presently on a monday/wednesday/friday dialysis schedule which she is tolerating well. 2.respiratory failure she required prolonged mechanical ventilation secondary to pneumonia and fluid overload. she grew out multiple sputum organisms, including acromobacter, which were appropriately treated with full courses of antibiotics. she has been off antibiotics since and has remained extubated since . presently she has no supplemental oxygen requirement, with normal wbc and no temperature. 3.melena immediately post procedure she had bloody diarrhea. the gi service was consulted gi was consulted on secondary to copius dark, liquid blood in the patient's flexi-seal bag along with anemia requiring a total of 14 units of prbcs for peri-surgical and ongoing maintenance of her hematocrit. she underwent an egd () which showed esophagitis, a capsule endoscopy () which showed a single nonbleeding spot vs avm in the distal small bowel, as well as a colonoscopy () which showed a question of ischemia in the rectosigmoid region along with a rectal ulcer with overlying clot; the questionable area of ischemia was biopsied - results are pending - the ulcer was treated with injection and bicap. she last was transfused with prbcs on . per gi's recommendations, she should be maintained on a ppi at least until she undergoes f/u egd as scheduled on . medications on admission: lipitor 10mg daily atenolol 100mg daily lisinopril 20mg daily hctz 12.5 mg daily amlodipine 5mg daily asa 325mg daily prednisone for respiratory infection and antibiotic for c-diff discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 3. hydralazine 50 mg tablet sig: one (1) tablet po q6h (every 6 hours). 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 5. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 6. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. . 7. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). 8. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: extended care facility: - discharge diagnosis: primary: ruptured abdominal aorta aneurysm, sp evar, acute bilateral kidney injury requiring hemodyalysis. secondary: diverticulosis, left carotid artery stenosis, sp carotid endarterectomy. discharge condition: mental status: clear and coherent. activity status: ambulatory - requires assistance or aid (walker or cane). level of consciousness: alert and interactive. discharge instructions: you were admitted to the hospital after a repair of a ruptured aneurysm. we put a stent in the aneurysm to stabilize it. medications: ?????? take aspirin 325mg (enteric coated) once daily ?????? do not stop aspirin unless your vascular surgeon instructs you to do so. ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect when you go home: it is normal to have slight swelling of the legs: ?????? elevate your leg above the level of your heart (use pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated it is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? drink plenty of fluids and eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication 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 ?????? call and schedule an appointment to be seen in weeks for post procedure check and cta what to report to office: ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site sudden, severe bleeding or swelling (groin puncture site or incision) ?????? lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call vascular office. if bleeding does not stop, call 911 for transfer to closest emergency room. you were treated for melena, or blood in your stools. you must continue to take your protonix twice daily for inflammation found in your esophagus. you were also found to have some inflammation of your colon and rectum. - you will follow up with the gastroenterologists as listed below for repeat imaging of your intestines. - no rectal tubes or enemas until seen and evaluated by your gastroenterologists. followup instructions: department: endo suites when: monday at 10:00 am department: digestive disease center when: monday at 10:00 am with: , md building: building (/ complex) campus: east best parking: main garage Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Hemodialysis Angioplasty of other non-coronary vessel(s) Venous catheterization for renal dialysis Laparoscopy Closed [endoscopic] biopsy of bronchus Endovascular implantation of other graft in abdominal aorta Other endovascular procedures on other vessels Endoscopic destruction of other lesion or tissue of large intestine Rigid proctosigmoidoscopy Endarterectomy, lower limb arteries Other diagnostic procedures on small intestine Procedure on two vessels Procedure on vessel bifurcation Diagnoses: Acidosis End stage renal disease Acute kidney failure with lesion of tubular necrosis Acute posthemorrhagic anemia Thoracic aneurysm without mention of rupture Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Peripheral vascular complications, not elsewhere classified Intestinal infection due to Clostridium difficile Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Unspecified disorder of kidney and ureter Hemorrhage of gastrointestinal tract, unspecified Ventilator associated pneumonia Diverticulosis of colon (without mention of hemorrhage) Arterial embolism and thrombosis of lower extremity Aneurysm of iliac artery Abdominal aneurysm, ruptured Hemoperitoneum (nontraumatic) Other atherosclerosis of native arteries of the extremities Other esophagitis Personal history of colonic polyps Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Arterial embolism and thrombosis of upper extremity Acute respiratory failure following trauma and surgery |
allergies: morphine attending: chief complaint: back pain, fever major surgical or invasive procedure: bedside incision and drainage of infection spine wound wash out and drainage of lumbar wound central line placement history of present illness: 28yo f s/p left l4-l5 microdiskectomy, left l5-s1 foraminotomy on returns to the ed on with increased back pain and possible fevers.she has been in a lot of pain since the operation last week. her mother called the on call neurosurgery pager to report a fever at home to 100.8 and purulent, foul smelling discharge from the patient's surgical wound. in the er, she reports increased low back pain. only admits to fever upon directed questioning. she denies any bowel or bladder dysfunction. she reports a new onset headache, worse when sitting upright. no difficulty with speech production or comprehension. she feels generalized weakness. no saddle anesthesia. past medical history: morbid obesity, s/p gastric bypass l5/s1 microdiscectomy l4/l5 microdicectomy. social history: lives with mother, has a 4 year old son. family history: non contributory physical exam: physical exam: o: t: 96.3 bp: 108/52 hr: 98 r 20 o2sats 100% ra gen: laying on her left side on ed gurney,cradling her head, appears uncomfortable. spine: l3-s1 incision is clean, dry and intact, no fluctuance or fluid could be expressed. neuro: mental status: awake and alert, minimally cooperative with exam. she is inattentive, unable to name dow backwards. naming is intact. orientation: oriented to person, place, and date. motor: d b t we wf ip q h at g r 5--------------------> 4* 5 5 5 5 5 l 5--------------------> 5 5 5 5 5 5 sensation: intact to light touch, pinprick and vibration bilaterally- no sensory level. propioception difficult to test given pt's inattention. exam on discharge: mental status intact. wound closure: nylon, matress closure slight left weakness 4+, otherwise intact pertinent results: gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and in short chains. wound culture (preliminary): beta streptococcus group b. sparse growth. sensitivity requested by dr. 9-0841. sensitivity testing performed by . dr. requested penicillin sensitivity . brief hospital course: the patient was admitted to the neurosurgery service on the intensive care unit. a local incision and drainage of the wound was performed at the bedside, and 20cc of fluid aspirated superficially. she remained in the icu for close monitoring of her meningeal signs (nucchal rigidity), and her fever and elevated wbc count. on the morning of hd3, she had been afebrile for over 24 hours, and her wbc count began to trend downwards. she was transferred to the step down unit. pain control was an issue for the patient, as she had been on percocet for years and developed a high pain tolerance. once transferred to the stepdown patient continued to have severe pain, a lumbar mri was performed which showed a subcutaneious fluid collection extending to the epidural space, pt. was subsequently taken to the or for a washout of the lumbar wound, a pin rose drain was paced for continours drainage and was removed on pod #2. pt. was cleared to go home after being afebrile for 24hrs. she will continue to be followed by infectious disease and have ongoing antibiotic therapy with penicillin g for 6 weeks. weekly labs will be reviewed by id. we will see the patient back in 3 weeks for suture removal and wound check. medications on admission: dilaudid 5mg po q4hrs discharge medications: 1. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. disp:*30 ml(s)* refills:*10* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*60 tablet(s)* refills:*2* 4. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day). disp:*180 capsule(s)* refills:*2* 5. diazepam 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for spasm. disp:*60 tablet(s)* refills:*1* 6. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical (2 times a day) as needed for rash . disp:*1 1* refills:*0* 7. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itching . disp:*qs * refills:*0* 8. hydromorphone 2 mg tablet sig: 2-4 tablets po q3h (every 3 hours) as needed for pain. disp:*80 tablet(s)* refills:*1* 9. outpatient lab work weekly cbc, bmp, lfts every other week: esr, crp 10. penicillin g potassium 1,000,000 unit recon soln sig: one (1) 4 million units q4hrs injection every four (4) hours: 4 million units q 4 hrs. x 6 weeks. end date: . disp:*1 1* refills:*1* discharge disposition: home with service facility: discharge diagnosis: strep b positive lumbar abscess menengitis oral varacella lower extremity rash discharge condition: stable, a&ox3 discharge instructions: you have developed a post-operative infection to your lumbar spine incision. this was drained at the bedside, and did not require operative draining. this wound has been left open to drain. you are to perform dressing changes at home with the help of a friend or family member. followup instructions: you are to call ( to make an appointment with dr. in 3 weeks, your sutures will also be discontinued at this time. please follow up with infectious disease on the following date: provider: , id west (sb) phone: date/time: 2:10 provider: , md phone: date/time: 10:00 md Procedure: Venous catheterization, not elsewhere classified Other exploration and decompression of spinal canal Other incision with drainage of skin and subcutaneous tissue Diagnoses: Other chronic pain Esophageal reflux Other postoperative infection Asthma, unspecified type, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Morbid obesity Rash and other nonspecific skin eruption Intraspinal abscess Bariatric surgery status Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B Meningitis, unspecified Varicella without mention of complication |
allergies: bactrim ds / cellcept attending: chief complaint: septic shock major surgical or invasive procedure: central line placement hemodialysis history of present illness: ms. is a 52 year old woman w/ esrd from sle s/p cadaveric renal transplant in which was complicated by fsgs and transplant failure now on hemodialysis who was recently treated for cmv viremia in the setting of c. difficle colitis, admitted with fever and hypotension from rehab. history per patient supplemented with i.d.: the admission was complicated by cmv viremia and c. diff colitis. she was discharged on iv ganciclovir (120mg iv daily), which was to continue until she had two negative cmv virals loads separated by one week's time. she finished iv ganciclovir treatment course and was transitioned to oral valganciclovir suppression. suppression therapy was discontinued on due to neutropenia (wbc 1.8, plt 59). per , pt had an interim hospitalization of a few days for septic shock in mid-, requiring pressors, details of which are unclear, which pt did not clearly confirm or deny. on pt began having fevers. a cmv viral load was rechecked (970) and repeat vl of 4059 on . it is unclear when ganciclovir was restarted, but by , she was on ganciclovir with hd dosing. she began to complain of dizzines and visual disturbances. then, still with fevers, she became hypotensive on without a localizing source of infection. she complained of some mild abdominal pain. she was transferred to for further management. in the ed, she had a temp to 100.3, bp 85/48 so levophed was started and she was transferred to the micu. past medical history: -esrd s/p cadaveric renal transplant in complicated by fsgs and transplant failure now on hd -sle, followed by dr. in rheumatology -paroxysmal atrial fibrillation -nsvt -hypertension -hyperthyroidism -s/p bilateral knee surgeries and r acl repair social history: single, lives with sister's family in . denies tobacco, etoh, and drugs. family history: mother and brother both with diabetes and , both deceased. physical exam: v/s: t 98 bp 117/63 hr 87 rr 17 02sat 98% on room air gen: aaox3, nad, pleasant heent: moon facies, no oral ulcers, mmm, supple, no lad, no jvp cardiac: rrr, no m/r/g, referred fistula bruit at lusb lungs: ctab a/p abdomen: bowel sounds present, soft, obese, nontender, nondistended; mass in rlq; no hsm. ext: warm, well-perfused. dp pulses difficult to palpate through lower extremity and pedal edema. no cyanosis or clubbing. striated ue bilaterally with loose adipose. left upper extremity with raises, scarred fistula tract. left hand with swan neck deformities. neuro: cn 2-12 intact, upper arm (prox + dist) strength, le strength, bilaterally derm: no rashes pertinent results: 01:51pm blood wbc-9.3# rbc-3.41* hgb-9.6* hct-32.1*# mcv-94 mch-28.0 mchc-29.7* rdw-17.8* plt ct-119* 01:51pm blood neuts-76* bands-7* lymphs-3* monos-9 eos-0 baso-0 atyps-0 metas-4* myelos-1* 01:51pm blood pt-14.0* ptt-29.7 inr(pt)-1.2* 01:51pm blood glucose-124* urean-12 creat-4.9* na-142 k-4.6 cl-108 hco3-24 angap-15 01:51pm blood alt-11 ast-16 ld(ldh)-336* ck(cpk)-10* alkphos-58 totbili-0.2 01:51pm blood albumin-2.4* calcium-7.8* phos-2.6* mg-1.5* cbc wbc-2.9 rbc-2.77 hgb-8.2 hct-27.0 mcv-98 mch-29.4 mchc-30.2 rdw-17.9 plt ct-126 pt-12.4 ptt-29.0 inr(pt)-1.0 k-2.8 glucose-79 urean-19 creat-4.7 na-144 k-3.9 cl-107 hco3-30 angap-11 microbiology 1) cmv viral load (final ): cmv dna not detected 2) direct influenza a antigen test (final ): negative for influenza a. direct influenza b antigen test (final ): negative for influenza b. 3) and 13: feces negative for c.difficile toxin a & b by eia. 4) clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. 5) stool culture negative for campylobacter, shigella, salmonella, enteric gram negative rods, viruses (final ) 6) bk virus pcr pending radiology cxr the cardiac, mediastinal, and hilar contours are unremarkable. except for right perihilar linear opacity, likely representing atelectasis, the lungs are clear without focal consolidation. no pleural effusion or pneumothorax is seen. the osseous structures demonstrate no acute skeletal abnormalities. kub there is no evidence of free air. there is no evidence of obstruction. there is no evidence of gas within the bowel wall. ct abd and pelvis 1. uncomplicated sigmoid diverticulitis. no evidence of abscess formation or perforation. 2. dilated main pancreatic duct worsened since . this might represent a segmental main duct ipmn (intraductal papillary mucinous neoplasm). consultation with the pancreas center at is recommended for further workup. 3. unchanged right anterior abdominal wall seroma. 4. transplanted kidney shows decreased enhancement consistent with history of evolving transplant failure. there is slightly increased perinephric stranding, but no evidence of abscess or acute infection. repeat cxr: compared to ap single view cxr on . previously identified right internal jugular approach central venous line remains in unchanged position terminating overlying the svc 2 cm below the carina. no pneumothorax is present. the pulmonary vasculature is not congested and the heart size has not increased. new, however, is a density occupying the left lower lobe basal portion and obliterating the diaphragmatic contours, most likely representing a new retrocardiac atelectasis, not identified on the next previous study of . in the right mid lung field, a plate atelectasis is seen, but appears as before. no other new abnormalities are seen. impression: development of sizeable left lower lobe atelectasis in retrocardiac position. renal u/s : findings: the transplant kidney is again seen in the right lower quadrant and it measures 12.1 cm in length. there is no hydronephrosis and no perinephric fluid collection is identified. no cyst or stone or solid mass is seen in the transplant kidney. within the superficial tissues a heterogeneous mass is again identified previously presumed to be a hematoma. this structure is unchanged in size and appearance from the prior ultrasound of measuring about 11 cm in its widest diameter. doppler examination: color doppler and pulse-wave doppler images were obtained. note is made that the doppler images were limited by the patient's body habitus. appropriate venous flow is seen within the main renal vein. limited views of the main renal artery demonstrate appropriate acceleration times. mildly elevated resistive indices are seen in the intraparenchymal arteries. impression: 1. somewhat limited doppler exam demonstrating essentially appropriate transplant vasculature. 2. no hydronephrosis or collections identified. 3. similar size and appearance of the subcutaneous hematoma in the right lower quadrant. echo : the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal(>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets(3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , the severity of mitral regurgitation is reduced (but was only mild on review of the prior study). brief hospital course: #septic shock - admitted to the micu and treated with vasopressor therapy, stress-dose steroids, and empiric po vancomycin, iv vancomycin, iv zosyn and iv gancyclovir. ct abd/pelvis showed uncomplicated sigmoid diverticulitis. all other culture data and infectious workup (including c. diff toxin negative x 3) was unrevealing as to another source of infection. due to asymptomatic relative hypotension after transfer to the medical floor, midodrine was started with improvement in blood pressure. metoprolol was discontinued due to hypotension. . #pancytopenia - counts remained stable off of zosyn. tacrolimus was decreased to 2 mg . . #renal transplant c/b graft fsgs and esrd on hd - continued usual schedule of hd tuthsa. prednisone tapered from stress-dose to 10 mg daily. tacrolimus dose decreased as above. . #cmv viremia: will continue iv ganciclovir pending cmv viral load results (sent ). #hyperglycemia: attributed to corticosteroid therapy. well-controlled on basal and sliding scale insulin. . #paroxysmal atrial fibrillation: in sinus rhythm on discharge. chads2 score of 1 so continued aspirin 325 mg. #anemia of chronic kidney disease: continued erythropoeitin and zemplar with hd. medications on admission: 1. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever/pain: not to exceed 4g tylenol per day. 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 4. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 5. petrolatum ointment sig: one (1) appl topical tid (3 times a day) as needed for for dry skin. 6. docusate sodium 100 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 8. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 9. insulin glargine 100 unit/ml cartridge sig: two (2) units subcutaneous at bedtime. 10. insulin lispro 100 unit/ml cartridge sig: as per sliding scale as per sliding scale subcutaneous qachs. 14. prednisone 5 mg tablet daily 15. vancomycin 125 mg capsule sig: one (1) capsule po q6h 16. ganciclovir 110 mg iv q24h start: in am give after hd on dialysis days 17. atovaquone 750 mg/5 ml suspension sig: two (2) po daily (daily). 18. tacrolimus 4.5 mg lactobacillus asa 325 nephrocaps erythropoetin 15,000u qhd magnesium oxide 200mg . medications on transfer: ganciclovir 110 mg iv qhd day 1= vancomycin 1000 mg iv hd protocol day 1 = piperacillin-tazobactam 2.25 g iv q 12h day 1 = tacrolimus 4.5 mg po q12h hydrocortisone na succ. 100 mg iv q8h insulin sc (per insulin flowsheet) sliding scale & fixed dose order aspirin 325 mg po/ng daily nephrocaps 1 cap po daily atovaquone suspension 1500 mg po/ng daily pantoprazole 40 mg po q24h heparin 5000 unit sc tid discharge medications: 1. atovaquone 750 mg/5 ml suspension sig: ten (10) ml po daily (daily). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 5. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a day). 6. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 days: through . disp:*2 tablet(s)* refills:*0* 7. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 2 days: through . disp:*6 tablet(s)* refills:*0* 8. tacrolimus 1 mg capsule sig: two (2) capsule po q12h (every 12 hours). 9. ganciclovir sodium 500 mg recon soln sig: one hundred-ten (110) mg intravenous qhd (each hemodialysis): please continue ganciclovir 110 mg iv qhd until instructed to discontinue this medication by the patient's infectious disease physicians (after cmv viral load sent returns negative). . 10. heparin (porcine) 5,000 unit/ml solution sig: one (1) unit injection tid (3 times a day). 11. transportation please provide transportation to and from appointments 12. insulin glargine 100 unit/ml cartridge sig: two (2) units subcutaneous at bedtime. 13. nph insulin human recomb 100 unit/ml cartridge sig: four (4) units subcutaneous qam. 14. humalog 100 unit/ml cartridge sig: asdir units subcutaneous qachs: per attached sliding scale. 15. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 16. ondansetron 4 mg iv q8h:prn nausea 17. epogen 10,000 unit/ml solution sig: () units injection qhd. 18. bisacodyl 5 mg tablet, delayed release (e.c.) sig: tablet, delayed release (e.c.)s po once a day as needed for constipation. discharge disposition: extended care facility: hospital- discharge diagnosis: septic shock cmv viremia acute uncomplicated diverticulitis end-stage renal disease on hemodialysis status post deceased donor kidney transplant 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 with fever and low blood pressure, most likely due to an infection in your large intestine called diverticulitis. your infection was partially treated with antibiotics. please continue taking the antibiotics as prescribed through sunday, . the following medication changes were recommended: 1) started ciprofloxacin, an antibiotic. 2) started flagyl, another antibiotic. 3) started midodrine, a medication to raise your blood pressure. 4) stopped metoprolol due to low blood pressure. 5) tacrolimus decreased to 2 mg twice daily. followup instructions: provider: , md phone: date/time: 3:00 pcp , . as needed follow up with nephrologists as provider: , md phone: date/time: 9:40 md Procedure: Venous catheterization, not elsewhere classified Hemodialysis Diagnoses: Chronic glomerulonephritis in diseases classified elsewhere Systemic lupus erythematosus Anemia in chronic kidney disease End stage renal disease Adrenal cortical steroids causing adverse effects in therapeutic use Unspecified septicemia Severe sepsis Atrial fibrillation Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Hypopotassemia Paroxysmal ventricular tachycardia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Antiviral drugs causing adverse effects in therapeutic use Septic shock Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Cytomegaloviral disease Complications of transplanted kidney Other abnormal glucose Diverticulitis of colon (without mention of hemorrhage) Other specified aplastic anemias Viremia, unspecified |
allergies: bactrim ds / cellcept / zosyn attending: chief complaint: fever major surgical or invasive procedure: hemodialysis history of present illness: 52 year old female with esrd on hd with recent admission for vre bacteremia, admitted to micu for sepsis evaluation, transferred to the floor, readmitted to micu for afib with rvr, then transferred to the floor once hemodynamically stable. she initially presented with fever to 101 after hd on treated with 650mg of tylenol at rehab, rechecked at 101.3, and noted have some chills by the nurse. she was subsquently sent to the ed. . the patient reports feeling well overall the days prior to admission. she denies any n/v, cough, shortness of breath, sore throat, rhinnorhea, or abdominal pain. she reports a good appetite. she does complain that the rehab was not dosing her antibiotics appropriately and was only giving her linezolid once daily until she corrected them a few days ago. . of note, the patient was recently admitted on for vre bacteremia and was treated with linezolid for a planned 4 week course; she subsequently had her hd lined removed, underwent a line holiday and then a new line was placed. also of note, she has been on dapsone for pcp prophylaxis as well as gancyclovir for cmv viremia. . on arrival to the ed, her vitals were: t 99.8 bp 93/60 hr 120 rr22 98%ra. labs were done which showed wbc 4 with 8% bandemia, lactate 4.8. cxr was negative, u/a not done as pt is anuric. blood cultures were drawn. ekg showed sinus tachycardia with flattening laterally. she was given 2l ivf and vanc/imipenem for empiric coverage of an unclear source given her history. a cvl was offered but the patient refused so an ej was placed. . in the micu, the patient was started on daptomycin, imipenem switched to meropenem and vanc continued. her hypotension resolved with ivf. she remained afebrile with stable vital signs. . ros: denies headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: - vre bacteremia, treated linezolid - esrd due to sle, s/p cadaveric renal transplant complicated by fsgs and transplant failure , now on hd - sle, followed by dr. in rheumatology - hypotension (started on midodrine ) - septic shock - cmv viremia - acute uncomplicated diverticulitis - hx of c. diff - paroxysmal atrial fibrillation - nsvt - hx of hypertension - hyperthyroidism - s/p bilateral knee surgeries and r acl repair social history: single, currently at rehab. denies tobacco, etoh, and drugs. family history: mother and brother both with diabetes and , both deceased. physical exam: vitals - t: 97.7 bp: 125/69 hr: 81 rr: 26 02 sat: 100% ra general: ill appearing female, in nad heent: o/p clear, mmm neck: no lad, left tunneled hd line in place, no erythema or tenderness over area cardiac: rrr, nl s1s3, no m/r/g lung: clear bilaterally, mild scatered wheezing abdomen: soft, nt, nd, +bs ext: no clubbing, edema, warm and well pefused, 2+ dp/pt pulses bilatearlly neuro: alert and oriented x3 pertinent results: ================== admission labs ================== 07:40pm wbc-4.0 rbc-2.84* hgb-7.8* hct-25.1* mcv-88 mch-27.4 mchc-31.0 rdw-18.3* plt ct-92* neuts-52 bands-8* lymphs-30 monos-8 eos-0 baso-0 atyps-2* metas-0 myelos-0 hypochr-3+ anisocy-1+ poiklo-occasional macrocy-normal microcy-1+ polychr-normal ovalocy-occasional plt smr-low plt ct-92* glucose-170* urean-10 creat-3.0*# na-137 k-4.3 cl-97 hco3-24 angap-20 ck(cpk)-13* calcium-7.6* phos-1.8*# mg-1.3* glucose-164* lactate-4.8* na-137 k-4.2 cl-96* calhco3-27 upright ap view of the chest: left-sided dual-lumen central venous catheter tip terminates within the mid svc. the cardiac silhouette is normal in size. the mediastinal and hilar contours are within normal limits. the lungs are clear without focal consolidation. pulmonary vascularity is normal. no pleural effusion or pneumothorax is present. the osseous structures are unremarkable. impression: no acute cardiopulmonary abnormality. ============== ekgs ============== cardiology report ecg study date of 7:14:44 pm sinus tachycardia with baseline artifact. non-specific anterolateral st-t wave changes. compared to the previous tracing of ventricular premature beats are not seen on the current tracing. otherwise, no diagnostic interim change. intervals axes rate pr qrs qt/qtc p qrs t 112 138 86 334/425 59 3 144 . cardiology report ecg study date of 1:11:50 am sinus rhythm. short p-r interval. st-t wave abnormalities. since the previous tracing of st-t wave abnormalities are less prominent at a slower rate. intervals axes rate pr qrs qt/qtc p qrs t 88 148 88 386/435 65 -16 70 . cardiology report ecg study date of 3:16:38 pm sinus rhythm. since the previous tracing baseline artifact is different. there is probably no significant change in previously noted findings. intervals axes rate pr qrs qt/qtc p qrs t 85 140 90 414/457 59 -12 62 . cardiology report ecg study date of 5:18:08 am probable atrial fibrillation with rapid ventricular response. since the previous tracing of atrial fibrillation is new. there is a single wide complex beat, probably ventricular, which is also new. intervals axes rate pr qrs qt/qtc p qrs t 145 0 84 318/466 0 -10 -142 . cardiology report ecg study date of 8:19:24 am sinus rhythm. since the previous tracing earlier on , atrial fibrillation is no longer present. there is marked q-t interval prolongation and there are inferolateral t wave inversions. clinical correlation is suggested. intervals axes rate pr qrs qt/qtc p qrs t 74 160 88 448/472 63 -3 -114 . cardiology report ecg study date of 9:37:40 am sinus tachycardia. diffuse st-t wave changes. cannot rule out myocardial ischemia. compared to the previous tracing of qtc interval prolongation has improved. otherwise, previously described multiple abnormalities are present. intervals axes rate pr qrs qt/qtc p qrs t 101 148 86 362/433 6 -12 -173 . cardiology report ecg study date of 20:21:24 pm *after 9 beats of nsvt* sinus rythm with pacs. extensive st-t changes may be due to myocardial ischemia. t wave inversion in i, ii, avf, v2-v6. intervals axes rate pr qrs qt/qtc p qrs t 82 118 86 412/450 -17 1 -128 . cardiology report ecg study date of 9:30:44 am *at the time, patient was nauseous* sinus rythm. possible lvh. extensive st-t changes may be due to hypertrophy and/or ischemia. t wave inversion in i, ii, and avf; biphasic t wave in v2, t wave inversion in v3-v6. intervals axes rate pr qrs qt/qtc p qrs t 121 160 84 334/ -154 . cardiology report ecg study date of 17:07:36 pm *at rest, asymptomatic* sinus rythm. extensive st-t changes may be due to hypertrophy and/or ischemia. t wave inversion in i, ii, and avf; biphasic t wave in v2, t wave inversion in v3-v6. intervals axes rate pr qrs qt/qtc p qrs t 80 152 80 414/449 21 -19 -169 . cardiology report ecg study date of 16:22:36 pm *during dialysis, asymptomatic* possible ectopic atrial rythm. left ventricular hypertrophy. extensive st-t changes may be due to ventricular hypertrophy. t wave inversion in i, ii, avf, v2-v6. in v2 t wave inversions are deep and symmetric. intervals axes rate pr qrs qt/qtc p qrs t 98 126 82 380/446 -35 -6 -161 . cardiology report ecg study date of 17:34:12 pm *post dialysis, back to floor, asymptomatic* sinus rythm. left ventricular hypertrophy. extensive st-t changes probably due to ventricular hypertrophy. t wave inversion in i, ii, avf, upright in v2, inverted in v3-v6. intervals axes rate pr qrs qt/qtc p qrs t 94 144 88 398/457 24 -17 -169. . cardiology report ecg study date of 9:54:46 am *nauseous* sinus tachycardia. left ventricular hypertrophy. extensive st-t changes probably due to hypertrophy and/or ischemia. t wave inversion in i, ii, avf, upright in v2, inverted in v3-v6. intervals axes rate pr qrs qt/qtc p qrs t 106 146 84 424/424 1 -18 -162 . ================== discharge labs ================== 06:00am blood wbc-2.1* rbc-2.50* hgb-7.1* hct-23.2* mcv-93 mch-28.4 mchc-30.6* rdw-21.4* plt ct-147* 06:00am blood plt ct-147* 06:00am blood pt-21.2* ptt-24.9 inr(pt)-2.0* 06:00am blood glucose-75 urean-8 creat-2.5*# na-143 k-3.3 cl-103 hco3-35* angap-8 06:00am blood calcium-8.0* phos-2.6* mg-1.3* ================== cardiac enzymes ================== 11:24pm blood ck(cpk)-13* 05:41am blood ld(ldh)-443* ck(cpk)-17* totbili-0.4 dirbili-0.1 indbili-0.3 11:37am blood ck(cpk)-15* 05:23pm blood ck(cpk)-10* 03:30am blood ck(cpk)-47 06:40am blood ck(cpk)-50 03:50pm blood ck(cpk)-56 11:24pm blood ck-mb-notdone ctropnt-0.02* 05:41am blood ck-mb-notdone ctropnt-0.02* 11:37am blood ck-mb-notdone ctropnt-0.08* 05:23pm blood ck-mb-notdone ctropnt-0.06* 03:30am blood ck-mb-notdone ctropnt-0.04* 06:40am blood ck-mb-notdone ctropnt-0.05* 03:50pm blood ck-mb-notdone ctropnt-0.04* brief hospital course: 52 year old female with esrd on hd, recent vre bacteremia, cmv viremia, sle presented with fever and hypotension, developed afib with rvr as well as labile t wave inversion, now hemodynamically stable. # early sepsis: patient presented with fevers, hyotension, tachycardia and a lactate of 4.8. in addition, her wbc was 4.0 but with an 8% bandemia. she has had a number of infections recently in the setting of immunosuppression. the differential was broad including line infection (new hd line placed on ), pneumonia (cxr without obvious infiltrate), cmv viremia (viral load negative), uti, c. diff (recent infection but without any symptoms to suggest this). patients bp/hr improved after administration of 2l ivf, and broad coverage with meropenem (gn coverage) plus daptomycin (gp coverage) as well as po vanc, given bandemia. bcx, c.diff cx, and cmv viral load were also obtained and were negative. however, after speaking with id valganciclovir was restarted. during hospitalization, antibiotics were narrowed to daptomycin. patient will need to complete 4 week course of daptomycin for vre bacteremia in setting of known thrombus that is possibly seeded. she will receive daptomycin when she receives hd. the renal team has arranged for her to get the medication at hd. the last dose will be on . . # t wave inversions: patient's t waves were upright at the time of admission. she then developed inverted t waves in v3-v6, i, ii, avf, and intermittently/biphasic in v2 (see attached ekgs copied from ), with repeated negative cardiac enzymes. then she developed more deeply inverted t waves in v2 that were deep and symmetrical during hd on that then turned upright. it was not clear that the t wave inversions were rate related. cardiology was . the ddx included: ischemia, takotsubo's, or a cerebral processes, however rapid resolution of the t waves made the later two less likely. she denied chest discomfort though she occasionally had nausea. she did not have any neurological symptoms. patient has no lvh on prior echos to invoke repolarization changes. recommend performing persantine study to r/o ischemia as an outpatient, not initiated as an inpatient given difficulty to instigate intervention in this setting with recent bacteremia and rue thrombus. in the mean time, patient is medically managed for coronary artery disease; she is on aspirin and small dose of beta-blocker. simvastatin was added during this admission. . # tachycardia: in addition to atrial fibrillation which is currently controlled, she had multiple episodes of regular tachycardia. ekg revealed sinus tach. in terms of the etiologies of sinus tachycardia, she had evidence of volume depletion, especially after hd, which likely led to low systolic blood pressures in the 90s and sinus tachycardia. sinus tachycardia invariably improved/resolved after gentle ivf (250cc-500cc ns). she also experienced nausea during some episodes of tachycardia, raising the question whether the tachycardia is due to discomfort. however, after treatment with zofran and resolution of nausea, her heart rate remained in the 120s, which argues against that theory. . # low blood pressure: patient's baseline systolic blood pressure is 100s to 110s, though was noted to occasionally be in the 90s, which responded to small ivf boluses (250-300cc). it was thought to be secondary to volume shifts and possibly be exacerbated by autonomic instability. she should continue on midodrine 10mg tid. . # esrd on hd s/p failed transplant: patient was continued on hd and maintained on prednisone. . # venous thrombus: patient was noted to have a complete thrombosis of the left av , left cephalic vein and left subclavian vein, and partial thrombosis of left brachiocephalic vein with extension to svc on her previous admission. she was unable to receive a picc on that side this thrombus (and not on the right presence of fistula). she was maintained on warfarin with goal and should continue anticoagulation until resolution of the thrombus or indefinitely. . # cmv viremia: patient has been treated with valganciclovir. this was briefly stopped out of concern for myelosuppression but subsequently restarted per id. plan is for her to f/u with outpatient id with dr. on regarding need to continue this treatment. . # atrial fibrillation with rvr: on patient was transferred to micu for afib with rvr and hypotension. she was treated with digoxin load and prn po metoprolol. she will continue on digoxin 0.125mg 3/week and metoprolol 12.5 as an outpatient, with holding parameters for sbp<95 or hr<55. . # nausea: patient had repeated bouts of nausea accompanied by tachycardia in the 120-140 and hypotension that resolved with ondansetron. this appears to occur after hd and may be related to volume depletion. she also often gets nausea after eating. patient repeatedly denied sob or chest discomfort. repeated cardiac enzymes were negative. . # anticoagulation: patient should continue on coumadin with goal inr . . # code status: full code medications on admission: aspirin 325 mg daily pantoprazole 40 mg daily prednisone 5 mg tablet daily valganciclovir 450 mg tablet sig: one (1) tablet po 2x/week (tu,th). midodrine 10mg tid linezolid 600 mg until oxycodone 5 mg q6 prn injection q dialysis. humalog 100 unit/ml cartridge sig: sliding scale subcutaneous qachs. warfarin 2.5 mg daily dapsone 100 mg daily zofran 4 mg tablet sig: one (1) tablet po twice a day as needed for nausea. atovaquone 1500 daily discharge medications: 1. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a day). 4. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 6. dapsone 100 mg tablet sig: one (1) tablet po daily (daily). 7. digoxin 125 mcg tablet sig: one (1) tablet po q tues, thurs, sat (). 8. valganciclovir 450 mg tablet sig: one (1) tablet po wed, sat (). 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 10. daptomycin 500 mg recon soln sig: four y (450) mg intravenous at dialysis: the last dose on . 11. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 12. insulin regular human 100 unit/ml cartridge sig: sliding scale injection qachs. 13. warfarin 2.5 mg tablet sig: one (1) tablet po once a day: goal inr . 14. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 15. epoetin alfa 2,000 unit/ml solution sig: at dialysis discharge disposition: extended care facility: discharge diagnosis: primary diagnoses: fever atrial fibrillation vre bacteremia on treatment . secondary diagnoses: esrd on hd sle lue venous thrombus discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:out of bed with assistance to chair or wheelchair discharge instructions: it was a pleasure to be involved in your care, ms. . you were admitted to because of fever and hypotension. you were then found to have a type of arrhythmia called "atrial fibrillation with rapid ventricular response". you were in the medical icu twice during this admission. for your fever, we did not find any source of infection, and your antibiotics was changed from linezolid to datpomycin because your blood counts went down on linezolid. you will receive daptomycin on the days of your dialysis, and you will finish it on . you were treated for atrial fibrillation with two medications, digoxin and metoprolol. please note that your medications have been changed: please continue daptomycin until we have added digoxin we have added metoprolol we also added simvastatin please continue to take coumadin please continue to take valganciclovir until when you are seen in the infectious disease clinic next week () followup instructions: provider: , md phone: date/time: 11:10 provider: , md phone: date/time: 1:00 provider: , md phone: date/time: 10:00 Procedure: Venous catheterization, not elsewhere classified Hemodialysis Diagnoses: Chronic glomerulonephritis in diseases classified elsewhere Systemic lupus erythematosus End stage renal disease Unspecified septicemia Atrial fibrillation Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Bacteremia Infection with microorganisms without mention of resistance to multiple drugs Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other specified antibiotics causing adverse effects in therapeutic use Cytomegaloviral disease Complications of transplanted kidney Other complications due to renal dialysis device, implant, and graft Unspecified disorder of autonomic nervous system Other specified aplastic anemias Chronic venous embolism and thrombosis of other thoracic veins Chronic venous embolism and thrombosis of subclavian veins Viremia, unspecified Chronic venous embolism and thrombosis of superficial veins of upper extremity |
allergies: bactrim ds / cellcept / zosyn attending: addendum: she was discontinued off her glargine and nph given she had low insulin requirements during her hospitalization. she was discharged with an insulin sliding scale to rehab. discharge disposition: extended care facility: hospital md Procedure: Venous catheterization, not elsewhere classified Hemodialysis Venous catheterization for renal dialysis Diagnoses: Systemic lupus erythematosus Anemia in chronic kidney disease End stage renal disease Urinary tract infection, site not specified Adrenal cortical steroids causing adverse effects in therapeutic use Unspecified septicemia Severe sepsis Atrial fibrillation Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease 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 Intestinal infection due to Clostridium difficile Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Complications of transplanted kidney Other complications due to renal dialysis device, implant, and graft Pseudomonas infection in conditions classified elsewhere and of unspecified site Other abnormal glucose Diverticulitis of colon (without mention of hemorrhage) |
allergies: bactrim ds / cellcept / zosyn attending: chief complaint: hypotension major surgical or invasive procedure: tunneled hemodialysis line placement history of present illness: this is a 52 yo female with esrd on hd, s/p failed renal transplant, who was discharged 1.5 wks ago for septic shock thought due to cmv viremia and diverticulitis, who presented yesterday to with a fever to 104. to summarize her recent history, she was admitted / with arf leading to her graft failure, found to also have cmv viremia and c. diff colitis. she was discharged on iv ganciclovir until 2 negative cmv vls, and transitioned to oral valganciclovir secondary ppx to continue for 3 mos from her admission. how this was discontinued is unclear: possibly on due to neutropenia, and outside records note negative cmv vl on . she was also at medical center from septic shock due to pseudomonas bacteremia, completing a course of ?zosyn on . on pt began having fevers. a cmv viral load was rechecked (970) and repeat vl of 4059 on . it is unclear when ganciclovir was restarted, but by , she was on ganciclovir with hd dosing. she became hypotensive on with mild abdominal pain, sent to and admitted to micu on norepinephrine. she was treated with stress-dose steroids, empiric po vancomycin, iv vancomycin, iv zosyn and iv gancyclovir. ct abd/pelvis showed uncomplicated sigmoid diverticulitis. all other culture data and infectious workup (including c. diff toxin negative x 3) was unrevealing as to another source of infection. she was started on midodrine for persistent hypotension to 70-80s systolic. also was progressively pancytopenic, though to be from pip-tazo. she was discharged on po cipro and flagyl for diverticulitis, 10 mg daily prednisone, with her tacrolimus decreased to 2mg . also discharged on iv ganciclovir, planning to switch to oral after 2 negative vls, although stopped at some point in rehab. while in rehab, bps had remained normotensive. yesterday am, she awoke nauseated and febrile, with a temp of 104.0. blood cultures (2 sets) were sent from rehab. also c/o llq pain. in the ed, her tmax was 102, with bp 142/82. ct abd showed diverticulitis similar to prior. ua was positive. cxr improved from prior. was given vanco/zosyn/flagyl and admitted. on arrival to hd today, she was tachycardic to 130s, apparently sinus rhythm. hd was stopped after 1 hour due to progressive tachycardia to the 160s, with fever to 103.2, despite running her volume even. after stopping hd, she became hypotensive to sbp 60s, with preserved mental status. after 1l ivf, her bp improved to 86/44 with hr 107. temp improved to 100.3 after acetaminophen. currently c/o nausea and fatigue, no resting abd pain but 10/10 l sided abd pain with palpation. also c/o fevers, no chills or sweats. has some diarrhea that pt notes as chronic and unchanged. makes small amt urine and confirms dysuria, frequency, urgency. denies vomiting, cp, sob, cough, sputum, wheezing, ha, vision changes, confusion. past medical history: - esrd due to sle, s/p cadaveric renal transplant complicated by fsgs and transplant failure , now on hd - sle, followed by dr. in rheumatology - hypotension (started on midodrine ) - septic shock - cmv viremia - acute uncomplicated diverticulitis - hx of c. diff - paroxysmal atrial fibrillation - nsvt - hx of hypertension - hyperthyroidism - s/p bilateral knee surgeries and r acl repair social history: single, currently at rehab. denies tobacco, etoh, and drugs. family history: mother and brother both with diabetes and , both deceased. physical exam: vitals: t 101.2 bp 105/49 hr 113 rr 18 o2sat 98ra general: nad, aaox3, appropriate, comfortable heent: ncat, eomi, aniceteric sclerae, mmm neck: no jvd cardiac: rrr, no m/r/g lung: ctab abdomen: nabs. soft, nd, exquisitely ttp with in luq/llq with + rebound and grimacing, pain with bed movement, no significant guarding, graft palpable in rlq without ttp ext: warm and dry, 2+ dp pulses, avf in lue. no edema. pertinent results: hematology: 12:40pm blood wbc-2.4* rbc-3.37* hgb-9.5* hct-32.6* mcv-97 mch-28.3 mchc-29.2* rdw-17.1* plt ct-97* 09:00am blood wbc-4.1 rbc-3.70* hgb-10.3* hct-35.4* mcv-96 mch-27.8 mchc-29.0* rdw-17.0* plt ct-144* 12:40pm blood neuts-51 bands-20* lymphs-12* monos-13* eos-2 baso-0 atyps-0 metas-2* myelos-0 09:00am blood neuts-67 bands-2 lymphs-20 monos-8 eos-0 baso-0 atyps-1* metas-1* myelos-1* 12:40pm blood plt smr-very low plt ct-97* 12:12pm blood pt-15.1* ptt-29.8 inr(pt)-1.3* 09:00am blood plt smr-low plt ct-144* chemistries: 12:40pm blood glucose-96 urean-24* creat-5.9*# na-147* k-4.2 cl-108 hco3-27 angap-16 09:00am blood glucose-130* urean-30* creat-5.1* na-143 k-4.0 cl-106 hco3-26 angap-15 12:40pm blood alt-15 ast-12 alkphos-57 totbili-0.3 12:45pm blood calcium-7.4* phos-2.7 mg-1.7 07:30am blood vanco-19.5 12:47pm blood lactate-1.0 imaging: ct abdomen and pelvis : 1. extensive diverticulosis with diverticulitis of the sigmoid colon and distal descending colon, similar in extent when compared to the most recent study of . no evidence of perforation or abscess formation. 2. mild enhancement of the transplanted kidney in the right lower quadrant, which is similar in appearance to the prior study. no evidence of perinephric fluid collection or abscess. 3. persistently dilated pancreatic duct may be related to ampullary stenosis or ipmn. as noted previously, if not already performed, consultation with the pancreas center may assist in evaluation. cxr : since interval examination from , there has been improvement in left lower lobe atelectasis and removal of a central venous catheter. the lungs are clear with no signs of pneumonia or congestive heart failure. no pleural effusions or pneumothorax. the cardiomediastinal silhouette is stable in size. microbiology: blood cultures , - pending urine culture - 10,000-100,000 klebsiella clostridium difficle - positive cmv viral load - negative discharge labs: hematology: blood wbc-2.7* rbc-2.85* hgb-7.7* hct-26.9* mcv-94 mch-27.1 mchc-28.7* rdw-17.3* plt ct-182 neuts-41* bands-8* lymphs-37 monos-11 eos-0 baso-2 atyps-1* metas-0 myelos-0 blood pt-11.9 ptt-25.3 inr(pt)-1.0 blood glucose-89 urean-17 creat-4.2* na-145 k-3.7 cl-105 hco3-32 angap-12 brief hospital course: 52 yo female with esrd on hd, recent admission for septic shock from diverticulitis vs cmv, here with fever and hypotension. hypotension/fevers: patient presented with evidence of septic physiology with fevers and hypotension, along with abdominal pain and diarrhea. cultures revealed negative blood cultures, urine culture positive for klebsiella 10-100,000 colonies and positive clostridium difficle. she had a ct of the abdomen which revealed diverticulitis. cxr did not show evidence of pneumonia. she was initially started on broad spectrum antibiotics with vancomycin and cefepime and this was transitioned to po vancomycin and tigacycline for coverage of clostridium difficle as well as iv gancyclovir given her history of cmv viremia. her hypotension resolved with 1 liter of normal saline. she also received stress dose steroids given her history of long term steroid use. she was transitioned to the floor. cortisol stim test was performed which was negative. her hypotension was responsive to fluid boluses. she was continued on midodrine. on the floor she was found to have a positive c diff toxin. she was started on vancomycin taper with resolution of her abdominal pain and diarrhea. fevers abated. she was covered with valgancyclovir for cmv prophylaxis and atovaquone for pcp . towards the end of her hospitalization, her fevers reappeared without accompanying hypotension. pan culture revealed no organism repeatedly. her left arm at the fistula site was painful and ultrasound revealed extensive clot burden. transplant surgery did not feel immediate correction was required; a tunneled line was placed for hd. picc line was removed and cultures were negative. her fevers were felt secondary to clot burden. she was discharged on empiric vancomycin to be given with each hd treatment for a total of four weeks. she was discharged on vancomycin taper for c difficile and prophylaxis as mentioned above in addition to the vancomycin with dialysis. pancytopenia: patient has a history of pancytopenia of unclear cause. differential diagnosis considered includes drug reaction from zosyn, cmv viremia versus lupus related. her blood counts were stable from recent admission and were trended. cmv viral load was negative. renal transplant: complicated by graft fsgs and esrd on hd. she received stress dose steroids as above in the setting of sepsis. she was followed by the renal consult and transplant services. she was continued on tacrolimus 1 mg (decreased from 2 mg ) and atovaquone for prophylaxis. she received hemodialysis treatments three times a week as per her home schedule. given her clotted fistula towards the end of her hospitalization, a tunneled hd line was placed as mentioned above. transplant surgery will see her in outpatient follow up for consideration of placement of new fistula on the right arm. her tacrolimus was discontinued at time of discharge given that she does not require tacrolimus any longer secondary to graft failure. hyperglycemia: attributed to corticosteroid therapy. she was treated with a humalog sliding scale. paroxysmal atrial fibrillation: in sinus rhythm on discharge 10 days ago and currently. not on warfarin. she was continued on aspirin. . dispo - discharged to rehab following resolution of abdominal pain, diarrhea, fever work up, and tunneled line placement. medications on admission: home medications: (from d/c summary dated ) - atovaquone 1500mg (10ml) po daily - aspirin 325mg po daily - pantoprazole 40mg po q24hrs - b complex-vitamin c-folic acid 1mg capsule po daily - midodrine 10mg po tid - ciprofloxacin 500mg po q24hrs - ended - flagyl 500mg po q8hrs - ended - tacrolimus 2mg po q12hrs - ganciclovir 110mg iv qhd - heparin 5000units sq tid - insulin glargine 2units sq qhs - insulin nph 4units sq qam - insulin humalog sliding scale - prednisone 10mg po daily - zofran 4mg iv q8hrs prn nausea - epogen 15000units qhd - bisacodyl 5-10mg po daily prn constipation discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a day). 4. epoetin alfa 10,000 unit/ml solution sig: one (1) injection asdir (as directed): to be administered during dialysis and dosed according to the epoetin alfa p&t guidelines. . 5. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 6. atovaquone 750 mg/5 ml suspension sig: two (2) po daily (daily). 7. vancomycin 125 mg capsule sig: one (1) capsule po as below: one (1) capsule po every twenty-four(24) hours: starting , take 125 mg daily for one week (- ) (b) then take 125 mg every other day for one week () (c) then take 125 mg every third day for two weeks (/10). 8. prednisone 5 mg tablet sig: one (1) tablet po once a day. 9. valganciclovir 450 mg tablet sig: one (1) tablet po once a day: one (1) tablet po 2x/week (tu,th). 10. insulin glargine 2 u sq qhs nph 4 u sq qam 11. vancomycin 1000 mg iv hd protocol please check trough prior to each dose 12. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. discharge disposition: extended care facility: hospital discharge diagnosis: 1. clostridium difficile colitis 2. fistula repair 3. chronic kidney disease discharge condition: stable for discharge. on room air, ambulating with assistance. resolved diarrhea and abdominal pain, intermittent continued low grade fevers. discharge instructions: dear ms , it was a pleasure caring for you while you were in the hospital. you were first admitted to the hospital because of pain in your abdomen that was caused by clostridium difficile. because of this infection, you developed pain in your abdomen, fevers, and your blood pressure was low. during dialysis, your blood pressure fell even further. to treat you, we started you on antibiotics for the infection and your pain and fevers improved. you will need to continue to take these antibiotics for several more weeks. the course of antibiotics is described below. . during your hospital stay, your fistula on your left arm also stopped working. because you needed dialysis, we placed a new line (called a tunneled line) that will allow us to continue dialysis. the transplant surgeons want to create a new fistula for you to use, and you have a follow up appointment set up with them as an outpatient to arrange this. we also decided to continue you on antibiotics to be given during dialysis to treat the possibility of infection in the area of the fistula. . the medication changes we made during this hospitalization were: 1. we started you on oral vancomycin. you should continue to take this with the following regimen: (a) take 125 mg daily by mouth for one week ( - ) (b) then take 125 mg every other day for one week ( - ) (c) then take 125 mg every third day for two weeks ( - ) 2. you can take 5 mg of the prednisone every day instead of 10 mg. 3. you will be receiving vancomycin intravenously with hemodialysis until to complete a 4 week course. 4. you should take vangancyclovir 450 mg twice a week with dialysis. 5. you can take oxycodone 5 mg as needed every 6 hours for pain. 6. you should stop taking gancyclovir iv. 7. you should stop taking tacrolimus. . please keep the follow up appointments scheduled for you below. followup instructions: 1) you have an appointment with a transplant infectious disease doctor, , on at 930 am. please call if you have any other questions. 2) you have an appointment with your kidney doctor, dr. on at 9:40 am. if you have any questions, his phone number is . . 3) you have an appointment with dr. from transplant surgery at 1:40 pm on . if you have any questions regarding this appointment, please call . md Procedure: Venous catheterization, not elsewhere classified Hemodialysis Venous catheterization for renal dialysis Diagnoses: Systemic lupus erythematosus Anemia in chronic kidney disease End stage renal disease Urinary tract infection, site not specified Adrenal cortical steroids causing adverse effects in therapeutic use Unspecified septicemia Severe sepsis Atrial fibrillation Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease 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 Intestinal infection due to Clostridium difficile Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Complications of transplanted kidney Other complications due to renal dialysis device, implant, and graft Pseudomonas infection in conditions classified elsewhere and of unspecified site Other abnormal glucose Diverticulitis of colon (without mention of hemorrhage) |
allergies: bactrim ds / cellcept attending: chief complaint: acute renal failure major surgical or invasive procedure: dialysis history of present illness: 52 yo f with sle s/p renal tx 2 years ago presents with b/l lbp, atraumatic. started acutely this am while watching television. also c/o abdominal fullness but no frank pain. no f/c/n/v/cp/sob. had been feeling her usual self until this am. . in the ed, vs: t98.4 bp 120/100 hr 86 100%ra. labs were notable for k 6.8, bun/cr 121/14.7. ekg showed mild peak ts in lead v2. she received 2g calcium gluconate, 10u insulin, kayexalate and 2l ns. she was given 4mg morphine for pain. ct abd/pelvis showed perinephric fat stranding. she was given levo flagyl for empiric abx coverage. while in the ed, she was seen by renal and transplant surgery with concern for acute rejection. she was started on high dose iv steroids and transferred to the micu for further management. . upon arrival stat labs were drawn, notable for increasing k to 7.4 with no changes on ekg from prior. patient had stat lue u/s which demonstrated patent fistula. she was started on dialysis. past medical history: s/p renal transplant sle followed by dr. in rheumatology. hypertension. history of hyperthyroidism. psh:lue avf history of bilateral knee surgeries and acl repair on the right knee. social history: single, lives alone, but has family in the area denied smoking/etoh family history: nc physical exam: vs: hr 75 bp 185/85 97% ra gen: african american female in nad heent: eomi, perrl neck: supple chest: ctabl, no w/r/r cv: rrr, s1s2 abd: soft/nt/nd ext: lue: fistula with bruit and palpable thrill skin: no rashes neuro: aaox3, no focal deficits pertinent results: 01:30pm blood wbc-3.9* rbc-3.20* hgb-8.1* hct-27.0* mcv-84 mch-25.2* mchc-29.9* rdw-16.8* plt ct-107* 06:10am blood wbc-2.9* rbc-2.98* hgb-7.7* hct-25.1* mcv-84 mch-25.9* mchc-30.8* rdw-17.9* plt ct-83* 05:10am blood wbc-3.9* rbc-2.52* hgb-6.7* hct-21.6* mcv-86 mch-26.5* mchc-30.9* rdw-17.5* plt ct-75* 06:44am blood wbc-10.2# rbc-3.11* hgb-8.4* hct-27.9* mcv-90 mch-27.0 mchc-30.1* rdw-17.4* plt ct-160 06:13am blood wbc-12.4* rbc-3.61* hgb-9.6* hct-32.0* mcv-89 mch-26.5* mchc-29.9* rdw-16.6* plt ct-244 06:13am blood neuts-73* bands-2 lymphs-20 monos-3 eos-0 baso-0 atyps-0 metas-1* myelos-1* nrbc-2* 05:00am blood neuts-86* bands-0 lymphs-11* monos-2 eos-0 baso-0 atyps-0 metas-1* myelos-0 10:12am blood pt-13.1 ptt-30.8 inr(pt)-1.1 06:00am blood qg6pd-10.0 05:10am blood ret aut-3.0 06:00am blood ret aut-2.2 09:54pm blood aca igg-5.6 aca igm-7.4 09:54pm blood lupus-neg 01:30pm blood glucose-141* urean-121* creat-14.7*# na-141 k-6.7* cl-113* hco3-11* angap-24* 08:22pm blood glucose-153* urean-113* creat-13.5*# na-139 k-7.6* cl-115* hco3-10* angap-22* 10:47pm blood glucose-171* urean-117* creat-13.3* na-141 k-7.2* cl-115* hco3-10* angap-23* 03:32am blood glucose-196* urean-73* creat-9.1*# na-141 k-4.2 cl-105 hco3-24 angap-16 03:39am blood glucose-179* urean-73* creat-9.1*# na-141 k-4.4 cl-101 hco3-26 angap-18 05:00am blood glucose-130* urean-94* creat-10.6*# na-141 k-4.3 cl-100 hco3-25 angap-20 04:56am blood glucose-109* urean-58* creat-7.0*# na-144 k-3.9 cl-104 hco3-29 angap-15 05:10am blood glucose-93 urean-42* creat-5.4* na-146* k-3.5 cl-108 hco3-27 angap-15 10:12am blood glucose-103 urean-61* creat-6.3* na-144 k-3.9 cl-107 hco3-24 angap-17 05:31am blood glucose-96 urean-83* creat-6.4* na-141 k-4.4 cl-105 hco3-21* angap-19 05:15am blood glucose-158* urean-102* creat-7.6* na-137 k-5.3* cl-103 hco3-24 angap-15 06:13am blood glucose-103 urean-64* creat-5.8*# na-139 k-5.2* cl-100 hco3-27 angap-17 05:16am blood glucose-120* urean-72* creat-6.7* na-136 k-5.3* cl-99 hco3-28 angap-14 06:13am blood alt-12 ast-15 alkphos-66 totbili-0.5 06:00am blood alt-7 ast-14 ld(ldh)-520* alkphos-27* totbili-0.7 01:30pm blood lipase-114* 04:53am blood ck-mb-notdone ctropnt-0.03* 02:36pm blood ck-mb-notdone ctropnt-0.04* 03:39am blood ck-mb-notdone ctropnt-0.04* 05:16am blood calcium-9.6 phos-4.6* mg-2.4 05:00am blood calcium-6.3* phos-8.8* mg-2.6 07:45pm blood calcium-6.8* 06:48am blood calcium-6.8* phos-5.3*# mg-2.0 04:41pm blood calcium-7.2* 05:10am blood vitb12-552 folate-11.2 hapto-95 ferritn-304* 03:32am blood caltibc-181* ferritn-925* trf-139* 09:54pm blood hbsag-negative hbsab-negative hbcab-negative hav ab-positive igm hav-negative 09:54pm blood anca-negative b 09:54pm blood -positive titer-1:40 dsdna-negative 09:54pm blood pep-no specifi igg-1192 iga-421* igm-27* ife-no monoclo 04:53am blood c3-107 c4-25 12:05pm blood hiv ab-negative 05:32pm blood tacrofk-13.3 09:54pm blood hcv ab-negative cxr : impression: ap chest compared to : . right pic line can be traced only as far as the mid svc. left lower lobe consolidation, new since , is unchanged since could be pneumonia or atelectasis. small right pleural effusion and generalized vascular engorgement have increased. mild cardiomegaly stable. no pneumothorax. . ct a/p : impressions: 1. colonic diverticulosis along the descending and sigmoid colon, with area of pericolonic fat stranding in the left lower quadrant, compatible with mild uncomplicated diverticulitis. no free air, free fluid, or fluid collection except for the seroma in ant wall. . 2. small bilateral pleural effusions are slightly increased compared to , with associated adjacent atelectasis in the lung bases. the study and the report were reviewed by the staff radiologist. . ac fistulogram : impression: fistulogram demonstrating dilated, tortuous and widely patent left cephalic venous outflow from fistula, and no central stenosis or clot. brisk inflow across arterial anastomosis implies no stenosis there. . ct c/t/l spine : impression: given limitations of the image acquisition and the patient's inability to cooperate, there is no evidence for fracture or dislocation. . ct head: : impressions: very limited study, particularly through the skull base due to patient motion. the visualized brain reevals no definite abnormality. if there remains concern for acute intracranial pathological process, reimaging would be recommended when the patient is able to be still for the exam. . note at attending review: the hyperdensity noted above likely is minimal hyperostosis frontalis interna, with a similar finding noted on the right side in an analogous locale. . cxr impression: increased right basilar opacity which may represent atelectasis or developing pneumonia. improved left basilar atelectasis. the study and the report were reviewed by the staff radiologist. . 2:13 pm immunology (cmv) source: line-picc. cmv viral load (pending): 6:44 am immunology (cmv) source: line-picc. **final report ** cmv viral load (final ): 861 copies/ml. performed by pcr. detection range: 600 - 100,000 copies/ml. for research use only. not for use in diagnostic procedures. this test has been validated by the microbiology laboratory at . time taken not noted log-in date/time: 1:27 pm urine site: not specified chem # 66381r . **final report ** urine culture (final ): enterococcus sp.. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s nitrofurantoin-------- 128 r tetracycline---------- 2 s vancomycin------------ =>32 r 12:17 pm blood culture **final report ** blood culture, routine (final ): no growth. 8:19 pm mrsa screen **final report ** mrsa screen (final ): no mrsa isolated. 9:47 am stool consistency: watery source: stool. **final report ** 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. . moderate polymorphonuclear leukocytes. few rbc's. clostridium difficile toxin a & b test (final ): reported by phone to g parsoparou @ 3:54a . clostridium difficile. feces positive for c. difficile toxin by eia. (reference range-negative). a positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). viral culture (final ): viral culture discontinued due to presence of clostridium difficile toxin. . brief hospital course: a/p: 52yo w with pmh of sle, renal failure s/p transplant presents with acute renal failure and likely rejection. . # acute renal failure: mrs. presented to the ed with hyperkalemia acute renal failure in her transplant kidney. due to faliure of medical management of the hyperkalemia, mrs. underwent emergent dialysis via her previous left arm fistula that remained patent by u/s. renal transplant ultrasound was normal except for large subcutaneous fluid collection that was also noted on ct. on hospital day 1, there was concern for rejection. she was started on solumedrol 500mg iv qday for this concern pending biopsy results. renal biopsy showed no signs of rejection, but was consistent with rapidly progressing fsgs. iv solumedrol was decreased from 500 to 100 mg qday on day 3 then ultimately switched to prednisone 60 mg qday on day 5--which was continued throughout admission and continued on discharge. studies into the etioogy of the fsgs were negative -- hiv negative, bk virius negative, anca negative, compliment levels normal, hepatitis serology negative, 1:40, parvo b19 and htlv negative. urine output was monitored as best as possible, however patient was non-compliant with collection. ua with no signs of urinary tract infection. on hospital day 3, plasmapheresis was empirically initiated. during her plasmapheresis courses, calcium levels were noted to be low and were repleted on an as needed basis. she received 4 sessions of plasmapheresis, however due to development of fever and signs of infection on hospital day 10 this was not continued. urine protein/creatinine ratio was monitored on a daily basis during the initial part of admission peaking at 30.7 then trending down to 1.7 after 2 weeks. throughout admission, hemodialysis was done on as needed basis with one 9-day period of no hemodialysis. patient will continue dialysis as outpatient, as well as prednisone and tacrolimus. she should follow up with transplant nephrology as arranged. should continue tacrolimus with goal trough . dose was decreased to 4mg on day of discharge for elevated trough 9.1. please contact transplant nephrology at for dose adjustments. please check tacro levels on thursday, , and regularly there after. she should continue prednisone at 60mg daily for now. she should remain on gi prophylaxis, ca/vit d as ordered. patient should be considered for starting dapsone for pcp prophylaxis in the future rather than atovaquone, but given h/o severe bactrim allergy did not challenge with dapsone on this hospitalization. g6pd testing was negative. -please send all lab work to dr. at - . # hemodialysis: patient to receive t/th/sa dialysis as outpatient. at dialysis, she should receive epogen. in addition, she should have pth, vitamin d and iron studies drawn at dialysis. she should continue cinacalcet as outpatient and vitamin d as follows (50,000 units weekly x 8 weeks, followed by 1000 units daily thereafter until replete.). patient has a slot at after she leaves rehab. . # c. difficile infection - on day 10 of admission, patient was noted to be febrile. patient was also complaining of llq abdominal pain, but no other associated symptoms. at this time patient was started empirically on cefepime and flagyl for suspected diverticulitis given findings of sigmoid colon wall thickening on ct abdomen and pelvis. blood and urine cultures were drawn and negative. ua negative for uti. cxr had no interval change of right basalar atelectasis and patient was asymptommatic. patient continued to have fevers and vancomycin added on hospital day 12. additionally valgancyclovir and atovoqoune were added at this time for prophylaxis while on high dose steroids. patient continued to be febrile and complained of diarrhea, id consult felt symptoms were most consistent for c. difficile (had recieved one dose of ceftazadime on admission). adenovirus pct, toxo serology and stool o&p were negative. stool was positive for c. diff and po vancomycin started. cefepime, flagyl and vancomycin were discontinued. patient had 2 more fevers over the first 48 hours of po vancomycin treatment then was afebrile. of note, diarrhea work-up was positive for cmv viral load in blood possibly consistent with cmv colitis (see below). patient should complete a 14 day course of po vancomycin to end on . . # cmv viremia - patient had detectable cmv viral load during diarrheal work-up. at the time of detection, patient had been on valgancyclovir prophylaxis for 4 days. initially, it was felt to be viremia w/o end organ involvement, however due to continued diarrhea on po vancomycin for c. difficile infection, treatment was changed from valgancyclovir to gancyclovir for treatment of possible cmv disease. she should be continued on iv ganciclovir for treatment of cmv viremia until she has 2 negative cmv viral loads separated by one week. (viral load 861, repeat viral load pending). . # hyperkalemia: mrs. was diagnosed with elevated potassium on admission to the ed. she had mild peaked t waves in v2. in the ed, she received 2 rounds of calcium, insulin and was transferred to the icu where medical management for hyperkalemia was more effective, but she still required emergent dialysis. after a short course of emergent dialysis there was improvement in her electrolytes. potassium was monitored closely throughout her admission while she underwent intermittant hemodialysis. . # atrial fibrillation: mrs. went into atrial fibrillation with rvr on the evening of after dialysis. she had no prior history. had some chest pain during episode and was ruled out. the atrial fibrillation was converted with metoprolol then diltiazem iv and she had no further episodes on telemetry. she was continued on metoprolol for rate control and hypertension. hydralazine was discontinued. echo showed a mildly dilated left atrium and lveh > 55%. tsh was wnl. after one week, telemetry was discontinued. . # hypertension: mrs. was not previously on anti-hypertensives prior to admission. on admission, she was noted to be hypertensive and started on hydralazine and amlodipine. after her episode of atrial fibrillation, she was also on hydralazine. hydralazine ws discontinued after 2 days with good blood pressure control on metoprolol and amlodipine. blood pressure was monitored and stable throughout her hospital course with some episodes of hypotension during dialysis. amlodipine was changed to be dosed after dialysis and metoprolol reduced to 12.5mg . at discharge, amlodipine was discontinued due to its tendency to cause lower extremity edema, and b/c hypotension had limited her hd sessions. metoprolol should be continued and titrated up as needed for hypertension. . # sle: stable; on prednisone for fsgs. . # anemia - continued iron supplement, epogen with hd as above, transfusions as needed. . # access: picc line in place. av fistula functional for now, but had difficulty during hospital stay. . # diabetes: presented during hospital stay while on treatment with high dose steroids. was covered with glargine qhs, and humalog sliding scale with meals. medications on admission: tacro 12mg epo iron vitamin d discharge medications: 1. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever/pain: not to exceed 4g tylenol per day. 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 4. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 5. petrolatum ointment sig: one (1) appl topical tid (3 times a day) as needed for for dry skin. 6. docusate sodium 100 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 8. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 9. insulin glargine 100 unit/ml cartridge sig: two (2) units subcutaneous at bedtime. 10. insulin lispro 100 unit/ml cartridge sig: as per sliding scale as per sliding scale subcutaneous qachs. 11. zofran 4 mg tablet sig: one (1) tablet po three times a day as needed for nausea. 12. vitamin d 50,000 unit capsule sig: one (1) capsule po once a week for 8 weeks. 13. cinacalcet 30 mg tablet sig: one (1) tablet po once a day. 14. prednisone 20 mg tablet sig: three (3) tablet po daily (daily). 15. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 7 days: to end on . 16. ganciclovir 120 mg iv q24h start: in am give after hd on dialysis days 17. atovaquone 750 mg/5 ml suspension sig: two (2) po daily (daily). 18. tacrolimus 1 mg capsule sig: four (4) capsule po every twelve (12) hours. capsule(s) discharge disposition: extended care facility: - discharge diagnosis: focal segmental glomerulosclerosis acute renal failure end stage renal disease c. diff colitis cmv viremia discharge condition: stable, aox3, appropriate. discharge instructions: you were admitted to the hospital for evaluation of kidney failure. you had a biopsy of your kidney that showed a reaction known as fsgs or focal segmental glomerulosclerosis. this was treated with high doses of steroids, and plasmapheresis. you had some mild improvement in your kidney function but required dialysis to replace your kidneys. you will need to continue on dialysis until your kidney function improves. during your hospital stay you also developed an infectious diarrhea known as c. diff. this diarrhea is treated with oral antibiotics such as vancomycin. you were also treated for cmv infection which occurs in patients on high doses of immunosuppression such as yourself. please continue to take all medications on discharge. . please return to the hospital should you experience any fevers, chills, night sweats, worsening diarrhea, or other symptoms concerning to you. followup instructions: provider: , md phone: date/time: 1:30 provider: , md phone: date/time: 1:20 md Procedure: Venous catheterization, not elsewhere classified Hemodialysis Closed [percutaneous] [needle] biopsy of kidney Arteriography of other specified sites Therapeutic plasmapheresis Diagnoses: Systemic lupus erythematosus Hyperpotassemia Anemia in chronic kidney disease End stage renal disease Urinary tract infection, site not specified Acute kidney failure, unspecified Atrial fibrillation Paroxysmal ventricular tachycardia Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Cytomegaloviral disease Complications of transplanted kidney Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease Hypotension of hemodialysis Diverticulitis of colon (without mention of hemorrhage) Chronic glomerulonephritis with lesion of membranous glomerulonephritis Enteritis due to other viral enteritis |
allergies: penicillins / gadolinium-containing agents attending: chief complaint: shoulder/back/neck pain and sob major surgical or invasive procedure: bronchoscopy endotracheal intubation femoral central line placement history of present illness: ms is a 38 yo female with pmh of lung cancer, cervical cancer, and thyroid cancer (all unknown types) reported to be in remission who presented to the morning of admission with neck and left lateral pain radiating toward the shoulder, with additional complaint of cough and fever. at the osh she underwent a ct which showed new lll consolidation vs. mass. she was given moxifloxacin, 2l ivf, and dilaudid and started becoming hypotensive. for concern for epidural abscess, she was transferred to the ed for further work-up and evaluation. on arrival to the ed here her vitals were 74/42 hr 109 rr 18 and sat of 97% on 4l nc. she received 3.5l of crystalloid in our ed, plus 2l of crystalloid at the referring hospital. she had a central line placed in the right femoral artery and was started on levophed. over the course of the day she had received 6 l ivf. her antibiotics were broadened with vancomycin. she was also sent for a thoracic spine mri, and developed an anaphylaxis reaction to receiving gadolinium, for which she received 0.3mg epinephrine, 125mg solumedrol, and was placed on non-rebreather for dropping o2 sats. ultimately she was intubated with etomidate and succinylcholine. gentamicin was ordered in the ew, but not received. she was intubated and sedated and admitted to the unit. past medical history: lung cancer, primary depression irritable bowel syndrome social history: current smoker 3cig/day. has 2 children, works as dialysis nurse. family history: nc physical exam: general appearance: well nourished eyes / conjunctiva: pupils constricted, reactive head, ears, nose, throat: normocephalic lymphatic: cervical wnl cardiovascular: (s1: normal), (murmur: systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (breath sounds: crackles : basilar) abdominal: soft, non-tender, no(t) distended extremities: right lower extremity edema: absent, left lower extremity edema: absent skin: not assessed neurologic: somonolent pertinent results: 05:45am blood wbc-6.2# rbc-3.93* hgb-11.7* hct-35.6* mcv-91 mch-29.7 mchc-32.8 rdw-15.0 plt ct-345 05:45am blood wbc-6.2# rbc-3.93* hgb-11.7* hct-35.6* mcv-91 mch-29.7 mchc-32.8 rdw-15.0 plt ct-345 05:45am blood neuts-63.5 lymphs-29.5 monos-3.7 eos-2.7 baso-0.6 07:29pm blood neuts-90.7* lymphs-5.7* monos-3.1 eos-0.3 baso-0.2 05:20am blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-occasional microcy-occasional polychr-occasional ovalocy-occasional schisto-occasional burr-occasional 02:21am blood hypochr-1+ anisocy-normal poiklo-occasional macrocy-normal microcy-normal polychr-normal ovalocy-occasional schisto-occasional 05:45am blood plt ct-345 05:45am blood glucose-91 urean-16 creat-0.8 na-139 k-3.9 cl-104 hco3-28 angap-11 07:29pm blood glucose-82 urean-8 creat-0.8 na-141 k-3.9 cl-110* hco3-22 angap-13 05:45am blood calcium-9.2 phos-4.2# mg-1.9 iron-26* 07:29pm blood albumin-3.8 calcium-7.9* phos-3.9 mg-1.6 05:45am blood caltibc-254* ferritn-161* trf-195* 05:03pm blood type-art po2-102 pco2-42 ph-7.33* caltco2-23 base xs--3 05:03pm blood lactate-0.7 blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient rapid respiratory viral screen & culture respiratory viral culture-final; respiratory viral antigen screen-final inpatient bronchial washings gram stain-final; respiratory culture-final; legionella culture-preliminary; potassium hydroxide preparation-final; immunoflourescent test for pneumocystis jirovecii (carinii)-final; fungal culture-preliminary; acid fast smear-final; acid fast culture-preliminary; viral culture: r/o cytomegalovirus-preliminary inpatient catheter tip-iv wound culture-final inpatient imaging: radiology ct chest w/o contrast impression: 1. evolution of new areas of mixed ground-glass and consolidative opacities bilaterally, which given their focality and the acuity of development are suggestive of bilateral infectious progression. follow up to resolution is recommended. 2. redemonstration and evolution of pleural effusions and tiny pericardial effusion. radiology chest (pa & lat) impression: ap chest compared to and 3: the frontal chest radiographs over the past 36 hours have suggested the development of a generalized interstitial pulmonary abnormality, but today's lateral view shows that the lower lobes are largely spared, and that the process has a great deal of coalescence in the right middle lobe. it also shows that the mass-like consolidation first seen on the chest ct, be shrinking. overall findings suggest multifocal infection, partially treated, but perhaps due to more than one pathogen. the interstitial abnormality is very mild, could be a pulmonary drug reaction and is unlikely to be garden variety pulmonary edema in the absence of mediastinal vascular engorgement, progressive cardiac enlargement or pleural effusions. findings were discussed over the telephone with the intern caring for this patient radiology ct chest w/o contrast impression: 1. no pulmonary embolism. no aortic dissection. 2. anteromedial left lower lobe opacity concerning for pulmonary mass, although consolidation is possible. 3. post-surgical changes and likely post radiation treatment changes of the right upper lung. right upper lobe pleural fluid and thickening. please correlate with medical and surgical history and prior chest cts. 4. right upper lobe focal opacity that may represent post-treatment change vs infection. these findings are of uncertain chronicity and comparison with prior studies would be helpful. 5. small pericardial effusion/thickening. brief hospital course: pneumococcal pna: met sirs criteria at admission given fever, leukocytosis, tachycardia, plus presumption of infection based on ct scan abnormality. she was intubated for respiratory distress in the context of anaphylactic reaction to gadolinium while in the er and admitted to the unit. she was extubated successfully on hd2. treated in micu with , vanco, levo. bronchoscopy done in the micu showed purulent secretions, gram stain negative, and culture negative. cxr showed worsening b/l infiltrates. ct chest revealed evolution of pleural effisions and tiny pericardial effusion and b/l mixed ground-glass opacities. meropenem and vancomycin stopped because mrsa was not grown. she was discharged on levofloxacin (to complete a 2 week course) as her osh reports were significant for pan senstive pneumococcus. pulmonology was consulted and felt that her consolidations found on repeat ct imaging were likely due to anaphylactic response to gad rather than worsening pna d/t lack of symtpoms. unfortunately, she did not finally see the pulmonary attending, as she left before this could happen. given her history of lung adenocarcinoma, she will need follow up chest imaging in weeks to ensure resolution of her pneumonia. anxiety/depression: she was continued on her home medication regimen. she was started on doses she could recall and did well in-house. she requested some xanax to hold her over until her next appointment and was given a 2 week prescription. anemia: she was found to have anemia (hct of 35.8) on admission with an unknown baseline. no clinical evidence of bleeding. as she has received multiple liters of ivf, this could be dilutional. her hct continued to be stable during her admission. respiratory failure: intubated largely secondary to bronchospasm and anaphylaxis d/t gadolinium used for mri. airway pressures suggested no significant airway resistance, implying that steroids and epinephrine helped reduce the bronchospasm. extubated on without subsequent dyspnea. a repeat chest ct on revealed worsening of consolidations, but per the preliminary pulmonary consult, these findings were felt to be secondary to her anaphylaxis to gadolinium rather than worsening of her pneumonia. they recommended follow up ct in weeks, which has been arranged. medications on admission: zoloft ritalin lamictal xanax trazadone albuterol prn combivent prn flonase neurontin discharge medications: 1. sertraline 50 mg tablet sig: two (2) tablet po daily (daily). 2. ritalin 10 mg tablet sig: one (1) tablet po three times a day. 3. lamictal 200 mg tablet sig: one (1) tablet po at bedtime. 4. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4h (every 4 hours). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 6. neurontin 300 mg capsule sig: one (1) capsule po at bedtime. 7. alprazolam 0.5 mg tablet sig: one (1) tablet po four times a day for 2 weeks. disp:*56 tablet(s)* refills:*0* 8. advair diskus 250-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day for 1 months. disp:*1 inhaler pack* refills:*2* 9. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fever. 10. levofloxacin 750 mg tablet sig: one (1) tablet po once a day for 10 days. disp:*10 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: 1. septic shock 2. community acquired pneumonia 3. anaphylaxis secondary diagnoses: 1. anxiety 2. leukocytosis discharge condition: stable discharge instructions: you were admitted with a severe pneumonia that required a stay in the intensive care unit. you were treated with antibiotics and have improved. you will need to have your ct scans followed closely in the future by your primary care physician and oncologist. . please return to the hospital or call your doctor if you develop worsening shortness of breath, chest pain, cough with bloody sputum, fever greater than 101, dizziness or lightheadedness, or any new symptoms that you are concerned about. . since you were admitted, we have made the following changes to your medication regimen: *started advair followup instructions: you have an appt with dr. at , phone: ( 1:30pm needs to follow-up with oncologist as planned. a follow-up ct scan should be done. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Anemia, unspecified Unspecified pleural effusion Unspecified septicemia Severe sepsis Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of bronchus and lung Dysthymic disorder Acute respiratory failure Septic shock Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Irritable bowel syndrome Other drugs and medicinal substances causing adverse effects in therapeutic use Other anaphylactic reaction |
allergies: iodine attending: chief complaint: superior mesenteric artery stenosis, nstemi major surgical or invasive procedure: 1. ultrasound-guided puncture of left brachial artery. 2. introduction of catheter into aorta. 3. abdominal aortogram. 4. selective first order catheterization of celiac artery. 5. celiac artery angiogram. 6. selective first order catheterization of the superior mesenteric artery. 7. superior mesenteric arteriogram. 8. primary stenting of superior mesenteric artery. 9. pressure measurement across the superior mesenteric artery. 10. percutaneous coronary intervention x 3 with placement of drug-eluting stents 11. hemodialysis history of present illness: 80 year old male with mmp including dmii, hyperlipedemia, crf, copd who presented with intestinal angina and was admitted by vascular surgery for possible stenting. as per the patient his abdominal symptoms occurred only when he was at dialysis about of the way through. patient was also having symptoms of abdominal cramping. both of these sytmpoms were felt to be related to poor abdominal blood floor. paitent was admitted to vascular surgery and underwent routine angiogram on with stent placement to sma. patient appparently in the pacu had very difficult to control pain requiring multiple nitroglycerins with some relief. patient ruled in with nstemi with troponins peaking to 0.89 and ck- mb to 34. cardiology was consulted and patient underwent cardiac catherization and was found to have 3vd. c-surgery was consulted and pt was deemed not a surgical candidate for cabg, thus it was decided that pt would undergo staged pci. plan current was for staged pci to begin on monday. on transfer patient denies any current symptoms. denies current chest pain, abdominal pain, or shortness of breath. patient has severly depressed exercise tolerance. patient states he can barely walk a few feet without getting short of breath. patient also endorses chest pain with exertion that occurs when patient walks just a few steps. patient states this pain improves with rest. patient also endorses sleeping sitting up as he feels uncomfortable if he is lying down flat. patient states that sometimes he sleeps upright in a chair because it is more comfortable. in addition, patient endorses + pnd. denies current lower extremity swelling although he states that he previously has had bilateral lower extremity swelling. past medical history: cad htn dmii - insulin dependent hyperlipedemia crf - hd m/w/f copd- home o2 2l at night carotid stenosis s/p lcea chf, dialstolic paget's disease b/l total knee replacement removal of neck cyst in social history: social history is significant for the absence of current tobacco use. pt quit smoking 4 years ago. prior to that patient smoked pack of cigarettes from age 6 on = 35 year pack smoking history. there is no history of alcohol abuse. patient states he drinks socially. family history: there is no family history of premature coronary artery disease or sudden death. physical exam: vs - temp 97.6, p 70, bp 133/72, r 18, 97% on ra gen: wdwn middle aged male in nad. oriented x3. mood, affect appropriate recieving dialysis. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva non-injfected. neck: difficult to assess jvp given positioning. cv: rr, normal s1, s2. distant. no m/r/g. no thrills, lifts. no s3 or s4. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. fine crackels at the bases, no wheezes or rhonchi. abd: soft, nt, nd. no hsm or tenderness. no abdominial bruits. ext: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: admission labs- 07:00am blood wbc-9.7 rbc-3.29* hgb-11.1* hct-31.4* mcv-96 mch-33.8* mchc-35.4* rdw-14.8 plt ct-185 07:00am blood pt-14.0* ptt-32.4 inr(pt)-1.2* 07:00am blood glucose-85 urean-43* creat-7.2*# na-140 k-4.0 cl-97 hco3-30 angap-17 05:40am blood wbc-11.9* rbc-3.36* hgb-11.0* hct-31.7* mcv-94 mch-32.8* mchc-34.8 rdw-14.7 plt ct-177 07:00am blood pt-14.0* ptt-32.4 inr(pt)-1.2* 05:40am blood glucose-114* urean-67* creat-9.3*# na-137 k-4.7 cl-95* hco3-25 angap-22* 01:30am blood ck(cpk)-24* 05:40am blood ck(cpk)-63 04:40pm blood ck(cpk)-223* 01:30am blood ck-mb-notdone ctropnt-0.05* 05:40am blood ck-mb-notdone ctropnt-0.10* 04:40pm blood ck-mb-34* mb indx-15.2* ctropnt-0.89* 08:52pm blood ck-mb-20* mb indx-12.7* ctropnt-2.18* 04:10pm blood alt-10 ast-15 ld(ldh)-145 ck(cpk)-38 alkphos-58 totbili-0.3 07:00am blood calcium-9.9 phos-5.1* mg-1.8 04:10pm blood caltibc-168* vitb12-414 folate-8.1 ferritn-1505* trf-129* 04:10pm blood triglyc-184* hdl-27 chol/hd-4.8 ldlcalc-65 04:10pm blood %hba1c-5.8 discharge labs- 07:25am blood wbc-10.4 rbc-2.98* hgb-9.6* hct-28.3* mcv-95 mch-32.3* mchc-34.0 rdw-15.1 plt ct-215 05:30am blood pt-15.1* ptt-34.4 inr(pt)-1.3* 07:25am blood glucose-91 urean-35* creat-6.8*# na-138 k-4.0 cl-98 hco3-30 angap-14 05:30am blood ck(cpk)-24* 07:25am blood calcium-9.7 phos-4.7*# mg-1.6 micro 5:37 am sputum site: expectorated source: expectorated. **final report ** gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. mrsa screen (final ): no mrsa isolated. blood culture, routine (final ): no growth ==================================== reports- cath comments: 1. coronary angiography of this right dominant system revealed three vessel cad. the lmca had mild luminal irregularities. the lad was a tortuous vessel with a 95% calcified mid vessel lesion. the lcx had a 99% mid vessel lesion. the rca serial 90% proximal and mid vessel lesions. 2. hemodynamic evaluation revealed severely elevated right and left sided filling pressures. the pulmonary arterial systolic pressure was severely elevated at 65mm hg. mean pcwp was elevated at 31 mm hg. systemic arterial pressures were elevated at 132 mm hg. cardiac index was preserved at 3.94 l/min/m2. 3. left ventriculography revealed no mitral regurgitation. lvef was 60% with normal regional wall motion. final diagnosis: 1. three vessel coronary artery disease. 2. severely elevated biventricular filling pressures. 3. pulmonary arterial systolic hypertension. ========================================= cath comments: 1- successful stenting of the mid lcx with two overlapping microdriver bmss (2.5x18 and 2.5x8 mm). final anfiography revealed 0% residual stenosis with timin iii flow and no dissection or distal emboli. 2- failed attempt to cross the lad into the diagonal. final diagnosis: 1. three vessel coronary artery disease. 2. successful stenting of the mid lcx with two overlapping bare metal stents. 3. failed attempt to cross the lad lesion. ========================================= cath comments: 1- sucecssful rotablation, ptca and stenting of the proximal-mid rca with two overlapping driver bmss (3.5x15 and 3.5x24 mm). final angiography revealed 0% residual stenosis and no dissection or distal emboli. 2- partially successful deployment of an 8 french angioseal closure device to the left cfa with limited bleeding that responded to compression. 3- vagal reaction requiring dopamine infusion. final diagnosis: 1. successful rotablation, ptca and stenting of the proximal-mid rca with two overlapping driver bms. 2. partially successful deployment of an 8 french angioseal. 3. vagal reaction secondary to groin compression requiring dopamine infusion. 4. consider ct scan to r/o retroperitoneal hemorrhage if dopamine requirement persists or significant hematocrit drop. ====================================== cardiology report ecg study date of 2:37:12 pm baseline artifact. sinus rhythm with borderline p-r interval prolongation. predominantly inferolsateral st segment depressions. since the previous tracing of atrial premature beats are no longer seen. read by: , a. intervals axes rate pr qrs qt/qtc p qrs t 72 /411 78 76 40 ======================================= brief hospital course: 80 year old male with mmp who presents for vascular procedure with sma stenting for mesenteric ischemia, having nstemi post procedure, found to have extensive cad not amenable to surgery, now status post staged pci. nstemi: on , patient had an nstemi (ruled in with troponins positive) and required increasing amounts of nitroglycerin. patient had unstable angina though he remained hemodynamically stable. patient underwent a cardiac catheterization with which showed extensive cardiac disease (the lad had a 95% calcified mid vessel lesion. the lcx had a 99% mid vessel lesion. the rca serial 90% proximal and mid vessel lesions.) he was evaluated for cabg and thought not to be a candidate given multiple medical problems including pvd and renal failure on hd. instead, staged pci was planned and medical therapy optimized including asa, clopidogrel, and heparin gtt until pcis were completed. because he had persistent chest pain and st depressions v4-v6 despite nitro gtt after catheterization, he was transferred to the ccu while awaiting the procedures. . on arrival to the ccu he was chest pain free but continued to have nitermittent symptoms. nitro drip was titrated to pain relief. asa, plavix, atorvastatin, metoprolol, and lisinopril were continued. he underwent staged pci with 2 bare metal stents to the lcx and then another pci with two bare metal stents to the rca. he will need continued plavix tx for at least 1 month. per pt request he will follow up with his cardiologist by his home. . #.esrd- patient had a history of esrd likely hypertension and diabetes, on mwf dialysis. on he became hypotensive during hd and was only able to have 1 l removed. because he had elevated r heart pressures on cath, the plan was made to undertake ultrafiltration with the plan to remove more fluid and prevent pulmonary edema. afte that he had his regular hd, with good results. he has an appointment to restart his mwf hd after discharge. sevalamer was continued; nephrocaps were started. . #. pump - patient had evidence clinically of heart failure by history with pnd, dyspnea on exertion as well as previous history of lower extremity edema, although ventrigulograph done with cath showed normal ef and wall motion. on arrival to the ccu, patient appeared euvolemic to slightly overloaded. acei and beta blocker were continued. . # diabetes - patient was not on outpatient medications. sliding scale was instituted. pt was discharged on diabetic diet. he will f/u with his pcp. . # hyperlipdemia - patient with history of hyperlipedemia. lipid panel showed ldl 65 on 20 mg atorvastatin as an outpatient. given nstemi, he was changed to atorvastatin 80mg. . # carotid stenosis s/p lcea: statin and asa were continued. . # anemia - normocytic and hematocrit of 28 in the setting of chronic renal failure. iron panel consistent with anemia of chronic disease. also with decreased epo production. goal hct >30 given nstemi and angina; no transfusion was required. # copd - on 2l nc at night prn at home, continued while in patient. will resume use at home. he was discharged home with home safety evaluation planned. he will have pcp and cardiology follow up. medications on admission: albuterol 90 1-2 puffs ihh q 6 hours prn albuterol nebs prn ipratropium 0.2 mg/ml 0.02% solution, 1 q 6 prn ipratropium-albuterol q 6 hours prn metoprolol tartate 50 mg po daily nitro prn omeprazole 20 mg po daily oxygen 2l at night ranitidine 300 mg po q hs sevelamer 2400 mg po qid simvastatin 20 mg po daily temazepam 30 mg po qhs prn acetominophen 650 mg po q 6 prn aspirin 81 mg po daily docusate 100 mg po prn mvi nut.tx.imparied renal fxn, soy 0.08 gram-1.8 kcal/ml ( 1 by mouth tid) omega 3- fatty acids 1 capsule at bedtime discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 2. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual q5min as needed for chest pain. 3. ranitidine hcl 300 mg tablet sig: one (1) tablet po hs (at bedtime). 4. sevelamer carbonate 800 mg tablet sig: three (3) tablet po tid w/meals (3 times a day with meals). 5. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*0* 6. temazepam 15 mg capsule sig: two (2) capsule po hs (at bedtime) as needed for insomnia. 7. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain, headache, fever. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 10. aspirin 325 mg tablet sig: one (1) tablet po once a day. 11. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours) as needed for sob. 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation q6h (every 6 hours) as needed for sob, wheezing. 13. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*3* 14. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 15. metoprolol succinate 50 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po daily (daily). disp:*90 tablet sustained release 24 hr(s)* refills:*0* 16. omega-3 fish oil 1,000-5 mg-unit capsule sig: one (1) capsule po at bedtime. discharge disposition: home with service facility: vna discharge diagnosis: primary: non-st elevation myocaridal infarction periphrial vascular disease s/p stenting to superior mesenteric artery secondary: chronic renal failure, end stage on hemodialysis hypertension diabetes mellitus, type ii hyperlipedemia copd chronic heart failure, diastolic carotid stenosis s/p lcea paget's disease discharge condition: stable, free of chest pain discharge instructions: you came to the hospital for a procedure to open the artery to your intestine which was done successfully. while in the hospital you had a heart attack and had 2 procedures to place stents in the arteries to the heart. you are now on several medications to help keep the arteries to your heart open. it is important that you take your plavix and aspirin every day. please keep your follow up appointments clopidogrel was added. the following medication changes were made: lisinopril was added. metoprolol was increased. atorvastatin was increased. your sevelamer should be taken three times daily with meals. nephrocaps have been added. please return to the emergency department if you have chest pain, shortness of breath, high fevers and chills, or other symptoms that are concerning to you. please follow the wound care instructions provided to you for your groin. followup instructions: please resume dialysis on monday, . please also follow up as below: . please follow up with your pcp . ( on tues. at 3pm. . please follow up with your cardiologist dr. ( on tuesday at 2:30 pm. . please follow up with vascular surgery: vascular lab phone: date/time: 10:45 , md phone: date/time: 11:30 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Left heart cardiac catheterization Hemodialysis Angioplasty of other non-coronary vessel(s) Aortography Arteriography of other intra-abdominal arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Arteriography of other specified sites Transfusion of packed cells Cranial or peripheral nerve graft Insertion of one vascular stent Cranial or peripheral nerve graft Insertion of one vascular stent Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Procedure on single vessel Procedure on single vessel Procedure on vessel bifurcation Intravascular pressure measurement, other specified and unspecified vessels Diagnoses: Other iatrogenic hypotension Anemia in chronic kidney disease End stage renal disease Renal dialysis status Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Personal history of tobacco use Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Hemorrhage complicating a procedure 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 Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Diarrhea Nonspecific abnormal findings in stool contents Knee joint replacement Osteitis deformans without mention of bone tumor Chronic vascular insufficiency of intestine Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Chronic diastolic heart failure Other dependence on machines, supplemental oxygen |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hepatic adenomatosis with concern for intra-and extra tumoral hemorrhage major surgical or invasive procedure: hepatic arteriogram and embolization performed of bleeding adenoma history of present illness: pt is a 49f who developed acute ruq pain tonight at 6pm. she denies previous episodes. pain is sharp in the ruq with occasional radiation to her back. also had one episode of emesis. no fever or chills. nl bm earlier, then loose stool once the pain started. no sick contacts. past medical history: 1. liver adenomatosis - seen in by dr. in the liver center, was to see him again this afternoon 2. car accident in , when she damaged her right knee 3. scoliosis 4. sickle cell trait. 5. s/p myomectomy with removal of uterine fibroid social history: associate teacher. no tobacco, no etoh. lives with husband and children family history: her father was killed in an accident when she was 7. her mother is alive and well. physical exam: pe: 97.6 76 125/79 16 100% ra nad, sleeping on the stretcher. wakes easily. rolls easily. no jaundice or icterus cta b/l rrr abd soft, nd. ttp ruq. no rebound or guarding. no tap or shake tenderness. no le edema pertinent results: 10:56pm blood wbc-7.9 rbc-3.63* hgb-10.4* hct-30.7* mcv-85 mch-28.8 mchc-34.0 rdw-13.8 plt ct-249 11:30am blood hct-22.6* 01:53am blood wbc-7.7 rbc-3.37* hgb-10.1*# hct-27.9* mcv-83 mch-30.0 mchc-36.2* rdw-14.5 plt ct-162 01:09pm blood hct-29.6* 05:30am blood wbc-9.0 rbc-3.42* hgb-10.5* hct-28.6* mcv-84 mch-30.6 mchc-36.6* rdw-14.0 plt ct-187 05:25am blood wbc-8.9 rbc-3.30* hgb-10.2* hct-27.7* mcv-84 mch-30.8 mchc-36.7* rdw-14.0 plt ct-218 11:30am blood pt-13.6* ptt-21.7* inr(pt)-1.2* 05:30am blood pt-14.7* ptt-25.6 inr(pt)-1.3* 05:25am blood glucose-120* urean-6 creat-0.5 na-141 k-3.4 cl-106 hco3-26 angap-12 10:56pm blood alt-96* ast-105* alkphos-90 totbili-0.3 06:20am blood alt-177* ast-182* alkphos-73 totbili-0.4 01:53am blood alt-454* ast-652* ld(ldh)-558* alkphos-96 totbili-0.6 03:00am blood alt-1016* ast-1355* alkphos-146* totbili-0.9 05:25am blood alt-679* ast-306* alkphos-209* totbili-1.3 06:05am blood alt-504* ast-182* alkphos-177* totbili-1.0 ct impression: 1. findings are consistent with acute hemorrhage of hepatic adenoma, with extensive perihepatic hemoperitoneum extending around the inferior edge of the liver. 2. gallbladder wall thickening consistent with adenomyomatosis as seen on previous ultrasound. no evidence of acute cholecystitis. 3. no other abnormalities noted on non-contrast exam. arteriogram : celiac, sma and hepatic arteriograms demonstrated the presence of a single hypervascular adenoma in the segment vi of the liver. ct impression: impression: 1. no evidence of active extravasation from the known hepatic adenomas. 2. persistent hemoperitoneum, now predominantly located around segment vi of the liver and in the pelvis. 3. no findings to suggest an abscess in the abdomen or pelvis. brief hospital course: patient initially admitted to dr. surgical service with diagnosis of acute cholecystitis. given initial presentation with acute onset epigastric pain, us ordered and results showing multiple hepatic lesions in a patient with known hepatic adenomatosis; heterogeneous lesion inferiorly, with a moderate amount of fluid in the abdomen is concerning for rupture and hemorrhage of adenoma; gallbladder mucosal irregularity and ringdown artifact indicating adenomyomatosis. no evidence to suggest cholecystitis. ct scan ordered to further evaluate lesions and results showed acute hemorrhage of hepatic adenoma, with extensive perihepatic hemoperitoneum extending around the inferior edge of the liver; gallbladder wall thickening consistent with adenomyomatosis as seen on previous ultrasound without evidence of acute cholecystitis. gi consulted for recommendations. plastic surgery also consulted for possible compartment syndrome to left forearm. ruled out and attributed to iv infiltration. started on flagyl and cipro for empiric coverage. she was transferred to dr. hepatobiliary service on . hematocrits were trended. initial signs of continued bleeding as hct decreasing from 34.4 - 30.7 - 23.2 - 22.6. taken directly to ir for angiogram and coil embolization. given 2 units of prbc. hct responding to 27. transferred to surgical care unit for close observation. hct continue to drop to 26 and was transfused another unit, responding to 28. patient continued to have fevers. cultures negative. clinically asymptomatic except for some abdominal tenderness. diet advanced to regular. transferred to the floor on as hct becoming more stable. she was transfused another unit for hct of 26, responding and stabilizing at 28.5 prior to discharge. patient received 4 units prbc this admission. antibiotics changed to unasyn. ct scan to reasses abdomen on . results showing hemoperitoneum now predominantly located around segment vi of the liver and in the pelvis, no active extrav, no abscess. plan to discharge patient with clear instructions to return if noting any signs of jaundice ( colored stools, tea-colored urine, yellowing of eyes) and continue augmentin for 5 days. medications on admission: none discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. senna 8.6 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. 5. augmentin 500-125 mg tablet sig: one (1) tablet po twice a day for 5 days. disp:*10 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: bleeding hepatic adenoma discharge condition: stable discharge instructions: please call or return to ed if fever > 101.5, severe pain unresolved in 24hrs, nausea with vomiting and dehydration without maintaining oral intake, any signs jaundice to the eyes, tea colored urine or colored stools. followup instructions: please follow up with dr. on . please call to make an appointment. Procedure: Aortography Arteriography of other intra-abdominal arteries Other endovascular procedures on other vessels Diagnoses: Acute posthemorrhagic anemia Scoliosis [and kyphoscoliosis], idiopathic Other and unspecified complications of medical care, not elsewhere classified Hemoperitoneum (nontraumatic) Other specified disorders of liver Benign neoplasm of liver and biliary passages Swelling of limb Sickle-cell trait |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: increased headache, numbness major surgical or invasive procedure: ->stx cyst aspiration & angio(neg) history of present illness: 35 y/o male who had been seen and diagnosed with a right sided hemorrhagic brain stem cyst. this cyst was partially drained under stereotactic guidance on . the patient had transient improvement of the numbness pattern described above post operatively but has since noticed that the numbness has been increasing in intensity since the date of surgery. he presents after having developed a headache that started yesterday morning and has not subsided. he has taken tylenol several times with good effect. he denies any visual changes, nausea or vomiting or memory loss. past medical history: as noted in hpi social history: social etoh family history: non-contributory physical exam: on admission: t:98.3 bp:147 /78 hr:75 r 16 o2sats: 100% ra gen: wd/wn, comfortable, nad. heent: pupils: 6 to 4 mm bilaterally, more brisk on the right eoms: intact neck: supple. extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. recall: objects at 5 minutes. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light,6 to 4 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch, proprioception toes downgoing bilaterally coordination: normal on finger-nose-finger on discharge: alert, oriented to person place and date, perrl, bilateral 6th and 4th nerve palsy. nystagmus in all fields, primarily in upgaze. full motor strength throughout all four extremities. right pronator drift pertinent results: labs on admission: 11:34am blood wbc-4.8 rbc-5.11 hgb-14.9 hct-42.2 mcv-83 mch-29.3 mchc-35.4* rdw-14.0 plt ct-176 11:34am blood neuts-68.1 lymphs-25.3 monos-5.5 eos-0.7 baso-0.4 11:34am blood pt-12.9 ptt-26.4 inr(pt)-1.1 11:34am blood glucose-107* urean-10 creat-0.9 na-141 k-4.4 cl-104 hco3-30 angap-11 labs on discharge: 03:24am blood wbc-7.4 rbc-4.30* hgb-12.9* hct-36.5* mcv-85 mch-30.1 mchc-35.4* rdw-13.7 plt ct-171 03:24am blood pt-14.0* ptt-27.8 inr(pt)-1.2* 04:51am blood glucose-143* urean-7 creat-0.8 na-136 k-3.6 cl-99 hco3-30 angap-11 04:51am blood calcium-9.2 phos-3.1 mg-1.8 imaging: head ct : findings: a left frontal burr hole is again noted. a 25 x 24 mm lesion in the left pons, extending into the cerebellar peduncle, has increased in size since , when it measured 22 x 20 mm. it contains a blood/fluid level, as before, with increased amount of blood. there is no adjacent edema. there is increased effacement of the left ambient cistern and partial effacement of the left anterolateral aspect of the fourth ventricle. the other ventricles are normal in size. impression: increased size and increased hemorrhagic component of the left pontine lesion, with increased mass effect. mri : technique: sagittal t1, axial t2, t2 stir, and flair images were acquired of the brain in the absence of intravenous gadolinium contrast. diffusion- weighted images were also reviewed. findings: a round cystic lesion measuring approximately 27 x 28 mm (3:12) in the left pons at the middle cerebellar peduncle junction is again visualized, comparable to the most recent prior examinations. images are notable for fluid-fluid level with layering seen inferiorly (3:12), overall suggestive of a hematocrit effect. there is subsequent mass effect on the left aspect of the fourth ventricle as before. the remainder of the ventricles is normal in size and configuration. there are no other intracranial masses, edema, or evidence of infarction. a small extra-axial fluid collection near the vertex (4:23) is consistent with history of previous cyst aspiration. impression: stable, predominantly cystic left pontine/middle cerebellar peduncle lesion, overall of nonspecific etiology. mri (preliminary read): increase in size of the left pontine cyst and mass effect on the 4 th ventrcile; hemorrhage into parenchyma cannot be excluded; small amount of intraventricula hemorrhage. close follow up if no itnervention is contemplated. head ct (post-aspirate) technique: axial ct images were acquired through the brain in the absence of intravenous contrast. findings: a cranial defect is seen at the left, near the vertex (2:28), consistent with recent stereotactic biopsy. a small amount of pneumocephalus is seen along the biopsy tract. the previously described cystic lesion in the region of the left pons is again visualized (2, 8) measuring 23 x 30 mm and contains a small amount of air, new from previous studies and likely sequelae of the stereotactic biopsy. also, new from previous studies is an inferior layering area of marked hyperdensity which is new from previous studies, appearing to be injected contrast material. superior to this and also layering is an area of more moderate hyperdensity, consistent with some residual blood products within this cyst. there are no new areas of intracranial hemorrhage. apart from surrounding edema around this cyst, there is no other evidence of edema. there is no evidence of infarction. slight effacement of the fourth ventricle is again visualized; however, the remainder of the ventricles is normal in size and configuration. the visualized osseous and soft tissue structures are unchanged since the previous studies. impression: post-stereotactic biopsy changes in the left pontine cystic lesion as detailed above. pathology : cytology report cyst fluid procedure date of report approved date: specimen received: 09- cyst fluid specimen description: received approximately 2 ml of brown fluid. prepared 1 thinprep slide. clinical data: brain stem cyst. report to: dr. diagnosis: cyst fluid from brain stem: negative for malignant cells. blood. pathology : procedure date tissue received report date diagnosed by dr. /ttl diagnosis: 1. brain stem cyst, biopsy "-20" (a): white matter and pigmented neurons (? dopaminergic) with focal gliosis, no tumor detected. 2. brain stem cyst, biopsy "-19" (smear): gliotic brain with numerous pilocytic astrocytes and fibers. 3. brain stem cyst, biopsy "-18" (b): white matter with focal gliosis. 4. brain stem cyst, biopsy "-17" (smear): gliotic brain with numerous pilocytic astrocytes and fibers. 5. brain stem cyst, biopsy "+4" (smear): gliotic brain with numerous pilocytic astrocytes and fibers. 6. brain stem cyst, biopsy "+5" (c): neuron cluster surrounded and white matter tracts with focally ectatic vessels, no tumor detected. 7. brain stem cyst, biopsy "-16" (d): neuron cluster and white matter tracts, no tumor detected. note: hemosiderin was found in one of the smear specimens and suggests the possibility of a remote hypertensive bleed with blood absorption and cyst formation with surround piloid gliosis and fiber formation. the low cellularity and lack of atypia argue for a reactive rather than neoplastic glial process. clinical: brain stem cyst. gross: the specimen is received fresh from the o.r. in seven parts, all labeled with the patient's name, ", " and with the medical record number. each part consists of a 0.1 x 0.1 x 0.1 cm fragment of white soft tissue. part 1 is additionally labeled "-20" and is entirely submitted in cassette a. part 2 is additionally labeled "-19" and is consumed entirely for intraoperative consultation. smear diagnosis by dr. is as follows: "gliotic brain with numerous pilocytic astrocytes and fibers". part 3 is additionally labeled "-18" and is entirely submitted. part 4 is additionally labeled "-17" and consumed for intraoperative consultation. smear diagnosis by dr. is as follows: "gliotic brain with numerous pilocytic astrocytes and fibers. differential diagnosis includes pilocytic astrocytoma and reactive gliosis". part 5 is additionally labeled "+4" and is entirely consumed for intraoperative consultation. smear diagnosis by dr. is as follows: "gliotic brain with pilocytic astrocytes and fibers". art 6 is additionally labeled "+5" and is submitted entirely in cassette c. part 7 is additionally labeled "-16" and is submitted entirely in cassette d. brief hospital course: patient is a 35m known to the nsurg service who was readmitted on for recurrent brain stem cyst and increased headache and numbness. he also later progressed to a left sided facial droop bilateral nystagmus , 6th nerve palsy and 4th nerve palsy and right pronator drift. on the evening of , he developed nausea that was refractory to pharmacological intervention and subsequently went to the operating room for emergent decompression and aspiration of the hemorrhagic cyst via stereotaxsis, followed by angiogram. angiogram was negative for any embolizable blood supply to halt the bleeding. , his exam was stable, but mri was done to further evaluate the effectiveness of the aspiration. mri showed recurrent cyst accumulation, larger in size with extravasation of blood product to the occipital horns and further compression of the 4th ventricle. given the cyst recurrence, and ongoing bleeding, it was determined that he would be best serviced by facilitating hospital transfer to the for consideration of open surgery by dr. . he was subsequently transferred to the in the evening of . medications on admission: ativan prn discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for headache. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po hs (at bedtime). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. hydromorphone 2 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 6. lorazepam 0.5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for anxiety. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. acetaminophen-codeine 300-30 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 9. ondansetron 4 mg iv q8h:prn n/v 10. prochlorperazine 5-10 mg iv q6h:prn 11. vancomycin 1000 mg iv q 12h duration: 2 doses 12. hydralazine 10 mg iv q6h sbp>160 13. metoprolol tartrate 5 mg iv once mr1 duration: 1 doses 14. dexamethasone 4 mg tablet sig: one (1) tablet po q8h (every 8 hours). discharge disposition: home discharge diagnosis: hemorrhagic brain stem cyst discharge condition: neurologically stable discharge instructions: general instructions ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? you may wash your hair only after sutures and/or staples have been removed. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: follow-up appointment instructions ??????please return to the office in days(from your date of surgery) for removal of your staples/sutures and a wound check. this appointment can be made with the nurse practitioner. please make this appointment by calling . if you live quite a distance from our office, please make arrangements for the same, with your pcp. ??????please call ( to schedule an appointment with dr. /, to be seen in 4 weeks. **all cranial imaging since has been copied to multiple cd's and is in the wife's possession Procedure: Other cranial puncture Computerized axial tomography of head Other immobilization, pressure, and attention to wound Diagnoses: Intracerebral hemorrhage Compression of brain Disturbance of skin sensation Facial weakness Cerebral cysts Nystagmus, unspecified Other cerebellar ataxia |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: seizure, altered mental status. major surgical or invasive procedure: lumbar puncture (). history of present illness: history obtained from hcp and neuro notes 52 y/o m with pmhx of type i dm, htn, ckd and dka c/b hypoxic brain injury who had a witnessed generalized tonic clonic seizure today this morning which lasted approximately 1 minute. per report, he was then noted to be postictal and yawning but "he was moving all 4 extremities at the time" and bs was >200. the rehab team cannot tell if there was a gaze deviation or bowel incontinence. he did not receive any meds. brother reports that at baseline the patient is able to converse and comprehend, but has difficulty with naming. at baseline patient is able to walk with assist using a belt and a person following with a wheelchair. has recently been able to walk up 16 stairs. per patient's brother/hcp, pt's blood glucose levels have been fluctuating recently and he reportedly had an episode of hypoglycemia yesterday with a glucose poc of 24 because the patient missed a meal. brother saw patient last night at which time he was able to discuss his children and his retirement. pt had a uti last week which was treated with ceftriaxone, last dose ~48 hours ago. of note, he has had a foley in since admission to the nh. hcp reported that he has had recurrent infections while at rehab and recently treated for cdiff (stopped abx for cdiff on ). initial vs on arrival to the ed: t 97.6 bp 173/94 rr 18 sats 95%2l nc. given new onset seizure and mental status changes, pt was given ativan 2mg iv and there were multiple unsuccessful attempts at lumbar puncture. head ct did not show any acute changes from baseline. neuro was consulted and pt was empirically treated with ceftriaxone 2grams, vancomycin 1gram, ampicillin 2grams, acyclovir 1gram. pt was given ivf but this was stopped after cxr showed increased pulm edema. on arrival to the micu, pt was somnolent but arousable to stimuli. pt would shout out in clear language to stop and says "" but otherwise, he does not follow commands. of note, he falls to sleep and exhibits cheynes breathing. family provided additional ros: pt has been c/o chills at night but denies fevers. good appetite, some diarrhea, recent uti, no significant cough or shortness of breath. improving with swallow function, advanced to regular diet approx wks ago. no nausea or vomiting. past medical history: dm1 since age 38, insulin pump requiring. hba1c 9.6 on hypertension diastolic heart failure hyerplipidemia ckd ( cr of 3.0) h/o acute pancreatitis h/o dka with associated hypoxic brain injury and prolonged icu stay requiring trach & peg (now weaned from trach but peg in place) social history: used to work as an mechanic, but had to stop working when he lost driver's license after repeated episodes of hypoglycemia. not married. pt has been living at rehab since admission in /. family history: non-contributory. physical exam: pe: 99.5 bp 169/74 hr 74 rr 3-12 sats 95% on ra gen: lying in bed, somnolent but arousable, not following commands and reports pain when touched anywhere heent: nc/at, dry mucosa neck: supple cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: not compliant with exam but subtle inspiratory crackles at bases bilaterally abd: soft, mildly ttp diffusely, no rebound/guarding, nabs. lower ext: no edema, warm, good dpulses rue: warm, erythematous, edematous pertinent results: labs at admission: 08:15am blood wbc-8.5 rbc-4.68# hgb-13.6*# hct-41.9# mcv-90 mch-29.1 mchc-32.5 rdw-17.1* plt ct-230 08:15am blood neuts-82.0* lymphs-11.7* monos-4.3 eos-1.5 baso-0.5 08:15am blood pt-11.1 ptt-26.9 inr(pt)-0.9 08:15am blood glucose-202* urean-61* creat-5.6*# na-137 k-4.2 cl-94* hco3-32 angap-15 08:13pm blood alt-22 ast-21 ld(ldh)-269* alkphos-126 totbili-0.3 08:15am blood calcium-10.0 phos-5.4* mg-2.3 04:15am blood osmolal-308 08:15am blood tsh-5.5* 08:15am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 08:22am blood lactate-1.4 csf fluid analysis: -wbc-2 rbc-2* polys-1 lymphs-56 monos-43 -totprot-75* glucose-136 ld(ldh)-38 -herpes simplex virus pcr- pending micro data: - bcx: pending - ucx: negative - csf hsv pcr: negative - csf: cryptococcal antigen negative gram stain (final ): no pmns. no microorganisms. fluid culture (preliminary): no growth. fungal culture (preliminary): no fungus isolated. viral culture (preliminary): - c. diff: negative - ucx: negative imaging studies: - ecg: sinus rhythm. borderline prolonged/upper limits of normal qtc interval is non-specific. otherwise, tracing is within normal limits. clinical correlation is suggested. since the previous tracing of the rate is slower and low amplitude t wave changes have decreased. intervals axes rate pr qrs qt/qtc p qrs t 63 126 94 444/449 59 18 70 . - ct head: 1. no acute intracranial process. 2. unchanged old infarctions. - cxr: 1. mild chf. 2. left retrocardiac opacity, most likely representing atelectasis, pneumonia cannot be excluded. - abd x-ray: no evidence of bowel obstruction. no free intraperitoneal air. - eeg: abnormal portable eeg due to the slow and disorganized background and frequent bursts of generalized slowing. these findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. there were some sharp features before the generalized slowing, but they were not simple spike or sharp and slow wave complexes, and they appeared repetitively for only a few seconds at a time. the tracing cannot rule out the occurrence of seizures at other times, but the bursts of slowing and even sharp waves appeared more likely related to the encephalopathy. if clinical suspicion for seizures persists, a repeat tracing or longer monitoring could be helpful. there were no areas of persistent focal slowing, but encephalopathies may obscure focal findings. - renal u/s: echogenic kidneys suggesting underlying medical renal disease. there is no nephrolithiasis, hydronephrosis, or renal mass lesion - right ue u/s: no right upper extremity dvt. brief hospital course: # seizure/altered mental status: neuro exam was generally non-focal aside from right sided and lower extremity weakness, which had reportedly been stable since his hypoxic brain injury several months ago. he was empirically treated with vanc, ceftriaxone, ampicillin and acyclovir for possible meningitis. lp was eventually obtained after an initially unsuccesful attempt. csf was not concerning for infection, and antibiotics/antivirals were discontinued. neuro was consulted and recommended starting keppra. in the micu, his toxic metabolic work up revealed a mildly elevated tsh and normal free t4. infectious workup was unrevealing. pt was initially continued on empiric metronidazole for possible c diff given his history of recurrent cdiff, recent abx course and elevated wbc count, but this was discontinued when his toxin assay came back negative. eeg was performed and showed findings likely related to encephalopathy. mental status was improved by day 2 of admission and pt was called out to the floor. he did not have any further seizures, and his mental status improved to his baseline mental status from prior to the seizure, according to his brothers. will follow up with neurology as an outpatient. # acute on chronic renal failure: pt has ckd with baseline creatinine of 3.5-3.9 and presented with a creatinine of 5.8 and a hemoconcentrated cbc. his creatinine had a variable result to volume repletion, but eventually improved to 5.0. nephrology was consulted. a family meeting was held between the patient, brothers, and the renal service, during which the brothers were told that hemodialysis may not have a significant benefit in the patient's quality of life. the family may consider seeing a local nephrologist to further discuss the risks/benefits of hemodialysis. # diastolic chf: the patient was generally euvolemic during the hospitalization. he was intermittently given iv fluids to treat his , and did not have significant edema, oxygen desaturation, or other signs of significant volume overload, despite holding diuretics. his respiratory status was stable. he was continued on hydralazine, amlodipine and labetalol for bp control. # typei dm: pt with h/o labile bs and severe episode of dka complicated by hypoxic brain injury. of note, his bs after the seizure was >170 though his family had been feeding him his meals and the day prior to admission, his bs was 24 due to missing a meal. given the lability of his blood sugars, the patient was given tube feeds at a low rate, and his initial insulin regimen was conservative to avoid repeat episodes of hypoglycemia. upon transfer to the floor, though, his blood sugars were somewhat labile, especially after the re-introduction of a diet. he was seen by who recommended adding bedtime glargine, and his fingersticks were subsequently better controlled. his insulin doses will likely have to be adjusted further as his oral diet and tube feeds are adjusted. . # obstructive sleep apnea: the patient underwent a sleep study as recommended by the neurology service. the neurology attending planned to evaluate the sleep study. the patient was recommended to sleep on his side. . # fen: the patient was given tube feeds. on , he was seen by speech and swallow therapy. he was written for a regular diet, which he tolerated, but did not have sufficient po intake to warrant discontinuation of his tube feeds. . # code: the patient was full code for the duration of the hospitalization, as confirmed with the health care proxy ( c; h) medications on admission: miconazole tp ranitidine 150mg amlodipine 10mg daily heparin 5000u sc tid insulin humolog ss labetalol 600mg tid calcium acetate 667mg nitroglycerin patch lasix 100mg lantus 16units daily metolazone 2.5mg daily hydralazine 50mg q6hr tylenol/percocet prn discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for axilla . 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. 3. heparin (porcine) 5,000 unit/ml solution sig: 5,000 units injection tid (3 times a day). 4. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 5. labetalol 200 mg tablet sig: three (3) tablet po tid (3 times a day). 6. insulin glargine 100 unit/ml solution sig: eighteen (18) units subcutaneous qam. 7. insulin glargine 100 unit/ml solution sig: eight (8) units subcutaneous at bedtime. 8. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 9. hydralazine 25 mg tablet sig: two (2) tablet po q6h (every 6 hours). 10. insulin lispro subcutaneous discharge disposition: extended care facility: - discharge diagnosis: primary: seizure acute on chronic kidney injury diabetes mellitus . secondary: history of hypoxic brain injury hypertension diastolic heart failure hyerplipidemia discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: mr. , you were admitted with a seizure. you were found to be hypogylcemic (low blood sugar) and this was treated. you had a lumbar puncture to evaluate for an infection in your spinal fluid. the lumbar puncture results did not show infection. you had worsening kidney function, which is now stable. your diabetes was difficult to control, but your blood sugars are now more stable. you have had some swelling of your right arm, but your ultrasound was negative for a blood clot. we made the following changes to your medications: -started levetiracetam 500 mg tabs, one tab by mouth twice daily -changed your insulin regimen: please see the attached sheet for your new regimen followup instructions: please follow up with your primary care doctor after you are discharged from rehab. department: neurology when: wednesday at 1 pm with: drs. & building: sc clinical ctr campus: east best parking: garage Procedure: Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Diagnoses: Obstructive sleep apnea (adult)(pediatric) Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other convulsions Chronic kidney disease, unspecified Alkalosis Encephalopathy, unspecified Chronic diastolic heart failure Nutritional marasmus Diabetes with other specified manifestations, type I [juvenile type], uncontrolled |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hyperglycemia major surgical or invasive procedure: g-tube placement cvl intubation picc line history of present illness: the patinet is a 52 year old male with a history of t1dm diagnosed at age 38 w/ 2 insulin pumps placed for the first time in the last month who presented to an osh with altered mental status. the patient is currently intubated and unresponsive, so most information is gained from the medical record. the patinet had been feeling unwell over the last few days, with decreased energy, nausea/vomiting. the patient was found by his daughters boyfriend on the day of presentation in respiratory distress and altered mental status, and was brought to an osh ed for further manegment. . on arrival to the osh, hr 88, bp 124/76, dyspneic with kussmal breathing. lab work up revealed a k of 8.8, sodium of 127, creatinine of 4.76, and glucose of 1157. he had an anion gap of 27. an abp was checked, with a ph of 6.98 / 17 / 253 / 4.6. the patinet develped hrs in the 40s, bps in the 50s. he was given 3 amps of nahco3, insulin gtt at 9 which was uptitrated to 15, and calcium gluconate. his ua was + for moderate ketones. a r sc line was placed without complications. the patinet was intubated for airway protection and respiratory distress. he was given 5l of ns. the patient was transfered to for further care. . on arrival to our ed, initial vs: 94.4 85 161/68 100% on the vent. his insulin was reduced to 8 units/hr. he was given an addition l of ns. the patient was given vanc/zosyn, but no blood cultures were sent. he blood sugars persisted in the 800s. he was admitted to the micu for further manemement. past medical history: dm1 (hbga1c 9.6 on ) htn cri ( cr of 2.3) dchf hl social history: patient is a former smoker, quit many years ago. works as a diesal mechanic. has 2 children. family history: nc physical exam: tmax: 37.1 ??????c (98.7 ??????f) tcurrent: 36.9 ??????c (98.4 ??????f) hr: 63 (62 - 69) bpm bp: 141/62(81) {121/52(69) - 147/68(87)} mmhg rr: 12 (8 - 17) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) wgt (current): 111.5 kg (admission): 107.5 kg height: 72 inch ventilator mode: mmv/psv/autoflow vt (set): 500 (500 - 500) ml vt (spontaneous): 477 (237 - 560) ml ps : 10 cmh2o rr (set): 8 rr (spontaneous): 12 peep: 5 cmh2o fio2: 40% rsbi: 38 pip: 15 cmh2o spo2: 100% gen: trach in place, winces to pain in le only cv: rr, no mrg pulm: coarse breath sounds abd: benign abdomen, g-tube in place, lap incisions well healing, no bleeding, erythema or oozing. no guarding or rebound peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) skin: not assessed neurologic: responds to pain (winces), pupils ~1mm with some response to light, eyes moving in same direction as head movement. no spontaneous movement of extremities pertinent results: admission: 12:19am blood wbc-18.1* rbc-3.15* hgb-9.7* hct-32.3* mcv-103* mch-30.7 mchc-29.9* rdw-14.0 plt ct-249 09:27pm blood neuts-91.3* lymphs-5.6* monos-2.8 eos-0.2 baso-0.2 12:19am blood plt ct-249 12:19am blood fibrino-544* 04:06am blood ret aut-0.6* 01:52am blood glucose-834* urean-66* creat-4.0* na-137 k-5.4* cl-106 hco3-13* angap-23* 12:19am blood alt-26 ast-33 ld(ldh)-319* alkphos-96 totbili-0.1 12:19am blood lipase-869* 03:17am blood calcium-7.6* phos-5.8* mg-2.5 09:27pm blood caltibc-174* ferritn-372 trf-134* 04:44am blood triglyc-191* 01:52am blood osmolal-362* 12:19am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 12:20am blood type-art po2-377* pco2-34* ph-7.15* caltco2-13* base xs--16 12:13am blood glucose-greater th lactate-2.6* k-5.7* discharge: 03:16am blood wbc-9.6 rbc-2.54* hgb-7.5* hct-22.7* mcv-89 mch-29.6 mchc-33.2 rdw-14.7 plt ct-245 03:16am blood plt ct-245 04:44am blood pt-12.5 ptt-28.0 inr(pt)-1.1 03:16am blood glucose-126* urean-97* creat-3.9* na-148* k-3.7 cl-104 hco3-34* angap-14 02:48am blood alt-21 ast-26 ld(ldh)-257* alkphos-82 totbili-0.1 03:16am blood calcium-8.2* phos-4.5 mg-3.4* 05:19pm blood type- temp-36.4 rates-/12 peep-5 po2-36* pco2-54* ph-7.50* caltco2-44* base xs-15 intubat-intubated 04:35pm blood lactate-1.4 cxr: ap supine chest radiograph: tracheostomy tube with its tip 4.9 cm above the carina and a right picc with its tip in the upper svc are unchanged. the nasogastric tube has been removed. the lungs are clear without effusion, consolidation or pneumothorax. heart size is normal. impression: no acute cardiopulmonary process. tte: the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 60-70%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: no obvious vegetations seen mri head: impression: 1. multifocal subacute infarction, configuration and distribution favor hypoxic ischemic insult such as sustained during acute hypotension, cardiac arrest. given gyriform configuration, the embolic etiology is felt less likely, however, remains a differential consideration. 2. no evidence of mass effect, edema, herniation or hemorrhage. 3. pansinusitis. ct-head impression: 1. bitemporal regions of low attenuation, not significantly changed since . ct appearance is non-specific and further evaluation with mr (preferably with contrast), if feasible, is recommended to exclude acute infectious/inflammatory process such as cerebritis/encephalitis, or ischemic causes vs. chronic encphalomalacia, perhaps related to old contusions. 2. persistent opacification of paranasal sinuses. ct-abd/pelvis: impression: 1. indistinct and hazy borders of the pancreas most compatible with acute pancreatitis. pancreatic necrosis and other complication cannot be evaluated on the current study due to lack of iv contrast. 2. extensive subcutaneous edema consistent with anasarca. 3. colonic diverticulosis. apparent descending colon wall thickening may be secondary under-distention, third-spacing, and/or colitis. 4. bilateral small pleural effusions with adjacent associated atelectasis; superinfection can not be excluded. brief hospital course: the patient is a 52 year old male with a history of dm1 with a recent insulin pump placement, cri (cr 2.3) who presented in respiratory distress and altered mental status, found to have profound hyperglycemia and metabolic acidosis. # dka: patient presented with profound dka with acidemia to 6.9 for an unknown period of time. the precipitant was unclear but he did have pancreatitis, with an elevated lipase. his dka resolved with aggressive ivfs and an insulin drip. # anoxic brain injury: he was intubated for lethargy in the setting of dka and was comatose off sedation early on during his hospital course. an lp was performed that did show pleocytosis and he was empirically treated with vanc/zosyn. an mri was also performed and had findings consistent with anoxic brain injury. nuero was consulted and felt that the anoxic injury was likely related to prolonged acidemia in the setting of dka. a review of the osh records also demonstrated intervals lasting minutes in which the patient had systolic bps in the 70s, though he was never asystolic. his family initially planned to withdraw care given the patient's preferences prior to illness and his poor prognosis but on , he withdrew to painful stimuli on his legs and ears. given this finding, they decided to proceed with tracheostomy () and peg, though they understood that despite these findings, his prognosis was still very poor. # respiratory failure: the patient was intubated in the setting of lethargy. he received tracheostomy on and peg as described above. he had periods of apnea and therefore required mmv; he did not tolerate trach collar for long periods of time. # pancreatitis: he had an elevated lipase thought to be secondary to dka. a non-contrast abdominal ct scan demonstrated findings consistent with acute pancreatitis but necrosis could not be visualized because of the lack of contrast, which was not used because of . surgery was consulted and felt that there were no acute surgical interventions indicated. # fevers: he continued to spike fevers throughout his hospital stay. cultures were consistently negative and he received broad spectrum antibiotics for meningitis. we felt his fevers were most likely central/neurologic in origin. patient finished a 14 day course of vancomycin and cefepime on . # acute on chronic kidney injury: he had in the setting of hypovolemia and dka and this improved with ivfs. renal was consulted and recommended continued diuresis given his >15l positive fluid balance. a lasix drip was initiated and he diuresed well and was transitioned to lasix boluses. he subsequently had worsening and renal re-evaluated; felt to have prerenal etiology given diuresis on top of atn; he was given 1/2ns for 1 day with no improvement. the patient should have his renal function assessed daily and may eventually require renal replacement therapy based on overall improvement, prognosis and plan of care. defer to rehab team. # hypernatremia: patient noted to have hypernatremia with average sodium concentration near 148 at time of discharge. patient required frequent free water flushes and will require ongoing monitoring given patients inability to express thirst on control fluid intake. please obtain daily sodiums and replete free water based on daily deficit. # anemia: he has anemia of chronic inflammation and was transfused 1u prbc on . there was no evidence of active bleeding. he will need to have his hematocrit checked weekly. # contact: next of : ( c; h)- brother son ter medications on admission: ramipril 10mg take 1 capsule (10mg) by oral route every day zestril 10mg 1 time per day simvastatin 40mg 1 time per day viagra 100mg as directed, before sexual intercourse furosemide 80mg take 1 tablet (80mg) by oral route 2 times every day aspirin 81mg take 1 tablet (81mg) by oral route every day avapro 300mg take 2 tabs/d discharge medications: 1. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 2. acetaminophen 650 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for fever. 3. labetalol 200 mg tablet sig: 1.5 tablets po tid (3 times a day). 4. white petrolatum-mineral oil 42.5-56.8 % ointment sig: one (1) appl ophthalmic prn (as needed) as needed for dry eyes. 5. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) u injection tid (3 times a day). 6. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for bm. 8. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 9. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 10. sodium chloride 0.9% flush 10 ml iv prn line flush temporary central access-icu: flush with 10ml normal saline daily and prn. 11. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 12. lantus 100 unit/ml solution sig: twenty four (24) u subcutaneous qam. 13. insulin regular human 300 unit/3 ml insulin pen sig: per sliding scale subcutaneous every six (6) hours: 120-159:14u 160-199:16u 200-239:18u 240-279:20u 280-319:22u 320-359:24u 360-399:26u >400: md. discharge disposition: extended care facility: - discharge diagnosis: diabetic ketoacidosis diffuse brain injury meningitis/encephalitis acute on chronic renal failure hypernatermia anemia discharge condition: poor mental status- does not withdraw to pain; no purposeful movements discharge instructions: . it was a pleasure taking care of you in the hospital. you were admitted to the hospital because of elevated sugars and severe acidosis. you required intubation and had a prolonged admission in the icu. you had fevers and were treated for an infection with antibiotics for 14 days. you were evaluated by neurology and it is unclear the level of neurologic improvement you will have. please see discharge summary for full hospital course. followup instructions: . you will need renal follow-up regarding your acute on chronic renal failure. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Other gastroscopy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Temporary tracheostomy Other gastrostomy Diagnoses: Anemia, unspecified Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other convulsions Chronic kidney disease, Stage III (moderate) Acute respiratory failure Anoxic brain damage Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Diastolic heart failure, unspecified Acute pancreatitis Diabetes with ketoacidosis, type I [juvenile type], uncontrolled Dependence on respirator, status Meningitis, unspecified Unspecified causes of encephalitis, myelitis, and encephalomyelitis Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled |
allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: talc pleurodesis () history of present illness: ms. is a 61 year old woman with a history of metastatic breast cancer to the lung and brain on weekly taxol, cycle 3 on , who presents to the emergency room from hospital with shortness of breath. she recently was found to have a right sided pleural effusion s/p thoracentesis with 2100 ml of fluid removed on . her week 3 taxol dose was held this day due to the pleural effusion. she initially improved; however felt more shortness of breath in the past 2 days. she initially presented to hospital where a cxr showed reaccumulation of pleural effusion on the right. she was then transferred to the er. . in the emergency department, initial vitals: 97.5 112 111/78 98% 2l nc. ecg showed sinus tachycardia with st depressions v4 to v6 which were new, thought to be rate-related. . on the floor, she reports dyspnea on exertion with taking 17 steps. she has a cough productive of clear/white sputum which has been present for the past few weeks. she reports minimal improvement in her dyspnea after the thoracentesis. she has occasional headaches, no vision changes, no numbness or tingling. she denies weakness. she has no chest pain but has a some palpitations when walking 17 steps. she denies fevers or chills. . review of systems: (+) 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. past medical history: - metastatic breast cancer (1) a right frontal craniotomy for resection of the metastasis by , m.d. on (2) cyberknife radiosurgery to the 1-right frontal lobe resection cavity to 2400 cgy (800 cgy x 3 fractions) at 84% isodose line from to (3) lumbar puncture on showed 0 wbc, 31 protein, and negative cytology for malignant cells (4) status post cyberknife radiosurgery on at 2-right frontal metastasis to cgy at 70% isodose line and 3-left frontal metastasis to 2200 cgy at 77% isodose line. . her fdg-pet from did not show fdg uptake. she underwent a thallium-spect today and the official result is pending. she reports some evidence of word-finding difficulty intermittently, particuarly when she is fatigued. her balance remains good. she remains off dexamethasone. she does not have headache, nausea, vomiting, seizure, imbalance, or fall. dr. will change her navelbine treatment to possibly doxil. . her oncological problem began in when she palpated a mass in the left breast. a mammogram showed suspicious breast tumor. she underwent a left mastectomy with none of 11 lymph nodes positive for tumor. the pathology showed er positive infiltrating ductal carcinoma. she received caf chemotherapy, followed by chest irradiation, and 5 years of tamoxifen. she was well until when she developed a cough and a chest x-ray showed a shadow. a work up at another institution revealed metastatic breast cancer to her subcarinal lymph node. biopsy showed adenocarcinoma that was er positive, pr negative, her-2 negative by fish. she was then treated with faslodex from to . subsequent work up revealed an esophageal metastasis. a right upper lobe transbronchial biopsy on showed adenocarcinoma, and her treatment was switched to xeloda on . she the received external beam mediastinum irradiation on to to 5,000 cgy. she started weekly navelbine on . . her neurological problem began in later and early , with pounding -frontal headaches that radiated to the occiput. these headaches were worse with motion but improved with aleve. she did not have night-time headache. she also had positional nausea and imbalance, but no vomiting. a gadolinium-enhanced head mri on showed a right frontal enhancing mass with surrounding cerebral edema, mass effect, and 2 mm of midline shift. she had a craniotomy by , m.d. on for resection of the right frontal mass. the pathology was er positive metastatic breast carcinoma. this was followed by cyberknife radiosurgery to the right frontal lobe resection cavity to 2400 cgy (800 cgy x 3 fractions) at 84% isodose line from to . she then had another session of cyberknife radiosurgery on at 2-right frontal metastasis to cgy at 70% isodose line and 3-left frontal metastasis to 2200 cgy at 77% isodose line. other past medical history: - diabetes - h/o seizures social history: married, two grown children in the area. no etoh. no illicits. family history: grandmother died of stomach cancer at age 76. no breast, ovarian, uterine, or colon cancers in the family. father- stroke and coronary artery disease. physical exam: on admission: physical exam: vs: t97 bp 118/60 hr 123 rr 22 96% 2l general: alert and oriented, nad heent: no scleral icterus. perrla/eomi. mmm. op clear. neck supple, no lad. cardiac: tachycardic. normal s1, s2. no m/r/g. lungs: decreased breath sounds on the right side, dullness to percussion through entire right lung field. abdomen: nabs. soft, nt, nd. no hsm extremities: no c/c/e, 2+ dorsalis pedis/ posterior tibial pulses. . at discharge: physical examination: vs: t 96.9 bp98-122/56-70s hr90-108 rr16-18 fsg 140-180s gen: nad, resting comfortably heent: mmm, o/p clear, sclera anicteric. no hair, craniotomy scars chest: ctab, pleurx in place cv: reg rate and rhthm, nl s1/s2 abd: soft, nt/nd, nabs, no hsm ext: no cc, trace - 1+ peripheral edema neuro: a&o x2, 4+/5 strength bilaterally upper and lower extremities, able to name objects without difficulty and converse, unable to state why she is here, she does endorse feeling "mixed up" pelvic: pelvic exam performed yesterday which showed normal external genitalia and stool coming from the vagina pertinent results: 06:40pm blood wbc-4.1 rbc-3.80* hgb-9.9* hct-31.2* mcv-82 mch-25.9* mchc-31.6 rdw-19.7* plt ct-384 06:40pm blood neuts-70.7* lymphs-20.1 monos-8.1 eos-0.9 baso-0.2 06:40pm blood pt-15.3* ptt-25.4 inr(pt)-1.3* 06:40pm blood glucose-74 urean-20 creat-1.1 na-138 k-3.5 cl-104 hco3-22 angap-16 studies: cxr : upright ap and lateral views of the chest: right-sided port-a-cath tip terminates within the svc. calcified prevascular lymph node is redemonstrated. a moderate-to-large right pleural effusion appears similar when compared to the prior reference chest radiograph, and has increased when compared to the prior chest radiograph of . previously noted right upper lobe consolidation persists, and may be slightly improved when compared to the prior study. no pneumothorax is demonstrated. left basilar atelectatic changes are present. the mediastinal contours appear unchanged, and assessment of the cardiac silhouette size is difficult given the presence of the moderate-to-large right pleural effusion. no acute osseous abnormality is seen. impression: moderate-to-large right pleural effusion, increased when compared to prior radiograph from . no pneumothorax. cxr : the port-a-cath catheter tip is at the cavoatrial junction. right chest tube has been inserted in the interim after pleuroscopy with interval decrease in the right pleural effusion. partial atelectasis of right lower lung is still present as well as apical accumulation of pleural effusion on the right. the left lung is essentially clear. no change in the mediastinal silhouette overall has been demonstrated including the left hilar calcified lymph nodes. cxr : findings: one portable upright ap view of the chest. a moderate right pleural effusion with fluid layering along the lateral right lung and apex as well as medially adjacent to the mediastinum is unchanged. mild right lower lobe atelectasis is unchanged. the cardiac, mediastinal and hilar contours are stable. calcified lymph node in the aortopulmonary window is unchanged. the left lung is clear. no left pleural effusion. impression: no significant change in moderate right pleural effusion. echo : the left atrium is normal in size. 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 diameters of aorta at the sinus, ascending and arch levels are normal. the number of aortic valve leaflets cannot be determined. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a prominent fat pad. impression: suboptimal image quality. normal global biventricular systolic function. technically suboptimal to exclude focal wall motion abnormality. . pathology: pleura, biopsy (a): poorly differentiated adenocarcinoma, morphologically consistent with metastatic breast carcinoma. right pleural fluid: atypical. rare atypical but degenerated epithelioid cells (see note). right pleural fluid, cell block: non-diagnostic; the specimen did not survive processing. discharge labs: 04:29am blood wbc-10.9 rbc-2.70* hgb-7.3* hct-23.9* mcv-89 mch-26.9* mchc-30.4* rdw-20.6* plt ct-250 04:29am blood glucose-101* urean-12 creat-0.5 na-136 k-4.0 cl-106 hco3-24 angap-10 05:32am blood pt-16.2* ptt-32.0 inr(pt)-1.4* 04:19am blood ld(ldh)-263* ck(cpk)-53 04:29am blood calcium-7.8* phos-2.3* mg-1.7 01:13am blood cortsol-24.8* brief hospital course: the patient is a 61 year old female with a history of metastatic breast cancer to the brain, lungs and adrenal glands who presents with shortness of breath and was found to have a recurrent pleural effusion which was drained at osh with transfer for pleurodesis. . # shortness of breath: she presented to osh with sob likely related to her recurrent pleural effusion, and had 2100 ml removed before transfer to . her effusion is most likely malignant in etiology and related to her metastatic breast cancer. talc pleurodesis was performed on by the ip service. she was drained daily, however got to the point where her drain was not removing fluid on 3 consecutive days so her pleurx catheter was removed by the ip service on . a stitch was placed that needs to be removed in 2 weeks. . # hypotension: following the procedure, the patient was still sedated and hypotensive and started on neo drip. her pressures did not respond to fluids. was thought that low pressures were most likely due to sedative effect, however, took a few days to wean patient off neo. antibiotics were not started given lack of fever and no localizing symptoms. the patient was volume resuscitated while being maintained on pressors. because of her prolonged pressor requirement and use of steroids as an outpatient, she was also started on hydrocort in the event of adrenal insufficiency despite normal am cortisol. the patient's blood pressures stabilized and we were able to wean off neo. the patient's blood pressures were stable on the oncology floor off of hydrocortisone and a random cortisol was 25 - it was felt it would be very unlikely for her to have adrenal insufficiency in that setting. . # oliguria: upon transfer to the micu, the patient had some oliguria. she was volume resucitated and her urine output ultimately improved. on transfer out of the unit, she was making good urine. she required periodic fluid boluses to keep adequate urine output. . # pleural effusion: the patient was found to have exudative pleural effusion based on light's criteria. cytology of pleural fluid was positive. pleural fluid was negative for fungus, afb, anaerobes, and culture did not grow out anything. the patient was hypoxic post procedure, and initially needed supplemental o2. however, the o2 was soon weaned, and on transfer out of the micu, the patient was breathing comfortably and satting well on ra, where she remained. . # stool in vagina: the patient was noted to have stool coming from her vagina. gynecology was consulted for concern of a rectovaginal fistula. their exam revealed no fistula, but an atrophic perineum, thought trauma from childbirth and poor nutritional status. stool was getting to the vagina because it was loose and this thin tissue did not prevent back passage of stool. she tested negative for c dificile infection twice. they felt she was not a surgical candidate and recommended stool bulking to help prevent stool from flowing into the vagina, and follow up in clinic as needed. . # delirium - the patient was intermittently confused, not knowing where she was or why she was in the hospital. she was easily redirectable and was not agitated. it was felt this was most likely secondary to a prolonged stay in the hospital and icu on top of poor substrate given her past cns metastatic disease and surgeries. this improved throughout her stay on the oncology floor. she was set up with follow up with her neuro-oncologist. . #dysphagia - on pt began to have some trouble swallowing pills and food. she stated that she had a sensation of something being "stuck" in her upper chest, but denied pain. there was concern for radiation encephalopathy as this coincided with some confusion/altered mental status. speech and swallow evaluated her on and felt that her swallowing was fine with the following recs: 1. continue po diet of thin liquids and regular consistency solids. 2. pills whole or crushed as tolerated. 3. alternate bites and sips as needed to clear mild oral residue. 4. assistance with meal set up as needed. 5. oral care. as the pt's mental status and alertness was improving somewhat along with her ability to swallow food and pills we felt that the dysphagia had been in the setting of needing to swallow a significant quantity of pills quickly and that she would be able to swallow pills over more extended periods of time. . # ecg changes: she was thought to have subtle lateral st depressions on her initial ekg in the ed, thought to be rate related. she denied any chest pain. troponins were negative, and repeat ecg the next morning was unchanged from prior. . # diabetes mellitus / hypoglycemia: she was hypoglycemic the morning after admission with glucose 48 on her am labs and fbg 65. this was likely related to her poor po intake and continued use of glimepiride at home. her glimepiride was held during her stay and she was placed on a humalog insulin sliding scale. her glimepiride was stopped on discharge pending pcp . her blood sugars the day of discharge were all > 90. . # seizure history: she was continued on levetiracetam 1000 mg qam, 500 mg at noon, and 1000 mg qpm. she did not have any apparent seizure episodes during her stay. . # depression / insomnia: she was continued on her home sertraline 150 mg po daily and lorazepam 0.5 mg po q6h prn. . # breast cancer: not an active issue during this admission. . # dvt prophylaxis: heparin 5000 units sc tid . transitional issues: - follow up with dr. and dr. of oncology and neuro-oncology - follow up with urogynecology as needed - number provided in discharge instructions - will need suture over right flank removed in 2 weeks - bulking of stool to prevent overflow to vagina medications on admission: glimepiride 2mg po daily levetiracetam 1000 mg in the am, 500 mg midday, 1000 mg pm lorazepam 0.5 mg po prn insomnia nystatin 500,000 units qid sertraline 150 mg po daily acetaminophen 500 mg po q4h prn pain omeprazole 20 mg po daily discharge medications: 1. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day): 1000 mg in the morning, 500 mg at lunch, 1000 mg in the evening. 2. levetiracetam 500 mg tablet sig: one (1) tablet po noon (at noon): 1000 mg in the morning, 500 mg at lunch, 1000 mg in the evening. 3. nystatin 500,000 unit tablet sig: one (1) tablet po qid (4 times a day). 4. sertraline 100 mg tablet sig: one (1) tablet po once a day. 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea, anxiety, insomnia. 7. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 8. sertraline 50 mg tablet sig: 1.5 tablets po daily (daily). 9. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea, anxiety, insomnia. 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 11. psyllium packet sig: one (1) packet po tid (3 times a day). 12. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8prn as needed for nausea. 13. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for loose stool. 14. miconazole nitrate 2 % powder sig: one (1) application topical qid;prn as needed for rash or vaginal dryness/itching. discharge disposition: extended care facility: care nad rehabilitation center discharge diagnosis: primary diagnoses: recurrent pleural effusion loss of perineal body delirium secondary diagnoses: metastatic breast cancer diabetes mellitus seizures 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 from a recurrent pleural effusion related to your breast cancer. the effusion was drained and talc pleurodesis was performed to help prevent the fluid from reaccumulating. after the procedure, your blood pressure was persistently low, so you were monitored in the icu. your blood pressure improved and you were cared for on the general medicine floor. your chest tube stopped draining fluid so it was removed. . you were noted to have stool coming from your vagina while in the hospital. you were seen by our gynecologists who felt you did not have a fistula. they felt this was most likely due to thinning of the skin between your vagina and rectum. as you are not a candidate for surgery at this time, they felt that stool bulking agents such as fiber and loperamide are the best options at this time. while in the hospital, you were found to have low blood sugar. this was likely related to your poor recent appetite and continued use of glimepiride. this medication can cause low blood sugars if taken without adequate food intake. you should stop taking this medication for now and discuss the various options for your diabetes control with your pcp and oncologist. . you were also seen by our speech and swallow specialists who felt that your swallowing was normal and you could tolerate regular foods. . you will leave on a new medication regimen that will be provided by your rehabilitation facility. acetaminophen mg po q6h:prn pain heparin 5000 unit sc tid levetiracetam 1000 mg po bid give total of 1000 mg in the morning, 500 mg at lunch, 1000 mg in the evening lorazepam 0.5 mg po q6h:prn nausea, anxiety, insomnia loperamide 2 mg po qid titrated to solid, formed bowel movement miconazole powder 2% 1 appl tp :prn candidal infxn nystatin 500,000 unit po qid ondansetron 8 mg po q8h:prn nausea omeprazole 20 mg po daily psyllium 1 pkt po tid sertraline 100 mg po daily followup instructions: name: e., md location: -division of hematology/oncology address: , 9, , phone: when: you will be called at home tomorrow with a follow up appointment. if you do not hear, please call the above number. department: neurology when: thursday at 11:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage please call to schedule an appointment with the urogynecology department - either dr. dr. . md Procedure: Insertion of intercostal catheter for drainage Injection into thoracic cavity Thoracoscopic pleural biopsy Diagnoses: Other iatrogenic hypotension Esophageal reflux Long-term (current) use of steroids Secondary malignant neoplasm of pleura Personal history of malignant neoplasm of breast Depressive disorder, not elsewhere classified Secondary malignant neoplasm of brain and spinal cord Epilepsy, unspecified, without mention of intractable epilepsy Hypoxemia Secondary malignant neoplasm of lung Diabetes with other specified manifestations, type II or unspecified type, uncontrolled Other alteration of consciousness Insomnia, unspecified Oliguria and anuria Candidiasis of vulva and vagina Secondary malignant neoplasm of other digestive organs and spleen Acquired absence of breast and nipple Dysphagia, unspecified Malignant pleural effusion Estrogen receptor positive status [ER+] Incompetence or weakening of rectovaginal tissue |
allergies: no known allergies / adverse drug reactions attending: chief complaint: seizures major surgical or invasive procedure: 1. resection of metastatic brain tumor 2. r craniotomy history of present illness: this is a 60 year old woman with classic migraines, breast cancer with metastasis including to the right frontal brain, s/p resection, currently on doxorubicin for chemotherapy presenting with increased seizures. the day of presentation, the patient reports she had 3 seizure episodes, each half an hour apart, and initially tried to wait for the seizure to self-resolve. the patient reports that, similar to her prior seizure episodes, she developed left gaze preference, left facial droop, expressive aphasia, and tonic clonic movements beginning at 10pm, which woke her from sleep and lasted about 5-15 minutes each. this was longer than her initial seizure episode . she was a&ox3 and reports she never lost consciousness, which is also typical of her seizures. she initially tried to wait for the seizures to resolve, but then presented to hospital where she had several two additional seizure episodes. the seizures were terminated with ativan 2mg, 1mg im and iv. she was given keppra 1000mg. per osh records, the patient was sitting in a chair and developed slurred speech and mild l facial droop, but was conscious throughout the seizure and had normal strength in her extremities. her symptoms were reported to resolve over 10 minutes. she reportedly developed increased seizure frequency 1 month ago when her anti-seizure medications were decreased. osh records also note that the patient developed a seizure after transfer to the hospital bed. a ct head was performed at which showed right encephalomalacia, and volume loss, no midline shift or ich. the patient denies recent fevers, productive cough, acute vision changes (but does report her vision has been blurry/slightly doubled without frank diplopia since her neurosurgical procedure), abdominal pain, diarrhea, dysuria, rash, focal numbness/tingling/weakness. she does report increased urinary frequency and increased urgency as well as foul smelling urine, which she states are her typical symptoms for a uti. she does report that since starting steroids, she has been unable to sleep more than 3 hours at a time and has been chronically sleep deprived. she drinks one cup of coffee daily which has not increased in quantity recently, denies alcohol intake. the patient was transferred from hospital to for further evaluation and management. past medical history: - metastatic breast cancer (1) a right frontal craniotomy for resection of the metastasis by , m.d. on (2) cyberknife radiosurgery to the 1-right frontal lobe resection cavity to 2400 cgy (800 cgy x 3 fractions) at 84% isodose line from to (3) lumbar puncture on showed 0 wbc, 31 protein, and negative cytology for malignant cells (4) status post cyberknife radiosurgery on at 2-right frontal metastasis to cgy at 70% isodose line and 3-left frontal metastasis to 2200 cgy at 77% isodose line. . her fdg-pet from did not show fdg uptake. she underwent a thallium-spect today and the official result is pending. she reports some evidence of word-finding difficulty intermittently, particuarly when she is fatigued. her balance remains good. she remains off dexamethasone. she does not have headache, nausea, vomiting, seizure, imbalance, or fall. dr. will change her navelbine treatment to possibly doxil. . her oncological problem began in when she palpated a mass in the left breast. a mammogram showed suspicious breast tumor. she underwent a left mastectomy with none of 11 lymph nodes positive for tumor. the pathology showed er positive infiltrating ductal carcinoma. she received caf chemotherapy, followed by chest irradiation, and 5 years of tamoxifen. she was well until when she developed a cough and a chest x-ray showed a shadow. a work up at another institution revealed metastatic breast cancer to her subcarinal lymph node. biopsy showed adenocarcinoma that was er positive, pr negative, her-2 negative by fish. she was then treated with faslodex from to . subsequent work up revealed an esophageal metastasis. a right upper lobe transbronchial biopsy on showed adenocarcinoma, and her treatment was switched to xeloda on . she the received external beam mediastinum irradiation on to to 5,000 cgy. she started weekly navelbine on . . her neurological problem began in later and early , with pounding -frontal headaches that radiated to the occiput. these headaches were worse with motion but improved with aleve. she did not have night-time headache. she also had positional nausea and imbalance, but no vomiting. a gadolinium-enhanced head mri on showed a right frontal enhancing mass with surrounding cerebral edema, mass effect, and 2 mm of midline shift. she had a craniotomy by , m.d. on for resection of the right frontal mass. the pathology was er positive metastatic breast carcinoma. this was followed by cyberknife radiosurgery to the right frontal lobe resection cavity to 2400 cgy (800 cgy x 3 fractions) at 84% isodose line from to . she then had another session of cyberknife radiosurgery on at 2-right frontal metastasis to cgy at 70% isodose line and 3-left frontal metastasis to 2200 cgy at 77% isodose line. other past medical history: - diabetes - h/o seizures social history: married, two grown children in the area. no etoh. no illicits. family history: grandmother died of stomach cancer at age 76. no breast, ovarian, uterine, or colon cancers in the family. father- stroke and coronary artery disease. physical exam: admission exam: vs: 97.3 128/61 79 18 100% 2l nc gen: aox3, alert, interactive, nad heent: perrla. mmm. no jvd. neck supple. cards: rrr, normal s1/s2, no murmurs/gallops/rubs. pulm: ctab, no wheezes/rales/rhonchi abd: bs+, soft, nt/nd, no rebound/guarding, no hsm extremities: wwp, no pedal edema. skin: no rashes or bruising neuro: cns ii-xii intact; left facial droop on observation but symmetric grossly when examined individually. 5/5 strength in u/l extremities. cerebellar fxn intact (ftn). gait deferred. at the time of discharge: she had right periorbital edema, she was neurologically intact. pertinent results: studies: mr spectroscopy : interval progression in the pattern of enhancement at the right temporal frontoparietal lesion with avid perfusion and increased signal on the corresponding asl sequence, concerning for tumor progression, there is also mild increase in vasogenic edema extending at the external capsule as described above. the most anterior frontal lesion appears unchanged. no other lesions are identified. mri brain functional : functional mri of the brain, demonstrating the expected activation areas for the primary motor cortex during the movement of the hands and feet and also during the movement of the tongue, no significant areas of bold activation are demonstrated adjacent to the right opercular mass lesion. mri brain there are stable post-surgical changes at the right frontoparietal region, the anterior right frontal lesion again measures 12 x 17 mm and the second right posterior frontal lesion is also stable in size and involves the adjacent dura. there is surrounding low signal intensity which is stable and most suggestive of vasogenic edema. there are no new brain lesions identified. the visualized paranasal sinuses are clear. impression: stable brain metastasis with no evidence of new lesions. ct head expected postoperative changes following right frontal craniotomy for right frontal and parietal lesions mri brain postoperative changes are seen in the right side of the scalp. there is also a small postoperative extra-axial collection. no large territorial infarction in the operative bed. there is a possible small focus of infarction in the right posterolateral frontal lobe, although this conceivably could be artifact from blood products. this can be assessed on followup imaging. intracranial flow voids are maintained. leptomeningeal enhancement in the right frontal lobe is likely to be post-surgical, and there is mild midline shift to the left for a few millimeters which is unchanged. impression: post-operative changes with probable residual neoplasm as detailed above. recommend attention on short-term followup imaging. brief hospital course: this is a 60 year old woman with classic migraines, breast cancer with metastasis including to the right frontal brain, s/p resection, currently on doxorubicin for chemotherapy presenting with increased seizures. she was admitted to med-onc and neurology was consulted. they felt that the patient's symptoms are consistent with her known seizure disorder, likely secondary to brain mets. her keprra dose was increased from 500mg to 1500mg , which was eventually changed to 1000mg tid. she underwent mr spectroscopy on which showed "interval progression in the pattern of enhancement at the right temporal frontoparietal lesion with avid perfusion and increased signal on the corresponding asl sequence, concerning for tumor progression, there is also mild increase in vasogenic edema extending at the external capsule". she was subsequently evaluated by the neurosurgical service on who recommended transfer to their service on . a functional mri was obtained preoperatively which showed no motor involvement of right frontal tumor. thus, on , patient underwent craniotomy for tumor resection. please review dictated operative report for details. she tolerated the procedure well and was extubated without incident. she was transferred to sicu for further management and frequent neuro checks. a ct and subsequent mri demonstrated no acute hemorrhage. she was stable for transfer to the floor on . she was seen and cleared by pt on . she was discharged to home on on a decadron taper. medications on admission: - dexamethasone - keppra 500mg - glipizide 5mg daily - prilosec 20mg daily - ativan po prn discharge medications: 1. glipizide 5 mg tablet sig: one (1) tablet po once a day. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). :*60 capsule(s)* refills:*2* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). :*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. percocet 2.5-325 mg tablet sig: 1-2 tablets po every hours as needed for pain: pain. :*30 tablet(s)* refills:*0* 5. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 6. lorazepam 0.5 mg tablet sig: 1-2 tablets po every twenty-four(24) hours as needed for anxiety : lorazepam - 0.5 mg tablet - 1 tablet(s) by mouth as needed as needed for anxiety. repeat x1. . 7. levetiracetam 500 mg tablet sig: two (2) tablet po tid (3 times a day). :*180 tablet(s)* refills:*2* 8. dexamethasone 2 mg tablet sig: 1-2 tablets po q12h (): taper schedule: 1) dexamethasone 3 mg (1.5 tabs) po q8h x 2 days, then 2) dexamethasone 2 mg po q8h x 2 days, then 3) dexamethasone 2 mg po q12h **continue this dose until told otherwise by your doctor. :*75 tablet(s)* refills:*0* 9. outpatient physical therapy discharge disposition: home discharge diagnosis: primary: -breast cancer with brain metastases -seizure disorder discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ms. , you were admitted to the hospital for seizures. we increased your keppra dose to 1000mg three times a day and you remained seizure-free while in the hospital. you went for an mri to address your brain metastases which suggested possible tumor progression. you underwent a craniotomy and the brain tumor was resected. we made the following changes to your medications: changed keppra to 1000mg 3 times daily please note your follow up appointment below. general instructions ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? you may wash your hair only after sutures and/or staples have been removed. if your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. followup instructions: ??????please return to the office in days (from your date of surgery) for removal of your sutures if necessary and a wound check. this appointment can be made with the nurse practitioner. please make this appointment by calling . ??????please call to schedule an appointment in the brain clinic. their phone number is . the brain clinic is located on the of , in the building, . please call if you need to change your appointment, or require additional directions. department: hematology/oncology when: tuesday at 10:00 am with: , np building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 11:00 am with: paddy , rn building: campus: east best parking: garage Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Excision of lesion or tissue of cerebral meninges Other repair of cerebral meninges Diagnoses: Urinary tract infection, site not specified Long-term (current) use of steroids Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Asthma, unspecified type, unspecified Secondary malignant neoplasm of brain and spinal cord Cerebral edema Epilepsy, unspecified, without mention of intractable epilepsy Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Secondary malignant neoplasm of other parts of nervous system Secondary malignant neoplasm of other digestive organs and spleen Malignant neoplasm of breast (female), unspecified Migraine with aura, without mention of intractable migraine without mention of status migrainosus Lack of adequate sleep Estrogen receptor positive status [ER+] |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache major surgical or invasive procedure: right frontal craniotomy with excision mass history of present illness: the patient is a 59 year old female with a history of metastatic breast ca who was reffered who presented with complaints of headaches. the patient was diagnosed with breast cancer in , and has undergone lupectomy with radiation. she was found to have metastatic disease with a subcarinal mass and mediastinal lymphadenopathy in . she was enrolled in an experimental protocol, and treated with fulvestrant. with disease progression in , she was switched to xeloda and underwent mediastinal xrt. in review of omr notes, it seems that she mediastinal lymph nodes, esophagus, right main stem bronchus, and possibly a new adrenal lesion. she has remained on xeloda with regular follow up with dr. . . she was seen in clinic yesterday, where she complained of headaches. she described as severe, with mild relief nsaids. the headahces were associated with nausea, but not vomiting. she endoresed symptoms of disoriention and confusion. her husband describes symptoms initially as mild, but with progression in the last two weeks. he now has to help her with a variety of adls. her memory has declined during this period as well. she denies any visual complaints, including blurred or double vision. she denies any focal neurologic symptoms, either sensory or motor. she was scheduled for an mri on the day of admission. with findings showing a frontal mass with surrounding edema and a midline shift, she was reffered to the ed for further evaluation. . in the ed, vitals were t 98.1 hr 95 bp 146/71 rr 16 o2 99% on ra. neurosurgergy was consulted, who read mri as with a 2x3cm r frontal mass at grey-white junction with large area of surrounding edema and mass effect, 1cm midline shift with slight subfalcine herniation with an appearence of a metastatic lesion. given mass effect steroids and empiric antiepileptics were felt to be indicated, and the patinet was given 10mg iv decadron and 500mg of kepra. she was initially given 4mg of iv morphine which induced nausea. no acute surgical intervention was felt to be warrented, and the patinet was admitted to omed for further manegment. past medical history: 1) breast cancer- dx in , s/p lumpectomy, radiation, chemotherapy, now complicated by esophageal mets and right mainstem bronchus mets, s/p mediastinal radiation. she is currently on xeloda (capecitabine) oral therapy that she takes . pet from with new fdg avid adrenal mass. oncologist is dr. at . 2) ? aura without migraine 3) patient recently diagnosed with a uti, and has 2d remaining of bastrim prescription. social history: married, two grown children in the area. no etoh. no illicits. family history: grandmother died of stomach cancer at age 76. no breast, ovarian, uterine, or colon cancers in the family. father- stroke and coronary artery disease. physical exam: general: vomiting upon arrival. appears comfortable though, conversive and jovial. lymphatics: there are no palpable lymph nodes in any distribution. neck: supple. the thyroid is not enlarged and there are no nodules. musculoskeletal: the spine and ribs are nontender. lungs: clear to percussion and to auscultation. cardiac: palpation is normal. heart sounds are normal. there are no murmurs, rubs, or gallops. breasts: she has no masses or suspicious thickenings in either breast. there are postsurgical changes on the treated left side which have been stable overtime. there are no skin or nipple changes and no nipple discharge. abdomen: soft and without organomegaly, masses, tenderness, or ascites. extremities: lower extremity exam reveals no cords, calf tenderness, or edema. neurologic: cnit, ue and le strength and no diminishment in light touch sensation. perrl, eomi. no nystagmus. ftk intact, no dydydokensisis. upon discharge: neurologically intact, right frontal incision, clean dry and intact. pertinent results: admission labs: 02:55pm blood wbc-6.5 rbc-4.28 hgb-13.7 hct-41.0 mcv-96 mch-31.9 mchc-33.3 rdw-16.3* plt ct-210 02:55pm blood neuts-75.1* lymphs-18.8 monos-3.4 eos-2.7 baso-0.1 02:55pm blood urean-19 creat-0.9 02:55pm blood alt-30 ast-34 ld(ldh)-202 alkphos-129* totbili-0.6 02:55pm blood cea-3.0 ca27.29-30 imaging: - mr : impression: solitary peripheral right frontal lobe mass with extensive vasogenic edema and mass effect. given the patient's history, this is concerning for a metastatic tumor, though a primary brain tumor cannot be excluded. mr head w/ contrast study date of 3:10 pm right frontal mass with extensive vasogenic edema and mass effect with leftward midline shift. no change from 2 days prior. ct head w/o contrast study date of 1:04 am status post right frontal craniectomy with expected edema in the postoperative site and continued subfalcine herniation of approximately 8 mm.no unexpected postoperative hemorrhage. mr head w & w/o contrast study date of 9:35 pm expected post-operative changes brief hospital course: 59 year old female with a history of metastatic breast ca presenting with complaints of ha and confusion, found to have a frontal mass with vasogeneic edema and mass effect on mri. . # brain mass: initial neurosurgery assessment in the ed was that the patient's condition was not a surgical emergency but needed oncological staging work up first. she was started on dexamethasone and keppra. mri revealed a solitary peripheral right frontal lobe mass with extensive vasogenic edema and mass effect. after further discussion between the oncology, neuro-oncology, and neurosurgery services, the patient was felt to be a surgical candidate, and was transferred to the neurosurgery service. she went to the operating room on . . # breast cancer: per the patient's primary oncologist, the patient's capecitabine was held, as the acute surgical issues were being addressed. on she underwent mri wand study for intraop image guidance and was taken to the or where under general anesthesia she underwent right frontal craniotomy with excision of mass. she tolerated this well, was extubated and transferred to icu for close monitoring. she woke up slowly and head ct was done which showed good post op appearance with no hemorrhage but slight edema. she was neurologically intact. on pod#1 she was transferred to the floor, diet and activity were advanced. incision was clean and dry. a slow steroid taper was begun. she was transferred to the floor. her wound was clean and dry. she remained neurologically intact.:physical therapy evaluated the patient and felt that she needed one more day of acute physical therapy. : the patient was seen by physical therapy and was given a walker for ambulation to assist in balance and energy conservation. the patient will be sent home with physical therapy and directions to ambulate with the walker at all times. on , the patient is looking forward to discharge. the patient husband is at the bedside. the patient is neurologically stable, ambulating with a walker, oriented to person place and time. medications on admission: xeloda,omeprazole,ativan, fish oil,vitamin q10 discharge medications: 1. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 4. senna 8.6 mg tablet sig: one (1) tablet po daily (daily). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain: no driving while on this medication. disp:*50 tablet(s)* refills:*0* 6. prilosec otc 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day for 1 months. disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 7. dexamethasone 4 mg tablet sig: one (1) tablet po q6h (every 6 hours): start and . disp:*8 tablet(s)* refills:*0* 8. dexamethasone 2 mg tablet sig: one (1) tablet po q6h (every 6 hours): start and . disp:*8 tablet(s)* refills:*0* 9. dexamethasone 2 mg tablet sig: one (1) tablet po q8h (every 8 hours): start and . disp:*6 tablet(s)* refills:*0* 10. dexamethasone 2 mg tablet sig: one (1) tablet po q12h (every 12 hours): start and continue this dose through to your follow up apointment. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: vna of upper discharge diagnosis: metastatic breast cancer discharge condition: neurologically stable neurologically stable oriented x 3 bilateral periorbital edema as expected 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: -narcotic pain medication such as dilaudid (hydromorphone). -an over the counter stool softener for constipation (colace or docusate). if you become constipated, try products such as dulcolax, milk of magnesia, first, and then magnesium citrate or fleets enema if needed). often times, pain medication and anesthesia can cause constipation. ?????? you have been discharged on keppra (levetiracetam) as an anti-seizure medication, you will not require blood work monitoring.take it as prescribed. ?????? 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: please follow up in days for staple removal with dr. , call to schedule appt. please follow up in brain clinic - dr. , mri at 9:55 am 4 and then in clinic at 11:30 on 8. call with questions. radiation oncology - dr will plan cyberknife in approximately 4 weeks. Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Urinary tract infection, site not specified Personal history of malignant neoplasm of breast Compression of brain Secondary malignant neoplasm of brain and spinal cord Cerebral edema Secondary malignant neoplasm of lung Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Secondary malignant neoplasm of other digestive organs and spleen Secondary malignant neoplasm of adrenal gland |
allergies: no known allergies / adverse drug reactions attending: chief complaint: etoh withdrawl major surgical or invasive procedure: intubation at osh, ; extubation history of present illness: history of present illness: 51 yo m with h/o bipolar do, distant anabolic steroid use, and active etoh abuse transferred from osh (mv) where he was noted to have agitation and then withdrawal seizure now s/p intubation. was combative and aggressive in their ed. intubated at osh. per ems report patient was visiting his gf's parents at and suffered a seizure sunday evening at their home. he was noted to be confused, tonic/clonic movements, eye-rolling and post-ictal confusion and loss of speech which resolved in the ed. . last drink was friday prior to arrival at mv. usual consumption is 160-200 oz of beer (drinks "40's") daily. has not been homeless for last 3 years, currently living with gf. has used cocaine in past. no ivda. abused anabolic steroids daily for 17yrs and quit 15yrs ago. has been in rehab for alcohol use in . stopped anti-seizure medications 9mo ago - self discontinued. . vitals on admission to osh 97.4 117 139/98 18 99% on ra. ems sheet from hospital said he has watery diarrhea for 2 days and taking immodium. reports him being confused post seizure. noted to be hallucinating in the ed per gf. at osh he was given 30meq of k, ativan, thiamine, etomidate, succ, rocuronium for intubation. labs notable for l 2.3->2.9, tsh 8.3. alt 188 ast 111 tbili 2.5. hepatitis panel: a-negative, hsag negative, hbsab positive, hcv negative. lp performed: negative for wbc or organisms. . in the ed, patient was given 1l fluid. k+ noted to be 2.3. cxr unremarkable. et at clavicle will be pushed in. ekg sinus tach to 113. urine dark. vitals now 97.3 118 25 98% 141/90. on propofol. vent cmv fi02 40%, 15 tv 500 peep 5. ct head negative from osh for mass/hemorrhage/infarct. . in the icu, patient was intubated but agitated. he was able to answer yes/no questions while intubated. he denied any pain aside from tracheal tube discomfort. . 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: -htn -seizure disorder, last seizure 1 year ago, stopped seizure meds 9 months ago -depression/anxiety, possible suicideal ideations in past -sleep disorder -bipolar disorder -alcoholism -hypothyroidism social history: unemployed, lives in ca, drinks (40oz beers daily), no smoking, h/o anabolic steroid use, clean 10 years family history: father died at 66 of lymphoma physical exam: admission exam (): vitals: t: bp:160/108 p:100 r: 15 o2:99% intubated cmv 100% fi)2, tv 500 peep 5 general: alert, oriented, no acute distress heent: sclera icteric, intubated 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, no fluid wave or ascites, no stigmata of chronic liver d gu: +foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . discharge exam: vss, on ra general: alert, oriented, no acute distress heent: mmm, op clear. +blister on the lower lip secondary to trauma for ett, no evidence of infection 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, no fluid wave or ascites, no stigmata of chronic liver d ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs (): cbc: wbc-7.5 rbc-4.08* hgb-14.1 hct-39.2* mcv-96 mch-34.5* mchc-35.9* rdw-12.6 plt ct-134* neuts-60 bands-1 lymphs-17* monos-21* eos-0 baso-0 atyps-1* metas-0 myelos-0 coags: pt-13.7* ptt-22.9 inr(pt)-1.2* chem/lfts: glucose-116* urean-10 creat-0.7 na-137 k-2.7* cl-99 hco3-30 angap-11 10:55am blood alt-99* ast-180* ck(cpk)-1316* alkphos-64 totbili-3.7* dirbili-1.1* indbili-2.6 albumin-4.3 calcium-8.0* phos-2.2* mg-1.7 abg: type-art po2-163* pco2-51* ph-7.35 caltco2-29 base xs-1 intubat-intubated tox screen: asa-neg ethanol-neg acetmnp-neg bnzodzp-pos barbitr-neg tricycl-neg . other labs: 09:45pm blood ck(cpk)-765* 10:45pm blood ck(cpk)-736* 10:55am blood ck-mb-11* mb indx-0.8 10:55am blood ctropnt-<0.01 10:55am blood vitb12-1491* 10:55am blood tsh-6.8* 03:00pm blood t4-7.8 . imaging: pcxr (): findings: portable supine ap view of the chest is obtained. endotracheal tube is unchanged with tip located approximately 5.2 cm above the carina. ng tube tip is coiled in the left upper quadrant. otherwise, no change. . micro: - bcx (): pending - ucx (): pending - rapid plasma reagin test (final ): nonreactive. - sputum cx: 5:34 pm sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): multiple organisms consistent with oropharyngeal flora. respiratory culture (preliminary): moderate growth commensal respiratory flora. . discharge labs: 06:05am blood wbc-7.1 rbc-3.90* hgb-12.8* hct-38.0* mcv-97 mch-32.9* mchc-33.8 rdw-12.2 plt ct-158 06:05am blood glucose-80 urean-8 creat-0.8 na-139 k-4.0 cl-103 hco3-29 angap-11 06:05am blood alt-154* ast-180* alkphos-90 totbili-2.1* 06:05am blood calcium-8.5 phos-2.1* mg-2.1 10:55am blood vitb12-1491* . ruq u/s: 1. diffusely echogenic liver is likely related to fat deposition, although more advanced liver disease such as cirrhosis and/or fibrosis cannot be excluded. 2. hepatomegaly without splenomegaly. 3. cholelithiasis without evidence of cholecystitis. . cxr: ap single view of the chest has been obtained with patient in sitting semi-upright position. the heart size is at the upper limit of normal variation. no typical configurational abnormality is seen; however, left ventricular contour prominence and moderately widened thoracic aorta is suggestive of systemic hypertension. the pulmonary vasculature is not congested. no evidence of acute infiltrates, the lateral pleural sinuses are free. no evidence exists in the apical area. when comparison is made with the next two previous chest examinations, the patient has now been extubated. similar as on the previous examination, there is no evidence of any acute pulmonary infiltrate or significant pulmonary congestion. brief hospital course: this is a 51 yo m w/ h/o etoh/opiate abuse transferred from an osh to after sustaining an alcohol withdrawal seizure, requiring brief intubtation. his course is summarized by problem below: . #alcohol withdrawal, c/b seizure - likely etoh withdrawl given history but etoh level negative on admission although sounds as if pt had stopped drinking roughly 48-72hrs before presentation, now intubated for airway protection at osh by time arrived at . no signs of meningitis. osh head ct wnl. initial electrolytes derangement may be contributing to and/or caused by seizures but likely at least related to alcohol abuse. pt had received benzos at osh for seizures and intubation but did not require benzos during icu stay and was extubated on afternoon of shortly after arrival to . tsh found to be elevated but t4 wnl. rpr neg. patient denied a primary seizure disorder and notes 2 prior seizures in the setting of prior alcohol use. no evidence of seizure activity noted in icu and pt was able be called out to floor the next afternoon. his ciwa score remained between 0-1 for the next 48 hours and he exhibited no further signs of withdrawal by the time of discharge. . #alcohol abuse - started on mvi, thiamine, and folate and discharged on these medications. he was seen by sw several times during his hospitalization and expressed motivation and desire to stop drinking. he feels well supported by his prior support groups in and plans to re-establish contact with them upon return home. . #alcohol hepatitis - ast>alt 2:1 with other lft abnormalities c/w etoh abnormalities. likely acute on chronic. also with elevated tbili and mildly elevated inr at 1.2. pt was given an initial banana bag and started on thiamine, folate, and mtv. lfts were trended and transaminases stable in icu with tbili downtrending slightly. pt was counseled about importance of not drinking alcohol in the future. vit b12 level 1491. his ruq u/s demonstrated hepatomegaly with changes consistent with chronic inflammation - cirrhosis could not be ruled out by imaging. he should be followed closely for this given elevated bilirubin and slight elevation in inr. the patient was counseled extensively regarding the need for close follow-up. . # thrombocytopenia - likely from chronic etoh use. no evidence of splenomegaly on the ruq u/s. . # hypothyroidism - pt carries diagnosis and had previously been on unknown synthroid dose as outpatient but endorsed not using his medications for last 3-4 months. tsh elevated but t4 actually wnl. due to this finding and unclear history of dose combined with fact that pt had been off medication in recent months, levothyroxine was not restarted during hospitalization but will need to be discussed with pcp in near future. tsh 6.8, t4 7.8 (wnl). . # anxiety/depression - pt with significant history in this area and reported to have been on celexa in past. however, pt reported that he also had stopped this medication a few months prior to admission. as a result celexa not restarted during hospitalization but will need to be discussed with outpatient provider. . # pt not on anti-hypertensives for last few months as not taking meds but prior to this was taking unknown dose of norvasc. due to persistently elevated bps in the 140s, he was restarted on norvasc 5 mg daily prior to discharge. medications on admission: -synthyroid -celexa -hydroxizine -norvasc discharge disposition: home discharge diagnosis: alcohol withdrawal seizure alcohol abuse alcoholic hepatitis thrombocytopenia htn hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital after a seizure from alcohol withdrawal. you had a breathing tube in place for one day. your symptoms improved quickly and you had no evidence of withdrawal symptoms for almost 72 hours. . you were started on 5 mg norvasc for your blood pressure, this may need to be titrated up based on your blood pressure control. . you need follow-up with your doctor for your blood pressure and hypothyroidism, as you are currently not taking medications for the thyroid. . the ultrasound shows enlargement of the liver, consistent with alcohol use. it could not rule out more advanced liver disease, such as cirrhosis, so you should be continued to have monitoring for this with repeat ultrasounds or even a liver biopsy. . please refrain from drinking, as it has already affected your health. please work with your social supports, as we discussed. . medication reconciliation: 1. start folate 1 mg daily 2. start thiamine 100 mg daily 3. start multivitamin daily 4. start norvasc 5 mg daily followup instructions: please follow-up with your pcp in regards to your blood pressure, hypothyroidism, and liver inflammation. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Thrombocytopenia, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Other convulsions Depressive disorder, not elsewhere classified Hypopotassemia Disorders of phosphorus metabolism Bipolar disorder, unspecified Other and unspecified alcohol dependence, continuous Acute alcoholic hepatitis Alcohol withdrawal Sleep disturbance, unspecified |
allergies: moexipril attending: chief complaint: splenic artery pseudoaneurysms major surgical or invasive procedure: splenectomy history of present illness: 82m who sustained left-sided rib fractures, left hemorrhagic pleural effusion and a splenic laceration with surrounding hematoma one month ago after falling from a chair. follow-up outpatient ultrasound approximately one month after the injury ultrasound which detected three splenic artery aneurysms. thus he was taken to the interventional suite with angiography today. the procedure was uneventful but they were unable to embolize either of the three aneurysms due to aberrant anatomy. during the procedure, pt hr dropped to 30s with advancement of guidewire and with breath holding. there was concern for rupture of pseudoaneurysm (per acs). pt went to pacu and became bradycardic to 30s when sheath was removed. sbp dropped to 70s. 1 amp atropine was given and 1.5l of fluid was given. he has been hd stable. patient was former athlete and used to run track. he walks at a fast pace on his treadmil 30 min every day. he denies having cp (had cp with previous mi), diaphoresis with any activity or during bradycardic events. past medical history: cad s/p quadruple cabg in htn hld anemia of chronic disease chronic kidney disease stage ii osteoarthritis, right knee r neck shingles, treated with acyclovir left inguinal hernia repair cataracts bilaterally s/p extraction at social history: quit smoking in , previously smoked half ppd for 20 years. minimal etoh socially. no illicit drugs. retired consultant, now working in public schools 9th grade. family history: no history of syncope, cardiovascular disease, stroke, seizures. mother had htn, died in 80s from gi blood loss, ?diverticulosis. father died in 50s from cancer. had 4 sisters, they died from childbirth, copd, cancer. physical exam: vitals: 97 105 126/82 22 97 3l gen: a&o, nad heent: no scleral icterus, mucus membranes moist. no scalp lacerations or hematomas. perrl, eomi. cspine: no ttp, full arom without pain cv: sinus bradycardia. well healed sternotomy incision pulm: clear to auscultation b/l, no w/r/r. abd: soft, non-tender, nondistended, no guarding. no masses palpated, incision cdi, jp drains x 2 ss output groin: no hematoma at previous ext: no le edema, le warm and well perfused pertinent results: laboratory: 2.8 >------< 162 30.6 cr: 1.2 wbc-4.5 hct-35.4 plt ct-170 wbc-2.8* hct-30.6* plt ct-162 wbc-5.6# hct-28.5* plt ct-162 wbc-5.0 hct-29.2* plt ct-161 wbc-5.0 hct-29.2* plt ct-161 wbc-11.7 hct-28.6* plt ct-122* wbc-13.7* hct-27.2* plt ct-156 brief hospital course: mr. was admitted to the tsicu from the angiography suite. he remained hemodynamically stable overnight. serial hematocrits were checked and remained stable. cardiology consult obtained. their suspicion was that he was hypovolemic in the setting of beta blockade, contributing to bradycardia and intermittent hypotension. he tolerated a regular diet and was transferred to the floor. once stabalized it was decided that he have a splenectomy given the high risk of a rebleed. he did so on hd 3 and tolerated the procedure well. post splenectomy he has tolerated a regular diet, is ambulating, and his pain is controlled with po pain medications. he will be discharged to home today and follow up in clinic in day's time. he will receive post plenectomy vaccines prior to discharge. medications on admission: amlodipine 10mg', atenolol 25mg', hctz 25mg', losartan 100mg', lovastatin 40mg', sildenafil 25mg', asa 81mg' discharge medications: 1. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). disp:*50 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*1* 4. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 5. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 6. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain for 2 weeks. disp:*40 tablet(s)* refills:*0* 7. losartan 50 mg tablet sig: two (2) tablet po daily (daily). 8. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). discharge disposition: home with service facility: vna discharge diagnosis: splenic artery pseudoaneurysms discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital after failed embolization of multiple splenic artery aneuryms. you had your spleen removed this admission and have done well since the operation. you are now ready to be discharged home. please return to the hospital if you develop chest pain, shortness of breath, abdominal pain, or if you increased or bloody output from the drains. the drains will stay in until your follow up appointment at which time they will be removed. please follow up as instructed below. followup instructions: please follow up in clinic in days. please call for a follow up appointment. the number to call is . md Procedure: Arteriography of other intra-abdominal arteries Total splenectomy Diagnoses: Anemia of other chronic disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of tobacco use Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Hypotension, unspecified Home accidents Hemoperitoneum (nontraumatic) Injury to spleen without mention of open wound into cavity, laceration extending into parenchyma Accidental fall from chair Chronic kidney disease, Stage II (mild) Aneurysm of splenic artery |
allergies: vicodin / tramadol / codeine attending: chief complaint: iph major surgical or invasive procedure: intabuated, extubated on history of present illness: 47 yo m with history of htn, dm2, transferred from hospital after he was found to have large left basal ganglia hemorrhage. as per chart review, the patient collapsed when going to sit on his couch earlier this evening. at time of arrival to osh, gcs was 9. he was non-verbal, eyes would open to verbal commands and he had right-sided neglect. systolic bp was 216 at time of arrival and max of 250. an examination at 0050 noted a r pupil of 7 mm and nonreactive, l pupil 5mm and recative and he was noted to have non-purposeful movement of his right side. a ct head showed a left parietal / superior basal ganglia acute iph 6.4 cm x 2.5 cm x 4 cm with mild surrounding edema, creating mass effect on left lateral ventricule without significant midline shift. he was given 1g fosphenytoin, labetalol and naloxone and transferred to for further care. en route he was noted to decomponsate and was no longer tracking with his eyes and bradycardic to the 40s and was subseuqently paralyzed with veccuronium, fentanyl, and versed, and intubated. past medical history: -htn -dm -sciatica -gout -unspecified myalgia, myositis social history: occasional etoh, no tobacco or drugs, however was utox positive for cocaine family history: nc physical exam: vs; bp 130/80 p 56 rr 16 100% on vent gen; intubated, lying in bed heent; nc/at cv; rrr pulm; cta anteriorly abd; soft, nt, nd extr; no edema neuro; (had been paralyzed for intubation approximately one hour prior to examination) mental status; unarousable to noxious stimuli. does not grimace to pain. cn; eyes in midposition when held open. pupils 3mm and minimally reactive. no corneals or gag. motor; normal bulk and tone. no movement to noxious stimuli sensory; does not withdraw to noxious stimuli reflexes; toes mute pertinent results: 05:46am blood wbc-12.8*# rbc-3.70* hgb-11.8* hct-35.4* mcv-96 mch-31.9 mchc-33.2 rdw-12.3 plt ct-235 05:46am blood plt ct-235 05:46am blood pt-12.3 ptt-26.5 inr(pt)-1.0 05:46am blood glucose-150* urean-20 creat-1.7* na-141 k-3.8 cl-111* hco3-24 angap-10 09:20am blood alt-45* ast-68* ld(ldh)-207 alkphos-60 amylase-147* totbili-0.5 09:20am blood ck-mb-7 ctropnt-0.01 03:10am blood ck-mb-10 mb indx-0.8 ctropnt-<0.01 05:46am blood calcium-8.4 phos-3.3 mg-2.2 09:20am blood caltibc-247* ferritn-322 trf-190* 05:46am blood osmolal-305 03:10am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 04:45am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-pos amphetm-neg mthdone-neg imaging: ct head : slight interval decrease in size of left basal ganglia hemorrhage with surrounding edema. unchanged effacement of sulci with no new bleed or evidence of herniation present. ct head: 1. 6.4 x 2.6 cm left basal ganglionic acute hemorrhage with transpendymal dissection and intraventricular extension. likely etiology for this hemorrhage is hypertension; however, underlying mass or vascular abnormality cannot be excluded, and this should be correlated with clinical information. 2. edema surrounds the hemorrhage, with local mass effect, effacing the lateral ventricular body and overlying temporal and frontal sulci and gyri. 3. no significant midline shift and no evidence for herniation. ekg: sinus bradycardia. baseline artifact. rsr' pattern in lead v1. prominent qrs complex with probable left ventricular hypertrophy. q-t interval prolongation. j point and st segment elevation in the lateral precordial leads may be related to early repolarization or injury. clinical correlation is suggested. no previous tracing available for comparison. ct head impression: 1. no significant interval change in size of a left basal ganglial hemorrhage, though the surrounding edema appears to be slightly increased. 2. tiny focus of intraventricular hemorrhage within the occipital of the left lateral ventricle, decreased in extent from prior study. 3. stable local mass effect, with effacement of the left lateral ventricle. upper extremity ultrasound impression: 1. occlusive thrombus seen in the segment of the right cephalic vein at the antecubital fossa and in the segment of the left cephalic vein in the left forearm. 2. no evidence of deep vein thrombosis in either arm. brief hospital course: 47 yo m with history of htn and transferred from hospital with large basal ganglia hemorrhage, most likely hypertensive in etiology. with addition of a urine toxicology positive for cocaine. he had been intubated at an outside hospital. the patient was admitted to the neuro icu, for monitoring and blood pressure control. he was started on a nicardipine drip. he did well overnight and on the morning of he was noted to be awake and alert and following commands when off sedation. he was extubated that morning and did well in regards to his respiratory status. he was restarted on some oral hypertensive medications -> initially amlodipine and hydralazine and was slowly weaned for his nicardipine drip. he was given less fluids and the attempt was made to keep his fluid status at least 300-500cc negative to ensure that there was not significant edema. he had a repeat ct the following day, which appeared unchanged, with a mild amount of edema surrounding the lesion. the patient, after extubation was noted to have a significant right sided weakness. he has a right field cut with 0/5 strength in his right upper and lower extremities. he appeared to present with a mixed aphasia. he appears to have intact comprehension, some difficult with repetition and a decent level of fluency but a number of paraphasic errors. his speech has been continuing to improve throughout his hospital course. his blood pressure has been well-controlled and it is thought he may be able to begin to wean off some of his antihypertensive medications. renal- the patient presented with a creatinine of 2.0 which improved with hydration and has been fluctuating between 1.3-1.6. his baseline creatinine is unknown. his creatinine at the time of discharge was 1.6. of note, the patient was restarted on his home actos the day prior and has been receiving hydralazine for blood pressure control. he was given additional fluids and it is suggested his creatinine continue to be monitored closely upon transfer and he may benefit from studies of urine creatinine, electrolytes, and eosinophils for further evaluation if his creatinine continues to trend up. vasc/id- patient was noted to have erythema and a palpable cord on his forearms b/l at sites of prior ivs. he had low grade temperatures and initially started on keflex . two days later the sites appeared essentially unchanged and his antibiotic was changed to vancomycin. he underwent upper extremity ultrasounds which confirmed b/l cephalic vein thromboses but no evidence of dvt. he was continued on antibiotics to complete a seven-day course and warm compresses which provided good symptomatic relief. medications on admission: -actos 15 mg daily -flexeril 10 mg tid prn -ibuprofen 400 mg prn -percocet prn discharge medications: 1. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 2. actos 15 mg tablet sig: one (1) tablet po once a day. 3. hydralazine 25 mg tablet sig: three (3) tablet po q6h (every 6 hours). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 5. clonidine 0.2 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsun (every sunday). 6. morphine 15 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. discharge disposition: extended care facility: state hospital discharge diagnosis: left basal ganglia hemorrhage cephalic vein thombosis b/l discharge condition: awake, alert, comprehension intact. occasional paraphasic errors. r facial droop, 0/5 strength in rue, rle. sensation intact to light touch. discharge instructions: you were admitted with a large bleed in a part of your brain called the basal ganglia. this was likely caused by high blood pressure as well as cocaine use. repeat imaging studies showed the bleed remained stable. you were also treated with antibiotics for superficial thrombophlebitis on your arms. followup instructions: provider: , .d. phone: date/time: 2:00 (neurology) please follow up with your pcp within one month. Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: Sciatica Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Gout, unspecified Cocaine abuse, unspecified Intracerebral hemorrhage Cerebral edema Unspecified disorder of kidney and ureter Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Phlebitis and thrombophlebitis of superficial veins of upper extremities Myalgia and myositis, unspecified Late effects of cerebrovascular disease, aphasia Muscle weakness (generalized) Late effects of cerebrovascular disease, dysarthria |
allergies: no known allergies / adverse drug reactions attending: addendum: pt was discharged home with services for home safety eval per patient's request. discharge disposition: home with service facility: vna md Procedure: Venous catheterization, not elsewhere classified Arteriography of cerebral arteries Arterial catheterization Insertion or replacement of external ventricular drain [EVD] Diagnoses: Other and unspecified noninfectious gastroenteritis and colitis Obstructive hydrocephalus Moyamoya disease Intracerebral hemorrhage Hypopotassemia Vomiting alone Benign essential hypertension Diplopia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: ivh major surgical or invasive procedure: left frontal evd placement cerebral angiogram history of present illness: ms. is a 57 y.o. f with history of and htn presents s/p headache that started at 3am this morning and was persistent with nausea and vomiting. patient states that her husband took her to the er where a head ct was done and revealed ivh. she reports a headache, but denies any n/v, dizziness, or change in vision at this time. past medical history: pmh: - - htn psh: - pial synangiosis - tah social history: - rare etoh - denies smoking - retired; teacher special education family history: only child and no children, but no other family members with physical exam: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. recall: objects at 5 minutes. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch physical exam upon discharge: non-focal incision- c/d/i. 2 staples at evd site pertinent results: ct head: intraventricular hemorrhage in both lateral ventricles, third ventricle and forth. no midline shift or other hemorrhages within the parenchyma. ct head: no significant interval change in hemorrhage within genu of corpus callosum and large diffuse intraventricular hemorrhage as compared to most recent preceding exam. ct head: placement of the external ventricular drain with the tip in the region of left foramen of and extending inferiorly. the temporal size is slightly decreased, but remains prominent. intraventricular blood again identified. ct head - angiogram - impression: - underwent cerebral angiography which showed occlusion of the right internal carotid artery with moyamoya disease on the right side. there was no evidence of an aneurysm that could account for hemorrhage. head ct: impression: since , there is significant decrease of the corpus callosum and intraventricular hemorrhage. reduction in ventricular caliber. no evidence of hydrocephalus. brief hospital course: patient was admitted to neurosurgery on and underwent an emergent right evd placement. please review dictated operative report for details. she tolerated the procedure and went to icu for further management. repeat ct head showed good placement of evd. on , patient underwent a diagnostic cerebral angiogram. she tolerated the procedure well. sheaths were removed in routine fashion. she remained neurologically stable overnight. on she was still neurologically stable and had improvement in her diplopia. an ophthamology consult was requested anyway for evaluation. they sited a normal exam and she should follow up as an outpt annually. she had a few non symptomatic episodes of hypertension and bradycardia which responded well to hydralazine. she was kept in the icu to further monitor this. she had a 24 hour gastroenteritis without neurological issue. she remained stable and was transfered to the step down unit. her gastroenteritis resolved and she was tolerating po intake. she was allowed to ambulate with the evd clamped, with assistance. she was clamped on the 31st and her head ct 48 hours later did not show any evidence of hydrocephalus therefore, her evd was removed on . on she was neurologically stable. evd site was c/d/i. she was cleared for d/c home at this time which she was in agreement with. now dod, patient is afebrile, vss, and neurologically stable. patient's pain is well-controlled and the patient is tolerating a good oral diet. pt's incision is clean, dry and inctact without evidence of infection. patient is ambulating without issues. he/she is set for discharge home in stable condition and will follow-up accordingly. medications on admission: lisinopril mvi discharge medications: 1. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po q6h (every 6 hours) as needed for headache. disp:*60 tablet(s)* refills:*0* 2. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 3. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). discharge disposition: home with service facility: vna discharge diagnosis: intraventricula hemorrhage hydrocephalus vomiting diarrhea / acute gastroenteritis diplopia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. ?????? if you were on a medication such as coumadin (warfarin), or plavix (clopidogrel), or aspirin prior to your injury, do not resume taking these until cleared by your surgeon. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion, lethargy or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? new onset of the loss of function, or decrease of function on one whole side of your body. followup instructions: follow-up appointment instructions ?????? you have 2 staples in your head where your evd was removed. these need to be removed on either friday or monday . you can have these removed at your pcp's office or you can call to make an appt to have them removed here. ?????? please call ( to schedule an appointment with dr. , to be seen in ____6__weeks. ?????? you will need a ct scan of the brain without contrast prior to your appointment. this can be scheduled when you call to make your office visit appointment. Procedure: Venous catheterization, not elsewhere classified Arteriography of cerebral arteries Arterial catheterization Insertion or replacement of external ventricular drain [EVD] Diagnoses: Other and unspecified noninfectious gastroenteritis and colitis Obstructive hydrocephalus Moyamoya disease Intracerebral hemorrhage Hypopotassemia Vomiting alone Benign essential hypertension Diplopia |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p motorcycle crash major surgical or invasive procedure: orif left tibia fracture c6-7 fusion soleus flap lle lumbar drain placement posterior cervical repair csf leak/repositioning of hardware history of present illness: 47 yo male s/p motorcycle vs car at unknown speed. +etoh. helmeted, ?loc. gcs14 (-1 for eye opening). past medical history: chronic low back pain social history: +etoh family history: noncontributory physical exam: upon admission: bp: 91/45 hr: 60 r: 16 o2sats: 100% awake, intoxicated, oriented x3; c/o of h/a and left leg pain; perla, eomi, face symetric, tongue midline motor: d b t we ff ip q at g r 5 5 5 5 5 5 5 5 5 5 l 5 5 4- 5- 5 nt nt nt nt nt sensation: decreased to lt in 2nd and 2rd finger, left hand; otherwise intact; reflexes: b t br pa ac right trace throughout ue and le left trace throughout ue propioception intact toes downgoing bilaterally pertinent results: 09:22am glucose-107* lactate-3.2* na+-135 k+-3.9 09:22am hgb-11.7* calchct-35 11:23pm hgb-15.2 calchct-46 11:00pm lipase-51 11:00pm asa-neg ethanol-262* acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 11:00pm wbc-9.1 rbc-4.35* hgb-13.8* hct-40.3 mcv-93 mch-31.8 mchc-34.3 rdw-13.1 11:00pm plt count-290 11:00pm pt-11.9 ptt-22.4 inr(pt)-1.0 11:00pm fibrinoge-223 ct c-spine impression: 1. fracture involving the left articular process of c7, with also minimally displaced fractures involving the inferior articular facet at c6. 2. interspace widening at c6-7, with concern for ligamentous injury. an mri is recommended for further evaluation to evaluate for any cord injury or ligamentous injury. 3. degenerative disk disease with canal narrowing at multiple levels due to disk bulges, protrusions, and osteophytes. mri c-spine impression: 1. edema within the c6/7 disc interspace with evidence for a small tear of the anterior longitudinal ligament at this level. known c6/7 fractures are better evaluated on the recent ct c-spine. 2. stir hyperintensity in the interspinous ligament at t1/ represent injury with possible ligamentum flavum tear at this level, though this is unclear. 3. mild degenerative disc changes, as described. brief hospital course: he was admitted to the trauma service. neurosurgery, orthopedics and plastics were consulted given his injuries. he was taken to the operating room for irrigation and debridement, open tibia fracture left lower extremity, irrigation and debridement, open fibular fracture left lower extremity, fasciotomies all compartments, intramedullary nailing left tibia, with 345 x 10-mm synthes nail, open reduction internal fixation of fibular segmental fracture with 3.5-mm extra-long locking plate, repair tendon extensor digitorum longus and placement of a vacuum sponge over wound. he was taken to the operating room by neurosurgery on for posterior laminectomy c6-c7, posterior hemi-laminotomy, open treatment cervical spine fracture dislocation, primary closure traumatic cerebrospinal fluid leak, posterior segment instrumentation c6-c7, posterior cervical fusion c6-c7, iliac crest autograft and repair of cerebrospinal fluid leak left c8 nerve root sleeve and lateral dural tear. postoperatively he developed erythema at posterior cervical spine incision with leakage of serous fluid. he underwent a ct of his cervical spine which did show a large fluid collection. discussions regarding surgical evacuation of seroma were underway and then the decision was made to instead place a lumbar drain. on he was taken again to the operating room for debridement of left lower extremity wound including skin subcutaneous tissue and muscle, coverage of left lower extremity wound with pedicled soleus flap and split-thickness skin grafting less than 100 cm2. he was kept non weight bearing on the lle and dangled for 10 minutes only. his cervical wound began to drain . on he returned to the or for posterior cervical wound exploration, repair of dural tear and repositioning of hardware. pt tolerated well. he was kept at bedrest with lumbar drain at 15cc/hr. his wound stayed dry. plastics and orthopedics followed his left lower leg. it was placed in splint and he was advanced to partial weight bearing. he had xray that was reviewed by orthopedics and showed no new fracture. on his lumbar drain and foley were removed, he worked well with pt and they recommended outpatient pt. medications on admission: none discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): take while on pain medication. disp:*60 capsule(s)* refills:*0* 2. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. disp:*60 tablet(s)* refills:*0* 3. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: s/p motorcycle crash injuries: left transverse, displaced tibia fracture left comminuted, displaced mid & distal fibula fracture, open left c7 art facet, c6 inferior facet, slight interspace wideneing csf leak from dural tear left c7 radiculopathy left 10th rib fracture l5 sp fracture left si joint widening discharge condition: neurologically stable discharge instructions: discharge instructions for spine cases ?????? do not smoke ?????? keep wound clean / no tub baths or pools until seen in follow up/ remove dressing / take daily showers ?????? no pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? limit your use of stairs to 2-3 times per day ?????? have a family member check your incision daily for signs of infection ?????? take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, ibuprofen etc. for three months. ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? clearance to drive and return to work will be addressed at your post-operative office visit call your surgeon immediately if you experience any of the following: ?????? pain that is continually increasing or not relieved by pain medicine ?????? any weakness, numbness, tingling in your extremities ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f ?????? any change in your bowel or bladder habits followup instructions: follow up with provider: , . for your rib fractures. call to schedule an appointment to be seen in 2 weeks; inform the office that you will need an end expiratory chest xray done on same day just prior to your appointment. follow up in 1 week with dr. , plastic surgery, call for an appointment. please return to dr. office in days for removal of your staples please call to schedule an appointment with dr. to be seen in 6 weeks. you will need xrays prior to your appoinment follow up with dr. - orthopedics in one month Procedure: Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Fasciotomy Other skin graft to other sites Graft of muscle or fascia Removal of implanted devices from bone, other bones Excision of intervertebral disc Debridement of open fracture site, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Excision of bone for graft, other bones Repair of vertebral fracture Internal fixation of bone without fracture reduction, other bones Other cervical fusion of the posterior column, posterior technique Other repair and plastic operations on spinal cord structures Other repair and plastic operations on spinal cord structures Other plastic operations on tendon Diagnoses: Alcohol abuse, unspecified Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Closed fracture of two ribs Closed fracture of C5-C7 level with unspecified spinal cord injury Open fracture of shaft of fibula with tibia Other mechanical complication of other internal orthopedic device, implant, and graft Sprain of sacroiliac ligament Post-traumatic seroma |
allergies: bactrim attending: chief complaint: upper airway abnormalities, respiratory failure major surgical or invasive procedure: cardiac catheterization intubation and extubation picc line insertion rigid bronchoscopy history of present illness: 84 yo m with cad s/p cabg, htn, hyperlipidemia, obesity, and recent admission for cellulitis, who initially presented to on with generalized weakness, difficulty walking, and 2 falls. his hospital course was complicated by respiratory failure, troponin elevation, and ett dislodgement requiring reintubation. pulmonary was consulted and found that the patient had arytenoid joint dislocations, subglottic stenosis, and tracheobronchomalacia. he was transferred to for evaluation by the interventional pulmonary service. the patient was initially hospitalized for bilateral lower extremity cellitis, treated with unasyn, and subsequently vancomycin when left ankle culture grew mrsa. he was discharged on bactrim and developed generalized weakness, difficulty walking, and 2 falls, leading to readmission on . exam was notable for fever to 102.2, tachycardia, lower extremity cellulitis, symmetric weakness. labs on admission notable for creatinine 2.0. the patient was felt to be dehydrated and was treated with iv fluids, along with vancomycin for cellulitis. on , he developed a sore throat and was noted to have pustules in his posterior oropharynx with surrounding erythema. rapid strep testing was negative. he was seen by id who was concerned about a drug reaction to bactrim versus a viral process, although this would not explain the patient's bandemia. on the afternoon of , the patient developed wheezing, respiratory distress. he was noted to have some swelling in the upper airway. he was treated for heart failure with lasix 40 mg iv and 2 inches of nitro paste, followed by nitro gtt. he was intubated, but then he dislodged the tube, requiring reintubation with a glide scope. this showed edema distal to the cords. the patient was seen by pulmonary consult on . the patient was then extubated. bronchoscopy showed arytenoid joint dislocations, subglottic stenosis, and tracheobronchomalacia. the patient's oropharynx showed increased pustules around the posterior pharynx as well as underneath the tongue and buccal mucosa. he was treated with solumedrol. the patient was reintubated, although the records are not clear on this point. of note, the patient had troponin elevations to 2.64, which had trended down to 0.89 by the time of discharge. ekg showed sinus rhythm, left axis deviation, twi in avl. past medical history: cad s/p cabg hyperlipidemia obesity htn cellulitis diphtheria spinal stenosis hearing loss cataracts spinal surgery social history: originally from . he is a survivor of the holocaust. came to the us in . was a professional soccer player, worked in apparel sales. he has also written and published a book titled "hitler's children". lives with his wife. tobacco or etoh. -has 2 children ( (), (phoenix), and 2 step-children ( (), ). family history: no early cad or sudden cardiac death. physical exam: admission physical exam hr 70 bp 137/35 sat 99%/vent settings (ac/500/18/5/0.4) general: intubated, sedated, synchronous with vent. heent: anicteric sclerae. moist mucous membranes. no oral lesions. resp: synchronous with vent. peak pressure 26. plataue pressure 20. ctab. subclavian cvl in place. cv: rrr. normal s1, s2. no m/g/r. abd: +bs. soft. nt/nd. ext: warm and well-perfused. no c/c/e. dp pulses 2+ bilaterally. no apparent cellulitis of lower extremities. back: stage 2 right gluteal ulcer. neuro: sedated. synchronous with vent. pupils post-surgical but reactive bilaterally. follows commands to move all extremities. discharge physical exam vs: tm98.3, tc96.4, bp 140s-170s/60s-70s (168/79), hr 60s-80s (65), rr 18, 96/ra gen: nad. responds to verbal stimuli, smiling, interactive heent: ncat, keyhole pupils, full neck neck: full, supple, difficult to assess jvp cv: distant heart sounds, rrr, no m/r/g noted chest: ctab anteriorly abd: obese, nttp, no hsm ext: trace pitting edema bl le, wwp. neuro: awake, a+ox1.5 gu: foley in place pertinent results: admission labs: 05:28pm blood wbc-11.3* rbc-4.11* hgb-12.2* hct-35.3* mcv-86 mch-29.7 mchc-34.5 rdw-15.4 plt ct-268 05:28pm blood neuts-91.0* lymphs-6.3* monos-2.3 eos-0.2 baso-0.1 05:28pm blood pt-14.4* ptt-21.6* inr(pt)-1.2* 05:28pm blood glucose-184* urean-39* creat-1.6* na-143 k-3.8 cl-111* hco3-22 angap-14 05:28pm blood alt-39 ast-22 ld(ldh)-187 ck(cpk)-46* alkphos-165* 05:28pm blood ck-mb-5 ctropnt-0.11* 05:28pm blood calcium-8.7 phos-2.4* mg-2.3 05:28pm blood vanco-7.8* imaging cxr findings: the tip of the endotracheal tube lies approximately 2.5 cm above the carina. nasogastric tube extends to the proximal to mid portion of the stomach. central catheter extends to lower portion of the svc. probable small pleural effusions with basilar atelectasis. 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 regional left ventricular systolic dysfunction with mid septal hypokinesis (although views are suboptimal). overall left ventricular systolic function is borderline normal (lvef=50-55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen (may be underestimated). the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. ct neck impression: 1. limited study due to lack of iv contrast. 2. limited evaluation of mucosal surfaces due to copious secretions around the et tube. mr could provide additional information as differentiation between secretions, mucosal and submucosal structures would be possible. 3. the orogastric tube is coiled within the pharynx, although subsequently passes into the esophagus. 4. dependent atelectasis and possible bilateral pleural effusions in the imaged upper lungs. 5. multilevel degenerative changes of the cervical spine including mild spinal canal narrowing at c5-6 secondary to a posterior disc osteophyte complex. cardiac cath comments: 1. selective coronary angiography in this right dominant system demonstrates severe three vessel coronary artery disease. the left anterior descending is totally occluded proximally and patent beyond the lima touchdown wiht an 80% lesion distal to the touchdown. the circumflex artery gives off a large first obtuse marginal that contains an 80% stenosis. the right coronary artery is occluded and the distal vessel is perfused via the vein graft to the pda. 2. bypass graft angiography demonstrates a patent vein graft to pda and patent lima. 3. limited resting hemodynamicsdemonstrate elevated systemic blood pressure. final diagnosis: 1. three vessel coronary artery disease. 2. systemic hypertension. ct head findings: there is no acute intracranial hemorrhage, major vascular territorial infarction, mass effect or edema. -white matter differentiation is preserved. periventricular and subcortical white matter hypodensity is compatible with chronic small vessel ischemic disease. age-appropriate prominence of ventricles and sulci is compatible with diffuse parenchymal volume loss. basilar cisterns are preserved. globes are intact. visualized paranasal sinuses and mastoid air cells are well aerated. no suspicious osseous lesions are identified. impression: no acute intracranial abnormality. cxr findings: in comparison with study of , there has been placement of a nasogastric tube that extends to the lower body of the stomach. atelectatic changes are again seen at the left base with blunting of the costophrenic angle suggesting small pleural effusion. central catheter remains in place. cxr findings: in comparison with the study of earlier in this date, there are slightly lower lung volumes. monitoring and support devices remain in good position. continued atelectatic changes at the left base. ekg sinus bradycardia - the first beat of the tracing is of uncertain mechanism. intra-atrial conduction delay. left anterior fascicular block. consider left ventricular hypertrophy. delayed r wave progression is non-diagnostic but cannot exclude possible septal myocardial infarction of indeterminate age. diffuse st-t wave abnormalities with prolonged qtc interval - cannot exclude ischemia. clinical correlation is suggested. no previous tracing available for comparison sinus rhythm. left anterior fascicular block. left ventricular hypertrophy. anterior t wave inversions raising consideration of myocardial ischemia. clinical correlation is suggested. compared to the previous tracing of no significant change. pertinent microbiology 8:46 am sputum source: endotracheal. **final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): budding yeast with pseudohyphae. smear reviewed; results confirmed. respiratory culture (final ): commensal respiratory flora absent. klebsiella pneumoniae. sparse growth. piperacillin/tazobactam sensitivity testing available on request. yeast. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 8 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ 2 s meropenem-------------<=0.25 s tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r 5:20 am serology/blood chm s# l rpr added . **final report ** rapid plasma reagin test (final ): nonreactive. reference range: non-reactive. 4:27 pm stool consistency: loose source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). discharge labs complete blood ct wbc rbc hgb hct mcv mch mchc rdw plt 05:26 12.9* 4.30* 12.7* 37.0* 86 29.7 34.4 15.7* 391 differential neuts lymphs monos eos baso 05:26 70.3* 12.2* 4.0 12.7* 0.8 renal & glucose gluc urean creat na k cl hco3 angap 05:26 118 27* 1.2 145 3.7 109* 25 15 enzymes & bilirubin alt ast alkphos totbili 04:59 26 21 161* 0.5 brief hospital course: 84 yo m with complicated recent outside hospital course involving treatment for cellulitis, bandemia, intubation and reintubation, ?mi, and bronchoscopy revealing multiple upper airway abnormalities, transferred for further management of airway abnormalities. the patient was transferred to our micu team with the two most active issues as respiratory abnormalities and h/o respiratory failure at osh, as well as ekg changes and cardiac enzymes concerning for nstemi. interventional pulmonary as well as cardiology were consulted, and pulmonary deferred any procedure until nstemi was taken care of. as such, the patient underwent a cardiac cath which showed 3vd as per report, and received a bms to the proximal lad. soon after, the patient underwent a rigid bronchoscopy which did not reveal any pathology. as such, the patient was transferred back to the micu and extubated a few days later, the delay largely ms issues. the patient was treated with ctx x 2 during his hospitalization. the first for klebsiella pna, the 2nd round for a uti that was found, and remaining scant klebsiella on sputum cx. after extubation, the patient continued to be altered in ms. neurology was consulted both for the pt's weakness as well as ams. a w/u was negative (including a head ct) and thought of ams was toxic/metabolic encephalopathy, and thought of weakness was icu and prolonged hospitalization. a ck was negative. after transfer to the medical floor, the patient was stable and continued to improve in terms of mental status. tethers and lines were discontinued, and the patient passed speech and swallow eval. as such his ngt that was previously used for tf was discontinued. he was eventually transferred to a rehab facility for further strength conditioning as well as clearing of his ms. did have a persistent leukocytosis which was downtrending at time of discharge and an eosinophilia which was stable. we ruled out all other infectious etiologies, and the patient did not have any focal findings to indicate an infection. hospital course by problem # coronary artery disease/nstemi: ekg changes/enzyme elevations concerning for ischemia versus strain. cardiac enyzmes downtrending. cardiology was consulted and recommended , echo, atorvastatin and hep gtt. beta blocker held given long qt. serial ekgs obtained and enzymes followed. echo revealed ef 50-55% and mild regional left ventricular systolic dysfunction with mid septal hypokinesis. trop trended up and plans were made for cardiac catheterization. he underwent cath with a bms to lad on and was started on , , atorvastatin, and metoprolol. he was also started on captopril, both of which were uptitrated during this hospitalization. after transfer to the medical floor, his captopril was converted to lisinopril 40 mg by mouth daily and his metoprolol was further titrated up. he remained cp free and repeat ekg was reassuring. we discharged him with /, and the previously mentioned medications with f/u with cardiology. # upper airways abnormalities: bronchoscopy showed arytenoid joint dislocation, subglottic stenosis, tracheobronchomalacia extending to the bim at the osh. etiology possibly infectious vs traumatic and possibly reaction. intubated, ct neck/chest without contrast obtained and ip consulted but wanted to hold off until cardiology cleared him. planned for trach on however ip did rigid bronch and did not appreciate upper airway abnormality. he did not receive a trach and was extubated on . notably, it is unclear as to the cause of his upper airway abnormality, and would wonder if pna from klebsiella was the cause vs. an allergic reaction to bactrim as previously documented in osh notes. he was transferred to the medical floor on 2l/nc and was easily weaned to ra where he maintained good respiratory status. we discontinued his bumex and he did not show any overt si/sxs of heart failure or volume overload. # respiratory failure: as above, etiology upper airway edema versus cardiogenic pulm edema versus post-obstructive pulm edema pna vs allergic reaction to medication. tolerating vent well and was on pressure support for majority of icu stay. sedating propofol/fentanyl. respiratory cultures were obtained from osh that showed klebsiella and his zosyn (that was started at the osh) was changed to ctx. patient had ongoing secretions, fever and leukocytosis that were concerning. sputum cultures showed sparse growth of gram negative rods speciated to klebsiella. diureses was initiated with improvement of pulmonary edema. he completed an 8 day course of ceftrixone x 1 in the icu. after transfer to the medical floor, his respiratory status as above was stable. we continued to treat with a 2nd round of ctx for both the persistent kleb pna, as well as a uti (see below). we held off on further diuresis as the patient seemed to be euvolemic and he was discharged without diuretics. this can be restarted as an outpatient or in the rehab setting. # delirium: neuro c/s is currently following, and most likely cause is delirium in the setting of prolonged hospitalization with multiple interventions. as such, the patient was moved to a private room which will be the most helpful in terms of disruptions. o/w, a head ct was done which was wnl. tsh, rpr, b12, folate were wnl. given leukocytosis (see below), there was concern for infx, and as such uti and kleb pna was treated with 2nd course of ctx. ultimately, complete w/u for infx was done, and we d/c'ed all tethers and lines (foley, flexiseal, ivs, ngt). he continued to improve over time, and hope is that he will continue to improve. his status is very c/w delirium given the waxing and that happens, and notably he does seem more interactive when family is around. # htn: after cath patient had htn urgency with bps to the 200s systolic. he was started on a nitroglycerin drip and weaned off. he was started on metoprolol and uptitrated to hr and bp goals. his atenolol was originally d/c'ed at time of transfer to the micu prolonged qtc. when off propofol, patient's bp noted to be more elevated which was thought to be related to agitation. ultimately, the patient was started on metoprolol and captopril, both of which had to be uptitrated after extubation for hypertensive. after transfer to the medical floor, the captopril was transitioned to high dose lisinopril, and his metop was further titrated. amlodipine 10 mg by mouth daily was added as well. his bps were under better control, however medication titration will likely need to be continued in the outpt setting. # uti: pt noted to have an infectious ua with a negative ucx. given the patient's persistent leukocytosis (see below), the patient was treated with a 2nd course of ctx, also given the klebsiella on sputum cx. of note, the patient was afebrile during her time on the medical floor. # eosinophilia: pt noted to have eosinophilia after being admitted here (admitted with normal eos). out of concern for adrenal insufficiency, am cortisol checked which was wnl. also thought about possible allergic rxn to medications, and nonessential meds were d/c'ed (most notably pantoprazole). also, lfts checked which were wnl to r/o dress. did not feel there was much in terms of infectious source. this should be f/u as an outpatient. # volume overload: pt was noted to be 4l positive los while in the icu. diureses with lasix 20mg was initiated to help with vent weaning which showed improvement of pulmonary edema. after transfer to the medical floor, all diuretics were held as the patient did not seem to be volume overloaded, and his respiratory status remained stable. as above, his diuretics were held at time of discharge. # qt prolongation: likely with bradycardia, aggressively replete k, mg. improved over course of admission. atenolol was originally held, however, metop was started and titrated up without issue with his qtc. # fever/bandemia: improved. source of infectious initially unclear. v pneumonia v pharyngitis. cultures revealed klebsiella in sputum so likely a pneumonia. abx changed to ceftriaxone. he completed a 8day course. upon transfer to the medical floor, he remained afebrile, however had a persistent leukocytosis (see below). we did a thorough w/u of further infection, and the patient was treated with another round of ctx x 8 days given uti and persistent scant kleb on sputum cx. # leukocytosis: the patient was noted to have a leukocytosis that peaked ~16, and downtrended to 14 and stayed stable x 3 days. a thorough evaluation was done for infection (blood cx, urine cx, lfts, cxr, skin evaluation) which was all negative. as the patient had no localizing si/sx, we held off on further w/u, and trended down to 12.9 at time of discharge. # acute kidney injury: creatinine 2.0 on presntation to osh with lytes c/w pre-renal picture. improved over course of hospital stay. baseline unclear. monitor uop. diuresed once cr stabilized, and remained stable. did receive some ivf when some prerenal component. pt will likely need to be encouraged to take po fluids to keep from being dehydrated. upon d/c, cr was around 1.1 to 1.2. # weakness: the patient's initial presenting complaint was weakness. following extubation, he was profoundly weak. neurology was consulted who felt this was likely prolonged hospitalization and component of icu myopathy. this improved throughout his hospitalization. ct head was wnl. tsh, b12, folate, rpr were normal. # lft elevations: osh ruq u/s with multiple tiny gallstones vs. echogenic sludge. nondilated bile ducts. trended lfts which improved but alk phos remained elevated. # hyperlipidemia: started atorvastatin given concern for acs. d/ced simvastatin. # intertrigo: pt started on miconazole powder here prn for the intertrigo. # fen: started on tube feeds. speech and swallow saw the patient and cleared him for a pureed solid, thin liquid diet. this was started and his ngt was d/c'ed. # communication: -wife . -son .***hcp -daughter . # code status: full code, confirmed with wife, son, and daughter. of note, hcp on form is wife, , however given family discussion, they have decided that his son should be the one to make healthcare decisions. this will need to be further elucidated as an outpatient. # follow up issues - will defer decision to restart diuretics to the outpatient setting - further titration of bp medication (increase in metop if necessary, or switch to labetalol, or perhaps start of other medication) - would consider further w/u of persistent leukocytosis and eosinophilia - patient will need encouragement for po intake to improve hydration and volume status. medications on admission: home medications: simvastatin 10 mg daily gabapentin 600 mg tid aspirin 81 mg daily fish oil 500 mg daily multivitamin 1 tab daily atenolol 25 mg daily tramadol 50 mg qid vicodin 5/500 1 tab q6h bumetanide 2 mg mupirocin 2% ointment *****allergic to bactrim******bactrim ds 800/160 1 tab medications on transfer: zosyn 2.25 gm iv q6h solumedrol 60 mg iv q6h propofol gtt protonix 40 mg iv daily lipitor 80 mg po daily racepinephrine 2.25% q4h prn mupirocin heparin 5000 units sc bid discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 2. gabapentin 300 mg capsule sig: one (1) capsule po every twelve (12) hours. 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. fish oil 500 mg capsule sig: one (1) capsule po once a day. 5. multivitamin tablet sig: one (1) tablet po once a day. 6. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po three times a day. 7. tramadol 50 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain: hold for sedation, rr<8. 8. docusate sodium 50 mg/5 ml liquid sig: ten (10) cc po bid (2 times a day): hold for diarrhea. 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 10. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 11. heparin (porcine) 5,000 unit/ml solution sig: one (1) cc injection tid (3 times a day). 12. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain,fever. 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb treatment inhalation q4h (every 4 hours) as needed for wheeze, sob. 14. ipratropium bromide 0.02 % solution sig: one (1) neb treatment inhalation q6h (every 6 hours) as needed for sob, wheeze. 15. lisinopril 40 mg tablet sig: one (1) tablet po once a day: hold for sbp<100. 16. amlodipine 10 mg tablet sig: one (1) tablet po once a day: hold for sbp<100. 17. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for rash. discharge disposition: extended care facility: bay skilled nursing discharge diagnosis: primary diagnoses: nstemi (non-st elevation myocardial infarction) respiratory failure pneumonia delirium secondary diagnoses: eosinophilia coronary artery disease hypertension discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: it was a pleasure taking care of you during your hospitalization. you were admitted to with an inability to breathe, as well as a heart attack. you were stabilized in our icu, got a stent in one of your heart vessels, and slowly were weaned from the ventilator. you were treated with antibiotics for a urinary tract infection as well as a pneumonia. you remained slightly confused when you left, and we did a work up that was negative. we feel and hope this delirium will get better over time and you were sent to rehab to help regain your strength. please make the following changes to your medications (please refer to the full list of discharge medications for your current medications) - stop taking the following: simvastatin, atenolol, vicodin, bumetanide, mupirocin - start taking atorvastatin 80 mg by mouth daily - start taking docusate 100 mg by mouth twice daily - start taking senna 1 tab by mouth twice daily as needed for constipation - start taking 75 mg by mouth daily - start using heparin 5000 units sq three times daily - start taking acetaminophen 325-650 mg every 6 hours as needed for pain and fever - start using albuterol nebs 1 treatment every 6 hours as needed for wheezing or shortness of breath - start using ipratropium nebs 1 treatment every 6 hours as needed for wheezing or shortness of breath - start taking lisinopril 40 mg by mouth daily - start taking amlodipine 10 mg by mouth daily - start using miconazole powder 1 application three times daily as needed for rash - change your dose of aspirin to 325 mg by mouth daily - change your tramadol to 25 mg by mouth every 6 hours as needed for pain - change your gabapentin to 300 mg by mouth every 12 hours please follow up with your physicians as indicated below. followup instructions: department: cardiac services when: wednesday at 9:40 am with: , m.d. building: sc clinical ctr campus: east best parking: garage Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Toxic encephalopathy Unspecified essential hypertension Acute kidney failure, unspecified Aortocoronary bypass status Other and unspecified hyperlipidemia Acute respiratory failure Cellulitis and abscess of leg, except foot Pressure ulcer, buttock Obesity, unspecified Hyperosmolality and/or hypernatremia Pneumonia due to Klebsiella pneumoniae Critical illness myopathy Chronic total occlusion of coronary artery Candidiasis of skin and nails Pressure ulcer, stage II Other specified erythematous conditions |
allergies: penicillins / attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: aortic valve replacement (#19mm pericardial)/septal myomectomy history of present illness: 69 year old female with a longstanding history of a heart murmur and aortic stenosis followed by serial echocardiograms. an echocardiogram in showed severe aortic stenosis with a peak gradient of 112mmhg across the valve as well as moderate regurgitation. she does note some dyspnea on exertion however she continues to particpate in and weight lifting. given the severity and progression of her disease, she is now referred for surgical consultation. past medical history: aortic stenosis and regurgitation hyperlipidemia hypothyroid hypertension skin cancer (multiple bcc + scc) acute angle glaucoma osteoarthritis sciatica depression rp bleed with cath past surgical history: laser eye surgery tonsillectomy social history: race: caucasian last dental exam: ? lives with: husband contact: phone # occupation: retired cigarettes: smoked no yes last cigarette 30-40 yrs ago other tobacco use: pipe cigars smokeless etoh: < 1 drink/week drinks/week glass wine/day >8 drinks/week illicit drug use: denies family history: no premature coronary artery disease physical exam: pulse: 67 resp: 16 o2 sat: 100% b/p right: 139/78 left: 136/68 height: 5' weight: 125lbs general: well-developed female in no acute distress skin: warm dry intact heent: ncat perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema/varicosities: none neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: 2+ carotid bruit: right: - left: - pertinent results: echo: pre-bypass: the left atrium is normal in size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is prominent septal hypertrophy extending into the lvot. c- distance is 1.66 with /pl ratio 1.36. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. there are simple atheroma in the ascending aorta, aortic arch, and in the descending thoracic aorta. the aortic valve is bicuspid. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). mild (1+) aortic regurgitation is seen. the aortic regurgitation jet is eccentric. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. post-bypass: there is a well seated #19 prosthetic valve in the aortic position. there is no evidence of a peri-valvular leak. mean gradient is 16mm hg. there is no evidence of aortic dissection. there is preserved left ventricular systolic function that is unchanged from prebypass . cxr: pa and lateral chest views were obtained with patient in upright position. comparison is made with the next preceding portable ap single view chest examination of . status post sternotomy and significant postoperative cardiac enlargement as before. pulmonary congestive pattern; however, has decreased and there is no evidence of acute pulmonary infiltrates. still, the diaphragms are concealed by bilateral pleural effusions that blunt the lateral and posterior pleural sinuses. also identified on the lateral view are the metallic components of a porcine aortic valve prosthesis in place and multiple surgical clips in the left anterior mediastinum related to the previous bypass surgery. a right internal jugular approach central venous line remains in place and terminates overlying the svc at the level 2 cm below the carina. comparison is also made with the preoperative chest examination of , . the pleural spaces were free and the now existing pleural effusions are considered to be of moderate degree. no pneumothorax is seen in the apical area. 05:50am blood wbc-9.8 rbc-2.90* hgb-9.0* hct-27.0* mcv-93 mch-31.0 mchc-33.3 rdw-17.2* plt ct-216 12:56pm blood wbc-21.1*# rbc-3.67* hgb-11.7* hct-34.5* mcv-94 mch-31.8 mchc-33.8 rdw-14.3 plt ct-108* 03:53am blood pt-14.5* ptt-38.2* inr(pt)-1.4* 11:36am blood pt-17.8* ptt-58.5* inr(pt)-1.7* 05:50am blood urean-15 creat-0.6 na-141 k-4.0 cl-103 12:56pm blood urean-12 creat-0.4 na-145 k-3.4 cl-124* hco3-18* angap-6* brief hospital course: the patient was brought to the operating room on where the patient underwent an aortic valve replacement(#19mm pericardial)/septal myomectomy. please see operative note for surgical details. overall the patient tolerated the procedure well and post-operatively was transferred to the cardiovascular intensive care unit in stable condition for recovery and invasive monitoring. post operative day one found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. on post-op day 4 she had an episode of atrial fibrillation and was given beta-blocker and amiodarone with good response. by the time of discharge on pod 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged home with vna services in good condition with appropriate follow up instructions. medications on admission: preadmission medications listed are correct and complete. information was obtained from webomr. 1. metoprolol succinate xl 12.5 mg po daily 2. atorvastatin 10 mg po daily 3. levothyroxine sodium 88 mcg po daily 4. coenzyme q10 *nf* 100 mg oral daily 5. aspirin 81 mg po daily 6. ascorbic acid 500 mg po daily discharge medications: 1. aspirin ec 81 mg po daily rx *aspirin 81 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*1 2. atorvastatin 10 mg po daily rx *atorvastatin 10 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*1 3. levothyroxine sodium 88 mcg po daily rx *levothyroxine 88 mcg 1 tablet(s) by mouth daily disp #*30 tablet refills:*1 4. acetaminophen 325-650 mg po q4h:prn pain/temp rx *acetaminophen 325 mg tablet(s) by mouth q6 hours disp #*240 tablet refills:*1 5. amiodarone 400 mg po bid x7 days, then decrease to 200mg x 7 days, then decrease to 200mg daily until cardiologist recommends otherwise rx *amiodarone 200 mg 2 tablet(s) by mouth twice daily x 7 days disp #*90 tablet refills:*0 6. docusate sodium 100 mg po bid rx *docusate sodium 100 mg 1 capsule(s) by mouth twice a day disp #*60 capsule refills:*0 7. metoprolol tartrate 50 mg po tid hold for hr < 55 or sbp < 90 and call medical provider. *lopressor 50 mg 1 tablet(s) by mouth three times a day disp #*90 tablet refills:*2 8. potassium chloride 20 meq po q12h hold for k+ > 4.5 rx *potassium chloride 20 meq 1 packet by mouth twice a day disp #*14 packet refills:*1 9. ranitidine 150 mg po bid rx *ranitidine hcl 150 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*1 10. ascorbic acid 500 mg po daily 11. coenzyme q10 *nf* 100 mg oral daily 12. furosemide 20 mg po bid duration: 7 days rx *furosemide 20 mg 1 tablet(s) by mouth twice a day disp #*14 tablet refills:*0 rx *furosemide 20 mg 1 tablet(s) by mouth twice a day disp #*14 tablet refills:*1 discharge disposition: home with service facility: / discharge diagnosis: aortic stenosis and regurgitation s/p aortic valve replacement and septal myomectomy past medical history: hyperlipidemia hypothyroid hypertension skin cancer (multiple bcc + scc) acute angle glaucoma osteoarthritis sciatica depression rp bleed with cath s/p laser eye surgery s/p tonsillectomy discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with tylenol incisions: sternal - healing well, no erythema or drainage edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns 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 1:00pm in the medical office building, , wound check: on at 10:00am in the medical office building, , cardiologist: dr. on at 3:20pm 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: Extracorporeal circulation auxiliary to open heart surgery Excision or destruction of other lesion or tissue of heart, open approach Open and other replacement of aortic valve with tissue graft Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Aortic valve disorders Other and unspecified hyperlipidemia Personal history of other malignant neoplasm of skin Other ill-defined heart diseases |
allergies: patient recorded as having no known allergies to drugs attending: addendum: patient remained on the medicine floor over the weekend awaiting placement at a psychiatric facility with a section 12 in the chart. he remained stable on the medicine floor without further complications. he was re-evaluated by psychiatry on the day of discharge who felt that he patient would benefit from a full psychiatrict evaluation. discharge disposition: extended care facility: hospital - md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Subendocardial infarction, initial episode of care Depressive disorder, not elsewhere classified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Fever, unspecified Rhabdomyolysis Suicide and self-inflicted poisoning by other specified drugs and medicinal substances |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cocaine overdose major surgical or invasive procedure: intubation history of present illness: pt is a 38 year-old male with no pmh presents with cocaine overdose. the patient was confronted by the /police during a drug deal and proceeded to ingest 14-16 grams of powder cocaine. there is a question as to whether he ingested multiple small bags or one large bag. there was a struggle and approx 1-2g were able to be removed from his mouth. the patient became increasingly agitated and was intubated by ems, paralyzed with vecuronium for agitation and brought to . at he was given a total of 14mg iv ativan and 20mg vecuronium. his labs were remarkable for a positive tox screen for cocaine and bzd. cpk was 252, cpk-mb: 8.4, mb/ck index:3.3, trop i 0.04. his lft were also elevated ast:234/alt:242. abg: 7.33/50.9/463/25. (unknown vent settings). he had elevated bp at with sbp 200's and a ct-head was performed to r/o bleed that was negative. an ng tube was placed 3l lavage was performed. he was given activated charcoal and golytley. he was transferred to the the ed intubated and paralyzed. past medical history: back pain social history: lives with his wife and 4 year old son. wife is currently 4 months pregnant. works construction, but currently unemployed. per family, dealt drugs due to financial hardships. family denied tobacco/etoh/other drug use. family history: mother with htn physical exam: pe on transfer out of : vitals: t:99.0 bp:127/79hr:98 rr:18 o2sat:100% nc 1l vt: 600, rr:15, peep:5 fio2: 40% gen: arousable to voice, intermittently sedated, nad, able to follow commands heent: r pupil 3mm-->2mm, sluggish, prosthetic left eye. anicteric, no epistaxis or rhinorrhea neck: supple cor: rrr, no m/g/r, normal s1 s2, radial pulses +2 pulm: lungs ctab, no w/r/r abd: soft, nd, +bs, no hsm, no masses ext: no c/c/e, no palpable cords skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. pertinent results: labs on admission : wbc-9.2 rbc-4.60 hgb-13.2* hct-40.9 mcv-89 mch-28.7 mchc-32.3 rdw-12.7 plt ct-204 neuts-78.0* lymphs-16.6* monos-4.6 eos-0.4 baso-0.3 pt-12.6 ptt-28.9 inr(pt)-1.1 glucose-113* urean-13 creat-0.7 na-141 k-3.7 cl-108 hco3-28 angap-9 alt-206* ast-199* ck(cpk)-1799* alkphos-63 totbili-1.2 ck-mb-41* mb indx-2.3 ctropnt-0.19* albumin-3.6 calcium-8.0* phos-2.0* mg-1.8 serum tox: asa-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg urine tox: bnzodzp-pos (received at osh), barbitr-neg opiates-neg cocaine-pos amphetm-neg mthdone-neg . labs on transfer to floor : wbc-15.0*# rbc-4.35* hgb-12.8* hct-38.8* mcv-89 mch-29.4 mchc-33.0 rdw-13.4 plt ct-177 neuts-83.6* lymphs-11.9* monos-4.3 eos-0.1 baso-0.1 pt-13.7* ptt-32.9 inr(pt)-1.2* glucose-88 urean-6 creat-0.7 na-142 k-3.5 cl-109* hco3-24 angap-13 alt-153* ast-131* ld(ldh)-435* ck(cpk)-3226* alkphos-68 totbili-1.8* ck-mb-27* mb indx-0.8 ctropnt-0.03* calcium-7.6* phos-3.1# mg-2.3 . 05:45am hbsag-negative hbs ab-positive hbc ab-negative hav ab-positive igm hbc-negative igm hav-negative 05:45am hcv ab-negative . bcx - ngtd . mrsa - ngtd . eeg: there was no evidence of discharging activity or electrical status. the tracing represented an anesthesized patient with pre-central beta activity extending somewhat more posteriorly and representative of a benzodiazepine effect. one isolated instance of vertex activity that might have represented stage ii sleep was seen. . ekg on admission: sinus rhythm at 94 bpm, normal axis, normal intervals, rsr' pattern in v2. tw flattening in iii/avf. otherwise no acute st or t-wave changes. . ekg on transfer to floor: nsr 95bpm, nl axis and intervals, no twi or st segment elevations or depressions . kub: no evidence of drug packing. ng terminates below the diaphragm . cxr: compared to , the bilateral subtle basal opacities have minimally improved. the opacity along the minor fissure is no longer visible. no newly occurred focal parenchymal opacity suggesting pneumonia. no pleural effusion, unchanged size of the cardiac silhouette. complete resolution of rul opacicity. . echo: the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. brief hospital course: #. cocaine overdose: pt with massive ingestion of 14g of crack cocaine. he was intubated in the field and transferred from . he was given 14mg ativan total at the osh and 40mg valium in the ed. pt underwent ng lavage and also received activated charcoal and started on golytely. ct-head was negative at osh. pt tachycardic and bp elevated at osh, but controlled in the ed with valium iv. tox screen neg at osh other then cocaine and bzd. in the , pt was extubated on and remained stable on oxygen by nc. additionally a toxicology cosult was called and recommended kub to rule out any retained packages in the bowel which is negative. his vitals signs: hr, bp, all remained stable after transfer to the floor. no additional benzodiazepine was required. # rhabdomyolysis: pt was started on ivf for elevated ck to 3226. pt was monitored for signs of hyperthermia and tachycardia. on the floor, ck steadily trended down and was 287 day before transfer. ua did not show myoglobinuria. his renal function remained stable. #. depression: on further questioning, the pt reported that the cocaine ingestion was a suicide attempt. he stated that he was having more financial difficulty over the past few months and thought that if he attempted suicide, his family would be able to receive his life insurance. a 1:1 sitter was ordered and psychiatry consult was called. he was placed on a section 12 and is currently awaiting an inpatient psychiatry bed for further evaluation. he denied any futher suicidal ideations while in the hospital. #. fever: pt developed fever to 101 with leukocytosis on . bcx were sent with no growth to date and cxr was concerning for aspiration pneumonia, but final read demonstrated no infiltrate. his fever defervesced while blood and urine culture remained negative. wbc also trended down and normalized. unasyn was dc'd on . pt was felt to have aspiration pneumonitis and therefore was not continued on antibiotics. he remained afebrile without cough or shortness of breath. #. nstemi: likely demand ischemia in the setting of cocaine overdose causing vasospasm and not acute thrombosis. no prior history of cad or risk factors per family. heparin gtt was held given risk for intracranial bleed. pt was started on asa 325mg and lipitor 80mg. beta blocker was contraindicated. cardiac enzymes trended downwards. ekg normalized. echo showed no lv/rv or valvular function. lipid panel was wnl and statin was stopped. pt switched to asa 81 mg given no cardiovascular risk factors. #. transaminitis: pt with elevated transaminitis with no prior for comparison. likely related to crack cocaine ingestion. non-obstructive picture. tylenol neg at osh. possible ischemia related in the setting of cocaine over dose. lfts began to trend downward while on the floor and normalized on . hepatitis serologies were negative. # comm: (wife) ; - # dispo - to psych inpatient unit for further management of depression medications on admission: tramadol discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). discharge disposition: extended care facility: hospital - discharge diagnosis: primary: cocaine overdose nstemi hyperthermia aspiration pneumonitis depression discharge condition: afebrile, vital signs stable, medically cleared for discharge. discharge instructions: you were admitted to the hospital after ingesting a large amount of cocaine. you were admitted to the intensive care unit for close monitoring. the large cocaine caused muscle pain and fevers, and also caused a small amount of damage to your heart muscle. you recovered quickly with treatment. we checked an echocardiogram and it showed no evidence of significant damage. you were evaluated by the psychiatrists, who feel that you'd benefit from inpatient psychiatric treatment. changes to your medications include: aspirin 81 mg daily. followup instructions: please follow per psychiatry recommendations. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Subendocardial infarction, initial episode of care Depressive disorder, not elsewhere classified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Fever, unspecified Rhabdomyolysis Suicide and self-inflicted poisoning by other specified drugs and medicinal substances |
allergies: amoxicillin attending: chief complaint: increase dyspnea on exertion/chest pressure with extertion major surgical or invasive procedure: aortic valve replacement (19mm st. mechanical) history of present illness: 51 year old female has been followed for several years for bicuspid aortic valve stenosis. she was recently seen by dr. in for routine follow up and also for cardiac clearance prior to a planned cataract surgery. during her visit, she reported new onset exertional dyspnea and chest tightness over the last few months. she describes shortness of breath occurring with activity such as climbing flights of stairs or walking uphill. she denies any chest discomfort or dyspnea at rest but does report frequently feeling fatigued. she does report having lower extremity edema which has been attributed to nifedipine which she takes for raynaud's. following her treatment for a uti with cipro it was noted that her lft's were markedly elevated. the cardiac cath was postponed. she was evaluated by dr and lft's where rechecked with significant improvement. she does have a history of hepatitis b from a needle stick in the ' however her serologies have been negative on numerous occasions. the elevated lft's were felt to possibly be related to the antibiotics. she has now been given clearance to proceed with cardiac catheterization. she is now being referred to cardiac surgery for possible aortic valve replacement. past medical history: aortic stenosis recurrent uveitis (inflammation of eye) hypertension type i diabetes diagnosed at age 11 - no insulin pump severe raynaud's syndrome thyroid nodules (euthyroid) s/p negative biopsy 4 yrs ago cataracts bilaterally - needs surgery glaucoma rotator cuff tear-treated with cortisone injections/pt infection- treated with erythromycin finished uti - currently on cipro 250mg started ? needle stick with resulting hepatitis b- although negative antigen past surgical history: s/p c section x 2 c/b post op kidney infection s/p wisdom teeth extraction s/p laparoscopies, d&c social history: race:cuacasian last dental exam:, has dental clearance lives with:husband occupation:homemaker tobacco: quit 30 years ago, smoked for 4 years etoh:denies family history: non-contributory physical exam: pulse:83 resp:20 o2 sat:100/ra b/p right:119/77 left:129/79 height: 5'3" weight:135 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur sem iv/vi abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: left: dp right: 2+ left:2+ pt : left: radial right: left: carotid bruit (b), pulse right: 2+ left:2+ pertinent results: echo: pre-bypass: the left atrium is dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen at rest. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve is bicuspid (fused right and left coronary cusps). the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. dr. was notified in person of the results on ms. before surgical incision. post-bypass: preserved biventricular systoilc function. lvef 55%. intact thoracic aorta. there is a mechanical prosthesis in the aortic position and stable functioning well with peak 20mm of hg and mean 11 mm of hg. cxr findings: cardiac silhouette is markedly widened compared to the preoperative chest x-ray and has also increased slightly since the earliest postoperative radiograph of . improvement in left retrocardiac atelectasis but slight worsening of right retrocardiac atelectasis. there are probable pleural effusions, improved on the right. retrosternal gas on lateral radiograph is likely related to recent surgery. a tiny right apical pneumothorax is in retrospect unchanged. enlargement of right lobe of thyroid gland results in focal deviation of trachea to the left above the thoracic inlet level. impression: 1. tiny right apical pneumothorax. 2. enlarged cardiac silhouette, probably reflecting a postoperative pericardial effusion. 3. bibasilar atelectasis, improvement on the left. 4. small pleural effusions. echo: the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 75%). right ventricular chamber size and free wall motion are normal. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is a small pericardial effusion. the effusion appears circumferential. there are no echocardiographic signs of tamponade. 10:25am blood wbc-5.9 rbc-3.01* hgb-9.5* hct-27.7* mcv-92 mch-31.6 mchc-34.3 rdw-13.9 plt ct-298 10:25am blood plt ct-298 10:25am blood pt-28.0* inr(pt)-2.7* 06:14pm blood pt-29.1* inr(pt)-2.9* 04:40am blood plt ct-255 04:40am blood pt-44.3* ptt-31.3 inr(pt)-4.7* 03:15pm blood pt-45.9* inr(pt)-4.9* 04:40am blood pt-34.4* ptt-28.3 inr(pt)-3.5* 04:35am blood plt ct-230 04:35am blood pt-15.9* ptt-26.2 inr(pt)-1.4* 10:25am blood urean-14 creat-0.8 na-137 k-3.9 cl-99 04:40am blood glucose-111* urean-17 creat-0.9 na-137 k-4.3 cl-102 hco3-30 angap-9 03:15pm blood alt-16 ast-21 ld(ldh)-196 alkphos-80 amylase-18 totbili-0.3 brief hospital course: mrs. was a same day admit after undergoing pre-operative work-up prior to surgery. on she was brought to the operating room where she underwent an aortic valve replacement. please see operative report for surgical details. following surgery she was transferred to the cvicu for invasive monitoring in stable condition. later that day she was weaned from sedation, awoke neurologically intact and extubated. on post-op day one beta-blockers and diuretics were started and she was gently diuresed towards her pre-op weight. later on post-op day one she was transferred to the step-down floor for further care. chest tubes and epicardial pacing wires were removed per protocol. coumadin was started on pod 1 and titrated for a goal inr of 2.5. she is sensitive to coumadin and peaked at inr 4.7, but trended down without intervention. the patient was evaluated by the physical therapy service on pod 2 for assistance with strength and mobility. postoperative echocardiogram showed small circumferential pericardial effusion, without signs of tamponade. by the time of discharge on pod 5, her inr was 2.7, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged in good condition with appropriate follow up instructions. she was instructed to take 2.5 mg of coumadin and and to have her inr checked on monday with results to dr. . medications on admission: alprazolam - (prescribed by other provider) - 0.5 mg tablet - 1 (one) tablet(s) by mouth up to three times a day prn butalbital-acetaminophen-caff - (prescribed by other provider; prn migraines) - 50 mg-325 mg-40 mg tablet - 2 (two) tablet(s) by mouth as needed for headaches currently taking only once day cetirizine-pseudoephedrine - (prescribed by other provider; prn allergies) - 5 mg-120 mg tablet sustained release 12 hr - 1 (one) tablet(s) by mouth once a day as needed citalopram - (prescribed by other provider) - 20 mg tablet - 1.5 (one and a half) tablet(s) by mouth once a day insulin glargine - (prescribed by other provider) - 100 unit/ml solution - 26-30 units at dinner daily insulin lispro - (prescribed by other provider) - 100 unit/ml solution - sliding scale with meals lisinopril - 40 mg tablet - 1 tablet(s) by mouth once a day nifedipine - 60 mg tablet extended rel 24 hr - 1 tab(s) by mouth once a day trazodone - (prescribed by other provider) - 100 mg tablet - 5 tablet(s) by mouth at bedtime discharge medications: 1. furosemide 40 mg tablet sig: one (1) tablet po once a day for 10 days. disp:*10 tablet(s)* refills:*0* 2. potassium chloride 20 meq tablet, er particles/crystals sig: two (2) tablet, er particles/crystals po once a day for 10 days. disp:*20 tablet, er particles/crystals(s)* refills:*0* 3. warfarin 2.5 mg tablet sig: one (1) tablet po once a day: reason: mechanical avr goal inr: 2.5-3.0 please have inr drawn daily. primary care physician to dose daily inr until within therapeutic range. disp:*60 tablet(s)* refills:*3* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*1* 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. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. 8. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 9. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*75 tablet(s)* refills:*0* 10. lorazepam 0.5 mg tablet sig: one (1) tablet po q 8h (every 8 hours) as needed for anxiety. 11. humalog sliding scale breakfast lunch dinner bedtime humalog glucose insulin dose 0-70 proceed with hypoglycemia protocol 71-90 0units 0units 0units 0units 91-130 4units 4units 4units 0units 131-160 7units 7units 7units 2units 161-190 10units 10units 10units 4units 191-220 13units 13units 13units 6units 221-280 16units 16units 16units 8units > 280 notify m.d. 12. lantus 100 unit/ml solution sig: thirty (30) units subcutaneously subcutaneous dinner. 13. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*2* 14. butalbital-aspirin-caffeine 50-325-40 mg capsule sig: caps po q8h (every 8 hours) as needed for head ache. discharge disposition: home with service facility: wolfboro vna discharge diagnosis: aortic stenosis s/p aortic valve replacement past medical history: recurrent uveitis (inflammation of eye) hypertension type i diabetes diagnosed at age 11 - no insulin pump severe raynaud's syndrome thyroid nodules (euthyroid) s/p negative biopsy 4 yrs ago cataracts bilaterally - needs surgery glaucoma rotator cuff tear-treated with cortisone injections/pt infection- treated with erythromycin finished uti - currently on cipro 250mg started ? needle stick with resulting hepatitis b- although negative antigen past surgical history: s/p c section x 2 c/b post op kidney infection s/p wisdom teeth extraction s/p laparoscopies, d&c discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with percocet incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema - 2+ 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: please come to 6 next wednesday or thursday, or , at 10am for wound check. you are scheduled for the following appointments surgeon: dr. on at 1pm cardiologist: dr. on at 1:40pm 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: mechanical aortic valve goal inr 2.5-3 inr to be drawn on monday inr to be drawn daily until inr within therapeutic range results to dr. phone: fax: Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Diagnoses: Abnormal coagulation profile Unspecified essential hypertension Unspecified glaucoma Congenital insufficiency of aortic valve Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Raynaud's syndrome Unspecified cataract |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: icd pocket swelling major surgical or invasive procedure: explantation of icd placement of picc history of present illness: 82-year-old-male with pmhx/o cad s/p des to lad in ', hypertension, atrial fibrillation on coumadin, symptomatic bradycardia s/p ppm placement in 1/99, icd placement ', cmp (last ef 50-55% in ) presents after having his icd generator changed in with worsening swelling and erythema of the pacer site. according to the patient, the pacemaker site has been "swollen to the size of a cantaloupe" since it was changed in . over the past couple weeks he has noted a "tugging" sensation, but attributed it to the healing process. patient states that as he came out of the shower last night, he noted that the icd site appeared erythematous. he also noted it to be warm, but denied any tenderness to palpation. the patient also denies discharge. he is unable to state whether or not the ppm site was especially warm, erythematous in days past because he stated that he was not paying attention to area - assumed everything was normal. . he first presented to hospital upon the recommendation of his personal care assistant and a visiting nurse from his doctor's practice. . of note, the patient was given a 10-day course of ciprofloxacin for swelling of the pacer site soon after it was changed. he took 3 of these pills. past medical history: past medical history: cardiac history: - cad s/p imi in ', lad stent to ', ptca of rca, - atrial fibrillation - tachy-brady syndrome s/p ppm placement in 1/99, s/p biv icd ' - hypertension - cardiomyopathy (last echo in , ef 50-55%) - aaa (4.4 cm) other past history: - dyslipidemia - "weak kidney" - degenerative kidney diseasse s/p bilateral arthroplasties (left in ', right in ') - duodenal ulcer - copd (patient denies this diagnosis) social history: - etoh: social use. qd. - tobacco: previously smoked 2 ppd, quit 50 years ago. - served in the u.s. armed forced in his early 20s. family history: - mother: died at 84 from "natural causes" vs mi. - father: died in 60s of esophageal cancer. physical exam: vs: 98.0, 148/77 (127-160/64-85), 75 (63-85), 20@98%(ra) i/o's = 1340/2525 gen: nad. alert and oriented x3. resting in bed. neck: supple. jvp not elevated. no carotid bruits noted. cv: reg rate, irreg rhythm. normal s1, s2. no murmur, rubs, or gallops. chest: basilar crackles, no wheezes abd: bs present. soft, some tympanic distention; non-tender ext: symmetric 1+pitting edema of bilateral le to shins, wwp. digital cap refill <2 sec. distal pulses radial 2+, dp 2+, pt 2+. skin: l chest icd explantaion site bandaged; no blood staining. pertinent results: 04:40am blood wbc-4.2 rbc-3.88* hgb-11.7* hct-35.5* mcv-91 mch-30.2 mchc-33.0 rdw-14.8 plt ct-146* 06:25am blood wbc-6.4# rbc-4.11* hgb-12.2* hct-37.7* mcv-92 mch-29.7 mchc-32.4 rdw-14.6 plt ct-138* 06:45am blood wbc-6.0 rbc-3.84* hgb-12.0* hct-35.3* mcv-92 mch-31.3 mchc-34.1 rdw-14.6 plt ct-124* 05:49am blood wbc-6.9 rbc-2.72* hgb-8.1* hct-24.8* mcv-91 mch-29.8 mchc-32.6 rdw-14.0 plt ct-147* 09:10am blood wbc-5.5 rbc-3.09* hgb-9.3* hct-27.7* mcv-90 mch-30.0 mchc-33.6 rdw-14.3 plt ct-183 07:20am blood wbc-5.1 rbc-2.85* hgb-8.5* hct-26.0* mcv-91 mch-29.9 mchc-32.8 rdw-14.3 plt ct-204 05:38am blood pt-15.9* ptt-93.4* inr(pt)-1.4* 07:20am blood pt-18.1* ptt-71.4* inr(pt)-1.6* 06:11am blood fibrino-581* 04:40am blood glucose-112* urean-34* creat-2.1* na-139 k-4.0 cl-102 hco3-27 angap-14 06:45am blood glucose-103* urean-30* creat-1.7* na-137 k-4.2 cl-100 hco3-30 angap-11 06:11am blood glucose-126* urean-40* creat-2.1* na-135 k-4.3 cl-105 hco3-23 angap-11 05:49am blood glucose-134* urean-40* creat-2.0* na-133 k-4.2 cl-106 hco3-21* angap-10 07:20am blood glucose-105* urean-25* creat-1.5* na-138 k-3.8 cl-101 hco3-28 angap-13 01:40am blood alt-10 ast-18 ld(ldh)-198 ck(cpk)-236 alkphos-84 totbili-1.7* dirbili-0.7* indbili-1.0 01:40am blood ck-mb-4 ctropnt-0.06* 06:25am blood calcium-8.7 phos-3.9 mg-2.0 cholest-91 05:49am blood calcium-7.7* phos-3.5 mg-2.6 07:20am blood calcium-8.5 phos-3.3 mg-2.0 06:25am blood vanco-5.1* 07:20am blood vanco-16.9 11:00 am swab pacemaker pocket. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final ): pseudomonas aeruginosa. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- <=1 s ceftazidime----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem------------- 1 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): anaerobic culture (final ): no anaerobes isolated. abd u/s dication: 82-year-old male with new abdominal distention, septic shock. no prior examinations for comparison. abdominal ultrasound: the liver is normal in echogenicity, without focal lesions. there is normal hepatopetal flow in the portal vein. the gallbladder is partially collapsed without stones, sludge, wall edema, or pericholecystic fluid. the pancreas was not well visualized. there is no intra- or extra-hepatic biliary dilatation. the spleen is normal in size at 10.4 cm. the right kidney measures 9.6 cm, and the left kidney measures 10.9 cm. there are no stones, masses, or hydronephrosis. the bladder is mildly distended. post-void images were not acquired. coarse calcifications are noted in the central prostate. there is no abdominal ascites. impression: unremarkable abdominal ultrasound. echo: there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated with depressed free wall contractility. trace aortic regurgitation is seen. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. impression: suboptimal image quality. trivial amount of pericardial effusion without evidence of tamponade physiology. the right ventricle is dilated and hypokinetic. ekg: atrial fibrillation. delayed precordial r wave progression. mild lateral st-t wave changes are less prominent since . tracing #2 brief hospital course: 82 y/o male with pmhx cad s/p des to lad in , htn, a fib on coumadin, symptomatic bradycardia s/p ppm placement in 1/99 with icd placement in ' with generator change at in who presented with an icd pocket infection. . # pocket infection: pt presented with pocket infection without systemic signs of infection. started on iv vanc/cefepime antibiotic regimen in consultation with id, and id followed throughout duration of admission. pacemaker and 4 leads explanted on complicated by hypotension and fever/rigors post-procedure. wound cx grew pseudomonas aeruginosa. pt transferred to ccu secondary to septic shock, was put on pressors and stabilized. pt weaned off pressors after a couple of days and then transfered back to . id recommended picc line for outpatient administration of vanc and cefepime. pt had picc placed on . pt sutures were removed on and that evening his wound dehisced and pt began bleeding from incision site. pt hematocrit was stable and pt sent to or for repair of dehiscense. wound has been stable since, and drain pulled on , wound site clean, non-erythematous, non-tender, no pus or foul smelling discharge from wound site. id signed off with opat recs and to have pt follow up in clinic. pt to receive vancomycin and cefepime until . . # septic shock: pt with evidence of septic shock with sbps to the 60s-70s, rigors, fever up to 103 s/p extraction of icd and leads with pocket infection. the patient was noted to be febrile and rigoring ~10 hours post-procedure, and trasnferred to ccu for pressor support and further care. it was initially thought he could be in cardiogenic shock from tamponade, however a pulsus was 10 and his bedside echo showed no effusion. he was fluid resuscitated with 6.5l ns within 2 hours, was started on dopamine for pressor support. blood cultures were drawn and no growth to date. his cortisol was 23 and central scvo2 in the 70s. lactate of 1.0. gentamycin was added to antibiotic regimen while would cx/sensitivities pending. he was weaned from dopamine and transferred back to floor. . # atrial fibrillation: patient had pacemaker placed for tachy-brady syndrome many years ago, however is not pacer dependent. in the icu he was in atrial fibriallation on tele and ekg and tachycardic on dopamine. his pressors were weaned and he had some 2s pauses at night while sleeping. he required theophylline given his bradycardia while weaning the dopamine. theophylline was stopped and patients hr has been stable. he was initially on a heparin gtt for atrial fibrillation and this was stopped and he was put on coumadin. inr at discharge was 1.9. please check inr on and adjust coumadin for inr goal . . # anemia: patient with hematocrit drop from 34.3 to 26.8. a component of dilutional effect from patient getting large volumes of fluid post septic shock. we trended his hct, which was stable. he was guiac negative, his dic and hemolysis panel was negative. there was no further work up for his anemia at this time. it can be followed on the outpatient setting. . # renal failure: patient with cr bump to 2.1 secondary to septic shock and poor perfusion of kidneys. trended cre, which returned to baseline on . pt had slight bump in creatinine on believed to be pre-renal in nature. pt given fluids. while in arf, antibiotics were renally dosed, and potentially nephrotoxic medications held or renally dosed until cre returned to baseline. on further review of creatinine labs. pt baseline varies between 1.5-1.9. pt discharge cr-2.0. . # cad: ekg without signs of current ischemia, no chest pain. continued atorvastatin. . # cardiomyopathy: minimal fluid overload on exam during admission. bedside echo with ef 55%. pt given lasix prn when not on home lasix dose. . # neuropathy: gabapentin initially continued at home dose, then renally dosed while pt with arf. once cre returned to baseline, restarted gabapentin home dose. also gave pt compression , pt request. . the patient was evaluated by pt and it was felt that when medically stable he should be discharged to a rehab facility and will be able to return in order to have reimplantation of his device. medications on admission: - diovan 80 mg 2xd - digoxin 125 mcg 1xd - lipitor 20 mg 1xd - coumadin 1 mg 1.5 pills 1xd - lasix 40 mg 2xd (pt states that he only takes 1xd) - gabapentin 300 mg 3xd - viagra 100 mg 1xd prn - levitra 20 mg 1xd prn (rx given on ) - omeprazole 20 mg 2xd - albuterol inhaler 1-2 puffs q8h - ciprofloxacin 500 mg 1xd for 10 days starting on - carvedilol 6.25 mg po/ng discharge medications: 1. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 2. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm. 3. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours) for 5 weeks. 4. cefepime 2 gram recon soln sig: one (1) recon soln injection q12h (every 12 hours) for 5 weeks. 5. gabapentin 300 mg capsule sig: one (1) capsule po once a day. 6. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 7. viagra 100 mg tablet sig: one (1) tablet po 1x prn as needed for erectile dysfunction. 8. levitra 20 mg tablet sig: one (1) tablet po 1x prn as needed for erectile dysfunction. 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: inhalation every eight (8) hours as needed for sob/wheeze. 11. carvedilol 6.25 mg tablet sig: one (1) tablet po twice a day. 12. digoxin 125 mcg tablet sig: one (1) tablet po once a day. 13. diovan 80 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: life care center of discharge diagnosis: primary diagnosis: infection at icd site secondary diagnosis: - coronary artery disease s/p inferior myocardial infarction in ', left anterior descending stent to ', ptca of right coronary artery, - atrial fibrillation - tachy-brady syndrome - hypertension - cardiomyopathy - abdominal aortic anuerysm discharge condition: activity status: ambulatory - requires assistance or aid (walker or cane). level of consciousness: alert and interactive. mental status: clear and coherent. discharge instructions: you are being discharged from the hospital 10 days after your admission. you were transferred to from hospital after you presented with swelling erythema and tenderness around the site of your defibrillator. we removed the defibrillator and started you on antibiotics for an infection that was found at that implantation site. during the admission, because of the infection, your blood pressures became very low and you required medication to help keep your blood pressures at a normal level. at this point in the admission, you required a high level of care and you were transferred to the cardiac intensive care unit. once you stabilized you were transferred back to the cardiac medicine floor. you had your sutures removed in anticipation for discharge, but the wound separated and began bleeding. you were taken to the or and the incision was re-sutured and stapled. the infection site grew bacteria that is sensitive to vancomycin and cefepime. you were started on these abx on and you will need to take this medication for 6 weeks, until . this medication will be given iv and in order for you to receive iv medication outside of the hospital a picc line was placed. you will be discharged from the hospital with instructions to receive these antibiotics for 6 weeks. you will return to the hospital in the next 1-2 weeks for reimplantation of your defibrillator. while at rehab please have the following labs drawn weekly: lab tests: cbc, bun, crea, lfts, vancomycin trough all laboratory results should be faxed to infectious disease r.ns. at ( you were started on the following medications: cefepime 2g q12h (renally adjusted) vancomycin 1g q24h (renally adjusted) these medications should be continued for a total of 6 weeks until the following medication was changed gabapentin 300mg tid --> 300mg daily (renally adjusted) warfarin 1.5mg --> warfarin 2mg (please decrease to 1.5mg once inr between 2 and 3) please continue your other medications as prescribed followup instructions: department: infectious disease when: tuesday at 3:30 pm with: , m.d. building: lm campus: west best parking: garage department: infectious disease when: monday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage you will have a scheduled readmission to the hospital for implantation of your icd. Procedure: Venous catheterization, not elsewhere classified Closure of skin and subcutaneous tissue of other sites Other irrigation of wound Removal of lead(s) [electrode] without replacement Revision or relocation of cardiac device pocket Diagnoses: Other primary cardiomyopathies Anemia, unspecified Coronary atherosclerosis of native coronary artery Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Septic shock Old myocardial infarction Long-term (current) use of anticoagulants Cardiac pacemaker in situ Abdominal aneurysm without mention of rupture Unspecified hereditary and idiopathic peripheral neuropathy Pseudomonas infection in conditions classified elsewhere and of unspecified site Disruption of external operation (surgical) wound Infection and inflammatory reaction due to cardiac device, implant, and graft |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: intubation extubation central line placed & removed history of present illness: 48f with copd and htn, presenting to osh with dyspnea and upper abdominal pain. he was recently admitted to osh (2 weeks ago) with 5 day stay for presumed copd exacerbation, ?pneumonia at that time. this started after doing some yardwork outside - thought perhaps had allergy to pollen. sent home on o2, levofloxacin, and prednisone. improved quite a bit at home, but again started feeling unwell yesterday. stayed in bed all day and had poor po intake. wife reports slightly loose bowel movements. also c/o mild abdominal pain and seemed to have worsening breathing difficulties. mild cough. no fevers. at 1 am today, asked his wife to call ems. per wife, has depression but does not believe he would be at risk for od of any type. . he presented to osh. o2 sat in 80s initially, started on bipap and nebs. sats did not improve and looked fatigued, so was intubated. pre-intubation developed hypotension and started on levophed. of note pulse as low as 49 even with hypotension. initial k was 7.5, bnp was 8500. he got lasix, d50, calcium, and possibly kayexalate. also given hydrocortisone 100 mg iv, vanco, zosyn, flagyl. medflighted to . en route hypotension worsened and he was started on dopamine. . in the ed, initial vs were: t97.1 p67 bp114/48 r16 o2 sat 97% on vent. lab derangements include arf, hyperkalemia, combined met/resp acidosis (7.16), transaminitis with hyperbilirubinemia. ct abdomen without contrast performed and showed multifocal pneumonia, equivocal peripancreatic stranding (lipase normal). head ct done prior to transfer - no bleed seen. patient was continued on pressors - currently 0.06 levophed and 15 dopa. also got zosyn here. cvl placed. current vent settings 550 x ?, fio2 1, peep 12, and satting low to mid 90s. . on the floor, patient intubated and unresponsive. per ed, unresponsiveness unexplained and has persisted, ?meds from osh. past medical history: - copd - htn - depression - history of bowel resection and anastamosis due to "kinking" 1.5 years ago - history of chronic back pain s/p surgery x3 social history: - tobacco: quit smoking 1 week ago. generally smokes 1.5-2 ppd, for 30 years. - alcohol: not much in last few weeks; prior was 10 beers per day. wife denies history of withdrawals. - illicits: wife denies, including all inhalants. no recent travel. no unusual hobbies/exposures. wife reports fire down the street that occurred about 3 weeks ago. family history: parents with hypertension. father died of lung cancer. physical exam: general: intubated, comatose, nonresponsive even to pain. heent: sclera anicteric, pupil 5mm and very slightly reactive (4-4.5). mmm, ett in place, difficult to see in op. neck: supple, obese, ij line in place, difficult to otherwise appreciate jvp, no lad lungs: right slightly decreased compared to left, generally coarse but no crackles or wheezes appreciated. cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops, abdomen: hypoactive bowel sounds, soft, non-tender, obese but non-distended, no rebound tenderness or guarding, no organomegaly ext: warm ues but feet cool, 2+ pulses, no clubbing, cyanosis or edema neuro: unresponsive to painful stimuli. . on discharge: ambulatory, conversational, diffuse expiratory wheezes, prolonged expiratory phase or respiration, 1+ b/l pitting edema at shins, distant heart sounds. pertinent results: admission labs: 04:00am blood wbc-7.1 rbc-4.06* hgb-13.2* hct-40.0 mcv-99* mch-32.6* mchc-33.0 rdw-14.7 plt ct-144* 08:13am blood neuts-76* bands-16* lymphs-4* monos-3 eos-0 baso-0 atyps-0 metas-1* myelos-0 08:13am blood pt-16.9* ptt-35.2* inr(pt)-1.5* 08:13am blood fibrino-689* 03:32am blood ret aut-1.9 04:00am blood glucose-158* urean-62* creat-3.0* na-131* k-7.3* cl-100 hco3-19* angap-19 04:00am blood alt-2458* ast-3251* ck(cpk)-1281* alkphos-68 totbili-3.1* dirbili-1.6* indbili-1.5 04:00am blood ck-mb-45* mb indx-3.5 ctropnt-0.01 probnp-6274* 08:13am blood calcium-7.7* phos-7.5* mg-1.7 04:00am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 09:11am blood type-art temp-36.3 tidal v-500 fio2-100 po2-81* pco2-59* ph-7.15* caltco2-22 base xs--9 aado2-587 req o2-94 -assist/con intubat-intubated 04:10am blood glucose-141* lactate-2.0 na-132* k-5.9* cl-100 calhco3-20* . anemia work-up: 03:32am blood ret aut-1.9 12:10pm blood caltibc-170* vitb12-1693* folate-11.6 ferritn-724* trf-131* 03:32am blood hapto-299* . thyroid: 08:13am blood tsh-0.66 08:13am blood free t4-1.2 . cortisol: 08:13am blood cortsol-56.6* . hepatitis labs: 08:13am blood hbsag-negative hbsab-negative hav ab-positive igm hbc-negative igm hav-negative 08:13am blood hcv ab-negative . discharge labs: 03:03am blood wbc-13.0* rbc-3.34* hgb-11.1* hct-32.2* mcv-97 mch-33.1* mchc-34.3 rdw-16.3* plt ct-211 02:06am blood pt-13.7* ptt-27.9 inr(pt)-1.2* 03:03am blood glucose-77 urean-53* creat-1.2 na-132* k-4.2 cl-94* hco3-30 angap-12 05:31am blood alt-238* ast-56* 02:06am blood calcium-8.0* phos-4.4 mg-1.8 . vancomycin on discharge: 08:10am blood vanco-22.8* (trough) . micro: 4:00 am blood culture site: arm **final report ** blood culture, routine (final ): presumptive peptostreptococcus species. isolated from one set only. anaerobic bottle gram stain (final ): gram positive cocci in pairs, chains, and clusters. . 10:00 pm catheter tip-iv source: right ij. **final report ** wound culture (final ): staphylococcus, coagulase negative. >15 colonies. coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. staphylococcus, coagulase negative. >15 colonies. second morphology. coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus, coagulase negative | staphylococcus, coagulase negative | | clindamycin-----------<=0.25 s <=0.25 s erythromycin---------- =>8 r =>8 r gentamicin------------ <=0.5 s <=0.5 s levofloxacin---------- =>8 r =>8 r oxacillin------------- =>4 r =>4 r rifampin-------------- <=0.5 s <=0.5 s tetracycline---------- <=1 s 2 s vancomycin------------ 2 s 2 s . ct abd/pelvis: 1. dense bibasilar pulmonary consolidations in the lower and less so right middle lobes, most likely reflecting multifocal pneumonia. given the location, component of aspiration cannot be excluded. follow-up with cxr is recommended. 2. mild peripancreatic edema adjacent to the pancreatic head and body. correlation with laboratory evaluation is advised to exclude pancreatitis. 3. aortic atherosclerosis. 4. unremarkable bowel anastomosis in the right lower quadrant. 5. umbilical and inguinal fat-containing hernias. 6. diverticulosis without diverticulitis. 7. age-indeterminate compression fracture of the t8 vertebral body. . cxr: in comparison with the study of , the monitoring and support devices remain in place. there again are multiple areas of increased opacification, especially in the left mid and lower lung zones, most compatible with multifocal pneumonia. small area of similar increased opacification is seen at the right base. this is superimposed upon some engorgement of pulmonary vessels consistent with increased pulmonary venous pressure. there is again prominence of both hila, which could be a manifestation of prominent perihilar edema or possibly enlargement of hilar lymph nodes. . cxr: impression: no evidence of fluid overload. bibasilar atelectasis. . echo: saline bubble contrast study was performed with cough and valsalva release as well as during rest. study was nondiagnostic due to the very suboptimal nature of the images. an intracardiac shunt can neither be ruled in nor ruled out on the basis of this study. consider tee with bubble study. impression: suboptimal image quality. nondiagnostic study . cta: 1. no acute pulmonary embolism or aortic pathology. no evidence of pulmonary avm. 2. mild-to-moderate centrilobular emphysema with upper lobe predominance. 3. improved bibasilar atelectasis. cannot exclude superimposed infection. 4. several scattered small multifocal patchy opacities, could infectious or inflammatory in etiology. mediastinal and left hilar lymphadenopathy, likely reactive. persistent bilateral pleural effusions. 5. unchanged severe t8 compression fracture without acute spinal malalignment . echo: the left atrium is normal in size. 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 structurally normal with good leaflet excursion. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. impression: suboptimal image quality. normal biventricular cavity size and global systolic function. mild mitral regurgitation. brief hospital course: 48m with copd and htn, presenting with hypoxic respiratory failure/ards and septic shock. . # ards/hypoxic respiratory failure/pneumonia. appeared to be pneumonia on presentation(aspiration vs. cap vs. hap given recent hospitalization) unlikely to be ards given focal consolidation on initital cxr. the patient was intubated prior to transfer and initially required fairly heavy ventilatory support- ac fio2 1.0 and peep 12 to keep sats in a good range. on hd3 the pt was transitioned to ps from ac with immediate improvement in serial abgs. ps and peep were able to be weaned rapidly, and the pt was extubated on hd4. post-extubation the pt was hypertensive and persistently hypoxic- this was thought to be flash pulmonary edema and responded well to nitro gtt, iv enalapril and lasix. it was thought that his hypoxia was related to a shunt phenomenon, due to the fact that his oxygen saturation did not change with large changes in his supplemental oxygen, a tte was done that was non-diagnostic due to image quality and a cta was done that ruled out a pe. his oxygen requirement continued to decrease and on the day he was transferred to the medical service he was on room air with oxygen saturations in the low 90's. on the floor, hypoxia continued to improve and patient saturated in the low 90s on either room air or 1-2 l nasal cannula. walked with pt, ate, all without sob or desaturation. discharged home with oxygen. . # septic shock. presumed pulmonary source/pneumonia- made more likely with blood cultures growing gpcs, presumably peptostreptococcus. started on broad spectrum coverage with vanc/levoflxacin/zosyn. bps rapidly improved with bolus ivf, weaned rapidly off dopamine then levophed on hd2. bps stable since then, eventually hypertensive which seems to be pts baseline. he completed a 7 day course of levo/zosyn and was transferred to the medical floor with a picc in place to complete a 14 day course of vancomycin for his gpc bacteremia. discharged home with plans for vancomycin administration q24h for 4 days more to complete the course, with pcp monitoring of vanc trough level. shock physiology had resolved, so patient was back on almost all of his antihypertensives (still holding atenolol on discharge) and without hypotension, and with improvement in his laboratory values that had previously been indicating septic shock. . # copd: patient with a history of copd, per his pcp prior to these episodes of pneumonia his pft's did not show severe copd. he was started on steroids, initially solumedrol, he left the icu on prednisone 40mg daily to complete a 14+ day taper. he will need outpatient pulmonary follow up which was scheduled for him, with a better daily regimen, so he was discharged with advair and spiriva and vna for inhaler teaching. . # arf. likely ischemic shock atn vs. prerenal. cr trended down with resolution of sepsis. . # transaminitis. likely shock liver. hep serologies negative. trended down with resuscitation. . # thrombocytopenia. unclear baseline, there seems to be some component of pancytopenia following septic event, gradually trended upward. . # leukocytosis: believed due to steroid administration. plan for outpatient vna check of cbc and faxing to pcp. . # anemia: believed d/t etoh use, septic physiology; not clinically bleeding. recommend outpatient anemia work-up. . # lower extremity edema: believed d/t post-sepsis fluid resuscitated state with fluid settling in legs; recommended leg elevation, ambulation, compression stockings, to help with mobilization of fluid. if not improving, could consider short course of lasix. medications on admission: medications (per osh and list reviewed with wife, though she was not 100% clear on all meds): - prednisone and levofloxacin 750 mg (?completed) - methadone 10 mg - hctz 25 mg daily - clonidine 0.1 mg - lisinopril 40 mg daily - verapamil 240 mg daily - atenolol 100 mg daily - lexapro 10 mg daily - doxepin 10 mg hs - gabapentin 500 mg tid - naproxen 500 mg - albuterol prn - combivent prn . medications on transfer: albuterol nebs captopril 50 tid clonidine 0.1mg doxepin 10mg po qhs colace famotidine 20mg daily gabapentin 300 mg po/ng q8h heparin sq hctz 25mg daily insulin ss ipratropium nebs lactulose q8h prn methadone 10mg metoprolol tartrate 50 mg po/ng tid morphine sulfate 2-4 mg iv q6h:prn pain prednisone 40 mg po/ng daily senna prn vancomycin 1000 mg iv q 12h verapamil 40 mg po q8h . allergies: nkda discharge medications: 1. methadone 10 mg tablet sig: one (1) tablet po bid (2 times a day). 2. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 3. clonidine 0.1 mg tablet sig: one (1) tablet po bid (2 times a day). 4. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 5. verapamil 120 mg tablet sustained release sig: two (2) tablet sustained release po q24h (every 24 hours). 6. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). 7. doxepin 10 mg capsule sig: one (1) capsule po hs (at bedtime) as needed for sleep. 8. gabapentin 100 mg capsule sig: five (5) capsule po three times a day. 9. continue 2l nasal cannula home oxygen. 10. vancomycin 1,000 mg recon soln sig: 1250 (1250) mg solution iv intravenous every twenty-four(24) hours for 4 days: starting the morning of wednesday through the morning of saturday . disp:*5000 mg solution iv* refills:*0* 11. compression stocking for bilateral lower extremity edema. 12. prednisone 10 mg tablet sig: see taper below. tablet po once a day for 13 days: 40mg daily on weds . 30mg daily for 3 days (thurs-sat, -15). 20mg daily for 3 days (sun-tues, -18). 10mg daily for 3 days (weds-fri -21). half a tablet daily for 4 days for total of 5mg daily (fri-mon -25). disp:*21 tablet(s)* refills:*0* 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*1* 14. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulized treatment inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 15. combivent 18-103 mcg/actuation aerosol sig: one (1) inhalation treatment inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. advair diskus 250-50 mcg/dose disk with device sig: one (1) inhalation inhalation twice a day. disp:*1 diskus* refills:*2* 17. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) inhalation inhalation once a day. disp:*30 capsules* refills:*2* 18. outpatient lab work on thursday lab check: vancomycin trough prior to thursday morning's vancomycin dose, cbc, chemistry 7, liver function tests, coagulation panel (pt/ptt/inr). discharge disposition: home with service facility: vna assoc. of discharge diagnosis: multifocal pneumonia copd exacerbation bacteremia shock liver septic shock acute renal failure respiratory failure discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital with respiratory distress, this was believed to be due to a pneumonia and an associated exacerbation of your copd. you were intubated, in the icu, required antibiotics, steroids, and blood pressure support. with these treatments, your respiratory status and overall clinical status improved. . continue to take your regular home medications except change the following: - start a new steroid (prednisone) taper over the 2 weeks - start vancomycin (an antibiotic), given iv once a day, for another 4 days by the visiting nurse team - stop naproxen (you were taking this for pain, but it can injure your kidneys, so don't take it until you follow-up with your primary care physician) - stop levofloxacin/levaquin and azithromycin (antibiotics you had been taking before, and now have completed the courses) - stop atenolol, because your blood pressure has been on the lower side; if you blood pressure is elevated, then you will restart this medicaiton at half dose and then up to full dose as needed - start colace, a stool softener, as needed for constipation - start advair inhalations to treat copd - start spiriva inhalations to treat copd followup instructions: please attend the following appointment with a pulmonologist (lung doctor): . name: , when: wednesday, , 2:15pm specialty: pulmonary location: medical associates address: 1st fl, n. , phone: . thursday , at 2pm - primary care physician : , address: 2621 cranberry hwy, , phone: Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Other chronic pain Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Acute and subacute necrosis of liver Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Obstructive chronic bronchitis with (acute) exacerbation Depressive disorder, not elsewhere classified Constipation, unspecified Acute respiratory failure Septic shock Hypoxemia Acute edema of lung, unspecified Mixed acid-base balance disorder Edema |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: gastrointestinal bleed, hypotension. major surgical or invasive procedure: coil embolization of left gastric artery esophagogastroduodenoscopy x2 central venous line placement to right internal jugular vein temporary dialysis catheter placement to left femoral vein radial arterial line placement history of present illness: patient is a 48 yo man h/o recent admission for pneumonia, septic shock, and bacteremia, also with history of hypertension, chronic obstructive pulmonary disease, and s/p bowel resection and anastamosis due to "kinking" 1.5 years ago, who presents from osh with gastrointestinal bleed, intubated and on two pressors. per osh report, patient presented yesterday morning to ed at osh after 4 dark bowel movements. his sbp was noted to be 80 with hct of 21.9 (down from 32.2 just one day prior to that at time of discharge from ). white count was 48 (increased from 13). patient was fluid resuscitated and transfused with two unit prbcs. yesterday afternoon, patient was noted to have increasing abdominal pain. kub was negative for free air, per report. follow-up ct showed possible sbo. sbp dropped to 40s and code blue was called. patient was intubated and transfused an additional 5u prbcs, for a total of 7u at time of transfer. in addition he was given 4u ffp for worsening coagulopathy, felt to be secondary to dic. cvl was placed and patient was started on norepinephrine and vasopressin. ngt per report was suctioning bloody fluid. in addition patient was noted to have melanotic stools in the setting of becoming increasingly coagulopathic with most recent inr 3.3 and ptt 78. his vitals at time of transfer are bp 119/87, hr 117, sat 100% on fio2 50%. most recent abg was 7.3/38/138. meds at time of transfer are iv flagyl and po vanco (for presumptive c dif), iv (unclear why), and iv vancomycin (for bacteremia from previous admission). of note, patient was recently admitted for hypoxic respiratory failure, ards and septic shock. he was intubated prior to transfer here, transiently on pressors, and extubated on the fourth hospital day. he was treated with broad spectrum antibiotics for sepsis from a presumed pulmonary source (vancomycin/levofloxacin/zosyn); in the end he completed a 7-day course of /zosyn and was discharged to complete a 14-day course of vancomycin for gpc bacteremia (peptostreptococcus on blood culture from with negative surveillance cultures). for what was felt to be a copd flair during that admission, he had been discharged to complete a 14-day course of prednisone. other issues during that admission included acute renal failure (felt to be secondary to shock atn versus prerenal) that resolved at discharge, transaminitis (felt to be secondary to shock liver), thromboctyopenia (uptrending at time of discharge). his hematocrit at time of discharge was 32, with white count of 13. past medical history: - copd - htn - depression - history of bowel resection and anastamosis due to "kinking" 1.5 years ago - history of chronic back pain s/p surgery x3 social history: - tobacco: quit smoking 1 week ago. generally smokes 1.5-2 ppd, for 30 years. - alcohol: not much in last few weeks; prior was 10 beers per day. wife denies history of withdrawals. - illicits: wife denies, including all inhalants. no recent travel. no unusual hobbies/exposures. wife reports fire down the street that occurred about 3 weeks ago. family history: parents with hypertension. father died of lung cancer. physical exam: general: intubated, sedated heent: left eye dilated and minimially reactive compared to right; bloody output from ngt neck: supple lungs: clear breath sounds anterior fields cv: rrr, tachycardic, normal s1/s2 abdomen: distended but soft ext: cold lower extremities, mottled. pertinent results: labs at admission: 02:32pm blood wbc-28.1*# rbc-2.67* hgb-8.2*# hct-22.3*# mcv-84# mch-30.7 mchc-36.8* rdw-18.4* plt ct-45*# 02:32pm blood neuts-86* bands-9* lymphs-3* monos-1* eos-0 baso-0 atyps-0 metas-1* myelos-0 nrbc-1* 02:32pm blood hypochr-normal anisocy-2+ poiklo-normal macrocy-normal microcy-1+ polychr-occasional 02:32pm blood pt-27.8* ptt-47.0* inr(pt)-2.7* 02:32pm blood glucose-247* urean-115* creat-2.7*# na-124* k-4.7 cl-86* hco3-23 angap-20 02:32pm blood alt-2694* ast-5230* ld(ldh)-* ck(cpk)-2741* alkphos-137* totbili-5.2* 02:32pm blood ck-mb-411* mb indx-15.0* ctropnt-8.33* 02:32pm blood calcium-6.1* phos-9.5*# mg-1.7 02:32pm blood d-dimer-* 12:15am blood caltibc-31* ferritn-greater th trf-24* 02:44am blood triglyc-1853* 02:32pm blood osmolal-320* 09:02am blood cortsol-168.4* 02:32pm blood vanco-15.4 studies/reports: liver ultrasound with duplex ():conclusion: this is a limited study with heterogeneous hyperechoic liver and no definite focal lesions seen, but views are technically challenging in this patient. portal vein is fully patent with forward flow. minimal perihepatic ascites is noted. brief hospital course: a 48 y/o man with history of copd and hypertension and recent admission for pneumonia and bacteremia presents with severe gib and possible sbo, currently on pressors and intubated. # hypotension and gastrointestinal bleed. patient was bleeding from ngt, bright-red blood, at time of transfer. additionally, his platelets were falling and inr/ptt were rising. he was transfused aggressively with blood products to maintain hct greater than 25, platelets greater than 50, inr greater than 2, and fibrinogen greater than 200. on the first hospital day, gi performed upper endoscopy x2 but unfortunately could not localize a bleeding source due to poor visualization of the gastric and small bowel mucosa, secondary to the abundance of blood. there were no esophageal varices. on the night of the first hospital day, patient went to interventional radiology where angiography revealed bleeding source in the left gastric artery. the bleeding was stopped with coil embolization. after this procedure, his hematocrit stabilized somewhat, although he was still requiring (less frequent) blood transfusions. furthermore, his lactic acidosis continued to worsen. throughout all of this, he was treated with broad spectrum antibiotics for gi flora, proton-pump inhibitor drip, stress-dose steroids, and norepinephrine titrated to maintain map >65. # lactic acidosis. his lactic acidosis improved initially, particularly after the ir-guided coil embolization. however, on the second to third hospital day, the lactic acidosis worsened. patient was started on cvvhd when serial abgs revealed worsening acidemia. there was no clear cause for his worsening acidemia. it was felt that the combination of findings may have been due to propofol infusion syndrome, especially in light of the worsening hypertriglyceridemia. # respiratory failure. patient was intubated for airway protection in the setting of code blue for worsening hypotension. ventilation settings were increased in an effort to compensate for the worsening metabolic acidosis, but ultimately he required cvvhd. # coagulopathy. his coagulopathy was felt to be secondary to dic. this improved initially but at time of death was worsening. # transaminitis. initially this was felt to be secondary to shock liver from hypotension during the code blue arrest at osh. his liver enzymes improved and then worsened on the second and third hospital day. liver was consulted and recommended for right upper quadrant ultrasound; this showed no evidence of portal venous clot. his liver function continued to worsen up until time of death. # acute kidney injury and hyponatremia. likely secondary to hypovolemia and prerenal azotemia. his renal function continued to worsen, possibly due to atn and/or increasing intra-abdominal pressure (from blood product infusion and capillary leak). he started cvvhd on the third hospital day. # chronic obstructive pulmonary disease. he was treated with bronchodilator inhalers standing and prn and stress-dose steroids. # elevated cardiac enzymes and ekg changes. patient had elevated troponins and ekg changes suggestive of global ischemia. additionally, there was frequent ectopy and runs of nsvt on telemetry. cardiology was consulted and recommended against starting amiodorone. electrolytes were repleted aggressively. unfortunately echocardiogram could not be obtained given his clinical instability. # goals of care. a meeting was held between family and primary icu team on the third hospital day. given that patient was not improving, and that he was requiring increasing doses of pressors and blood products with worsening liver, renal and cardiac function, his family decided to change goals of care to comfort measures only. he passed away on sunday . his family provided consent for post-mortem autopsy. medications on admission: - methadone 10 mg - hctz 25 mg daily - clonidine 0.1 - lisinopril 40 mg daily - verapamil 240 mg daily - escitalopram 10 mg daily - doxepin 10 mg qhs - gabapentin 500 mg tid - vancomycin 1250 mg qday through - prednisone taper to end on - docusate - albuterol nebs q4h prn - advair diskus 250-50 - spiriva 18 mcg once daily discharge medications: deceased. discharge disposition: expired discharge diagnosis: deceased. discharge condition: deceased. discharge instructions: deceased. followup instructions: deceased. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Other endoscopy of small intestine Hemodialysis Venous catheterization for renal dialysis Arterial catheterization Endoscopic control of gastric or duodenal bleeding Arteriography of other intra-abdominal arteries Transcatheter embolization for gastric or duodenal bleeding Diagnoses: Acidosis Hypocalcemia Unspecified essential hypertension Acute and subacute necrosis of liver Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Depressive disorder, not elsewhere classified Paroxysmal ventricular tachycardia Acute respiratory failure Defibrination syndrome Cardiogenic shock Hemorrhage of gastrointestinal tract, unspecified Hypovolemia Acute myocardial infarction of other specified sites, initial episode of care Unspecified intestinal obstruction Diverticulosis of colon (without mention of hemorrhage) Other and unspecified alcohol dependence, continuous Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] |
allergies: wellbutrin / ciprofloxacin attending: chief complaint: altered mental status major surgical or invasive procedure: percutaneous nephrostomy tube (left) history of present illness: ms. is a 64 year old female transferred from for altered mental status and hyperkalemia. she was originally seen by her pcp after her husband found her with ams. her pcp had found elevated potassium and sent her to the ed at . there she was delirious and removed her pivs. at that time she reported abdominal pain and ct of the abdomen should left-sided hydroureter and hyrdonephrosis near the surgery site from prior colostomy. she also had a positive urinalysis and was given flagyl 500mg iv and ceftriazone 1g iv. the gynecologic oncologists at who had performed her initial surgery evaluated her and felt it was not related to her procedure. she also had a head ct showing no intracrainal hemorroage. she was given 10mg haldol and ativan 2mg and there was concern for a proglonged qtc. cr was acutely elevated to 2.8. a foley was placed and she was transferred to . of note, her son died a week ago of possible suicide. in the ed, initial vitals were: 99 57 189/90 16 100%rat. patient had a piv placed. she required a possey for restraints and removed 3 pivs. ekg showed qtc with 452. on the floor, pt was very confused and unable to answer most questions except for yes or no, but not always appropriately. past medical history: hospital admission for rectal bleeding -clear cell vaginal ca s/p resection with descending colostomy; finished xrt 3 months ago -type 2 dm -htn -gerd -hypercholesterolemia -endometriosis s/p exploratory laparotomy, lysis of adhesions, resection of left pelvic lymph nodes; had a hysterectomy and uso in for the endometriosis oncologic history clear cell vaginal ca - presentation: with vaginal bleeding stage iiib, fungating mass at vaginal cuff with ext to pelvic sidewall on the left side and posteriorly to the rectosigmoid, but not through the muscularis. - pet scan revealed a 4.5 x 4.0 cm fdg avid mass superior to the left side of the vaginal cuff. no abnormal fdg focus was identified elsewhere. - underwent 6 wks cisplatin and daily xrt - per tumor board rec, s/p exlap, resection of pelvic nodes, and diverting colostomy and s/p interstitial implants for brachytherapy - implants did not penetrate tumor - s/p colostomy by dr. - disease ext to the serosal surface of the bowel - underwent cyberknife rt social history: lives with husband. she denies tobacco, drug, or alcohol use. no h/ . family history: her mother had breast cancer in her 50s. physical exam: on admission: vitals: t: 98.3 bp: 189/90 p: 98 r: 18 o2: 100% general: not orietated, somulent, opens eyes to voice, only answers yes or no, not always appropriate, no acute distress heent: sclera anicteric, dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi back: no cva tenderness cv: regular rate and rhythm, normal s1 + s2, systolic murmur loudest at llsb abdomen: soft, slightly tender in left quadrant, non-distended, bowel sounds present, gu: foley present ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: ct ab/pelvis impression: 1. left hydronephrosis and hydroureter to a moderate degree with transition at the left cuff soft tissue mass and surgical clips/fiducial seeds. 2. left vaginal cuff mass that is poorly defined without contrast but inseparable from the left posterior lateral aspect of the bladder, the left anterolateral aspect of the rectum, the sigmoid colon, the left levator ani, the left superior obturator internis and possibly the left sciatic nerve. it is uncertain how much of this is tumor versus scarring. 3. cholelithiasis without evidence of cholecystitis. 4. a 1.8 cm segment 4a liver lesion is likely a cyst but incompletely characterized in this patient with known cancer. 12:17pm urine rbc-0-2 wbc-* bacteria-occ yeast-none epi-<1 12:17pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-sm urine culture (final ): <10,000 organisms/ml mixed bacterial flora ( >= 3 colony types), consistent with fecal contamination. admission labs: 12:17pm wbc-8.5 rbc-2.96* hgb-8.1* hct-25.9* mcv-87 mch-27.4 mchc-31.3 rdw-14.0 12:17pm plt count-383 12:17pm glucose-90 urea n-17 creat-2.3* sodium-140 potassium-3.5 chloride-103 total co2-24 anion gap-17 discharge labs: 05:38pm blood wbc-8.4 rbc-3.25*# hgb-9.5*# hct-28.9*# mcv-89 mch-29.1 mchc-32.7 rdw-14.4 plt ct-417 06:09am blood glucose-92 urean-12 creat-1.5* na-140 k-3.6 cl-109* hco3-25 angap-10 brief hospital course: 64 year old female with h/o vaginal clear cell ca who presented to with ams, elevated potassium, and acute renal failure and was found to have hydroureter and obstruction. she was originally admitted to the medical icu and then transferred to the floor for further care. # acute renal failure/renal obstruction: her creatinine on admission was 2.8 on presentation to and she was hyperkalemia. ct abdomen showed hydroureter on the left side and she had a positive urinalysis. her renal failure was thought to be both prerenal and caused by obstruction. she received a percutaneous nephrostomy tube on the left side by interventional radiology without complication. she also received iv fluids and her creatinine trended down to 1.5 on discharge. she also had a positive urinalysis at and was started on treated with cefepime for a complicated obstructive uti. she will need at least two weeks of treatment with cefepime depending on the duration of her nephrostomy tube and when her urine cultures are clear. she was discharged with iv antibiotics and was instructed to continue her antibiotics for a least two weeks until she is seen by ir for possible internalization of her nephrostomy tube. there is some concern that recurrence of her cancer is causing obstruction on the left side, and further imaging/workup will likely be needed as an outpatient. # altered mental status: she was acutely delirious on admission, likely from her uti, renal obstruction, hyperkalemia, and uremia. her ams resolve with treatment of her renal failure and hyperkalemia. she had a negative head ct and had returned to baseline mental status at the time of discharge. # hypertension: she was hypertensive throughout her admission. initially her home dose of lisinopril was held due to acute renal failure. however, as her renal failure resolved it was restarted prior to discharge. she was also started on amlodipine for closer bp control. she still had high blood pressures (190's/90's), typically at night, throughout the hospitalization and was managed occasionally with iv hydralazine. she remained asymptomatic during these episodes. # type 2 diabetes mellitus: she was managed on an insulin sliding scale and her metformin was held during her stay. it was restarted at discharge. # anemia: she has a history of anemia. her hematocrit trended down slightly during her stay, thought to be related to her nephrostomy tube procedure. prior to discharge, she received 1 unit of blood with an appropriate bump in her hematocrit. she should have her hematocrit checked as an outpatient. she did not have any episodes of rectal bleeding during this admission. # hyperkalemia: resolved with ivf and resolution of her renal failure. she was monitored on telemetry for any ecg changes associated with increased potassium but did not have any. # vagnial cancer: she is status-post treatment but there is some concern for recurrence vs scarring on the outside hospital ct scan. she is concerned about possible recurrence and will need close follow-up with surgery or gynecologic oncology. her fentayl patch was continued while in house. # history of gi bleed: she has a recent history of rectal bleeding, but had no episodes during her stay. she was continued on her home ppi. # depression/anxiety: she recently lost her son to suicide and expressed some depressive symptoms such as sadness and some lack of energy. she was continued on her home dose of citalopram and discharged on her home ativan. she was encouraged to follow-up with a mental health provider. # communication: with patient and her husband ; cell: # code: she was dnr/dni during this hospitalization, confirmed on admission to the floor medications on admission: citalopram 40mg qday fentanyl 12mcg/hr patch q72 h lisinopril 40mg qday lorazepam 1mg prn q6h for nausea metformin 500mg metoprolol 100mg morphine 15mg q4h prn pain omeprazole 20mg qday ondansetron 8mg tid prn nausea miralax qday coalce 200mg discharge medications: 1. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush. disp:*100 ml(s)* refills:*0* 2. cefepime 1 gram recon soln sig: 0.5 g intravenous once a day. disp:*15 doses* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. miralax 17 gram powder in packet sig: one (1) dose po once a day as needed for constipation. 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). disp:*40 tablet(s)* refills:*0* 7. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). 8. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 9. fentanyl 12 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 10. morphine 15 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 11. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 12. zofran 8 mg tablet sig: one (1) tablet po three times a day as needed for nausea. 13. lorazepam 1 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. 14. metformin 500 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home with service facility: home care solutions discharge diagnosis: primary diagnosis: acute renal failure secondary diagnoses: altered mental status hypertension type ii diabetes discharge condition: good, ambulating independently, vital signs stable discharge instructions: you were admitted to the hospital with altered mental status and acute kidney failure. you initially went to the intensive care unit and were given iv fluids and had a nephrostomy tube (a tube from your kidney to your skin) placed. in addition, your potassium level was very high. your kidney failure and your high potassium resolved. you were also found to have a urinary tract infection at an outside hospital and you are now being treated with iv antibiotics. changes to your medications: added amlodipine 10mg po daily (for blood pressure) added cefepime 500mg iv daily until your primary care doctor l radiologist tells you that you can stop. if you experience any chest pain, shortness of breath, altered mental status or confusion, call 911 or go to the hospital immediately. if you have fevers, abdominal pain, diarrhea, constipation or other symptoms, go to the hospital or call your primary care doctor. it is important that you go to your follow-up appointments as scheduled. you need to be treated with antibiotics for at least two weeks until your urine cultures are clear or until your nephrostomy tube is removed. you will need to follow-up with your primary provider or interventional radiology to ask when to stop taking your antibiotics. you had a urine culture drawn before you left the hospital that is still pending at this time. in addition, your blood count (hematocrit) was low during your hospitalization. you were given one unit of blood before discharge. it is important that you have your hematocrit checked when you visit your primary care doctor. you should also have your kidney function (creatinine) and blood pressure checked as you had high blood pressure during your hospitalization and you were started on a new blood pressure medication. followup instructions: you have the following appointments: provider: , md phone: date/time: 11:30 provider: , md phone: date/time: 3:30 provider: , md phone: date/time: 2:45 you should also follow-up with interventional radiology (ir). their office will be in contact with you regarding a follow-up appointment. if you do not hear from them in the next 2-3 days, please call their office to make an appointment. md, Procedure: Percutaneous nephrostomy without fragmentation Diagnoses: Hyperpotassemia Anemia, unspecified Esophageal reflux Pure hypercholesterolemia 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 Dysthymic disorder Hydronephrosis Colostomy status Personal history of malignant neoplasm of other female genital organs Secondary malignant neoplasm of large intestine and rectum Other ureteric obstruction |
allergies: codeine attending: chief complaint: shortness of breath major surgical or invasive procedure: embedded stent removal and tracheostomy. history of present illness: 52f with dwarfism, asthma, chf, copd, osa on cpap and severe tracheobronchomalacia s/p tracheal stent x2 and left main bronchial stent x1 on . on she was hospitalized at for respiratory distress with increased dyspnea and fever, diagnosed with pneumonia and chf started empiric treatment with vancomycin, cefepime and levofloxacin, cultures postive for staph, plus diuresis. on left main bronchus stent was removed. patient was transferred to for further evaluation and management. a rigid bronchoscopy was performed on . the metal stents were visualized in the trachea but were unable to be removed as extensive granulation tissue was present and the stents were embedded. thoracic surgery is consulted for stent removal and possible tracheoplasty. past medical history: dwarfism syndrome, glaucoma, asthma, copd, chf, osa on cpap 13 cm of h2o, osteoporosis social history: lives in with her husband. occupation attorney smoking history quit 4-5 years ago after ~15-20 pack family history: father and son with the same syndrome physical exam: vs: temp: 99.1, bp 93/51, pulse 100-110 st reg rr 30 97% on 50% tc pe: gen: pleasant resting in her hospital bed in nad lungs: wheezed and rales t/o bilaterally cv: rrr s1, s2, no mrg abd: soft, nt, nd ext: warm, no edema iv: right picc intact without redness, purulence or drg pertinent results: cxr on 1. bilateral parenchymal opacity most likely pneumonia, increased on the right side and improved on the left. 2. airless appearance of the trachea and bronchi most likely related to underlying tracheobronchomalacia as well as postoperative edema-secretions. 01:56am blood wbc-5.8 rbc-3.38* hgb-9.8* hct-30.2* mcv-89 mch-29.0 mchc-32.4 rdw-15.0 plt ct-411 01:56am blood glucose-117* urean-12 creat-0.6 na-142 k-3.9 cl-101 hco3-35* angap-10 brief hospital course: mrs. was transferred from to where she underwent bronchoscopy which revealed embedded stents. the patient was taken to the operating room on and had stents removed with tracheostomy by dr. . the patient was taken to the sicu for further recovery. her future goals are for tracheoplasty scheduled , however she is being transfered as cleared by dr. and dr. to on for vent rehab and weaning to prepare for surgery. below is her systems hospital course: neuro: a and o x 4. had issues with anxiety due to airway secretion management and spasms. psychiatry was heavily involved and recommended fluoxetine 40 mg daily and prn ativan for anxiety. the patient is currently controlled on this regime. respiratory: completed a seven day course of levofloxacin for pna. sputum cx on were negative despite some radiologic concern for pna. the patient has been afebrile without wbc elevation. trach collar 45% during day and cpap at night to rest, only required 2 hrs of cpap night. the patient should have lower cpap pressures in rehab. the patient had a bronchoscopy showing distally, there were thin secretions in both bronchial trees and these were aspirated. heent: speech and swallow evaluated the patient recommending electrolarynx for communication but no passey muir valve. the patient can eat soft solids and thin liquids with cuff deflated. cal counts recommended. the patient should have 3 ensure cans a day for nutrition. cv: hx chf, however unknown lvef. no echo done inhouse, and no outside reports available. stable cardiac rhythm. lasix/kcl per home dosing. no edema. will need rehab lyte monitoring. abd: refused dobhoff. see heent. having normal bm- last on date of transfer id: no active id issues. completed 7 day course of levofloxacin for pna. ohs cx showed + s.aureus sensitivy to all but pcn. also completed 7 day course of acyclovir for gluteus herpes. line: right picc placed . does not need picc after arrival, but kept for acls transport. please dc on arrival. thanks. discharge medications: 1. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: three (3) ml inhalation q4h (every 4 hours). 2. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 3. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) unit injection tid (3 times a day): subcutaneous. 4. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 5. lidocaine (pf) 10 mg/ml (1 %) solution sig: 2.5 mls injection q4h (every 4 hours) as needed for spasm. 6. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 7. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 8. lorazepam 1 mg tablet sig: 0.5-2 tablets po q4h (every 4 hours) as needed for anxiety. 9. fluoxetine 20 mg capsule sig: two (2) capsule po daily (daily). 10. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for cough. 11. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4h (every 4 hours) as needed for pain. 12. acetaminophen 160 mg/5 ml solution sig: twenty (20) ml po q6h (every 6 hours) as needed for pain. 13. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 14. potassium chloride 10 meq tablet sustained release sig: one (1) tablet sustained release po once a day: take only while taking lasix. may need adjustment based on potassium and lasix dosing. 15. vitamin d 50,000 unit capsule sig: one (1) capsule po once a day. 16. fosamax 70 mg tablet sig: one (1) tablet po once a week. discharge disposition: extended care facility: - discharge diagnosis: tracheobronchomalacia dwarfism syndrome asthma obstructive sleep apnea copd chf glaucoma chf discharge condition: stable discharge instructions: walk three times a day. call if fevers, chills, difficulties breathing, or any questions. cpap at night, trach collar during day- wean to trach collar and off ventilator, aggressively. followup instructions: on in cdc you have an appointment with dr. 10:30, dr. 11:00, followed by bronchoscopy. call if you have questions: . do not eat or drink after midnight prior to seeing us, for your bronchoscopy. md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Fiber-optic bronchoscopy Temporary tracheostomy Bronchoscopy through artificial stoma Bronchoscopy through artificial stoma Diagnoses: Obstructive sleep apnea (adult)(pediatric) Congestive heart failure, unspecified Unspecified glaucoma Anxiety state, unspecified Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Osteoporosis, unspecified Methicillin susceptible pneumonia due to Staphylococcus aureus Mechanical complication due to other implant and internal device, not elsewhere classified Rash and other nonspecific skin eruption Unspecified accident Chronic obstructive asthma, unspecified Injury to bladder and urethra, without mention of open wound into cavity Hematuria, unspecified Other diseases of trachea and bronchus Unspecified adjustment reaction Dwarfism, not elsewhere classified |
allergies: codeine attending: chief complaint: tracheobronchomalacia major surgical or invasive procedure: - flexible bronchoscopy with aspiration, thoracic tracheoplasty with mesh, right mainstem bronchus/bronchus intermedius, bronchoplasty with mesh, left mainstem bronchus, bronchoplasty with mesh. history of present illness: mrs. is a pleasant 52 year old woman with dwarfism, asthma, chf, copd, osa on cpap and severe tracheobronchomalacia, who recently underwent embedded tracheal stent removal in the operating room on with tracheostomy by dr. with plan for tracheobronchoplasty on a future admission. the patient states she has progressed well in rehab without any major issues. she had a mucus plug last saturday requiring aggressive pt for 45 minutes, resolving with nebulizers and suctioning. otherwise has been discharged from pt/ot, is ambulating, caring for herself, and on ra, without any major shortness of breath. she denies any fevers or active id issues. past medical history: dwarfism syndrome, glaucoma, asthma, copd, chf, osa on cpap 13 cm of h2o, osteoporosis social history: lives in with her husband. occupation: attorney. smoking history quit 4-5 years ago after ~15-20 pack-years. two sons. family history: father and son with the same syndrome physical exam: avss gen: pleasant, nad cv: rrr chest: mild expiratory wheezes at bases bilaterally; no rhonchi or rales abd: soft, nondistended ext: wwp, 1+ edema in feet bilaterally pertinent results: - cxr: the tracheostomy is in place with its tip approximately 5.3 cm above the carina. the right chest tube was inserted after recent surgery. the fifth rib is partially resected as a part of the surgery as well. there is no evidence of pneumothorax. the lungs are well aerated bilaterally. there is no appreciable pleural effusion. cardiomediastinal silhouette is unremarkable. the epidural anesthesia catheter tip is projecting over the level of the t10. right chest wall subcutaneous air is small. - cxr: findings: in comparison with the study of , there is again a small right apical pneumothorax, with area of consolidation involving the right upper and lower lung zones. there may also be a small patchy area of opacification in the retrocardiac region on the left. tracheostomy tube remains in place. of incidental note is gas within soft tissues along the lower right chest and upper abdomen wall. - wbc 7.5 hct 34.2 plt 375 brief hospital course: ms. was admitted to the sicu on following her tracheobronchoplasty. the following is a summary of her hospital course from until her discharge to rehab on : neuro: epidural placed prior to surgery on was split to bupivicaine and a dilaudid pca on pod #1 for optimization of pain control. her postoperative pain control regimen was expanded to include toradol, as well as po tylenol and ultram once she was tolerating pos, and she was ultimately transitioned to ms contin with percocet for breakthrough pain. her pain control did improve steadily however she continues to have some discomfort at the incision site, especially with coughing or movement. cv: she was hemodynamically stable throughout this admission, and she was started on her home dose of lasix. resp: aggressive pulmonary toilet was initiated immediately postop, and she was weaned off cpap to trach mask on pod #1. she continued to tolerate trach mask for increasing periods of time each postoperative day, and at time of discharge she was requiring only minimal periods of cpap support overnight. she was proactive in using her incentive spirometer and getting out of bed. she continued to have a moderate amount of clear secretions and underwent a bronchoscopy on which did not demonstrate any abnormality or mucus plugging. she was continued on her home nebulizer treatments. gi: she was kept npo following surgery until she underwent a formal speech and swollow evaluation on . her diet was advanced to pureed solids and thin liquids at that time, which she tolerated well. gu: foley catheter was discontinued following removal of the epidural catheter, and she voided on her own without difficulty. she was continued on her home dose of lasix 20mg po daily. heme: she remained hemodynamically stable throughout the admission and did not require any transfusions of blood products; her discharge day hct was 34.2. id: she received 3 doses total of perioperative cefazolin. she had a low-grade fever of 101.3 on pod #1 which was treated with tylenol. blood cultures and urine cultures were sent on which demonstrated no growth, and she remained afebrile with a normal wbc from pod #2 until the time of discharge. endo: she was started on an insulin sliding scale in the perioperative period though her blood sugars remained normal or near-normal and insulin was not required. tubes/lines/drains: a right-sided chest tube was removed on and cxr demonstrated a tiny pneumothorax which remained stable on cxr over the next two days. at time of discharge she has a peripheral iv and a tracheostomy tube. prophylaxis: she was maintained on heparin 5000 units sc tid for pe prophylaxis and she continued her home omeprazole for gi prophylaxis. medications on admission: 1. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: three (3) ml inhalation q4h (every 4 hours). 2. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 3. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) unit injection tid (3 times a day): subcutaneous. 4. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 5. lidocaine (pf) 10 mg/ml (1 %) solution sig: 2.5 mls injection q4h (every 4 hours) as needed for spasm. 6. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 8. lorazepam 1 mg tablet sig: 0.5-2 tablets po q4h (every 4 hours) as needed for anxiety. 9. fluoxetine 20 mg capsule sig: two (2) capsule po daily (daily). 10. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for cough. 11. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4h (every 4 hours) as needed for pain. 12. acetaminophen 160 mg/5 ml solution sig: twenty (20) ml po q6h (every 6 hours) as needed for pain. 13. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 15. vitamin d 50,000 unit capsule sig: one (1) capsule po once a day. 16. fosamax 70 mg tablet sig: one (1) tablet po once a week. 17. protonix 40 mg po daily discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 3. salmeterol 50 mcg/dose disk with device sig: one (1) disk with device inhalation q12h (every 12 hours). 4. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 5. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for anxiety, insomnia. 6. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 7. tramadol 50 mg tablet sig: one (1) tablet po qid (4 times a day). 8. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 9. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 2-6 puffs inhalation q4h (every 4 hours). 10. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for cosntipation. 13. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for contipation. 14. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 15. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 16. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 17. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). 18. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. discharge disposition: extended care facility: - discharge diagnosis: tracheobronchomalacia discharge condition: stable; mental status fully intact, ambulating with assistance discharge instructions: weigh yourself every morning, md if weight goes up more than 3 lbs. please call dr. office or return to emergency room if you epxerience fevers, chills, nausea/vomiting, chest pain, shortness of breath, or increased drainage or redness around your incision sites. followup instructions: please call dr. office to schedule a follow-up appointment in 2 weeks. call . Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Other intubation of respiratory tract Other repair and plastic operations on trachea Other repair and plastic operations on bronchus Bronchoscopy through artificial stoma Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Diagnoses: Obstructive sleep apnea (adult)(pediatric) Congestive heart failure, unspecified Unspecified glaucoma Iatrogenic pneumothorax Osteoporosis, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Chronic obstructive asthma, unspecified Tracheostomy status Other diseases of trachea and bronchus Other specified congenital anomalies Dwarfism, not elsewhere classified Postprocedural fever |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: diarrhea, shortness of breath major surgical or invasive procedure: ir-guided picc line history of present illness: 89 year old male with h/o dm, htn, ra, cri presents from home with severe diarrhea x5 days. he recently was treated with po vancomycin at rehab for c.diff colitis although was discharged home and the medication was never filled so didn't complete the course. yesterday his daughter called his pcp for and po vancomycin was restarted. last night the patient felt weak and fell; although denies loc/hitting head. this morning he was going to the bathroom and felt weak and sob; felt unable to get up. he denies any chest pain or palpitations. denies any recent fevers/chills, nausea or vomiting. does endorse poor po intake over past few days. of note, the patient was admitted for pneumonia treated with vanc/cefepime/azithromycin. initially in the ed at triage he was noted to be hypoxic and hypotensive but pink/warm; he was given fluids and placed on a nrb. vitals were:97.0 84/50 hr 60 rr 16 90% on 100%face mask-->after fluids bp improved to 105/47. a cxr was done which showed possible blunting at left cp angle/haziness at left base. labs notable for wbc 17.4, lactate 2.8, bun 77, cr 2.8 (up from baseline 1.3). ekg was nsr with new twi v1-v3, trop 0.11. he was given 4liters ns and sbp improved to 100s. he was also given a dose of levofloxacin. the patients daughter also reported a fall yesterday thus ct head/cspine done which were both negative. the patient was noted to have his o2 sat drop to 70s on room air when sleeping and thus there was concern so admitted to micu for closer monitoring. currently, 97/60 hr 64 rr 15 98%ra. ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: type 2 diabetes mellitus hypertension chronic renal failure, stage ii rheumatoid arthritis bph s/p turp s/p appendectomy s/p uvula polypectomy s/p back surgery with ivc filter placement cervical stenosis mitral regurgitation chronic le edema social history: patient denies current tobacco use, but has a 10 pack year smoking history, quit in . no alcohol. patient was married, but his wife passed away . he is currently living at , but his daughter is reconfiguring the house so that he can move into the lower floor apartment. previously, he was upstairs and she was downstairs. family history: father with leukemia and his mother died of "old age". his brother died with als. his son died of leukemia as well. physical exam: 97.2 99/46 22 94% ra general: comfortable in bed heent: perrl, mm slightly dry, sclera anicteric neck: no jvd cardiac: rrr, 2/6 sem lung: clear bilaterally abdomen: soft, nt, nd +bs in all 4 quadrants, no rebound/guarding ext: 1+ edema bilaterally, venous statis changes with mild erythema b/l, no warmth neuro: a&ox3 pertinent results: ================== admission labs ================== wbc-17.4*# rbc-3.79* hgb-11.3* hct-36.0* mcv-95 mch-29.8 mchc-31.5 rdw-14.8 plt ct-249 neuts-61 bands-30* lymphs-3* monos-4 eos-0 baso-0 atyps-1* metas-1* myelos-0 hypochr-normal anisocy-occasional poiklo-normal macrocy-normal microcy-normal polychr-normal pt-14.6* ptt-35.7* inr(pt)-1.3* glucose-74 urean-77* creat-2.8*# na-138 k-4.7 cl-102 hco3-22 angap-19 alt-36 ast-59* ld(ldh)-209 ck(cpk)-279 alkphos-93 totbili-0.5 ck-mb-15* mb indx-4.3 ctropnt-0.11* albumin-2.6* calcium-7.9* phos-5.0* mg-2.1 lactate-2.8* k-4.6 ------------- microbiology ------------- . : stool positive for c diff toxin. culture negative. : ova and parasites neg urine culture negative, pending blood culture , , negative . ------------- radiology ------------- . ct c-spine: () no evidence of acute fracture or acute misalignment of the cervical spine on the background of severe degenerative change as described above. a few foci of air in the visualized soft tissues may be within the venous structures or subcutaneous tissues related to intravenous injection or trauma. in case of clinical concern for underlying severe injury or infection, a chest ct can be obtained to evaluate the extent of this gas. partially imaged areas of ground-glass opacity in bilateral lung apices. mild subcutaneous soft tissue edema. in case of clinical concern for cord or ligamentous injury, an mri of the cervical spine is suggested. stable c1-2 pannus formation narrowing the craniocervical junction. the study and the report were reviewed by the staff radiologist. . non-contrast head ct: () there is no intracranial hemorrhage, mass effect, or -white matter differentiation abnormality. multiple focal areas of hypodensity in the subcortical, periventricular, and subinsular region are most compatible with chronic ischemic small vessel disease. prominence of the ventricles and cerebral sulci are most compatible with age-appropriate volume loss. intracranial arterial calcifications especially in the carotid arteries are noted. there is no evidence of fracture. mucous retention cyst in the left sphenoid sinus (2:8) is stable. there is mild to moderate mucosal thickening in bilateral frontal and ethmoid sinus air cells. there is a right bullosa. impression: 1. no acute intracranial abnormality. 2. mucosal sinus disease . ct abd/pelvis : the evaluation is limited without intravenous contrast. at the lung bases, small-to-moderate sized bilateral pleural effusions with associated compressive atelectasis have increased in size. contrast is seen within the distal esophagus and there is a moderate-sized hiatal hernia. the liver, spleen, and adrenal glands are unremarkable. there are multiple hypo- and hyper-dense lesions within both kidneys. the largest is an exophytic hypodense lesion measuring 4.4 x 4.2 cm arising off the lower pole of the left kidney. additional hyperdense lesions are not characterized on this examination and are best evaluated on the renal ultrasound of . the gallbladder appears distended, however, the wall is not appreciably thickened. a small 3-mm focus of soft tissue attenuation is seen in the right upper quadrant, adjacent to the region of the anterior gallbladder wall and the peritoneum. abdominal loops of small bowel appear unremarkable. the amount of intra-abdominal ascites continues to increase. the abdominal aorta is tortuous and calcified. there is an infrarenal ivc filter which appears collapsed. there is no pneumoperitoneum or pneumatosis. there is persistent wall thickening of the transverse, descending and sigmoid colon. ct pelvis without intravenous contrast: there is extensive sigmoid diverticulosis with wall thickening, which is unchanged. air within the bladder is likely secondary to recent foley catheter placement. the prostate gland appears unremarkable. there is a small amount of fluid within the pelvis. there is anasarca. there are extensive degenerative changes of the lumbar spine with marked s-shaped rotary scoliosis. degenerative changes are also seen in both hips. on the left, there is cortical and trabecular thickening consistent with paget's disease. mild wedging of the t10 vertebral body is unchanged. impression: 1. increased bilateral pleural effusions and ascites. 2. persistent transverse, descending and sigmoid colonic wall thickening, likely secondary to known c. difficile colitis. 3. bilateral renal cysts, some of which appear hyperdense, but are better characterized on recent ultrasound. 4. moderate sized hiatal hernia. . cxr pa and lateral : evaluation of patient with leukocytosis and history of prior pleural effusion. pa and lateral upright chest radiographs were reviewed in comparison to . the current study demonstrates contrast material within the esophagus and stomach. bibasal atelectasis had progressed in the interim with most likely interval increase in bilateral pleural effusion. upper lungs are essentially clear. cardiomediastinal silhouette is stable. the contrast material is also outlying the oropharynx. . kub : findings: there is a moderate amount of contrast seen throughout the stomach, duodenum and small bowel that is likely related to recent prior video oropharyngeal swallowing examination. there is questionable bowel thickening of the duodenem, could be related to collapsed appearance. the bowel gas pattern is otherwise unremarkable with no dilated loops of colon to suggest megacolon. no evidence of pneumoperitoneum. no soft tissue calcification or radiopaque foreign bodies. note is made of dextroscoliosis centered about the l3 vertebral body and ivc filter. in addition note is made of pelvic phleboliths. impression: no dilated loops of colon compatible with megacolon. significant amount of retained contrast seen within the small bowel and stomach likely related to recent video oropharyngeal swallowing study. questionable bowel thickening of the duodenem, could be related to collapsed appearance. . portable kub : a moderate amount of contrast is present throughout the colon and rectum, likely related to recent video swallowing study. loops of colon are well opacified with no evidence of megacolon. there is no pneumoperitoneum. severe dextroscoliosis of the lumbar spine is unchanged. there is no acute fracture or dislocation. an ivc filter is present at the l3 level. impression: no dilated loops of colon compatible with megacolon. brief hospital course: 89 y/o gentleman w/dm2, htn, cri, rheumatoid arthritis initially admitted to the icu with diarrhea leading to hypotension/hypoxia. he was given fluids and placed on a nrb. labs were notable a leukocytosis of 17.4 and arf with cr 2.8 (up from baseline 1.3). ct head and c spine were performed because daughter reported recent fall, and were negative. he received levofloxacin and was admitted to the micu, where he was treated with antibiotics and iv fluids. he was transferred to the floor on . in the days prior to micu transfer on , patient was noted to be increasingly delirious. he was initially treated with haldol, then transitioned to zyprexa. on a post-pyloric dobhoff was placed in hopes that nutrition would improve his overall status. on , patient was more somnolent and hypotensive. early , patient was noted to be difficult to rouse, with worsening hypotension and unattainable temperature. he was transferred back to the icu. upon transfer, dnr/dni status was confirmed. the patient's daughter (hcp) was contact. she relayed that she didn't want anything that would be painful or cause discomfort. no further central venous lines, arterial lines or other invasive procedures were performed. the patient became progressively more hypotensive despite iv fluids and antibiotics, and passed away peacefully on the morning of . medications on admission: glipizide 2.5mg daily omeprazole 20mg daily oxycodone - 10 mg tablet sustained release flomax 0.4mg qhs verapamil - 60mg tylenol 650mg tid aspirin 81mg daily iron 325mg daily multivitamin vancomycin po 500mg q6 discharge medications: expired discharge disposition: expired discharge diagnosis: primary diagnosis: clostridium difficile colitis hypotension secondary to hypovolemia, sepsis of unknown source acute on chronic renal failure secondary diagnoses: discharge condition: patient expired. discharge instructions: patient expired. followup instructions: patient expired. md, Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Diagnoses: Anemia of other chronic disease Mitral valve disorders Unspecified pleural effusion Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Personal history of tobacco use Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Sepsis Pulmonary collapse Diaphragmatic hernia without mention of obstruction or gangrene 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 Pneumonitis due to inhalation of food or vomitus Intestinal infection due to Clostridium difficile Other complications due to other vascular device, implant, and graft Rheumatoid arthritis Accidents occurring in other specified places Hypoxemia Hypovolemia Cyst of kidney, acquired Other venous embolism and thrombosis of inferior vena cava Chronic kidney disease, Stage II (mild) |
allergies: keflex attending: chief complaint: gib major surgical or invasive procedure: hd intubation cvl placement history of present illness: mr. a 69-year-old gentleman with a pmh significant for cryptogenic cirrhosis admitted for brbpr, arf, and ecg changes. the patient initially presented to the osh ed from his nursing home for generalized weakness. at the osh, he received narcan with good response. he was then noted to have a hct of 32.1 with associated melenic stools. at that time, ecg demosntrating x mm ste in the inferolateral leads. the patient received 2 units prbc, 1 unit ffp, 1l ivf, and was transferred to for further evaluation. . in the ed, initial vs 97.2 110 117/63 18 98%2l nc. he was noted to have gross blood in the rectal vault, and labs notable for a hct of 33.9, creatinine of 4.5 from 1.6, and a tnt of 0.2 without ck unchanged. liver was consulted, and ngl demonstrated gastric contents without gross blood or coffee grounds. cardiology was faxed the ecg, and the ste were to be stable and representign demand ischemia. the patient was transfused an additional 2 units ffp, started on a ppi gtt and octreotide gtt, had and was then admitted to the micu for further management. . of note, the patient was recently admitted to under neurosurgery from for shoulder pain felt by neurosurgery and orthopedics to be due to djd, with his hospital course complicated by a uti speciated as mrsa with treatment plan of 7d ciprofloxacin. on the day of discharge, the patient's creatinine was found to be 1.6 from 1.1-1.2 prior. past medical history: cirrochis, obestity, htn, gout, bradycardia, hypothyroidism. social history: lives at . tobacco - none. etoh - none. denies any iv, illicit, or herbal drug use. family history: nc physical exam: vs: 97 116/61 23 93%ra gen: nad heent: ngt in place cv: irregular s1+s2 pulm: ctab abd: s/nd/nd +bs hematoma over left periumbilical area ext: trace pitting edema bilaterally. signs of chronic venous stasis. neuro: oriented to person. -asterixis. right pupil with cornea and strabismus with dropped lid, chronic per patient since a child. pertinent results: 05:49pm blood wbc-3.9* rbc-2.59* hgb-8.6* hct-24.7* mcv-95 mch-33.1* mchc-34.7 rdw-17.3* plt ct-39* 03:15am blood neuts-81.5* lymphs-12.3* monos-5.2 eos-0.6 baso-0.3 05:49pm blood pt-22.5* ptt-48.2* inr(pt)-2.1* 02:47pm blood glucose-145* urean-137* creat-5.9* na-139 k-3.8 cl-106 hco3-22 angap-15 03:15am blood glucose-152* urean-130* creat-5.8* na-139 k-3.6 cl-104 hco3-20* angap-19 03:51am blood glucose-157* urean-151* creat-6.5* na-140 k-4.3 cl-109* hco3-16* angap-19 01:43pm blood glucose-156* urean-147* creat-6.7* na-140 k-4.3 cl-108 hco3-17* angap-19 11:30pm blood glucose-101* urean-103* creat-4.5*# na-132* k-5.1 cl-98 hco3-21* angap-18 03:15am blood alt-37 ast-87* alkphos-93 totbili-2.2* 09:18pm blood ck-mb-2 ctropnt-0.19* 12:21pm blood ck-mb-2 ctropnt-0.19* 11:30pm blood ctropnt-0.20* 02:47pm blood calcium-8.9 phos-5.2* mg-2.6 12:21pm blood caltibc-109* ferritn-599* trf-84* 12:21pm blood hbsag-negative hbsab-negative hbcab-negative hav ab-negative 12:21pm blood ama-negative smooth-positive * 06:02am blood crp-156.3* 12:21pm blood -negative 04:38pm blood pep-polyclonal igg-3110* iga-1482* igm-65 ife-no monoclo 08:58pm blood type-art po2-60* pco2-48* ph-7.49* caltco2-38* base xs-11 tte (): the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). 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 masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. no mass or vegetation is seen on the mitral valve. the pulmonary artery systolic pressure could not be determined. there is a moderate sized pericardial effusion. in supine position, there is little fluid around the apex and lateral lv, but ~2 cm posterior to the right atrium. there is very brief right atrial diastolic collapse without any echocardiographic signs of tamponade. impression: no vegetations seen. mild aortic regurgitation. mild symmetric lvh with vigorous biventricular systolic function. pericardial effusion as described above. ct chest: 1. bilateral basal lung consolidation / atelectasis. 2. cirrhotic macronodular liver with sequelae of portal hypertension with extensive splenic collaterals with splenorenal shunt and splenomegaly. no evidence for ascites. 3. no evidence for intra-abdominal free fluid, collection or abscess. 4. scattered diverticula of the sigmoid colon without evidence for acute diverticulitis. 5. incompletely characterized left lower pole hypodense lesion. renal us advised to compare with prior from as a renal abscess cannot be fully excluded. 6. non-obstructing 3mm left renal calculus cth: no acute intracranial pathology. abdominal u/s: 1. limited examination demonstrating patency of the portal vein, with hepatofugal flow. 2. marked splenomegaly.. 3. gallbladder sludge. 4. limited evaluation of the kidneys but no evidence of hydronephrosis. brief hospital course: mr. a 69 year old gentleman with a pmh significant for cryptogenic cirrhosis admitted for brbpr with hospital course complicated by acute renal failure, high grade mrsa bacteremia, and respiratory failure requiring intubation. 1. bradycardic pea arrest: patient had witnessed bradycardic pea arrest with rn at the bedside. cpr and first round of epinephrine given immediately, and pea cardiac arrest algorythmn performed with multiple rounds of epinephrine, atropine, bicarb, insulin/d50, and calcium administered. abg during cardiac arrest 7.49/48/60, k 4.5, hct 25. pericardiocentesis attempted with <5 ml blood returned. patient expired at 9:05 pm on . attending, pcp made aware. family notified and declined post-mortem exam. 2. acute renal failure: felt to be due to atn given numerous muddy brown casts. renal ultrasound did not show any vascular lesions or hydronephrosis. the patient was followed by renal during his hospitalization, and hd was attempted on but aborted in setting of hypotension. urine output initially fluid responsive, but patient became increasingly anuric during his hospital course. 3. mrsa bacteremia: patient noted to have mrsa on urine culture from neurosurgery admission 1 week prior. he was subsequently found to have a high grade mrsa bacteremia with mrsa or gpc in clusters isolated in sputum, urine, and joint arthrocentesis. patient was followed by id and plastic surgery for wrist tap. he was treated with vancomycin, dosed by level. he had a tte during his admission that did not demonstrate any vegetations, but did demonstrate a moderate sized pericardial effusion with posterior assymetry. cth, ct neck, and ct torso failed to isolate a fluid collection or abscess. 4. respiratory failure: patient was intubated during icu course given increased work of breathing and pulmonary edema in setting of renal failure. 5. gib: while gi bleed was initially impetus for icu admission, patient did not have active gi bleeding during admission. 6. cirrhosis: due to unclear etiology. hepatology followed during admission. medications on admission: allopurinol 100 mg daily hydralazine 25 mg po tid feso4 famotidine 20 mg po bid metoprolol 50 mg po bid mvi heparin sq levothyroxine 125 mcg daily bisacodyl 10 mg daily colace cipro 500 mg po bid x8 days (d/c on ) acetaminophen 500 mg po q6h senna fentaynl 100 mcg/hr patch q72h hydromorphone 2-4 mg q6h prn ibuprofen 400 mg prn bacitracin ointment discharge medications: patient expired discharge disposition: expired discharge diagnosis: patient expired discharge condition: patient expired discharge instructions: patient expired followup instructions: patient expired Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Hemodialysis Other electric countershock of heart Venous catheterization for renal dialysis Arterial catheterization Arthrocentesis Diagnoses: Acidosis Hyperpotassemia Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Urinary tract infection, site not specified Cirrhosis of liver without mention of alcohol Unspecified acquired hypothyroidism Gout, unspecified Atrial flutter Acute respiratory failure Cardiac arrest Bacteremia Blood in stool Ventricular fibrillation Obesity, unspecified Hepatic encephalopathy Hypotension of hemodialysis Other acute and subacute forms of ischemic heart disease, other Methicillin resistant pneumonia due to Staphylococcus aureus Personal history, urinary (tract) infection Physical restraints status Pyogenic arthritis, forearm Osteoarthrosis, localized, not specified whether primary or secondary, shoulder region Hemarthrosis, forearm |
allergies: fish product derivatives attending: chief complaint: several weeks of increasing dyspnea on exertion. major surgical or invasive procedure: s/p cabgx5(free lima->lad and diag 2(y graft), svg->om1, om2, diag 1) history of present illness: this 71 year old russian speaking male and several weeks of worsening chest pain. he presented to his primary care physician's office and she sent him to the mwmc ed. he was admitted and had a positive exercise tolerance test. he underwent cardiac cath which revealed: 60-70% lm stenosis, 75-80% stenosis of the first and second diagonals, 75% stenosis of the om1 and om2, and occluded rca. he was transferred to for cabg. past medical history: hypertension s/p appendectomy h/o seizures at age 20 social history: the patient lives with his wife and is retired. he does not smoke and rarely drinks alcohol. family history: the patient's father died of coronary artery disease. physical exam: discharge: vitals: 98.5 148/80 68sr 20 97% 2l nc neuro: alert, oriented, non-focal pulmonary: lungs clear to auscultation bilaterally cardiac: regular rate and rhythm sternal incision: no drainage or erythema, sternum stable abdomen: normoactive bowel sounds. soft and nontender. extremities: warm with trace edema leg incision: clean and dry pertinent results: echocardiography report , (complete) done at 1:47:44 pm final referring physician information , division of cardiothoracic , status: inpatient dob: age (years): 71 m hgt (in): 67 bp (mm hg): 123/67 wgt (lb): 185 hr (bpm): 63 bsa (m2): 1.96 m2 indication: intraoperative tee for cabg procedure. hypertension. left ventricular function. preoperative assessment. icd-9 codes: 402.90, 786.05, 786.51, 440.0, 424.0 test information date/time: at 13:47 interpret md: , md test type: tee (complete) son: , md doppler: full doppler and color doppler test location: anesthesia west or cardiac contrast: none tech quality: adequate tape #: 2008aw5-: machine: aw5 echocardiographic measurements results measurements normal range left ventricle - septal wall thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.1 cm <= 5.6 cm left ventricle - ejection fraction: 45% >= 55% aorta - ascending: 3.0 cm <= 3.4 cm findings right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness. normal lv cavity size. mild regional lv systolic dysfunction. mildly depressed lvef. no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. pulmonic valve/pulmonary artery: mild pr. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. no tee related complications. the patient appears to be in sinus rhythm. results were personally reviewed with the md caring for the patient. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions prebypass 1. no atrial septal defect is seen by 2d or color doppler. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. 3. there is mild regional left ventricular systolic dysfunction with hypokinesia of the apex, apical portion of the anterior wall and the apical portion of the anterior septum.. overall left ventricular systolic function is mildly depressed (lvef= 45 %). 4. right ventricular chamber size and free wall motion are normal. 5. there are simple atheroma in the descending thoracic aorta. 6. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 7. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 8. dr. was notified in person of the results on at 1230pm. postbypass 1. patient on no infusions 2. left venticular function appears mildly improved, with improvement of apical segments 3. aorta walls are smooth after decannulation i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 09:35 carotid series complete study date of 9:08 am , r. csurg fa6a sched carotid series complete clip # reason: preop cabg medical condition: 71 year old man preop cabg reason for this examination: carotid stenosis- please do first thing-going to or 2nd case today -thank you! final report history: pre-assessment for cardiac bypass. findings: there is minimal isoechoic plaque involving the right ica and minimal heterogeneous calcific plaque involving the left ica. the peak systolic velocities bilaterally are normal as are the ica/cca ratios. there is antegrade flow involving the left vertebral artery, the right vertebral artery is not visualized, presumed hypoplastic or occluded. impression: 1. no significant ica stenosis bilaterally (graded as less than 40% bilaterally). 2. non-visualized right vertebral artery, presumed hypoplastic or occluded. dr. approved: fri 2:43 pm imaging lab 09:19pm pt-13.2 ptt-25.9 inr(pt)-1.1 09:19pm plt count-214 09:19pm wbc-12.2* rbc-5.11 hgb-16.0 hct-44.7 mcv-88 mch-31.4 mchc-35.9* rdw-13.4 09:19pm %hba1c-6.3* 09:19pm albumin-4.6 calcium-9.6 magnesium-2.0 09:19pm ck-mb-4 ctropnt-<0.01 09:19pm lipase-39 09:19pm alt(sgpt)-36 ast(sgot)-25 ld(ldh)-184 alk phos-60 amylase-103* tot bili-0.9 09:19pm estgfr-using this 09:19pm glucose-102 urea n-20 creat-1.1 sodium-140 potassium-3.8 chloride-102 total co2-27 anion gap-15 brief hospital course: mr was transferred from mwmc after his catheterization revealed severe coronary artery disease. he was evaluated in the usual pre-operative manner. he was brought to the or on with dr and underwent coronary artery bypass grafting x 5. please see operative note for complete details. post-operatively he was brought to the cvicu for invasive hemodynamic monitoring. he was weaned from his drips and extubated on post-operative day 1. he was transferred down to the stepdown floor on the same day. he was gently diuresed towards his pre-operative weight. physical therapy was consulted to work on strength and balance. he continued to progress well and was cleared to be discharged on post-operative day 5. medications on admission: none discharge medications: 1. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours) for 7 days. disp:*14 tab sust.rel. particle/crystal(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. disp:*50 tablet(s)* refills:*0* 5. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 7. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. lasix 20 mg tablet sig: one (1) tablet po twice a day for 7 days. disp:*14 tablet(s)* refills:*0* discharge disposition: home with service facility: family care extended discharge diagnosis: coronary artery disease. hypertension discharge condition: good. discharge instructions: take medications as directed on discharge instructions. do not drive for 4 weeks. do not lift more than 10 lbs. for 2 months. shower daily, let water flow over wounds, pat dry with a towel. do not use creams, lotions, or powders on wounds. call our office for temp>101.5, sternal drainage. followup instructions: make an appointment with dr. for 1-2 weeks. make an appointment with dr. for 2-3 weeks. make an appointment with dr. for 2 weeks at office. md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of four or more coronary arteries Transfusion of packed cells Diagnoses: Acidosis Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other acquired absence of organ Family history of ischemic heart disease Epilepsy, unspecified, without mention of intractable epilepsy Chronic total occlusion of coronary artery |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: increasing pleural effusion major surgical or invasive procedure: pleurex catheter drainage history of present illness: 77m with history of recently diagnosed metastatic nsclc and known malignant right effusion, presenting with enlarging effusion at rehab, now admitted to micu with tachypnea and respiratory distress. he was diagnosed with lung cancer in now follows with dr. at hospital. in he developed acute cord compression and had decompression on . discharged to rehab. he was readmitted to from for shortness of breath with new finding of large right sided pleural effusion and a rul post obstructive pneumonia; mass abutting rul bronchus and pa. during last admission he underwent thoracentesis and, later, pleurex catheter placement on . pleural fluid positive for malignant cells, afb smear negative. also initiated palliative xrt to rul. ip did not feel mass was amenable to stenting. notes in discharge summary state that patient was dnr/dni at discharge. patient was discharged to rehab. at rehab this morning it was discovered that there were not appropriate supplies to drain pleurex. had his usual session xrt this am. he also had cxr which was read as complete r sided opacification. when arrived back at rehab, he was sent to the ed due to inability to drain the effusion. in the ed, initial vs were: t96.8 70 146/88 22 96% on 15l o2. hrs have since been in the 130s - not clear if hr 70 truly accurate. has been tachypneic to 30s. cxr performed with finding of interval increase in pleural effusion and r lung base opacificition. ip saw patient and drained 550 cc fluid from patient's pleurex catheter. a bedside ultrasound was obtained showing no pericardial effusion. patient was given vancomycin and zosyn. attempts were made to contact interpreter but this was not possible - could not confirm dnr status and seemed to suggest that patient was full code. in the micu, patient interviewed with an interpreter. notes he gets dyspneic at times but no different lately. actually denies shortness of breath currently. + cough, productive of white sputum, denies hemoptysis. no cp, no pleuritic pain. notes occasional palpitations. no fevers/chills. endorses thirst and general poor po intake. notes continued numbness and weakness in his lower extremities since his acute cord compression. +lower extremity edema x few weeks. + weight loss. past medical history: 1. nonsmall cell lung cancer with metastatic disease to the spine - s/p t7-l1 laminectomy, decompression, fusion, and tumor debluking and fusion for acute cord compression on - primary oncologist dr. 2. h/o c diff colitis in 3. copd 4. atrial fibrillation social history: originally from , immigrated to the us > 10 years ago; was living with his son and daughter until discharge yesterday (discharged to rehab in ). worked as a factory worker in . previous history of heavy tobacco use (at least 1ppd x 50 years); not currently smoking. no known tb contacts. family history: no family history of malignancy physical exam: vitals: t: 99.2 bp: 128/59 p: 76 r: 26 sao2: 97 ra general: cachectic male, alert, oriented, moderately tachypneic with some accessory muscle use. heent: perrl, sclera anicteric, mm slightly dry, oropharynx view poor but appears clear neck: supple, jvd low at 1-2 asa. lungs: decreased breath sounds on right, few rales, somewhat rhonchorous with ?pleural rub. left relatively clear. no wheezes. cv: tachycardic, irregularly irregular, no murmurs, rubs, gallops appreciated abdomen: soft, thin, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. suprapubic area feels slightly ?firm though nontneder. +ttp over lower right anterior ribs. ext: warm, well perfused, + le edema, symmetric bilaterally. no calf tenderness. neuro: a/o x 3. cn ii-xii intact, ue strength and sensation grossly intact. reports le numbness bilaterally. le strength impaired - cannot lift r leg off bed, l can be lifted very slightly. pertinent results: admission labs: 06:15am wbc-15.8* rbc-3.95* hgb-11.9* hct-37.7* mcv-95 mch-30.1 mchc-31.5 rdw-17.1* 06:15am plt count-332 04:20pm ck-mb-3 04:20pm ctropnt-<0.01 04:20pm glucose-109* urea n-18 creat-0.5 sodium-144 potassium-4.7 chloride-106 total co2-31 anion gap-12 07:06pm lactate-1.8 07:06pm type-art po2-204* pco2-47* ph-7.42 total co2-32* base xs-5 studies: 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 global left ventricular hypokinesis (lvef = 45 %). systolic function of apical segments is relatively preserved suggesting a non-ischemic etiology. tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is mild pulmonary artery systolic hypertension. there is a trivial anterior pericardial effusion. impression: normal left ventricular cavity size with mild global hypokinesis c/w diffuse process (toxin, metabolic, etc.). mild pulmonary artery systolic hypertension. bilateral lower extremity ultrasound: peroneal veins not visualized. no evidence of deep venous thrombosis. chest xray there is essentially no change in chest findings with right upper lobe complete opacification, right pleural effusion, ground-glass opacity and mass-like consolidation in the right lower lobe, nodular opacity projecting in the left upper lobe and peribronchial abnormalities in the left lower lobe or due to patient's known non-small cell lung cancer. there are no new lung abnormalities. cardiomediastinal contours are unchanged. right apical chest tube remains in place. spinal hardware is present. there is no pneumothorax. brief hospital course: 77 year old male with metastatic lung cancer and malignant pleural effusion admitted for pleural catheter drainage. # pleurex catheter drainage: he initially presented to the emergency room after a radiation oncology appointment and inability to drain pleurex at rehab facility. per son, this was likely due to not accessing pleurex catheter appropriately. in total, patient has had approximately 2500 cc of fluid removed during his stay. he was initially admitted overnight to the micu after experiencing shortness of breath, tachypnea and hypoxia in the emergency room; however, this quickly resolved. # shortness of breath: he has baseline shortness of breath due to persistent malignant effusion and post-obstructive pneumonia secondary to mass. resolved with drainage of pleurex catheter. this should be drained daily after discharge. information provided to nursing director at rehab by interventional pulmonary service and video is sent with patient. please call if any questions or concerns regarding drainage. # pneumonia/hypoxia: patient completed a course for post-obstructive pneumonia and other than leukocytosis as below has no other signs or symptoms of infection. has been c. diff negative during this admission. ua negative, cxr without new findings, c. diff negative as above, blood cultures are no growth to date and patient ruled out for flu, parainfluenza, adenovirus and rsv. tachypnea and hypoxia improved as above with drainage of pleurex. lenis negative as well making pe less likely. he was given a few doses of vancomycin and cefepime while in the intensive care unit, but these were discontinued upon transfer to the floor. # stage iv nscl and malignant effusion: known mets to spine and malignant effusion. already undergoing palliative xrt, last dose today. too debilitated for chemo at this time. we continued pain control as per prior to admission. follow up scheduled with oncology service as per discharge paperwork. # leukocytosis: c. diff negative, cxr unchanged other than effusion, ua negative and blood cultures no growth to date. patient remained afebrile and non-toxic appearing, though chronically ill. be secondary to malignancy. # tachycardia: sinus tach vs mat. no clear afib history and he was intermittently irregular making mat more likely (though difficult to appreciate p waves when accelerated rhyhtm). rate controlled with metoprolol which was increased to 37.5 mg three times daily. # prophylaxis: continued on fondaparinux, ppi # code status: dnr/i # communication: liping (daughter) , (son) medications on admission: - morphine sr 15 mg q12h - acetaminophen 325 mg q6h as needed for pain, fever. - roxanol 0.25 ml q3h prn pain - omeprazole 40 mg daily - guaifenesin 100 mg/5 ml: 5-10 mls po q6h as needed for cough. - benzonatate 100 mg tid - megestrol 400 mg/10 ml : twenty (20) ml po once a day. - fondaparinux 2.5 mg subcutaneous once a day. - albuterol sulfate nebs q4h prn shortness of breath or wheeze. - catheter drainage please drain ip catheter three times/wk - docusate sodium 100 mg twice a day. - senna 8.6 mgtwo (2) tablet po twice a day discharge medications: 1. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). 2. acetaminophen 650 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 3. roxanol concentrate 20 mg/ml solution sig: 0.25 ml po q3h as needed for pain. 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 5. guaifenesin 100 mg/5 ml liquid sig: ml po every six (6) hours as needed for cough. 6. benzonatate 100 mg capsule sig: one (1) capsule po three times a day. 7. megestrol 400 mg/10 ml (40 mg/ml) suspension sig: twenty (20) ml po once a day. 8. fondaparinux 2.5 mg/0.5 ml syringe sig: 2.5 mg subcutaneous daily (daily). 9. albuterol sulfate 0.63 mg/3 ml solution for nebulization sig: nebulizations inhalation every four (4) hours as needed for shortness of breath or wheezing. 10. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 12. catheter drainage please drain pleurex catheter daily after discharge. for any questions or if it is felt that it can be drained less often, please contact the interventional pulmonary office at at . 13. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 14. ipratropium bromide 0.02 % solution sig: one (1) nebulization inhalation q6h (every 6 hours). discharge disposition: extended care facility: rehabilitation & nursing center - discharge diagnosis: primary diagnosis: non-small cell lung cancer malignant pleural effusion secondary diagnosis: copd discharge condition: mental status: clear and coherent level of consciousness: sleepy but arousable activity status: bedbound discharge instructions: you were admitted to the hospital to have your pleurex catheter drained. you experienced an episode of shortness of breath and were initially admitted to the medical intensive care unit. your catheter was drained three times while you were in the hospital. you also had a fast heart rate (atrial fibrillation). we increased your metoprolol from 25 mg three times daily to 37.5 mg three times daily. it is important that you go to your follow-up appointments as scheduled. please take all your other medications as you were prior to hospitalization. please also read the aftercare instructions regarding the radiation therapy of your chest. followup instructions: you have the following appointments scheduled: neurosurgery provider: , md phone: date/time: 11:45am thoracic hematology/oncology provider: , md phone: date/time: 10:30am and provider: , md phone: date/time: 10:30am interventional pulmonology: md: of interventional pulmonology day & time: at 8:30 am (xray at 8:00 am) phone: special instructions: you need a chest x-ray before this appointment. please show up at the of the clinical center at 8:00am on for a chest radiograph. afterward your interventional pulmonology appointment is on the of the connected building. Procedure: Other radiotherapeutic procedure Diagnoses: Pneumonia, organism unspecified Unspecified protein-calorie malnutrition Chronic airway obstruction, not elsewhere classified Atrial fibrillation Other chronic pulmonary heart diseases Malignant neoplasm of bronchus and lung, unspecified Pressure ulcer, lower back Secondary malignant neoplasm of bone and bone marrow Leukocytosis, unspecified Paroxysmal supraventricular tachycardia Arthrodesis status Pressure ulcer, stage II Myelopathy in other diseases classified elsewhere Malignant pleural effusion |
allergies: patient recorded as having no known allergies to drugs attending: addendum: on at 1408 i spoke with dr. , patients oncologist and reported on his procedure, hosptitalization an our recommendations for resuming chemo and radiation. discharge disposition: extended care facility: & rehab center - md Procedure: Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Repair of vertebral fracture Fusion or refusion of 4-8 vertebrae Fusion or refusion of 4-8 vertebrae Diagnoses: Other iatrogenic hypotension Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Malignant neoplasm of bronchus and lung, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other constipation Unspecified accident Injury to bladder and urethra, without mention of open wound into cavity Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Secondary malignant neoplasm of bone and bone marrow Paraplegia Myelopathy in other diseases classified elsewhere Pathologic fracture of vertebrae Body Mass Index less than 19, adult |
allergies: patient recorded as having no known allergies to drugs attending: addendum: please note acute renal failure on cr. bump from 1.7-2.1 discharge disposition: extended care facility: & rehab center - discharge diagnosis: transient acute renal failure md Procedure: Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Repair of vertebral fracture Fusion or refusion of 4-8 vertebrae Fusion or refusion of 4-8 vertebrae Diagnoses: Other iatrogenic hypotension Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Malignant neoplasm of bronchus and lung, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other constipation Unspecified accident Injury to bladder and urethra, without mention of open wound into cavity Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Secondary malignant neoplasm of bone and bone marrow Paraplegia Myelopathy in other diseases classified elsewhere Pathologic fracture of vertebrae Body Mass Index less than 19, adult |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: lower extremity weakness major surgical or invasive procedure: lumbar laminectoy (t7-l1) with posterior fusion and anterior corpectomy and tumor debulking. history of present illness: 77y/o male with known h/o of non small cell lung cancer, diagnosed just one week ago. had not yet initiated any chemotherapy or treatment. progressive le weakness r>l. sensation intact in le. past medical history: lung ca, former smoker social history: mandarin speaking only. former smoker family history: non-contributory physical exam: his physical examination on admission was: motor: d b t we wf ip q h at g r 5 5 5 5 5 0 0 0 0 0 0 l 5 5 5 5 5 2 2 2 2 2 2 sensation: intact to light touch in lower extremities. feels noxious stimuli in bilateral extremities, but no movement to noxious stimuli physical exam at discharge: d b t we wf ip q h at g r 5 5 5 5 5 4 4 4 4 4 l 5 5 5 5 5 4 4 4 4 4 thoracic and lumbar spinal incision closed with staples, c/d/i. brief hospital course: the patient was admitted to the hospital on the morning of with a 2 days history of progressively worsening lower extremity weakness. in the emergency department he had complete paralysis of his rle, with minimal movement in his lle. his initial labs demonstrated a wbc count of 15.2 with a normal hgb and hct. he was placed on steriods, and a morning ct scan demonstrated a t10 compression fracture with retropulsion and compression into the spinal cord. he was urgently taken to the or for a t7 to l1 laminectomy, decompression and fusion with corpectomy and tumor debulking. prior to the or, he pulled out his foley ca with the bulb inflated and had frank blood coming from the tip of his penis. urology was consulted and instructed to replace the foley and irrigate as needed. perioperatively there was a period of hypotension, duration unknown, please refer to anesthesia records, secondary to over medication. the patient was transferred to the icu intubated. post operatively the patient had sensation in his lower extremities, but was transiently plegic. a post op ct and mri done emergently did not show any epidural hematoma or overt cord impingement or edema. over the next few days, on steroids the patient regained near full motor strength. he was ordered a tlso brace and should wear this brace at all times when out of bed and when the hob is greater than 30 degrees. he is being discharged to a rehab facility. he should follow up with us as directed and also with his oncologist. he may resume chemo or radiation as indicated in three weeks. medications on admission: none discharge medications: 1. hydralazine 10 mg iv q4h:prn for sbp > 140 2. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheeze. 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 8. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 9. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 10. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily) as needed for htn. 11. dexamethasone sodium phosphate 4 mg/ml solution sig: one (1) injection q12h (every 12 hours): 2mg q 12 for 24 hrs. then 2mg qd x 2 days then d/c. discharge disposition: extended care facility: & rehab center - discharge diagnosis: metestatic t10 lesion discharge condition: stable discharge instructions: ?????? do not smoke. ?????? keep your wound(s) clean and dry / no tub baths or pool swimming for two weeks from your date of surgery. ?????? no pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? limit your use of stairs to 2-3 times per day. ?????? have a friend or family member check your incision daily for signs of infection. . you are required to wear your tlso brace at all times, put on prior to getting out of bed. ?????? take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, and ibuprofen etc. unless directed by your doctor. ?????? increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. we recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. call your surgeon immediately if you experience any of the following: ?????? pain that is continually increasing or not relieved by pain medicine. ?????? any weakness, numbness, tingling in your extremities. ?????? any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? fever greater than or equal to 101?????? f. ?????? any change in your bowel or bladder habits (such as loss of bowl or urine control). followup instructions: follow up instructions/appointments ??????please return to the office in __7__days for removal of your staples. if your sutures are under the skin, you will not need to be seen until the follow up appointment. ??????please call ( to schedule an appointment with dr. to be seen in __6__weeks. ??????you will need ct-scan prior to your appointment. md Procedure: Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Repair of vertebral fracture Fusion or refusion of 4-8 vertebrae Fusion or refusion of 4-8 vertebrae Diagnoses: Other iatrogenic hypotension Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Malignant neoplasm of bronchus and lung, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other constipation Unspecified accident Injury to bladder and urethra, without mention of open wound into cavity Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Secondary malignant neoplasm of bone and bone marrow Paraplegia Myelopathy in other diseases classified elsewhere Pathologic fracture of vertebrae Body Mass Index less than 19, adult |
allergies: penicillins / aspirin attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with bare metal stent to ramus history of present illness: mr. is 74 with hypertension, hyperlipidemia, coronary disease, abnormal nuclear stress test in the past and history of remote stroke who is transfered from osh after presenting with chest pain. . his pain was substernal, burning and radiated up to his throat. it was in severity. the pain was associated with abdominal bloating, and burping. he took calcium carbonate at home and had about 15 minutes of relief. when the pain returned, he tried more calciumc carbonate and again had 15 minutes of relief. when the pain returned again, he took 3 sl ntg. his pain was relieved for about an hour but returned. when the pain recurred, he tried sl ntg again, but this time had no relief, so asked his wife to drive him to the hospital. . he reported that the pain improved with walking around and by bending forward while standing. he felt that it was associated with his abdominal bloating. he had never had pain like that before, and it is not similar to his anginal pain. . he has been followed by cardiology every six months over the last year and a half. per notes he has had a nuclear stress in 06, suggesting disease involving the right coronary circulation. he's had a cath in 96, but the results are not known. he has been having intermittent anginal symptoms for which he has been using ntg. . at osh his vitals were 97.9 80 190/84 20 98ra. his ecg demonstrated inferior st depressions. his troponin i was noted to be elevated (0.74) and he was given asa, ntg, and clopidrogel. his pain improved with these interventions. he was not given iib/iiia inhibitors. he was noted to have guaiac positive stool. his hct was 42.8, cre 0.8, tropi 0.23, ck 172, mb 5.9. inr 1.1. he denies a history of hematochezia or melena in the past. in addition he also received zofran, magic mouthwash, ntg drip, pantoprazole, lorazepam, morphine and metoprolol. . upon arrival, patient was complaining of pain. ecg here showed no evidence of st depression. . on review of systems, he denied any prior bleeding, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denied exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems was notable for absence dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. past medical history: orthopedic surgeries complicated by dvt/pe hernia repair abnormal nuclear stress test with an inferior defect normal lv function hypertension peripheral sensory stroke arthritis ? being evaluated for gastric mass social history: he does not drink or smoke or do drugs family history: no family history of early mi, otherwise non-contributory. physical exam: admission 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 jvp of 8cm. 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, ttp with pain radiating to chest wall, reproduced chest pain that patient was experiencing duirng the day. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. no rebound, no rosvigs no mcmurphys. heme+ stool 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: 07:20am blood wbc-7.9 rbc-3.94* hgb-12.5* hct-36.9* mcv-94 mch-31.9 mchc-34.0 rdw-12.4 plt ct-242 05:07am blood wbc-8.5 rbc-3.88* hgb-12.6* hct-37.0* mcv-95 mch-32.4* mchc-34.0 rdw-12.8 plt ct-239 09:00am blood wbc-11.6* rbc-4.05* hgb-13.2* hct-37.2* mcv-92 mch-32.5* mchc-35.5* rdw-12.5 plt ct-269 12:08am blood wbc-8.6 rbc-4.41* hgb-14.3 hct-40.6 mcv-92 mch-32.3* mchc-35.1* rdw-12.4 plt ct-270 07:20am blood pt-13.1 ptt-24.8 inr(pt)-1.1 05:07am blood pt-12.7 ptt-25.9 inr(pt)-1.1 12:08am blood pt-14.2* ptt->150* inr(pt)-1.2* 07:20am blood glucose-96 urean-20 creat-0.8 na-140 k-4.2 cl-104 hco3-28 angap-12 05:07am blood glucose-113* urean-15 creat-0.8 na-137 k-4.1 cl-102 hco3-28 angap-11 09:00am blood glucose-138* urean-12 creat-0.7 na-135 k-4.4 cl-99 hco3-27 angap-13 12:08am blood glucose-314* urean-14 creat-0.6 na-134 k-3.5 cl-100 hco3-21* angap-17 05:07am blood ck(cpk)-684* 05:14pm blood ck(cpk)-1465* 12:08am blood alt-21 ast-26 ld(ldh)-271* ck(cpk)-183* alkphos-83 amylase-52 totbili-0.5 05:07am blood ck-mb-41* mb indx-6.0 05:14pm blood ck-mb-179* mb indx-12.2* 09:00am blood ck-mb-76* mb indx-13.0* ctropnt-0.40* 12:08am blood ck-mb-12* mb indx-6.6* ctropnt-0.21* 07:20am blood calcium-9.0 phos-3.2 mg-2.5 09:00am blood calcium-9.3 phos-3.4 mg-2.2 12:08am blood albumin-4.3 calcium-9.0 phos-2.6* mg-1.9 12:19am blood d-dimer-792* 03:15am blood lactate-1.7 echo the left atrium is dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with mid to distal lateral segments. diastolic function could not be assessed. there is no ventricular septal defect. 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. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric lvh. mild focal lv hypokinesis consistent with ischemia/infarction. trace aortic regurgitation. mild pulmonary artery systolic hypertension. cta ct of the chest: thoracic aorta is normal in size, with ascending aorta measuring 31 mm at the level of the right main pulmonary artery. at the same level the descending aorta measures 26 mm. presence of coronary artery calcifications. there is no evidence of aortic dissection. no evidence of pulmonary embolism. please note that there are two areas with apparent filling defect (3:56, 60) that correspond to partial volumes from branching, confirmed in the sagittal and coronal views. presence of linear atelectasis in lung bases. heart size is within normal limits. there is no pericardial or pleural effusion. no pathologically enlarged mediastinal or hilar lymph nodes. visualized portions of the airways are patent to the subsegmental levels bilaterally. ct abdomen and pelvis: abdominal aorta is normal in size, present with minimal atherosclerotic calcifications and mural plaques. the origin of the celiac trunk is narrowed, presenting with a post-stenotic dilatation. the renal arteries, superior and inferior mesenteric arteries are widely patent. the liver, gallbladder, spleen, pancreas, adrenal glands are unremarkable. the kidneys enhance and excrete contrast symmetrically. the left kidney is smaller than the right (left kidney measures up to 87 mm and the right kidney measures up to 125 mm in the sagittal view). normal-sized bowel loops with oral contrast in its interior. urinary bladder is unremarkable. prostate gland measures 54 x 46 mm and presents with gross calcifications. visualized portions of the iliac arteries are widely patent. there is no free fluid. no pathologically enlarged mediastinal or retroperitoneal lymph nodes. bone windows: degenerative changes and schmorl's nodes are noted in the spine. a 6-mm air containing lesion noted in the left sacrum adjacent to the left sacroiliac joint, corresponds to an intraosseous pneumtocyst, and does not have clinical significance. ipression 1. normal-sized aorta. minimal atherosclerotic disease in the normal-sized aorta. narrowing calcification at the origin of the celiac trunk causing narrowing and post-stenotic dilatation. 2. coronary artery calcifications. cath comments: 1. coronary angiography of this right dominant system revealed 2 vessel epicardial cad. the lmca and rca systems had no angiographically apparent flow limiting epicardial disease. the lad system had a long 70% stenosis of the d1 branch. the lcx system had a totally occluded ramus intermedius branch. 2. resting hemodynamics revealed systemic arterial hypertension with aortic systolic pressure of 167 mm hg. 3. left ventriculography was not performed. 4. successful ptca and stenting of the ramus with a minivision (2x15mm) bare metal stent. final angiography demonstrated no angiographically apparent dissection, no residual stenosis and timi iii flow throughout the vessel (see ptca comments). 5. successful closure of the right femoral arteriotomy site with a mynx closure device. final diagnosis: 1. two vessel coronary artery disease. 2. totally occluded proximal ramus intermedius. 3. systemic arterial hypertension. 4. successful bare metal stenting of the ramus. 5. successful closure of the right femoral arteriotomy site with a mynx closure device. brief hospital course: in brief this is a 74 with hypertension, hyperlipidemia, coronary disease, abnormal nuclear stress test in the past and history of remote stroke who is trasfered from osh after presenting with chest pain . # chest pain: initial concern for acs with nstemi/troponin leak at osh. at osh st depressions in inferior leads, which was consistent with reported history of rca disease by nuclear stress in 06. his hct at osh was 43 (after 2 lt ns) and this precluded demand ischemia. possibilities included acs, gi outlet obstruction (epsecially if his history of possible gastric mass), early pancreatitis, billiary tract disease, aortic disection, or pericarditis. a ct torso with contrast was negative. lfts, lipase, and lactate were normal. initially was managed for acs with clopidrogel, heparin ggt, asa and nitro ggt. pt's ck increased to 1400 and he was taken to cath lab were he was found to have to of ramus. a bms was placed. he was discharged on asa, clopidrogel and beta blocker. ace was not started on discharge as it was not on the pre admission medication list. please consider adding this medication unless otherwise indicated. # sinus tachycardia: most likely related to pain. # htn: since he initially was noted to have htn associated with ecg changes when presented to osh, most likely this represented emergency. his ecg changes were not present at but he continued to experience cp. otherwise no renal, retinal or cns involvement. initially on nitroglycerin ggt for sbp<150. subsequently he was transitioned to his oral antihypertensive regimen from home. # heme postive stool: ddx included upper bleed, such as pud, gastritis, avms or lower gi bleed such as diverticular, hemorrhoids, mass etc. no history of ibd and this is remote possibility (may be associated with arthritis). monitored hct, vs and stool guaiacs overnight. pt's aggrenox was d/c'ed on admission and he was be discharged on asa and plavix. when these medicines are finished in 1 month, a decision must be made regarding restarting the aggrenox for stroke protection. # h/o vte (post surgical dvt, pe): presenting symptoms were felt unlikely to be related to pe. he was placed on heparin ggt. medications on admission: per patient list and confirmed with caremark pharmacy and local cvs: aspirin-dipyridamole (aggrenox) 25/200 one tab twice daily oxybutynin 5 mg qhs tamsulosin 0.4 mg qam esomeprazole 40 mg qd nitrostat 0.4 mg prn chest pain paroxetine 37.5 daily fluvastatin 80 mg per day nifedipine-xl 90 mg daily nabumetone 500mg 2 tablets carafate 2 mg carbamazepine xr 200 mg twice daily metoprolol succinate 50 mg daily oxycodone/acetaminophen 5/325 one tab 3-4 times per day lumigan 0.03% ou patanol 0.15 one drop twice daily tobradex prn azopt eye drops one gtt left eye three times per day refresh tears as needed. viagra 50 mg po as directed discharge medications: 1. clopidogrel 75 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). 3. oxybutynin chloride 5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). disp:*30 tablet(s)* refills:*2* 4. carbamazepine 200 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po bid (2 times a day). 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. atorvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*90 tablet(s)* refills:*3* 7. paxil cr 37.5 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 8. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). disp:*30 tablet sustained release(s)* refills:*2* 9. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po once a day. disp:*90 tablet sustained release(s)* refills:*3* 10. patanol 0.1 % drops sig: one (1) ophthalmic tid (). 11. lumigan 0.03 % drops sig: one (1) ophthalmic qhs (). 12. azopt 1 % drops, suspension sig: one (1) ophthalmic tid (). 13. 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* 14. 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* 15. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*90 tablet, delayed release (e.c.)(s)* refills:*3* 16. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 17. sucralfate 1 gram tablet sig: two (2) tablet po bid (2 times a day): do not take within 1 hour of any other medications. . disp:*120 tablet(s)* refills:*2* 18. flomax 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po once a day. discharge disposition: home discharge diagnosis: non st elevation myocardial infarction gastrointestinal bleeding, nos discharge condition: stable discharge instructions: you had a heart attack and a bare metal stent was placed in your coronary artery to keep the artery open. you will need to take a full aspirin and plavix daily for at least one month. do not skip any doses or stop taking plavix unless dr. tells you to. please watch your right groin and call dr. if you notice any increase in bruising, pain or a growing lump underneath the skin. no lifting more than 10 pounds for one week, no pools or baths, you may take a shower. you have been started on the following new medicines: 1. clopodigrel (plavix) 75 mg once daily: to keep the stent open 2. aspirin 325 mg (not baby aspirin) daily: to prevent blood clots 3. atovastatin 80 mg daily: to lower your blood cholesterol levels 4. nifedipine was increased to 90 mg daily 5. pantoprazole: to protect your stomach from acid and treat heartburn. this is a better medicine than nexium for you to take with the plavix. . stop taking: 1. nexium 2. aggrenox . viagra: please talk to dr. about this as it is dangerous to take this with nitroglycerin. carafate: do not take this medicine within 1 hour of taking any other medicine. . please call dr. if you notice any dark stools, abdominal pain, bleeding at the right groin site, chest pain, nausea, sweating, trouble breathing or any other unusual symptoms. followup instructions: primary care: dr. phone: date/time: office will call you with an appt. . cardiology: dr. phone: ( date/time: at 1:40pm. office may call you with an earlier appt. if you don't hear from them please call the office. provider: phone: date/time: 10:40 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Left heart cardiac catheterization Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other and unspecified hyperlipidemia Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Nonspecific abnormal findings in stool contents |
allergies: vioxx / lipitor / colchicine attending: chief complaint: decompensated heart failure with failure of outpatient management major surgical or invasive procedure: medical icu admission arthrocentesis left knee (, ) history of present illness: 79m with history of severe systolic chf, atrial fibrillation, cad, dm; presents from rehab with dyspnea and edema concerning for chf exacerbation. patient was recently admitted from on cardiology service for similar problems of acute on chronic systolic chf. diuresed with lasix gtt up to 20 mg/hr with 500 mg diuril. improved symptoms and transitioned to torsemide 20 mg twice daily. creatinine 1.4 at discharge (range 1.4-1.7 during hospital course). . since recent discharge to rehab, pt has had some dizziness, fatigue and occasionally hypotensive with sob. on his torsemide was incrased to 25mg . on he had an acute episode of sob and was dizzy/fatigued., he was given zaroxylyn 2.5mg po and 40mg iv lasix w/relief. he was evaluated by neurology at the rehab who felt his symptoms were most likey chf. today, the torsemide was increased to 30mg and was subsequently transferred for ongoing hypotension and sob. . currently patient reporting shortness of breath. denies cp, palpitiations. + pnd. denies lh, dizziness. past medical history: past medical history: 1. cardiac risk factors: +diabetes, -dyslipidemia, +hypertension 2. cardiac history: -cabg: -percutaneous coronary interventions: -pacing/icd: s/p ddp pacemaker placement, ivcd implantation: concerto biventricular icd 3. other past medical history: -cad, s/p cabg in ( and women??????s) -chf, nyha class iv, ef ~ 15% -htn -s/p ddp pacemaker placement, ivcd implantation: concerto biventricular icd -atrial fibrillation (on coumadin) s/p avj ablation and pacer placement -mitral regurgitation -ventricular tachycardia s/p ablation of vt -iddm (type 2) -chronic renal insufficiency -chronic left knee pain, s/p steroid injections -gout with known colichicine myopathy -pseudogout social history: married. former smoker, quit 20 years ago formally, but still smokes once or twice a year. drinks 1 etoh beverage per day. retired mechanical engineer. was a fighter pilot for and then nato, and survived a crash in . also, was a wrestler with the turkish olympic team in . since retiring, he enjoys photography and volunteers at his local senior center. -tobacco history: quit regularly smoking 20 years ago, still smokes 1-2 times per year. -etoh: 1 drink daily -illicit drugs: denies family history: long history of cardiac disease, osteoarthritis in siblings. no history of gout in family. physical exam: on admission: vs: t 96.3 bp 103/64 hr 83 rr 20 96%4l general: elderly male with inability to talk more than 4 words w/o sob, no use of accessory muscles heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink neck: supple with jvp of 12cm cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. holosystolic murmur lungs: rales heard 1/2 up bases bilaterally abdomen: soft, ntnd. no hsm or tenderness extremities: 3+ pitting edema to knees . on transfer to micu: vs: general: drowsy, waxing/, oriented place and year, month reported as may, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp elevated to jaw, no lad lungs: bibasilar rales, with decreased bs at bases cv: regular rate and rhythm, normal s1 + s2, hs distant, difficult to assess significant respiratory sounds, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: cool, 1+ pulses, pitting edema to knees b/l . on discharge: vs: 97.7 78 (-86) 80-90/50-60 18 95%ra, i/o -350cc/24h, +200cc/8h gen: nad, sleepy but not as drowsy as heent: perrl, eoemi neck: jvp 6cm lungs: cta b/l no crackles cv: rrr nl s1/s2 ii/vi systolic murmur abd: +bs, soft, obese, nt, nt ext: increased edema left foot/ankle, well perfused, fluid reaccumulation and warmth left knee pertinent results: 07:02pm blood wbc-20.7*# rbc-3.41* hgb-10.0* hct-33.0* mcv-97 mch-29.3 mchc-30.3* rdw-19.1* plt ct-238 06:30am blood neuts-91.4* lymphs-5.8* monos-2.2 eos-0.3 baso-0.3 07:02pm blood pt-35.6* ptt-46.1* inr(pt)-3.7* 07:02pm blood glucose-71 urean-58* creat-1.8* na-137 k-4.0 cl-91* hco3-36* angap-14 07:02pm blood calcium-8.9 phos-3.9 mg-1.9 11:24am blood lactate-1.0 . 06:30am blood ck(cpk)-46 ck-mb-notdone ctropnt-0.11* 03:30pm blood ck(cpk)-57 ck-mb-notdone ctropnt-0.11* 10:00pm blood ck(cpk)-114 ck-mb-6 03:33am blood ck(cpk)-24* ck-mb-notdone ctropnt-0.09* . 07:02pm blood probnp-* . , bcx ngtd . urine cx: no growth . urine legionella ag: negative. . : sputum cx: contaminated sample. . 9:07 pm influenza a/b by dfa source: nasopharyngeal swab. direct influenza a antigen test (final ): positive for influenza a viral antigen. reported by phone to alesandra on at 11:15 cc6d. direct influenza b antigen test (final ): negative for influenza b viral antigen tested negative after treatment . ecg: ventricular paced rhythm. compared to the previous tracing of no change. . cxr: findings suggestive of a developing right lower lung and possibly also left lower lung pneumonia. . cxr: no interval change in bibasilar lung findings. considerations would include ongoing chf, though basilar pneumonia can have a similar appearance. . cxr: in comparison with the study of , there is little overall change. enlargement of the cardiac silhouette persists in the patient with what clinically appears to be pulmonary vascular congestion. however, the possibility of supervening areas of consolidation cannot be excluded. lateral view would be most helpful if the condition of the patient permits. . : the left atrium is moderately dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is severely dilated. there is an apical left ventricular aneurysm. there is severe global left ventricular hypokinesis (lvef = 15-20%). no masses or thrombi are seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular cavity is moderately dilated with mild global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: severely dilated left ventricle with severe global systolic dysfunction, c/w multivessel cad. moderate mitral and tricuspid regurgitation. moderate pulmonary hypertension. compared with the prior study (images reviewed) of , mitral regurgitation is more clearly visualized, although its severity may have been similar on the prior study. pulmonary pressures are higher today. the other findings appear similar. . caltibc 215, ferritin 117, trf 165 . digoxin : 0.9 . cxr: impression: heterogeneous opacities in right lung with slight improvement in right lower lobe on lateral view. this may reflect improving pneumonia in response to therapy. clinical correlation suggested . : alt 16, ast 22, alkphos 86, tb 1.1 . blood ctxs : ngtd . : joint fluid, left knee, wbc, <2.0 hct, 92 polys, mod crystal neg birefri, c/w monosodium urate; ctx negative final : wbc, <2.0 hct, 97 polys, few crystals, same make-up ua : no infxn . 8.2 ca, 2.9 ph, 2.0 mg dig 1.4 . labs at discharge: 19.2>8.9/29.7<345 pt 26.3 ptt 35.8 inr 2.5 137/4.1/91/38/51/1.9<95 brief hospital course: floor course prior to micu: on the floor, patient was treated with 80mg iv lasix on admission for concern of chf exacerbation. iv vancomycin and zosyn were also started for possible hospital-aquired pneumonia. on , team noted pt to be more somnolent with increased confusion, and he was triggered for hypotension 60s/30s while sleeping which resolved w/ arousal to 110/60. an abg was obtained 7.39/63/107 on 4l nc and then repeated when his somnolence persisted 2 hours later returning at 7.36/71/81. he was transferred to the micu for monitoring and possible non-invasive ventilation. . micu course: patient was admitted to the micu from the floor for somnolence in setting of pco2 of 70s. . # respiratory distress, hypercarbic/hypoxic: likely multifactorial from influenza, pna, and chf. clinical exam and data showed a mixed picture w/ bnp , peripheral edema, b/l crackles, elevated wbc without fevers. neg. tte showed stable ef with worsened right heart pressures. he received 1 dose of 80mg iv lasix with good urine output. further diuresis was held as patient had borderline low bps (baseline is systolic in the 90s) and other reasons for hypoxia. his cardiac enzymes remained flat. o2 was weaned down. repeat chest xr after lasix was unchanged with bilateral infilrates. dfa was positive for flu and he was started on oseltamivir () and continued on vanc/zosyn for hap as had been living in rehab. sputum culture was rejected and he was continued on nebs. . # transient hypotension: differential included cardiogenic given cool extremities vs. septic given ? b/l ll pna vs. ai given long-standing steroid use. did improve when iv steroids were initiated and he was continued on stress dose steroids (started ). an echo was performed that showed no change in ef or pericardial effusion. resolved without further intervention. . # acute on chronic systolic heart failure: depressed ef of 15% at baseline. chf exacerbation possibly triggered by decreased diuresis in the setting of a rising cr at the rehab facility. also question of lv pacer wire has also been failing to capture properly although ep team feels its working properly. cardiac enzymes were cycled and remained flat. digoxin, ace, and beta blocker were continued. repeat tte was essentially unchanged as above. he was given one dose of 80mg iv lasix and had good uop. further lasix was held given hypotension and he continued to be net negative without meds. . # gout: continued allopurinol, renally dose. switched outpt methylpred to stress dose. . . floor course after micu: . # drowsiness- on am . pt. was drowsier than usual with bg in 40s, given food and 1amp glucose-> bg 200. pt. was still drowsy though responsive. his vs were within normal, the repeat glucose was in the 100s, and there were no significant morning lab abnormalities. during the course of the morning the patient became more alert and it was determined that that this episode of drowsiness was likely secondary to hypoglycemia and insomnia as well as decreased blood pressures from recent diuresis. - would follow glucose closely and adjust insulin regimen as needed. . #influenza continued oseltamivir (d1=) x 5 days. mantained droplet precautions during that time only. oxygen requirement continued to improve. . #hcap - remained afebrile, wbc# trending down, oxygenation stable. mr was continued on zosyn (d1=) x 7 days. vanco was continued for a 7 day course, dosed by vanco troughs, stopped , given pts severe presentation and lack of positive cult data, and propensity for staph infections with flu. he was continued on ipratropoium and albuterol nebs. blood cultures were negative . #dizziness / vertigo/ diplopia - on presentation had dizziness and diploplia which was positional, after call out pt with continuous diplopia and dizziness (intermittently vertigo like). supratherapeutic inr raised concern for ich. ct head negative for hemmrhogage. neurology was consulted who felt his symptoms were a combination of othrostatic hypotension and orthopnic dyspnea. . #vt s/p biv-icd - multiple runs of 30+ beats on telemetry; icd did not fire as rate was below threshold for capture. icd just interogated without signs of abnormality. after discussion with ep increased carvedilol to 6.25 . #hypotension - resolved though baseline in 90s without symptoms; likely overdiuresis (recent uptitration of torsemide and admit wt below dry wt on last discharge). adrenal insufficiency also possible and mr was continued on a hydrocortisone taper until methylprednisolone 4mg daily. this dose will be continued at least until rheumatology follow-up for gout. -if patient sbps <80, place in bed and elevate legs before any ivf to see if it resolves as this has worked in the past and any ivf may cause pulmonary edema given heart failure severity. . #chronic systolic heart failure - stable oxygenation, wt consistent with dry wt on last discharge. therefore sob thought to be mostly infectious etiology. he was continued on torsemide 20mg with a goal volume status even to -500 x 24 hrs. he was continued on bb, acei, digoxin, spironolactone. palliative care consult was obtained as mr has end stage chf and family desires to take pt home. pt. was eventually places on toresemide 40mg , and after switched to a lasix gtt 5-10cc/hr for approximately 3 days with good urine output and decreased peripheral edema. on because of some proclaimed difficulty with ambulation with pt, and bps to the 80s, lasix was stopped and torsemide was resumed. pt.'s weight on day of discharge was: 81.8kg with low of 79.9kg two days prior. . #cad s/p cabg - stable, contined asa, bb, acei (allergy to statin) . #afib - pacer functioning appropriately per ep. continued on coumadin, dig, and bb. . #ckd - cr stable, una <10 reflects intravascular volume depletion and poor forward flow (as well salt retention corticosteroids). creatinine decreased with increased diuresis on lasix to 1.9. . #macrocytic anemia - stable @ b/l; folate, b12 wnl in . #dm - continued basal, sliding scale insulin. pt. had multiple episodes of asymptomatic early morning hypoglycemia with bg 30s-40s, resulting in decreasing long term and evening and dinner short acting insulin s/s. . #gout: continued steroid taper, as above. continued allopurinol. on pt. c/o left knee pain and on hematology was consulted due to fluid accumulation. the knee was tapped on , and again on . though the knee was painful to passive extension/flexion, it was not believed to be a septic joint. the ctx from was negative (final read) and the wbc in the first aspiration was 165,000 while the second was 85,000, both with needle shaped, monosodium urate crystals c/w gout. vancomycin was started again on because of concern of infection with a high peripheral blood wbc count and the knee fluid accumulation, however was stopped on because of continued wbc count, no fever, and belief that the wbc count was from gout flare due to increased steroid taper and increased diuresis. the pt. will be followed by rheum as an outpatient with possible steroid injection and plan for long term antibiotics and washout if knee declares itself as septic over the next several days. . #fen -hh/dm diet -1500 cc fluid restriction . #prophylaxis: -systemic ac -ppi while on steroids -bowel regimen . #code: full (confirmed with patient & wife ) . #communication: patient; , wife, . #disposition: patient & wife prefer to return home with many services after short term rehabilitation stay. . medications on admission: combivent 2 puffs qid flovent mdi 1 puff spironolactone 25 mg tablet sig: one (1) tablet po daily carvedilol 3.125 mg captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day). digoxin 125 mcg tablet sig: one (1) tablet po every other day aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). pantoprazole 40 mg tablet, delayed release (e.c.) sig: one 1)tablet, delayed release (e.c.) po q24h (every 24 hours). allopurinol 100 mg tablet sig: four (4) tablet po daily (daily). methylprednisolone 2mg qod until trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. docusate sodium 100 mg capsule sig: one (1) capsule po bid senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. warfarin 3mg daily torsemide 30mg bisacodyl 10 mg tablet, delayed release (e.c.) sig: tablet, delayed release (e.c.)s po daily (daily) as needed for constipation. acetaminophen 500 mg tablet sig: one (1) tablet po every six 6) hours as needed for pain. lantus twenty eight (28) units subcutaneous once a day. humalog sliding scale os cal d 500mg mvi discharge medications: 1. fluticasone 110 mcg/actuation aerosol sig: one (1) puff inhalation (2 times a day). 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. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. allopurinol 100 mg tablet sig: four (4) tablet po daily (daily). 8. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 9. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 10. combivent 18-103 mcg/actuation aerosol sig: two (2) puffs inhalation four times a day. 11. carvedilol 6.25 mg tablet sig: one (1) tablet po bid (2 times a day). 12. torsemide 20 mg tablet sig: two (2) tablet po bid (2 times a day). 13. warfarin 2.5 mg tablet sig: one (1) tablet po daily (daily). 14. methylprednisolone 2 mg tablet sig: two (2) tablet po daily (daily). 15. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 16. trazodone 50 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 17. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation. 18. os-cal 500 + d 500 mg(1,250mg) -200 unit tablet sig: one (1) tablet po twice a day. 19. multivitamin tablet sig: one (1) tablet po once a day. 20. lantus 100 unit/ml cartridge sig: twenty (20) units subcutaneous at bedtime. 21. humalog 100 unit/ml cartridge sig: one (1) units subcutaneous four times a day: see insulin sliding scale sheet attached. 22. venlafaxine 37.5 mg tablet sig: one (1) tablet po bid (2 times a day). 23. outpatient lab work check inr daily with goal of 2.0-3.0 and increase or decrease coumadin as necessary, continue to check electrolytes 24. outpatient physical therapy 25. pm snack be sure to give evening snack since glucose has a tendency to drop in the early morning. 26. lisinopril 5 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 27. glucose fingersticks check glucose on fingersticks with meals and at night 28. hypotension control patient can have asymptomatic systolic blood pressures from 80s-90s. if this happens, place patient in bed with legs raised and then recheck as this usually resolves and the patient does not tolerative iv fluids because of his chf. discharge disposition: extended care facility: - discharge diagnosis: influenza a hospital acquired pneumonia class iv heart failure diabetes hypertension cad atrial fibrillation s/p pacer cri gout pseudogout discharge condition: stable, breathing improved discharge instructions: you were transfered to for evaluation of low blood pressure and shortness of breath. you were found to have influenza and a pneumonia. you were treated with antiviral and antibacterial medications. your heart failure was not felt to be a significant contributor to your shortness of breath. your dizziness was evaluated by neurology who felt that it was because of low blood pressure from taking too much fluid off of your body too quickly. you lost a lot of weight in fluid which helped your lungs and your swelling. you had a flare of gout in your left knee. . the following changes were made to your medication regimen: coreg was increased to 6.25mg twice a day torsemide was increased to 40mg twice a day venlafaxine 37.5 mg twice a day was added for depression lisinopril 5mg once a day was added for blood pressure methylprednisolone was increased to 4mg daily since you are being slowly tapered off of steroids . please follow up with your doctors as detailed below. . if you develop fevers, chills, chest pain, worsening shortness of breath, vomiting, abdominal pain, or any other worrisome symptom please call your doctor or go to the emergency room. . weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet and <1000 fluid restriction. followup instructions: rheumatology for left knee gout follow-up: provider: , md phone: date/time: 10:00 . cardiology (you should also have your pacmaker interrogated at this appointment): provider: , m.d. phone: date/time: 3:20 . provider: / phone: date/time: 10:00 md, Procedure: Arthrocentesis Arthrocentesis Diagnoses: Mitral valve disorders Congestive heart failure, unspecified 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 Gout, unspecified Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of tobacco use Chronic kidney disease, unspecified Acute respiratory failure Long-term (current) use of insulin Chronic systolic heart failure Cardiac pacemaker in situ Toxic myopathy Unspecified hereditary and idiopathic peripheral neuropathy Unspecified deficiency anemia Influenza with pneumonia Uric acid metabolism drugs causing adverse effects in therapeutic use |
allergies: penicillins / sulfa (sulfonamide antibiotics) attending: chief complaint: upper gi bleed major surgical or invasive procedure: egd - several ulcers and erosions in the duodenal bulb history of present illness: mr is an 80 year old man who per the va pharmacy is on warfarin, digoxin and insulin as well as anti-hypertensives, and who himself is a somewhat unclear medical historian, who presents with a two day history of dark stools. he says that on tuesday he had a "major black bowel movement" and was alarmed by this but did not know what to do so he drank water and went to bed. he says that he then had a black stool with additional red blood in the bowl today, and he called 911. he requested to go to the va which is where he gets all his care but was brought to the because it was closer. on review of systems he said that he had gotten light-headed on trying to get up from bed and was very weak and sometimes had to call 911 for this; he appears to have had several falls. denied chest pain, palpitations, or shortness of breath; he said that he sometimes has nausea which gets better when he drinks ice water. in the emergency department his initial vitals were 97.5, 114/70, 88, rr 14, 100% on room air. he was ng lavaged and by the ed resident's report did have some blood on the return which appeared to clear. he received 10 mg vitamin k and 2 units of ffp. he got 2 l ns. he had some intermittent systolic blood pressure in the 80s and 90s which responded well to iv fluid boluses and his hemodynamics were otherwise stable in the ed by report. he was also nauseous in the ed and received 2 doses of 4 mg iv zofran for this. he was transferred to the micu for further management. in the micu, he received no blood products. he underwent egd, which was remarkable for superficial ulcers in the duodenal bulb. he did not require pressors or intubation. he was transferred to the floor in stable condition. past medical history: atrial fibrillation hypertension diabetes hypercholesterolemia sleep apnea, on cpap congestive heart failure, unspecified social history: occupation: retired mechanical engineer; wwii veteran of air force, was translator of japanese drugs: denies tobacco: 30 py hx, quit 3 years ago alcohol: likes a bottle of wine a day, "but i keep running out of wine"; denies any hx of withdrawals other: lives alone, wife left him 3 years ago, not in family history: nc physical exam: temp 35.5 ??????c hr: 83 bp: 108/44(58) rr: 16 spo2: 100% in 2l general: nad skin: warm and well perfused, no excoriations or lesions, no rashes heent: at/nc, eomi, perrla, anicteric sclera, pink conjunctiva, patent nares, mmm, poor dentition, nontender supple neck, no lad, no jvd cardiac: irregularly irregular, s1/s2, 2/6 sem at base lung: ctab abdomen: nondistended, +bs, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly m/s: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities pulses: 2+ dp pulses bilaterally neuro: cn ii-xii intact pertinent results: imaging: ======= radiology cxr pa/lat : findings: the patient's condition required ap positioning. there is a slight increase in density in the lateral portion of the right lower lobe which may be partly due to patient's gynecomastia and a small right pleural effusion. cardiomegaly is unchanged. right-sided icd leads in appropriate position remain unchanged. impression: no significant change in the right lower lobe opacification. part of this density may be due to overlying gynecomastia. . egd : several superficial non-bleeding ulcers and erosions were found in the duodenal bulb. there was also duodenitis. ulcers appeared to be low risk for rebleeding, thus procedures were not performed for hemostasis. labs: ==== 10:30am blood wbc-8.2 rbc-3.17* hgb-9.4* hct-27.5* mcv-87 mch-29.7 mchc-34.3 rdw-15.2 plt ct-329 02:37am blood wbc-7.9 rbc-2.84* hgb-8.6* hct-24.3* mcv-85 mch-30.3 mchc-35.5* rdw-16.9* plt ct-269 02:40pm blood hct-26.2* 06:30am blood wbc-8.7 rbc-2.93* hgb-8.8* hct-25.4* mcv-87 mch-30.0 mchc-34.5 rdw-16.7* plt ct-277 05:45pm blood hct-25.5* 11:51am blood hct-27.9* 10:30am blood pt-19.2* ptt-27.6 inr(pt)-1.8* 04:39pm blood pt-17.4* ptt-26.2 inr(pt)-1.6* 02:37am blood pt-15.8* ptt-23.1 inr(pt)-1.4* 06:30am blood pt-14.8* ptt-23.8 inr(pt)-1.3* 07:45am blood pt-15.9* ptt-26.3 inr(pt)-1.4* 10:30am blood glucose-188* urean-65* creat-1.5* na-135 k-4.2 cl-98 hco3-23 angap-18 04:39pm blood glucose-221* urean-59* creat-1.3* na-139 k-4.4 cl-103 hco3-26 angap-14 02:37am blood glucose-204* urean-50* creat-1.2 na-140 k-4.3 cl-106 hco3-26 angap-12 06:30am blood glucose-147* urean-31* creat-1.1 na-141 k-3.9 cl-108 hco3-26 angap-11 07:45am blood glucose-131* urean-28* creat-1.2 na-140 k-3.7 cl-104 hco3-27 angap-13 04:39pm blood alt-14 ast-19 ld(ldh)-228 alkphos-46 amylase-88 totbili-0.6 06:30am blood alt-8 ast-17 alkphos-48 totbili-0.8 02:37am blood calcium-8.3* phos-3.0 mg-2.2 06:30am blood calcium-8.4 phos-2.5* mg-2.1 07:45am blood calcium-8.4 phos-3.5 mg-1.8 02:37am blood tsh-0.79 04:39pm blood digoxin-0.7* 04:39pm blood ethanol-neg micro: ===== blood cultures: ngtd rpr: negative h. pylori: pending brief hospital course: 80 yo male with history of chf, cad, a-fib on coumadin, pacer/icd placement with melena s/p egd without obvious source. duodenitis and gastritis: he was initially started on iv ppi and received 2u prbcs. he remained hemodynamically stable while in-house with a stable hct, and his egd revealed evidence of duodenal ulcerations. he remained on iv ppi for ~72 hours and then transitioned to po ppi , that of which he will require for 6 weeks. also, given that this may be due to h. pylori, serologies were sent and he was started empirically on triple therapy may need to contact if the serologies are negative, as he will not require treatment. rll consolidation: pt was initially started on levofloxacin in unit for concern of pneumonia, although the lack of fevers, cough or white count suggested the absence of infection and this was held. he remained hemodynamically stable with this change. cad native vessle, benign hypertension, atrial fibrillation: - cad - his asa and coumadin were held initially but restarted without complications prior to discharge. he was kept on his statin throughout the hospitalization. - pump - given the ongoing bleeding on admission his anti-hypertensives were held and then restarted 24 hours after the egd. he tolerated this well. - rhythm - pt has a-fib, on coumadin as an outpt. inr on admission was 1.4. his coumadin was restarted at 5mg, which is change in his basline of 5 mg alternating daily with 7.5 mg, and this will need to be followed in . the inr also may be affected due to the initiation of antibiotics. it is suggested that the patient go to the va on the monday following discharge. he was maintained on his home digoxin dosing throughout the hospitalization. obstructive sleep apnea: continued on cpap diabetes type ii uncontrolled: continue nph 9 units + humalog sliding scale alcoholdependence: the patient reports that he drinks a bottle of wine a day and serum tox was negative on admission. he was maintained on a valium ciwa scale although did not require treatment for withdrawal. he was given mvi, thiamine and folate and educated about the risks of continued alcohol use. falls: patient reports a history of falls that appear may be a result of medications. he reports them as happening when he stands quickly from a seated position, and denies any associated chest pain, diaphoresis or sob. he was seen by physical therapy who suggested home physical therapy. medications on admission: per va pharmacy absorbase topical ointment cyanacobalamin 1000 mcg/ml inj 1x/month digoxin 0.125 mg daily enalapril maleate 2.5 mg furosemide 40 mg insulin nph 18 units breakfast and hs; insulin regular 5 units at breakfast and dinner metoprolol succinate 100 mg daily simvastatin 40 mg daily warfarin 5 mg sat/sun/tues/thurs, 7.5 mg daily mwf miconazole powder nystatin cream discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. enalapril maleate 5 mg tablet sig: 0.5 tablet po bid (2 times a day). 7. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 8. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 9. 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:*3* 10. metronidazole 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 14 days. disp:*28 tablet(s)* refills:*0* 11. clarithromycin 250 mg tablet sig: two (2) tablet po q12h (every 12 hours) for 14 days. disp:*64 tablet(s)* refills:*0* 12. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. discharge disposition: home with service facility: homecare discharge diagnosis: primary diagnosis: ugib secondary to duodenal ulcerations. . secondary diagnoses: atrial fibrillation hypertension diabetes hypercholesterolemia sleep apnea, on cpap congestive heart failure, unspecified discharge condition: afebrile, stable vital signs, tolerating pos, ambulating without assistance. discharge instructions: you were admitted with an upper gi bleed that may be due to ulcerations that were seen in your small bowel. this may be due to a bacterial infection and we have started you on acid blockers that you'll need to take twice a day, and you've also been empirically started on a 2-week course of antibiotics and you will be contact if you can stop these earlier. . 1. please take all medication as prescribed. 2. please make all medical appointments. 3. please return to the emergency room if you have any concerning symptoms. followup instructions: please follow-up with your pcp as previously scheduled. Procedure: Other endoscopy of small intestine Transfusion of packed cells Transfusion of other serum Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Long-term (current) use of insulin Long-term (current) use of anticoagulants Automatic implantable cardiac defibrillator in situ Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Duodenitis, without mention of hemorrhage Helicobacter pylori [H. pylori] Chronic diastolic heart failure |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: coronary artery bypass grafting x4: left internal mammary artery to left anterior descending artery, and reverse saphenous vein grafts to the left posterior descending artery, ramus intermedius artery, and diagonal artery. cardiac catheterization history of present illness: 70 year old female progressive dyspnea on exertion over the last few months, presented getting sob on walking from room to room. night prior to admission developed sub sternal chest tightness with radiation to the jaw, associated with nausea. cardiac catheterization left dominant lmca 60-70% distal bifurcation lesion involving orgin lad & lcx lad : mid stent widely patent; 70% disease proximally in d1; diffuse < 50% disease lcx 70% stenosis proximal to stent which is widely patent ramus ostial 80% disease 70% disease in stent rca diffuse severe disease, moderately small acute marginal without significant disease. she was referred for bypass surgery based on cath results. past medical history: diabetes mellitus hypertension hyperlipidemia cad s/p multiple coronary interventions, most recently des to left circ '. retinopathy s/p laser surgery pvd obesity light headedness diabetic neuropathy cellulitus s/p chole s/p left common femoral artery to above-knee popliteal artery bypass graft with nonreversed greater saphenous vein, angioscopy and valve lysis percutaneous flexor tenotomy on the fourth and fifth toe performed - on bactrim for 5 days social history: lives with: alone - daughter lives near and able to help occupation: works in office doing payroll tobacco: 40 pack year history-current smoker etoh: denies family history: father died at 42 of lung ca. mother is still living at age . physical exam: pulse: 57 resp: 26 o2 sat: 95 ra b/p right: left: 104/39 height: 5'8" weight: 113.4 kg general: nad skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally anterior heart: rrr irregular murmur none abdomen: soft non-distended non-tender bowel sounds + large no palpable masses, right lateral surgical scar, redness under abdominal folds extremities: cool, pulses with doppler, multiple varcosities, surgical scar left thigh, no edema rt le, lt with +1 pitting neuro: grossly intact pulses: femoral right: +1 left: +1 dp right: d left: d pt : d left: d radial right: +1 left: +1 carotid bruit right: no bruit left: no bruit pertinent results: 09:45pm ptt-26.8 09:45pm ck-mb-33* mb indx-8.4* ctropnt-0.44* 09:45pm ck(cpk)-391* 05:35am blood pt-12.5 ptt-28.4 inr(pt)-1.1 05:35am blood glucose-66* urean-40* creat-1.8* na-138 k-4.1 cl-102 hco3-26 angap-14 04:15am blood ck-mb-7 ctropnt-0.71* probnp-* 04:15am blood %hba1c-7.4* 05:01am blood wbc-11.4* rbc-2.86* hgb-8.3* hct-25.5* mcv-89 mch-29.1 mchc-32.6 rdw-15.6* plt ct-266 05:01am blood plt ct-266 01:56pm blood pt-13.1 ptt-29.9 inr(pt)-1.1 05:01am blood glucose-50* urean-23* creat-0.9 na-138 k-4.4 cl-101 hco3-31 angap-10 04:15am blood alt-26 ast-34 ld(ldh)-248 ck(cpk)-165 alkphos-119* totbili-0.4 05:01am blood mg-2.2 echocardiography report left atrium: mild la enlargement. right atrium/interatrial septum: normal ra size. normal interatrial septum. pfo is present. left ventricle: mild regional lv systolic dysfunction. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. focal calcifications in ascending aorta. normal aortic arch diameter. simple atheroma in aortic arch. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. no ms. mild (1+) mr. prolonged (>250ms) transmitral e-wave decel time. tricuspid valve: mildly thickened tricuspid valve leaflets. physiologic tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. no pr. pericardium: no pericardial effusion. conclusions pre bypass: the left atrium is mildly dilated. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch and the descending thoracic aorta. lv function is borderline normal with mild inferior hypokinesis. lvef 50%. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. there is a small pfo. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is no pericardial effusion. post bypass: slight improvement in inferior lv wall motion, lvef 50-55%. preserved rv function. mr remains mild. no change in other valves. aortic contours intact. chest (pa & lat) clip # final report indication: 70 year-old woman status post cabg for evaluation of left effusion. comparison: multiple prior exams including chest radiograph. pa and lateral chest: a right central catheter with its tip in the upper svc is unchanged. there is bibasilar atelectasis and small bilateral (left greater than right) pleural effusions which have slightly improved since since . mild cardomegaly and post-cabg changes are stable. impression: slight improvement in atelectasis/effusions since . no acute process. the study and the report were reviewed by the staff radiologist. dr. dr. brief hospital course: transferred from outside hospital for cardiac workup. cardiac catheterization revealed 2 vessel coronary artery disease with preserved ef and patient was referred for surgical evaluation. she underwent preoperative workup and on was brought to the operating room for coronary artery bypass graft surgery. see operative report for details. in summary she had coronary bypass grafting x4 with left internal mammary artery to left anterior descending artery, and reverse saphenous vein grafts to the left posterior descending artery, ramus intermedius artery, and diagonal artery. her bypass time was 96 minutes with a crossclamp of 85 minutes. she received vancomycin for perioperative antibiotics. post operatively she was transferred to the intensive care unit in stable condition on neosynephrine, insulin and propofol infusions. in first twenty four hours, she was weaned from sedation, awoke neurologically intact, and extubated without complications. all tubes lines and drains were removed per cardiac surgery protocols. she continued to progress but remained in the intensive care unit for pulmonary management. on pod3 she was transferred from the cardiac surgery icu to the stepdown floor. physical therapy worked with her on strength and mobility. nph was adjusted for hypoglycemia on the step down unit. she continued to progress slowly and was ready for discharge to rehab on post operative day 6. medications on admission: norvasc 10mg daily hydralazine 50mg twice a day hctz 25mg once a day lisinopril 40mg twice a day toprol xl 50mg daily simvistatin 80mg daily timoptic maleate 0.5 % 1 drop os at bedtime aspirin 325mg daily insulin humulin 70/30-65units twice a day nicotine patch plavix - last dose: 600mg osh allergies: nkda discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 3. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic qhs (once a day (at bedtime)). disp:*qs * refills:*2* 4. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day). disp:*qs * refills:*0* 5. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 6. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 8. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain . 9. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). disp:*qs * refills:*2* 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q2h (every 2 hours) as needed for wheezing . disp:*qs * refills:*0* 13. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 14. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily) for 6 weeks. disp:*42 patch 24 hr(s)* refills:*0* 15. nicotine 7 mg/24 hr patch 24 hr sig: one (1) transdermal once a day for 2 weeks: begin following 6 week course of 14mg/day patch. disp:*14 * refills:*0* 16. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 17. insulin nph & regular human 100 unit/ml (70-30) suspension sig: as directed below units subcutaneous twice a day: 65 units qam 30 units qpm. 18. insulin regular human 100 unit/ml solution sig: sliding scale units injection qac&hs. 19. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 20. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 2 weeks. discharge disposition: extended care facility: - discharge diagnosis: coronary artery disease s/p cabg x4 pmh: diabetes mellitus hypertension hyperlipidemia cad s/p multiple coronary interventions, most recently des to left circ '. retinopathy s/p laser surgery pvd obesity light headedness diabetic neuropathy cellulitus s/p ccy s/p left common femoral artery to above-knee popliteal artery bypass graft with nonreversed greater saphenous vein, angioscopy and valve lysis percutaneous flexor tenotomy on the fourth and fifth toe performed discharge condition: alert and oriented x3 nonfocal ambulating with assist sternal pain managed with ultram and tylenol prn sternal wound healing well, no erythema or drainage discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 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 followup instructions: provider: , md phone: date/time: at 1:00 pm provider: , md phone: date/time: 2:15 provider: , .d. phone: date/time: 11:40 please call to schedule appointments primary care dr. in weeks Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Tobacco use disorder Urinary tract infection, site not specified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Peripheral vascular disease, unspecified Chronic kidney disease, unspecified Ulcer of other part of foot Other and unspecified hyperlipidemia Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Long-term (current) use of insulin Morbid obesity Candidiasis of skin and nails Long-term (current) use of aspirin Other specified counseling |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: -left heart catheterization with balloon angioplasty to the proximal and mid rpda artery -right heart catheterization to evaluate asd history of present illness: 83 yo m with hx of prior mi (), dmii, htn, dyslipidemia, gerd, depression, glaucoma presented to osh with complaints of chest pain since last night and bp elevated to 190/80 and transferred to for stemi. . patient was in usoh, pain described as intermittent with radiation to his left arm and jaw, associated with nausea but denies palpitations, shortness of breath, dizziness, vomitting. . osh course: first ekg and cardiac enzymes at osh was normal (415 am). however he continued to complain of chest pain. second set of enzymes showed elevated troponin to 0.15, ck-mb 22 and repeat ekg showed st elevation in inferior leads (12:15 pm). he was started on a nitroglycerin drip, heparin drip and received iv morphine, aspirin, lopressor 25mg po, and plavix 75mg po. he was then transfered to for emergent catheterization. . in the cath lab, he received heparin, fentanyl, ntg. cardiac surgery was consulted but touchdowns were unsuitable for cabg. poba to prox and mid rpda. had lvedp of 26, dx with severe lv diastolic heart failure. angioseal placed and sent on ntg drip to ccu. . at baseline, he reports being able to walk mile. he is limited by leg cramping, but denies any chest pain or shortness of breath. endorses 1 pillow orthopnea, denies pnd. . on review of systems, he endorses chest pain, leg cramping, orthopnea. 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. all of the other review of systems were negative. . cardiac review of systems is notable for presence of chest pain and orthopnea. notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. cardiac history: mi , cad - cabg: none - percutaneous coronary interventions: none - pacing/icd: none 3. other past medical history: - gerd - depression - glaucoma - pseudophakia - ectropion - l wrist fx social history: he was widowed in , lives alone, has no children. he is currently retired, formerly worked as a prison guard. has a who lives across the street. formerly independent adl's. - tobacco history: quit 10 years ago - etoh: beer on weekends - illicit drugs: denies family history: family history: - mother: died of mi at age 76 - father: died of emphysema at 71 - brother: stomach cancer physical exam: on admission vs: t=96.8 bp= 147/83 hr=89 rr=12 o2 sat= 99% general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. mmm neck: supple,no jvd cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. no femoral bruits. no hematomas at cath site skin: intact. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ . on discharge general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. mmm neck: supple,no jvd cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. no femoral bruits. no hematomas at cath site skin: intact. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ harge pertinent results: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:30 10.6 4.41* 13.9* 42.2 96 31.6 32.9 14.3 134* 07:30 11.7* 4.53* 14.2 43.0 95 31.3 33.0 14.3 146* 07:25 13.6* 4.25* 13.6* 41.1 97 31.9 33.0 14.3 137* 06:16 38.8* 155 21:04 16.0* 4.43* 14.3 42.0 95 32.4* 34.1 14.2 152 renal & glucose glucose urean creat na k cl hco3 angap 06:30 232*1 31* 1.4* 138 4.3 104 28 10 07:30 240*1 30* 1.5* 136 3.8 100 28 12 07:25 220*1 27* 1.4* 138 3.5 103 25 14 06:16 27* 1.4* 136 3.3 101 21:04 285*1 22* 1.3* 138 3.8 102 22 18 cpk isoenzymes ck-mb mb indx ctropnt 07:25 15* 6.8* 06:16 137* 21:04 155* 11.7* 3.31* diabetes monitoring %hba1c eag 21:03 6.7*1 146* chemistry calcium phos mg cholest 07:30 1.8 07:25 8.2* 1.8* 2.1 21:04 8.5 2.9 2.0 175 left heart catheterization (): 1. severe three vessel coronary artery disease. cardiac surgery consulted who did not fel anatomy suitable for cabg given severity of native vessels without adequate graft targets. 2. severe systemic hypertension. 3. severe left ventricular diastolic heart failure post-pci. 4. successful balloon angioplasty of the proximal and mid rpda. 5. successful rfa angioseal closure. 6. aspirin given at the conclusion of the case given vomiting of undetermined pill fragments. 7. consider clopidogrel re-load and 75 mg daily for at least 1 month for secondary prevention post-mi and post-pci, with assessment of benefits with respect to secondary prevention post-pci versus bleeding risks. dual anti-platelet therapy is not mandatory as stent was not deployed (due to small vessel size <2 mm reference vessel diameter and poor runoff). 8. follow up with dr. . . echo (): the left atrium is elongated. a left-to-right shunt across the interatrial septum is seen at rest. a secundum type atrial septal defect is present. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. lv systolic function appears globally depressed (ejection fraction 30-35 percent) with regional variation: the posterior wall is akinetic, the inferior and lateral walls are severely hypokinetic, and most of the other walls of the left ventricle are mildly hypokinetic. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular free wall is hypertrophied. right ventricular chamber size is normal. with borderline normal free wall function. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . right heart catheterization (): 1. no significant left to right shunt. 2. moderate pulmonary hypertension. 3. elevated filling pressures. 4. preserved cardiac output. . brief hospital course: 83 yo m with hx of prior mi (), dmii, htn, dyslipidemia, who presented to osh with complaints of chest pain and elevated transferred to for an inferior stemi. pt was not a cabg candidate so he is s/p poba and medical management of his stemi. . active issues . # stemi: on presentation to , pt was taken to cardiac catheterization where he was found to have extensive three vessel disease which cardiac surgery deemed unsuitable for cabg due to the severity of disease in the native vasculature and the absence of adequate graft targets. pt underwent poba to the proximal and mid-rpda and was subsequently transferred to the ccu post-procedure for monitoring and medical management. pt had vomited all of his pills at the end of the case so in the ccu he was reloaded with plavix, to be continued for a one month course. he was also kept on a nitro drip, asa, lopressor, captopril, and started on atorvastatin. pt was soon stable enough to be transitioned to metoprolol xl and lisinopril 20 mg and was transferred to the cardiac floor. . # hypertension: pt's bps were very elevated to the 190s on admission and were elevated to the 160s-170s intermittently over the course of his hospital stay, requiring much titration of his blood pressure medications. likely etiology is progression of pt's severe long-standing hypertension. pt's bps were improved at discharge to the 140s on a regimen of metoprolol and lisinopril. . # fever: on , pt spiked a fever to 101.5, experienced 5 minutes of atrial tachycardia and his bps were elevated to 170s. pt denied any chest pain, sob, cough, or dysuria and cultures drawn at the time were still pending at the time of discharge. pt received 6.25mg captopril with improvement of his blood pressures and an ecg at the time showed no evidence of acute ischemia. pt remained afebrile and showed no signs of infection over the remainder of his hospital stay. . # acute diastolic chf: during his left heart cath, patient was noted to have severe left ventricular diastolic dysfunction with an lvedp of 26. patient was diuresed with 40mg iv lasix to good effect (net out 1.2l) in an effort to improve his volume status. in order to determine pt's baseline pump function, a prior echo was obtained from his outpt provider which showed left-to-right shunt across the interatrial septum. right heart catheterization was performed to evaluate the size of the shunt and to determine whether it was contributing to his diastolic dysfunction, but the shunt was not found to be hemodynamically significant. . chronic issues . #diabetes: stable. was controlled on insulin sliding scale during his admission and his home meds were re-started at discharge. . # depression: stable. continued celexa. . transitional issues pt was reloaded with plavix due to vomiting of medicine after the procedure, and it is recommended that pt be continued on it for a one month course. if pt's blood pressures remain elevated post-discharge, consider re-starting pt's home dose of imdur. medications on admission: - xalatan eye drops and dorzolamide eye drops - imdur 60mg po daily - lopressor 25 mg po bid - lovastatin 10 mg po daily - prilosec 20 mg po daily - precose 50 mg po qac - aspirin 81mg po daily - vitamin c 500 mg po daily - vitamin e 400 mg po daily - glipizide 5 mg po daily - celexa 20 mg po daily discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 3. dorzolamide 2 % drops sig: one (1) drop ophthalmic as directed. 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). disp:*30 tablet extended release 24 hr(s)* refills:*2* 9. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. precose 50 mg tablet sig: one (1) tablet po before meals. 11. glipizide 5 mg tablet sig: one (1) tablet po once a day. 12. vitamin c 500 mg tablet sig: one (1) tablet po once a day. 13. outpatient lab work please check chem-7 on tuesday with results to dr., 14. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet sublingual as directed. disp:*25 tablets* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: non st elevation myocardial infarction acute systolic duysfunction: ef 35% diabetes type 2 hypertension 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 needed a cardiac catheterization with a balloon angioplasty to open up 2 arteries on the right side. this procedure went well and you did not have any further chest pain. you will be sent home on some new medicines to help your heart recover from the heart attack and optimize your heart function. if you have chest pain at home, you can take a nitroglycerin tablet under your tongue to see if this help the chest pain. you can take 2 tablets 5 minutes apart. please call dr. if you have any chest pain at all at home. your heart is weaker after the heart attack and you will need to watch your legs for signs of swelling. you may also have trouble breathing or trouble lying flat to sleep. if you notive these things, please call dr. . weigh yourself every morning before breakfast, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . we made the following changes to your medicines: 1. start taking plavix (clopidogrel) and full dose aspirin (325mg)every day to help your heart arteries stay open 2. stop taking omeprazole as it can interfere with the plavix, take ranitidine instead 3. change metoprolol to a long acting version (succinate) and increase the dose to 100 mg to help your heart recover from the heart attack 4. start taking lisinopril to lower your blood pressure and help your heart recover from the heart attack 5. discontinue lovastatin and take atorvastatin inestead, this is better for your heart to recover from the heart attack 6. stop taking vitamin e followup instructions: primary care: , m. his office is closed on friday so please call the office on to make an appt in the next 5 days. . cardiology: , hospital , tuesday at 3:00pm Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Right heart cardiac catheterization Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other chronic pulmonary heart diseases Personal history of tobacco use Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Acute myocardial infarction of other inferior wall, initial episode of care Old myocardial infarction Fever, unspecified Acute combined systolic and diastolic heart failure |
allergies: penicillins attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: coronary artery bypass grafting x2 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery. mitral valve repair with cg future annuloplasty ring, size 26 mm, model #638r. aortic valve replacement with a st. epic tissue valve model #esp100-21-00. cardiac catheterization history of present illness: 72 year old female with an extensive smoking history presents with one day of intermittent left chest pain and worsening shortness of breath. was comfortable when ems arrived, but on transport, her breath sounds became less clear with crackles to the mid lung fields and she became tachypneic. was given 6 sprays of ng, 40mg of lasix, 4mg of morphine and put on bipap. highest sbp is reported but not documented at 180. while on bipap she was tachypneic to 32-40. she admits to eating some sausage today prior to feeling short of breath. also, she visits her husband at a long term care facility and said that many people had "colds" there. she has had chills, and developed a cough, but did not measure her temperature. past medical history: aortic stenosis coronary artery disease diabetes mellitus gastroesophageal reflux disease hypertension social history: tobacco history: quit smoking 3 weeks prior to presentation was smoking ppd recently (down from 1 ppd); smoked approx 30-40 years etoh denies cares for her husband with . family history: brother had an mi at 42. positive fhx of htn. physical exam: physical examination on admission: 62" 142# vs: t= bp=125/76 hr=92 rr=30 o2 sat=88% on 6l nc general: elderly woman in mild respiratory distress. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of ~20 (at her earlobe). cardiac: normal rate regular rhythm. lusb crescendo/decrescendo murmur, and holosystolic low pitch murmur. lungs: no chest wall deformities. resp were mildly labored, with accessory muscle use. diffuse crackles bilaterally with decreased breath sounds at the bases. wheezes bilaterally. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: 1+ pitting edema skin: warm, dry. no lesions pulses: right: carotid 2+ dp 2+ pt 2+ left: carotid 2+ dp 2+ pt 2+ pertinent results: 10:32pm blood wbc-12.4* rbc-3.78* hgb-11.8* hct-34.5* mcv-91 mch-31.1 mchc-34.0 rdw-14.2 plt ct-212 04:30am blood wbc-11.5* rbc-3.56* hgb-11.0* hct-32.2* mcv-91 mch-31.0 mchc-34.3 rdw-14.3 plt ct-201 02:57am blood wbc-8.0 rbc-3.49* hgb-10.9* hct-30.9* mcv-89 mch-31.1 mchc-35.1* rdw-14.3 plt ct-187 10:32pm blood neuts-67.8 lymphs-26.9 monos-3.5 eos-1.2 baso-0.6 10:32pm blood plt ct-212 10:32pm blood pt-11.9 ptt-25.0 inr(pt)-1.0 04:30am blood plt ct-201 02:57am blood pt-13.3 ptt-38.2* inr(pt)-1.1 02:57am blood plt ct-187 10:32pm blood glucose-236* urean-8 creat-0.7 na-123* k-4.1 cl-94* hco3-19* angap-14 04:30am blood glucose-95 urean-9 creat-0.7 na-128* k-4.4 cl-94* hco3-22 angap-16 11:13am blood glucose-124* urean-10 creat-0.6 na-128* k-4.1 cl-94* hco3-21* angap-17 04:30am blood ck(cpk)-118 11:13am blood alt-21 ast-29 ld(ldh)-213 alkphos-62 totbili-0.4 10:32pm blood ctropnt-0.04* 10:32pm blood probnp-1210* 04:30am blood ck-mb-10 mb indx-8.5* ctropnt-0.08* 04:30am blood calcium-9.3 phos-4.4 mg-1.1* 11:13am blood albumin-4.0 calcium-9.0 phos-4.4 mg-2.4 02:57am blood calcium-9.1 phos-3.5 mg-1.9 03:19pm blood %hba1c-6.1* eag-128* 10:40pm blood ph-7.35 comment-green top 12:33am blood po2-92 pco2-35 ph-7.36 caltco2-21 base xs--4 comment-trauma 10:40pm blood glucose-230* lactate-2.4* na-125* k-4.0 cl-91* calhco3-20* 12:33am blood lactate-1.3 k-3.8 10:40pm blood freeca-1.13 . ecg study date of sinus rhythm. there is slurring of the upstroke of the qrs complex consistent with pre-excitation. compared to the previous tracing voltage for left ventricular hypertrophy is slightly less. intervals axes rate pr qrs qt/qtc p qrs t 86 158 116 392/437 58 19 41 . cardiac cath study date of comments: 1. coronary angiography in this right dominant system demonstrated two vessel disease. the lmca had no angiographically apparent disease. the lad had a 80% proximal stenosis. the lcx had minimal diffuse disease. the rca had a 90% stenosis in the mid-portion. final diagnosis: 1. two vessel coronary artery disease. . chest (pre-op pa & lat) study date of findings: there has been marked interval improvement in pulmonary edema. cardiomediastinal and hilar contours are within normal limits. minimally increased pulmonary vasculature and blunting of the costophrenic angles remain. no focal consolidation or pneumothorax. there are low lung volumes. impression: 1. marked interval improvement in pulmonary edema. 05:12am blood wbc-11.0 rbc-3.22* hgb-9.2* hct-29.1* mcv-90 mch-28.6 mchc-31.7 rdw-16.3* plt ct-336 03:21am blood neuts-88.2* lymphs-8.9* monos-2.5 eos-0.2 baso-0.2 05:12am blood plt ct-336 05:12am blood pt-13.9* inr(pt)-1.2* 05:12am blood glucose-135* urean-21* creat-0.6 na-138 k-4.0 cl-102 hco3-25 angap-15 04:00am blood alt-29 ast-45* ld(ldh)-333* alkphos-83 amylase-26 totbili-0.6 04:30am blood ck-mb-10 mb indx-8.5* ctropnt-0.08* 10:32pm blood probnp-1210* 05:12am blood phos-2.6* mg-1.6 03:19pm blood %hba1c-6.1* eag-128* pa and lateral views of the chest: reason for exam: status post avr and mvr repair and cabg. comparison is made with prior studies . moderate cardiomegaly is stable. now mild to moderate pulmonary edema has markedly improved. small-to-moderate bilateral pleural effusions are decreased associated with adjacent atelectasis. left picc tip is in the upper to mid svc. sternal wires are aligned. brief hospital course: presented to emergency department tachypneic to 32-40 while on bipap and hypotension. she was admitted and transferred to the ccu at which time she was chest pain free; vitals on transfer to the ccu t 98.0, hr 83, bp 105/63, rr 30, 100% on bipap. she was actively diuresed and put out over 4l with significant improvment in pulmonary edema seen on cxr and concomitant improvement in respiratory status. given severity of as and resent exacerbation, pt was evaluated for avr and felt to need valve replacement. pre-op work-up intiated and she underwent repeat cxr, carotid ultrasound and cardiac catheterization. cardiac catheterization revealed coronary artery disease. on she was brought to the operating room and underwent aortic valve replacement and coronary artery bypass graft surgery. she received vancomycin for perioperative antibiotics and was trasnfered to the intensive care unit for post operative management. she remained intubated, as she remained lethargic and unable to protect airway. she was transfused two units of packed red blood cells for anemia due to blood loss and hemodilution. she was extubated on pod 3, by this time she had been weaned from inotropic and vasopressor support. beta blocker was initiated and she was gently diuresed toward the preoperative weight. she did develop post-op atrial fibrillation and was treated with amiodarone, beta blocker and anti-coagulation for a goal inr 2-2.5. additionally, she developed bilateral weakness of upper and lower extremities. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 8 she remained weak, ambulating few feet with walker and assistance. she was discharged to rehab macu on telemetry due to continued atrial fibrillation. medications on admission: atorvastatin 40 mg po daily hydrochlorothiazide 25 mg po daily lisinopril 60 mg po daily metformin 1,000 mg po bid pantoprazole - 40 mg po bid sucralfate 1 gram q6h aspirin 81 mg po daily calcium carbonate-vitamin d3 omega-3 fatty acids discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever, pain. 4. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 6. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 7. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). 8. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day): stop when inr > 1.8. 9. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 10. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 11. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): please give 400 mg twice a day for six days, decreased to 400mg once a day for seven days, then 200 mg daily until follow up with cardiologist . 12. magnesium oxide 400 mg tablet sig: one (1) tablet po daily (daily). 13. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 14. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day): 75 mg three times a day . 15. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 16. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 17. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po daily (daily). 18. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). 19. warfarin 2 mg tablet sig: one (1) tablet po once a day for 1 days: please give 2 mg on thrusday - then check inr for further dosing - had received 2mg on and at . 20. outpatient lab work chem bun/cr, potassium and magnesium twice a week while on lasix 21. heart monitor telemetry to monitor rhythm due to atrial fibrillation rate controlled discharge disposition: extended care facility: hospital - discharge diagnosis: aortic stenosis s/p avr coronary artery disease s/p cabg mitral regurgitation s/p mv repair post operative atrial fibrillation non st elevation myocardial infarction gastroesophageal reflux disease hypertension discharge condition: alert and oriented x3 ue strength 5/5 le re le ambulating with walker and assistance few feet unsteady gait incisional pain managed with acetaminophen prn incisions: sternal - healing well, no erythema or drainage leg right - healing well, no erythema or drainage steri strips edema trace lower extremities 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. wednesday @ 1:45 pm 2a cardiologist:dr. @ 10:20 am please call to schedule appointments with your primary care dr. in weeks labs: pt/inr for coumadin ?????? indication atrial fibrillation goal inr 2.0-2.5 first draw day after discharge friday then please do inr checks monday, wednesday, and friday for 2 weeks then decrease to twice a week rehab physician to dose coumadin while at rehab **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Open heart valvuloplasty of mitral valve without replacement Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hyposmolality and/or hyponatremia Atrial fibrillation Personal history of tobacco use Other and unspecified hyperlipidemia Mitral valve insufficiency and aortic valve stenosis Other encephalopathy Acute combined systolic and diastolic heart failure Unspecified sedatives and hypnotics causing adverse effects in therapeutic use |
allergies: penicillins attending: chief complaint: fever. major surgical or invasive procedure: 1. central venous access insertion. history of present illness: pt is a 72yo f with dm2, htn, cad, s/p cabg in with mvr and avr who presents with bladder pressure for 2 days and fever and chills since this morning. pt states that she saw her ob/gyn for vaginal spotting. she had a pelvic u/s down which she states was normal & there was no evidence of bleeding seen. since thursday, 3 days ago, she had bladder pressure sensation with sensation that she was unable to void completely. she denied any nausea, vomiting, back pain, dysuria, hematuria, or odor to her urine. she felt cold over the weekend, and then developed fever and chills this morning. she said she was shaking a lot and her daughter decided to bring her to the . they did not take a temp prior to coming to the ed. . in the ed, initial vs were: t 101.7 p 116 bp 106/72 r 18 o2 sat 100% on ra. ua was positive. patient was given 3l iv fluids, tylenol 1000mg, ceftriaxone 1g, 4g of iv magnesium. the patient was started on levophed gtt for persistent pressures in the 80's. lactate went from 3.3-->2.3 after 3l ivf. prior to transfer to the floors, she was on levophed 0.04. . . on the floor, she feels like her mouth is dry, but has no other complaints. she currently denies any abdominal pain or back pain. bp apparently runs in 110s at home. pt has not taken am bp meds. pt does not recall prior utis and has not taken any recent abx. . review of systems: (+) per hpi. also with some itching from her cabg scar, but this is unchanged. (-) denies 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 arthralgias or myalgias. denies rashes or skin changes. past medical history: cad s/p mi in . cabg and avr and mvr in . dm2 htn anemia gerd proteinuria non-immune hemolytic anemia avr hld thyroid nodule social history: she has over 40 years of smoking and stopped last year in the fall of . she smoked approximately one or more pack per day. she denies any alcohol abuse history or illicit drug use. she currently lives with her son and daughter since her surgery in . family history: mother had heart disease. her brother died at the age of 42 from heart disease. physical exam: admission physical: vitals: t: 98.9 bp: 116/66 p: 86 r: 10 o2: 97%ra cvp 13 general: alert, oriented, no acute distress, pleasant, sitting up in bed heent: sclera anicteric, dry mm, oropharynx clear neck: supple, jvp not elevated, no lad, r ij in place lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: well-healed midline vertical cabg scar, 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 ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema; scarring of left hand (from burn many years ago) neuro: a&ox3, cn ii-xii grossly intact, moving all extremities, no gross deficits pertinent results: admission labs: 07:00am blood wbc-11.0 rbc-3.70* hgb-11.2* hct-32.8* mcv-89 mch-30.2 mchc-34.1 rdw-15.3 plt ct-150 07:00am blood neuts-88.9* lymphs-7.7* monos-2.5 eos-0.7 baso-0.2 07:00am blood glucose-236* urean-34* creat-1.4* na-133 k-5.2* cl-98 hco3-20* angap-20 07:00am blood calcium-8.8 phos-3.3 mg-1.0* 07:15am blood lactate-3.3* 08:59am blood lactate-2.3* k-4.2 03:33pm blood lactate-1.5 k-3.3* 12:19pm blood o2 sat-66 labs prior to discharge: 07:00am blood wbc-9.1 rbc-3.64* hgb-11.0* hct-32.8* mcv-90 mch-30.2 mchc-33.6 rdw-16.1* plt ct-424 11:00am blood neuts-72* bands-1 lymphs-13* monos-11 eos-2 baso-1 atyps-0 metas-0 myelos-0 07:20am blood neuts-50 bands-3 lymphs-38 monos-6 eos-1 baso-1 atyps-0 metas-1* myelos-0 07:00am blood neuts-68 bands-2 lymphs-24 monos-4 eos-0 baso-0 atyps-1* metas-0 myelos-1* 07:00am blood glucose-197* urean-12 creat-1.1 na-142 k-4.0 cl-107 hco3-23 angap-16 07:25am blood lactate-1.8 micro: blood cultures pending x2 blood cultures pending x2 blood cultures pending urine culture negative blood cultures pending mrsa screen: negative urine culture: pansensitive e.coli blood cultures x2: pansensitive e.coli images: ruq ultrasound: liver echotexture is normal. there are no focal hepatic lesions. the previously demonstrated right liver lobe abnormality on ct is not visualized on this ultrasound study. the portal vein is patent with normal hepatopetal flow. there is no ascites. there is no intra- or extra-hepatic biliary duct dilatation with the common bile duct measuring 4 mm. the spleen is normal measuring 9 cm. impression: no us finding that would be corresponding to the previously seen lesion on ct. ct abd/pelvis: 1. bilateral patchy enhancement of the renal parenchyma, consistent with the stated history of pyelonephritis, without evidence of renal or perinephric abscess. additional areas of scarring suggest previous infection or ischemic change. no hydronephrosis. 2. 12 mm focal hypodense lesion within the right lobe of the liver, not fully characterized, could be further assessed with ultrasound when clinically appropriate. 3. severe atherosclerotic change of the abdominal aorta and iliac arteries. 4. diverticulosis without evidence of diverticulitis. cxr: as compared to the previous radiograph, the opacities indicative of pulmonary edema have minimally decreased. no focal parenchymal opacities have newly appeared. presence of a minimal left pleural effusion cannot be excluded. unchanged alignment of the sternal wires, unchanged position of the right internal jugular vein catheter. unchanged size of the cardiac silhouette. tte: poor image quality.the left atrium is elongated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is probably mildly depressed (lvef= 40 %) with global hypokinesis. there is no ventricular septal defect. with depressed free wall contractility. a bioprosthetic aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. no aortic regurgitation is seen. a mitral valve annuloplasty ring is present. the gradient across the mitral valve is increased (mean = 10 mmhg). trivial mitral regurgitation is seen. tricuspid regurgitation is present but cannot be quantified. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the report of the prior study (images unavailable for review) of , the degree of mr is less. if indicated, a tee would better assess the degree of mr due to poor tte quality and acoustic shadowing from the mitral ring. cxr: one portable view. comparison with the previous study of . there is diffusely increased parenchymal density bilaterally with increased interstitial markings most suggestive of edema. the patient is status post median sternotomy and mvr as before. mediastinal structures are unchanged. a right internal jugular catheter remains in place. impression: diffusely increased pulmonary parenchymal density most suggestive of edema. cxr: ij in place. cxr: no acute cardiopulmonary process. mild cardiomegaly, stable. mild fluid overload. ekg: st at 122, lvh, na, ni, ste in v1 and v2 unchanged from prior brief hospital course: 72 yo female with history of type 2 diabetes, htn, and cad s/p cabg in with mvr and avr who presents with fevers, uti and hypotension found to have pansensitive e.coli urosepsis. # septic shock secondary to e.coli bacteremia from e.coli uti: patient presented with symptoms of bladder pressure, incomplete emptying, fevers, and rigors. labs revealed a left shift with . urinalysis was grossly positive with pansensitive e.coli growing in urine and blood cultures from the day of admission. she had criteria for sepsis on admission with fever, tachycardia, hypotension, and a source. she went to the micu initially with a l-ij, requiring ivf and levophed for support. she has been maintained on ceftriaxone with white count and fever curve trending down. she had another fever after one week of ceftriaxone, so a ct abdomen/pelvis was done which revealed with pyelo. a ruq was done to evaluate a liver hypodensity seen on ct abd/pelvis, but this was not visualized. blood cultures are pending at the time of discharge. she was continued on oral ciprofloxacin for a total antibiotic course of 14 days given bacteremia (). # acute kidney injury: cr 1.4 upon admission with baseline of 0.8. likely hypovolemic in the setting of fever, sepsis, and poor po intake. she received four liters of ivf in the micu and ed with partial resolution of her . her diuretics were held initially so a component of poor forward flow. her creatinine has been stable on her home bumex regimen. she was euvolemic on exam prior to discharge. # normocytic anemia: hct 32 at baseline of 33. she has a history of non-immune hemolytic anemia avr. she is followed as an outpatient with heme. no history of iron deficiency, but is on iron and vitamin c. # cad s/p cabg with avr and mvr: ekg on admission stable from prior, with exception of tachycardia which has resolved. she was continued on asa, atorvastatin and lisinopril. metoprolol was initially held in the setting of septic shock. she was titrated to lower dose of 25 mg po bid instead of 37.5 mg po tid prior to discharge. with lvef of 40% she would benefit from metoprolol xl which we will defer to her pcp. # acute on chronic chf exacerbation: secondary to ivf received during initial resuscitation efforts for urosepsis. most recent tte with ef 40% from , confirmed on tte and tee during this admission. patient restarted on her home dose of bumex. she was also continued on asa, atorvastatin, metoprolol, and lisinopril. # cad s/p cabg, avr, mvr: continued on asa, atorvastatin. as above, initially held lisinopril, metoprolol, bumex given hypotension. ecg was unchanged. # dm2: held metformin given acute renal failure. placed on qid fingersticks & iss. # gerd: continued protonix 40mg per home dosing. follow up for pcp 1. with lvef of 40% she would benefit from metoprolol xl which we will defer to her pcp. medications on admission: medications: per omr & confirmed with patient atorvastatin 40mg po daily bumex 1mg mwf lisinopril 10mg po daily metformin 1000mg po bid metoprolol 37.5mg po tid pantoprazole 40mg po bid potassium chloride 40meq daily ascorbic acid 1000mg po daily asa 81mg po daily calcium carbonate vit d3 cyanocobalamin 1000mcg po daily ferrous gluconate 240mg omega 3 fatty acids daily magnesium oxide 500mg 2 caps mwf, 1 cap tuthsasu discharge medications: 1. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. bumetanide 1 mg tablet sig: one (1) tablet po three times per week. 3. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 4. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 7. ascorbic acid 1,000 mg tablet sig: one (1) tablet po once a day. 8. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 9. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 10. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po once a day. 11. cyanocobalamin (vitamin b-12) 1,000 mcg tablet sig: one (1) tablet po once a day. 12. ferrous gluconate 325 mg (37.5 mg iron) tablet sig: one (1) tablet po daily (daily). 13. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). 14. magnesium oxide 250 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 15. ciprofloxacin 250 mg tablet sig: three (3) tablet po q12h (every 12 hours) for 2 doses. disp:*6 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: gram negative rod bacteremia with septic shock secondary to uti and pyelonephritis secondary diagnosis: cad s/p cabg, avr, mvr, hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you during your stay here at . you were admitted for fever and chills. you had a urinary tract infection that spread to your kidneys and into your bloodstream. you were given iv antibiotics until transitioning to oral antibiotics. the following changes were made to your medication regimen: start ciprofloxacin for two more days to treat your urine infection decrease metoprolol to 25 mg by mouth twice a day decrease magnesium to 250 mg by mouth once a day stop potassium as you had high levels on admission followup instructions: the following appointments were made for you: department: when: tuesday at 11:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage name: , location: , , ma phone: appt: at 1:30pm Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Diagnoses: Acidosis Anemia, unspecified Esophageal reflux Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Severe sepsis Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of tobacco use Septic shock Heart valve replaced by transplant Septicemia due to escherichia coli [E. coli] Acute on chronic systolic heart failure Pyelonephritis, unspecified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain, shortness of breath major surgical or invasive procedure: cardiac catheterization aortic valve replacement with #25 st. tissue valve, coronary artery bypass grafting x2 with left internal mamary artery to left anterior descending artery and reverse saphenous vein graft to obtuse marginal coronary artery history of present illness: 77 year old male with history of hypertension, hyperlipidemia, peripheral vascular disease presenting to osh ed last night with chest pain, shortness of breath, nausea and elevated blood pressure to 200s/100s. over the last 2 years, he has experienced intermittent chest pain, unable to define how often it occurs, that starts in the abdomen and radiates to the chest, which resolves on its own after about 15-20 minutes. he does note that it's associated with activity, but anxiety is also a component. in addition, over the last 2 years he has felt weaker and gets more short of breath when walking, and occasionally chest pain with activity. no symptoms at rest. pt had stress mibi in that showed poor exercise tolerance, no angina but reversible mild perfusion defect. over the last week, episodes have increased in frequency, about 2-3 times over the last week he has experienced chest pain, which resolved within 15 minutes as usual, but on night of presentation he had chest pain that lasted for about 2 hours, did not resolve. onset was while driving and worsened after he sat down to watch tv. . he presented initially to hospital because his pain did not resolve. bp on prsentation initially 133/94, increased to 169/104 and later noted to be 200s/100s per report (although this is not documented in osh dc summary). on ekg , depressions noted in anterolateral leads, q waves in v1 v2, st elevations in v1-v2. on f/u ekg, findings were similar, but in addition noted to have st elevation in avr. he ruled in for nstemi at osh st changes as above, in addition noted to have elevated enzymes (trop i increased from .06 -> 32.9, ckmb 5.4 -> 162.9. he was started on ntg gtt, morphine, aspirin, and loaded with plavix 300 mg, heparin gtt was started with bolus. also given metoprolol and lasix with relief of chest pain. he was admitted to ccu at osh where he experienced no further chest pain. he was continued on ntg gtt at 10 mcg. referred to for left heart cath. vs on transfer 198/99 temp 98.5, hr 67, rr 15-20, sat 97% on 2l nc. . l heart cath showed diffuse disease, with stenosis of 70% l main, 70% prox lad, 80% ostial rca, ef 45%. lvedp noted to be 35 mmhg. femoral sheath was left in place and cardiac surgery team was called to evaluate for bypass surgery. patient is currently chest pain free and has been since admission to osh. past medical history: 1. cardiac risk factors: -diabetes, +dyslipidemia, +hypertension 2. cardiac history: - cabg: none - percutaneous coronary interventions: none - pacing/icd: none 3. other past medical history: - pvd - s/p umbilical hernia repair acute renal failure ( pre-op) social history: lives with granddaughter, 4 children. - tobacco history: former smoker, quit 20 yrs ago - etoh: denies - illicit drugs: denies family history: - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - mother: pvd - father: stroke at age 45 physical exam: admission physical exam: 5'" 195 # 88.5 kg 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 of 5 cm, laying down cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. crescendo-decrescendo systolic murmur best heard at rusb radiating to carotids. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. bilateral crackles noted at bases on anterior auscultation abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. extremities: no c/c/e. no femoral bruits. r groin with arterial sheath in place skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: femoral 2+ dp 1+ pt 1+ left: femoral 2+ dp 1+ pt 1+ pertinent results: admission labs/studies: - ecg: pre cath hr 60, sinus, ste in v1-v2, lbbb . - cardiac cath: ef 45-50% with global hypokinesis, lmca origin 80%, lad: ostial 80%, mid vessel 60%, diffusely diseased small diagonal. lcx: mild luminal irregularities, proximal 40%, rca: small nondominant 80% ostial. lvedp 35 mmhg . - cxr: mild chf at osh - laboratory data: trop .06 -> 32.9; ckmb 5.4 -> 162.9; na 136, k 3.7, bun 22, crt 1.0, wbc 9.3, hgb 11.7, hct 34.4, plt 253, inr 1.0, ptt 44. pt 12.9, gluc 124 fasting lipids: tg 144, total cholesterol 211, ldl 132, hdl 50, tsh 2.22 conclusions pre-bypass: mild spontaneous echo contrast is seen in the body of the left atrium. mild spontaneous echo contrast is present in the left atrial appendage. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is mildly depressed (lvef= 40-45 %). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. there are simple atheroma in the ascending aorta. the aortic arch is mildly dilated. there are complex (>4mm) atheroma in the aortic arch. the descending thoracic aorta is mildly dilated. there are multiple complex (mobile) atheroma in the descending aorta. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results at time of surgery. post-bypass: the patient is on no inotropic infusions. there is a bioprosthetic valve in the aortic position. no aortic regurgitation is seen. there is a peak gradient of 16 mmhg and a mean gradient of 8 mmhg across the aortic valve. biventricular function is unchanged. mitral regurgitation is unchanged. the aorta is intact post decannulation. i certify that i was present for this procedure in compliance with hcfa regulations. interpretation assigned to , md, interpreting physician 06:25am blood wbc-10.7 rbc-2.78* hgb-9.1* hct-24.9* mcv-89 mch-32.7* mchc-36.5* rdw-15.3 plt ct-222 01:23pm blood pt-14.0* ptt-35.9* inr(pt)-1.2* 06:25am blood glucose-113* urean-47* creat-1.3* na-137 k-4.7 cl-103 hco3-24 angap-15 brief hospital course: mr. was transferred in from osh for evaluation of coronary artery revascularization. he was initially plavix loaded and patient was stable,therefore surgery was postponed for plavix washout. iabp placement was deferred due to tortuous vessels/pvd and patient remained hemodynamically stable and chest pain free. he was continued on a ntg drip to decrease preload / diastolic pressures improve coronary blood flow. he was continued on a heparin drip and his home asa was increased to 325 mg po daily. his atenolol was changed to metoprolol, and his simvastatin 40mg daily was changed to atorvastatin 80mg daily. he was started on lisinopril, but this was the held secondary to acute renal failure. creatinine on admission 1.1, increased to 1.6 after cath. his lisinopril was held. referred for surgery and underwent avr (#25mm st. tissue)/coronary artery bypass grafting x2(left internal mammary artery grafted to the left anterior descending/saphenous vein to obtuse marginal)with dr. on . please refer to operative note for further details. he tolerated the procedure well and was transferred to the cvicu intubated and sedated in stable condition on titrated phenylephrine and propofol drips. he awoke neurologically intact and was extubated that evening. all lines and drains were discontinued per protocol. beta blockade/aspirin/statin were initiated, along with gentle diuresis. his creatnine trended down. an ace-i was not resumed secondary to allowing his renal function recovery. this should be readdressed as an outpatient. pod #1 he was transferred to the step down unit to begin increasing his activity level.physical therapy was consulted for evaluation of strength and mobility. the remainder of his postoperative course was essentially uneventful. pod#4 he received 1 unit of packed red cells for postoperative anemia likely due to volume resucitation. he continued to progress and on pod#4 he was cleared for discharge to rehab. all follow up appointments were advised. medications on admission: home medications: - simvastatin 40 mg daily - aspirin 81 mg daily - atenolol . medications on transfer: - lisinopril 10 mg daily - heparin gtt - metoprolol 25 mg - colace - aspirin 325 mg daily - protonix iv - plavix 75 mg daily discharge medications: 1. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 8. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 9. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 10. hydralazine 25 mg tablet sig: three (3) tablet po q6h (every 6 hours). 11. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 12. metoprolol tartrate 50 mg tablet sig: 2.5 tablets po tid (3 times a day). 13. lasix 20 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: rehabilitation & care center - discharge diagnosis: s/p coronary artery bypass grafting x2(lima->lad, svg->om1)aortic valve replacement(25 st. tissue valve) acute renal failure ( pre-op) acute on chronic systolic heart failure pmh:aortic stenosis, coronary artery disease, hypertension, hyperlipidemia, anxiety, pvd discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with tramadol incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema:1+ ble 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 wednesday @ 1:30 pm in the medical office building cardiologist:, m. ( his office will contact you with appt- you should be seen in 3 weeks) please call to schedule appointments with your primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Aortography Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Aortic valve disorders Other and unspecified hyperlipidemia Acute on chronic systolic heart failure Atherosclerosis of native arteries of the extremities, unspecified Surgical or other procedure not carried out because of contraindication |
allergies: no known allergies / adverse drug reactions attending: chief complaint: right cerebellar hemorrhage major surgical or invasive procedure: suboccipital crani for evacuation of the right cerebellar hemorrhage right frontal evd placement history of present illness: this is a 73 year old man with hypertension and vascular disease transferred from hospital with reported cerebellar hemorrhage. he reportedly was brought to the osh after developing nausea, vomiting, and diaphoresis at his apartment complex. he arrived complaining of a headache; the nursing notes says he was awake and speaking and denied cp/sob on arrival. he was markedly hypertensive on arrival -- bp was recorded initially as 232/132 (vs otherwise unremarkable). cbc and coags were normal (inr 0.9 and no known h/o a/c); bmp was pending. ecg remarkable for obvious lvh (voltage criteria) and ?rbbb (rsr' in iii), with nsr. he was given zofran and labetalol, and when his systolics remained elevated in the 200s, he was started on a nitroprusside drip. he was taken for nchct, which showed a 3cm right cerebellar hemorrhage. at some point during this initial evaluation, he became acutely non-responsive, so he was intubated (induced with etomodate and succinylcholine, also fentanyl) and med-flighted here to . he was continued on the nipride gtt en route, and paralyzed for transport using rocuronium and propofol gtt. he arrived here around 21:30 with bp 267/131, down to 168/96 with increased nitroprusside gtt rate. he was flaccid (paralyzed). the ed resident informed me that someone had commented on "asymmetric pupils" at some point, but the personell said that his pupils were 2mm and equal the entire trip (they were this size of smaller, non-reactive, on my arrival to the ed a few minutes after his arrival). past medical history: 1. hypertension 2. renal artery stenosis 3. aaa endovascular repair c/b r ext iliac pseudoaneurysm, also s/p repair 4. peripheral vascular disease 5. nephrolithiasis 6. hyperlipidemia 7. copd social history: lives alone, ex wife lives in u.s. but the rest of extended family resides in . he is primarily arabic speaking, but understands some english. no tobacco. family history: non-contributory physical exam: on admission: mental status: sedated / non-responsive. does not blink or track. later, as paralytic lifted, he grimaced inconsistently to noxious stimulation and spontaneously moved his right shoulder and both legs. -cranial nerves: pupils are equally small (1.5-2mm), round, and non-reactive to light (?"pontine" pupils). no good view for fundoscopy (small pupils). no doll's eye response initially. eyes mid-position with no movement. initially, no corneal response or response to nasal tickle. later, bilateral weak eyelash-blink responses and legs moved to bilateral nasal tickle. face was symmetrically lax; when he later furrowed his brow to noxious stimulation, it elevated symmetrically. initially, no gag or cough; later strong cough (tracheal suction) and weak gag (gentle ett-wiggle). initially, not over-breathing the vent and not initiating full breaths on cpap. -motor: initially, flaccid x all extremities and axially. later, spontaneous minimal movements of rue and bilatearl les. at discharge: awake, alert to self, hospital, month. following all commands. mae with full strengths. incision well healed. pertinent results: head ct : findings: centered within the right cerebellum, there is a 5.4 x 3 cm hyperdense hemorrhage with surrounding edema (previously 2.8 x 3 cm); this hemorrhage crosses the cerebellar vermis into the left cerebellar hemisphere. hyperdense blood is seen within the fourth ventricle extending up into the third ventricle. the lateral ventricles and third ventricle are dilated measuring up to 4.4 cm. hyperdense blood is seen layering within the occipital horns bilaterally. there is no significant shift of normally midline structures. the basal cisterns inferiorly are obliterated. the posterior fossa is expanded with mass effect on the brainstem. the cerebellar tonsils are at the level of the foramen magnum. no acute fracture is seen. the visualized portions of the paranasal sinuses and mastoid air cells are well aerated. retained secretions are noted in the nasopharynx. impression: large parenchymal hemorrhage centered in the right cerebellar hemisphere with intraventricular extension, mass effect, and hydrocephalus as above, increased since 2 hours prior. head ct 1. interval occipital craniectomy with increased but residual hyperdense blood in the cerebellum and ventricles; evaluation of mass effect is suboptimal on this study due to portable technique. 2. interval placement of a right frontal approach ventricular catheter with persistent hydrocephalus. ct head impression: 1. interval significant decrease of the hydrocephalus with normal size of the lateral ventricles and with the evd in place. 2. increase of subarachnoid hemorrhage in the both temporal and occipital lobes, likely due to redistribution of the intraventricular hemorrhage. 3. compared to the most recent prior study from , unchanged amount of hemorrhage in the fourth ventricle and the cerebellar hemispheres. ct head overall stable examination without significant hydrocephalus in the setting of external ventricular drain. parenchymal hemorrhage centered in the right cerebellum with extension into the fourth ventricle and biparietal/bitemporal subarachnoid hemorrhage, similar to 20 hours prior. ct head 1. interval removal of the right transfrontal ventriculostomy catheter with hyperdensity along catheter tract, representing minor parenchymal hemorrhage with trace intraventricular extension. 2. otherwise, the appearance is largely unchanged with biparietal and bitemporal subarachnoid blood, likely redistributional, related to the right cerebellar hemispheric hemorrhage with fourth ventricular extension, status post occipital craniectomy. ct head unchanged right cerebellar hemorrhage with intraventricular extension into the fourth ventricle. unchanged biparietal and bitemporal subarachnoid blood. unchanged minor parenchymal hemorrhage along the prior ventriculostomy catheter tract. unchanged ventricle size. no evidence of vascular territorial infarction lenis impression: no evidence of deep venous thrombosis in the lower extremities. chest xray : pa and lateral radiograph demonstrates unremarkable mediastinal, hilar and cardiac contours. lungs are clear. previously noted pulmonary edema has resolved. small bilateral pleural effusions noted. left subclavian line tip is terminating in the mid-to-distal superior vena cava. no pneumothorax. lower extremity doppler ultrasound : no evidence of deep vein thrombosis in either right or left lower extremity. lenis : no evidence of deep vein thrombosis in either leg. nchct: : impression: 1. increased prominence of the extra-axial csf spaces, particularly evident in the right posterior fossa and right frontal region. this may be related to volume loss from surgery, but the patient should be followed for intracranial hypotension with clinical correlation. indentation on the right cerebellar hemisphere from the right posterior fossa extra-axial fluid collection. 2. expected evolution of intracranial hemorrhage with decreased density of right cerebellar hemispheric hemorrhage, and near complete resolution of subarachnoid and ventriculostomy catheter tract hemorrhage. brief hospital course: pt was taken to the or emergently for suboccipital craniectomy and evacuation of ich. prior to this procedure a r frontal evd was placed without difficulty. he did recieve 2 units of platelets for his use of plavix. post operatively he remained intubated and was taken to the icu for further care including sbp control and q1 neurochecks. his evd was kept at 15cm above the tragus. on post op exam he was not following commands but moved everything to noxious. his pupils were equal and reactive. a head ct on the morning of showed good evacuation of ich and decreased hydrocephalus. on he was extubated without difficulty. he was noted to be awake and alert to self, following commands and moving all extremities with full strength. on , the patient experienced respiratory issues overnight into am. bipap ventilation was started at 930 am. teh patient was given lasix. a cxr was consistent with worseing consolidation and empiric antibiotic therapy was initiated for for ventilatory aquired pneumonia. the wbc level was 17.2 from 14.8 on . the external ventricular drain exhibited poor output of 4cc from 7-9am. the evd was distally/proximally flushed and the extrenal ventricular drain decreased to 10 and left open. icps were correlating with patient's activity and were . a nchct was performed which was consistent with good placement evd and no hydrocephalas. emergent reintubation at 1230pm for poor ventilatory status. a triple lumen placed. and a bronchcoscopy was performed at the bedside and a bal was sent. on , the patient's exam improved and he was able to follow some simple commands. the external ventricular drain was discontinued as there was no drainage of csf from the evd and the patient's 4th ventircle was noted to be patent on head ct. there staples were placed for closure. on , the patient neurological exam was improved and he was able to follow commands in all four extremities with full strength. eyes were open sponanteously, pupils were equal and reactive. the patient was electively extubated after diuresis with lasix. he tolerated extubation well. the steroids were discontinued as the patient has pneumonia and cdiff concurrently. he was agitated on and seroquel was increased. in the evening he did well on q2 hr neuro checks. he was less agitated. staining was noted on his pillowcase and there was a concern for csf leak. a clean dressing was applied and scant staining only was noted. he had no sign of hydrocephalus on . he was more oritented and appropriate. orders to the sdu were done. pt and sw were consulted. on , patient was transferred to the step down unit. his evd staples were removed. his catheter was removed, but unfortnately patient was unable to void on his own requiring him to undergo a straight catheterization. on his dressing remained clean and dry without evidence of leak and the patient continued to improved neurologically. he worked with pt and was found to be orthostatic. on he continued to improve and worked with pt and began being screened for rehab. attempts were made to contact the family in but three numbners were disconnected. he had some hypotension on that responded to fluid bolus. he was stable on . on his abdomen was found to be distended and post void bladder scan revealed 1000cc remaining in the bladder so a foley was replaced and the patient was started on flomasx. his creatinine bumped on to 2.1 (baseline elevated > 1.3) likely due to mild dehydration as his oral intake was poor. he was given a fluid bolus and placed on low iv maintenence fluids. his labs were trended. on his creatinine decreased to 1.8, and we again attempted to remove his foley. his sutures were removed on .....he had screening lenis on that were again negative for dvt. he remained stable - . disposition planning continues. a stool sample was sent on which was negative for cdiff. on he remained stable and his creatinine was done to 1.7 from 2.0 he was seen by ot and c/o dizziness - he vomited x 1 with ? of some small blood tinged mucus. this was discarded and not seen by staff. he did vomit again while oob to chair without any blood. labs and ct were ordered after reviewing omr. his ct was stable with no changes. quetiapine dosing was decreased by half. on he continued to have nausea and poor po intact. nutrition was consulted and stool was sent for c-diff. nystatin and second alpha blocker were discontinued. on the patient was orthostatic when he got up with pt. he was given an ivf bolus and standing ivf due to his continued poor po intake. he was started on calorie counts. on he was neurologically stable. he continued to have abdominal discomfort despite c-diff negative x3. stool o+p were sent, although discomfort is likely just due to history of + cdiff. laboratory values were stable. throughout his hospital course, he coninued to have episodes of nausea with occasional vomiting. this responded well to zofran and fluid resuscitation. on , he remained stable. his po intake remained poor and the psychiatry team was consulted as it was felt his poor po intake could be a result of depression. the psychiatry team recommended starting remeron to help with sleep/wake cycle. on a foley catheter d/c trial was once again initiated but the pt failed to void so it was replaced. the urology team was consulted since this was the 4th time he failed. they recommended keeping the foley in place for an additional 6 days then following up in the urology clinic. the patient continued to remain stable awaiting his family's arrival from . on the patient's ex-wife arrived and worked with pt/ot. teaching was initiated on how to care for the patient upon leaving the hospital. he remained stable on . he continued to await disposition to an extended care facility. he had another repeat lenis on which showed no evidence of dvt. a ct head was obtained on which showed expected evolution of intracranial hemorrhages. no acute infarct or hemorrhage. no evidence of hydrocephalus. on the patient failed another voiding trial and the foley catheter was replaced. on urology was re-consulted for persistent failure to void. they continued to recommend a urodynamic study as an outpatient. they also recommended intermittent catheterization, which is preferred over indwelling foley catheter but this was not possible due to patient's lack of participation. on the patient and his ex-wife worked with pt and ot with the help of an interpreter and he was cleared for discharge. he is afebrile, vss, and neurologically stable. patient's pain is well-controlled and the patient is tolerating a good oral diet. pt's incision is clean, dry and inctact without evidence of infection. patient is ambulating safely over short distances and has been given a wheelchair for longer distances. medications on admission: 1. plavix 2. simvastatin 3. amlodipine 4. labetatlol 5. lisinopril 6. cardura (doxazosin) 7. percocet 8. ambien 9. atrovent 10. advair 11. miralax 12. colace 13. vitamin c discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. doxazosin 1 mg tablet sig: two (2) tablet po hs (at bedtime). 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 4. labetalol 200 mg tablet sig: two (2) tablet po tid (3 times a day). 5. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). disp:*15 tablet(s)* refills:*2* 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 7. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 8. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. megestrol 400 mg/10 ml (40 mg/ml) suspension sig: one (1) po daily (daily). disp:*1 bottle* refills:*2* 10. advair diskus 250-50 mcg/dose disk with device sig: one (1) inhalation inhalation once a day. 11. atrovent hfa 17 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation inhalation q6hr as needed for shortness of breath or wheezing. discharge disposition: home discharge diagnosis: right cerebellar hemorrhage intraventricular hemorrhage hydrocephalus cerebral edema confusion c-diff vap respiratory failure requiring intubation hypotension urinary retention nausea vomiting orthostasis malnutrition discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: general instructions ?????? you may shower ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. followup instructions: please follow-up with dr in 4 weeks with a head ct w/o contrast. please call to make this appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours 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 Other incision of brain Insertion or replacement of external ventricular drain [EVD] Diagnoses: Obstructive hydrocephalus Unspecified protein-calorie malnutrition Chronic airway obstruction, not elsewhere classified Peripheral vascular disease, unspecified Intracerebral hemorrhage Nausea with vomiting 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 Acute respiratory failure Atherosclerosis of renal artery Intestinal infection due to Clostridium difficile Cerebral edema Retention of urine, unspecified Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Accidents occurring in residential institution Other alteration of consciousness Physical restraints status Unspecified renovascular hypertension |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: worst headache of life, after exercising major surgical or invasive procedure: and : diagnostic angiogram(negative for aneurysm) history of present illness: patient is a 63 year old female with no significant pmh who presented with the worst ha of her life after exercising. she states she was at a fitness class and she was doing jumping jacks when she had the sudden onset of a severe occipital ha at around 6:45pm. the pain increased in severity to the point where she described it as the worst headache in her life. at this point her friends insisted that she call ems, and at this point she was taken to an osh. at that hospital a head ct was done and the patient was found to have a sah and she was transferred to for further evaluation. at the time of initial eval, she described the quality as a bifrontal severe, throbbing ha. she has significant nausea and has vomited a number of times. she does not feel that position changes the quality of the headache but she prefers to be still. there was no photo/phono-phobia and the pain is not made significantly worse with movement neuro ros, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. denies difficulties producing or comprehending speech. denies focal weakness, numbness, parasthesiae. no bowel or bladder incontinence or retention. past medical history: per patient she has no medical problems, s/p appy many years prior, and a d+c in for irregular menstrual bleeding social history: patient lives alone, has a long past smoking history (quit in ). 3 cig x 10 years, no etoh, no drugs. family history: non-contributory physical exam: on admission: t: 97.8 bp: 141/69 hr:55 r:18 97% on ra o2sats gen: patient lying in bed, moaning and uncomfortable heent: nc at neck: supple patient complains of mild inc in ha with neck movement lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, if not engaged frequently patient would fall asleep. orientation: oriented to person, place, and date. recall: objects at 5 minutes. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 4 to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk, tone throughout. no pronator drift bilaterally. no adventitious movements, such as tremor, noted. no asterixis noted. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: no deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. no extinction to dss. -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 toes downgoing bilaterally coordination: normal f-n-f. exam on discharge: xxxxxxxxxxx pertinent results: labs on admission: 10:37pm blood wbc-14.2*# rbc-4.69 hgb-12.3 hct-39.0 mcv-83 mch-26.3* mchc-31.7 rdw-13.0 plt ct-291 10:37pm blood neuts-87.9* lymphs-9.7* monos-1.7* eos-0.4 baso-0.2 10:37pm blood pt-12.6 ptt-22.3 inr(pt)-1.1 10:37pm blood glucose-151* urean-21* creat-0.8 na-136 k-3.8 cl-104 hco3-22 angap-14 01:56am blood alt-21 ast-23 ld(ldh)-128 alkphos-35* totbili-0.4 06:15am blood calcium-7.2* phos-3.1 mg-1.7 01:56am blood phenyto-10.5 labs on discharge: xxxxxxxxxxxxxx imaging: cta head : findings: head ct. diffuse subarachnoid hemorrhage identified in the basal cisterns, including the perimesencephalic cistern, suprasellar cistern and the right sylvian fissure as well as left parietal convexity sulci medially. there is no hydrocephalus seen. ct angiography of the head: ct angiography of the head demonstrates no evidence of a distinct aneurysm in the arteries of anterior and posterior circulation. no vascular stenosis is identified. impression: 1. cta head demonstrates diffuse subarachnoid hemorrhage. 2. ct angiography fails to demonstrate a discrete aneurysm. however, with the presence of subarachnoid hemorrhage, suspicion for an aneurysm is high and further evaluation with cerebral angiography is recommended. mra/v of head/neck : technique: routine enhanced mr examination of the brain, including t1-weighted axial se and sagittal mp-rage sequences, post-gadolinium, the latter with coronal and axial reformations, unenhanced sagittal 2d-tof mrv with coronal and axial reformations, and 3d coronal gre acquisition of the neck vessels, following dynamic intravenous gadolinium administration, with rotational targeted and large field-of-view mip reconstructed images. findings: the study is compared with the enhanced cranial cta (with additional 3d-volume-rendered reconstructions), as well as conventional contrast angiography, both performed . the axial flair sequence is notable for persistent subarachnoid hemorrhage which again appears relatively localized to a few left paramedian occipital cortical sulci, the trigones of both lateral ventricles, and the right sylvian and suprasellar and interpeduncular cisterns, as on the presentation ct (, ). though there is global cortical atrophy, there is no evidence of progressive ventricular dilatation or periventricular interstitial edema to suggest the development of hydrocephalus. other than the expected demonstration of "blooming" susceptibility artifact at these sites, above, there is no specific focus of susceptibility abnormality to suggest a culprit vascular lesion as source of the hemorrhage. allowing for the susceptibility artifacts, above, there is no evidence of restricted diffusion to suggest an acute ischemic event. post-contrast imaging is similarly unremarkable, with normal enhancement of the principal vessels of the circle of and major deep and superficial cerebral venous structures (see mrv, below). there is no pathologic focus of parenchymal, leptomeningeal, or dural enhancement. the mrv demonstrates normal flow-related enhancement in the major dural venous sinuses, other than an apparent roughly 2.6-cm segmental flow gap within the proximal left transverse sinus at its junction with the torcular, demonstrated only on the reformatted images. this appears to relate to a "mipping" artifact as there is continuous flow signal throughout this portion of the transverse sinus on the source images and the sinus demonstrates a completely unremarkable appearance on post-contrast mp-rage sequence. similarly, there is normal flow-related and contrast enhancement in the major deep cerebral veins, concordant with the normal appearance of these structures on yesterday's cta. there is a normal appearing three-vessel aortic arch with normal origins of the great vessels. the common and cervical internal carotid arteries demonstrate normal course, caliber, contour, and enhancement from their origins through the level of skull base. there is similarly normal course, caliber, contour, and enhancement of roughly "co-dominant" vertebral arteries from their subclavian origins through the vertebrobasilar confluence. there is no significant mural irregularity, flow-limiting stenosis, or evidence of dissection involving these vessels. impression: 1. persistent subarachnoid hemorrhage, not significantly changed since the presentation ct of ; there is a small amount of intraventricular hemorrhage now layering in the trigones of both lateral ventricles. 2. no evidence of development of hydrocephalus or transependymal migration of csf. 3. no new hemorrhage seen. 4. no vascular lesion or pathologic focus of enhancement identified. 5. unremarkable cranial mrv, with no evidence of thrombosis, stenosis, or abnormal shunting; this is concordant with the results of yesterday's ct and catheter angiography. 6. normal cervical contrast mra, with no evidence of carotid or vertebral stenosis or dissection. brief hospital course: patient is a 63f who was admitted to after complaining of sudden onset, worst headache of life while exercising. ct of the head revealed a pericisternal subarachnoid hemorrhage. cta was performed and did not reveal aneurysm. urgent angiogram was done on for definitive diagnosis, and was interpreted as negative for aneurysmal causation of hemorrhage. mra/v of both head and neck were also done to further evaluate possible etiology of bleeding; studies were negative. during this time, she was admitted to the neurosurgical icu for continuous monitoring, systolic pressure control and nimodipine administration. on cta/perfusion study was done to evaluate for possible vasospasm, and was determined to be negative as well. she was cleared to transferred to the neurosurgical step down unit but beds were not available on . she was intermittantly nausea and receiving anti-emetics. she was transitioned out of bed. on day of discharge she was cleared by pt ambulating in the hallway occassionally her headaches were worse with ambulation. she was tolerating a regular diet and voiding without difficulty. neurologically she was intact. extensive discussion was had about sequelae of nonanuerysmal subarchnoid hemorrhage medications on admission: none discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): use while on dilaudid. 2. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 3. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day) for 30 days. disp:*90 capsule(s)* refills:*0* 4. hydromorphone 2 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*60 tablet(s)* refills:*0* 5. ciprofloxacin 250 mg tablet sig: two (2) tablet po q12h (every 12 hours) for 2 days. disp:*8 tablet(s)* refills:*0* 6. nimodipine 30 mg capsule sig: two (2) capsule po q4h (every 4 hours) for 20 days. disp:*240 capsule(s)* refills:*0* 7. nimodipine 30 mg capsule sig: two (2) capsule po every four (4) hours for 1 days. disp:*12 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: pericisternal subarachnoid hemorrhage discharge condition: neurologically stable discharge instructions: general instructions ?????? take your pain medicine as prescribed. it is expected that you will continue to have some form of a headache for several weeks; though this should continually improve. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. ?????? you have been prescribed dilantin (phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. this can be drawn at your pcp??????s office, but please have the results faxed to . - do not take tub baths for one week due to angio site, showering is okay - if you develop any swelling in your groin or your right leg becomes cool,numb or swollen go to the nearest er call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion, lethargy or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? new onset of the loss of function, or decrease of function on one whole side of your body. followup instructions: follow-up appointment instructions ??????please call ( to schedule an appointment with dr. , to be seen in 4 weeks. ??????you will need a ct scan of the brain without contrast prior to your appointment. this can be scheduled when you call to make your office visit appointment. Procedure: Arteriography of cerebral arteries Arteriography of cerebral arteries Diagnoses: Subarachnoid hemorrhage Osteoporosis, unspecified Encephalopathy, unspecified Cervicalgia Meningismus |
allergies: crestor / ace inhibitors / lipitor attending: chief complaint: upper gi bleed major surgical or invasive procedure: endoscopy history of present illness: history of present illness: patient is an 80yo male with pmh of duodenal ulcer, copd, and cad s/p cabg who presents with several days of black tarry stools. patient was last in his usual state of health approximately 4 days prior to presentation when he presented to his pcp for diffuse abdominal pain. at the time he did not have bloody bm and he was discharged with instructions to be mindful for the development of this. he then developed black, tarry bowel movements the following day at home. he attempted to contact his pcp and defer treatment until he could see his pcp at the next available appointment but presented to the ed after he had uncontrollable black tarry bm's resulting in him soiling 8 pairs of underpants. in the ed, initial vs were 96.8 71 148/72 16 98%. he was having melanic stool with fresh blood consisting of one large bowel movement but has had none since. there was a little blood on ng lavage which cleared with 400cc. he had a lactate of 2.1. in the ed he endorsed chest pressure and had and ecg with non-specific changes and troponin was sent. vs prior to transfer were 97.6 65, 144/68. he arrived to the floor with no further bloody bm and no more chest pain or pressure. 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, constipation, denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: obesity hypertension diabetes hyperlipidemia cad status post cabg x3 vessels. copd peptic ulcer disease gout osteoarthritis renal insufficiency cataracts chronic back pain allergic rhinitis gerd diabetic nephropathy status post pilonidal cyst resection. status post anorectal fistulotomy with recurrent revisions. status post cataract extraction, right eye. social history: - tobacco: quit 20+ years ago - alcohol: drinks 1 per night family history: not obtained physical exam: admission physical exam: heent: normocephalic, atraumatic oropharynx within normal limits chest: clear to auscultation cardiovascular: normal first and second heart sounds, regular rate and rhythm abdominal: soft, nontender, nondistended rectal: black stool with some maroon stool on rectal exam; + hemorrhoids gu/flank: no costovertebral angle tenderness extr/back: no cyanosis, clubbing or edema skin: no rash, warm and dry neuro: speech fluent psych: normal mood, normal mentation heme//: no petechiae discharge physical exam: afebrile, normotensive. gen: elderly, obese gentleman in nad heent: mm dry, mild pallor. eomi, perrl, op clear cv: rrr, systolic murmur heard best at rusb, no gallops or rubs resp: ctab, no w/r/r abd: soft, nondistended, nontender, bs present extr: wwp, no e/c/c neuro: cns grossly intact, 5/5 strength, no focal deficits pertinent results: admission physical exam: 04:13pm wbc-10.4 rbc-3.85* hgb-11.7* hct-35.3* mcv-92 mch-30.5 mchc-33.2 rdw-14.3 04:13pm plt count-196 04:13pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 04:13pm urine rbc-0 wbc-0 bacteria-none yeast-none epi-<1 11:50am lactate-2.1* k+-4.8 11:40am alt(sgpt)-22 ast(sgot)-39 alk phos-49 tot bili-1.1 11:40am lipase-41 11:40am ctropnt-0.04* 11:40am ck-mb-3 11:40am albumin-3.9 calcium-10.0 phosphate-2.6* magnesium-2.3 11:40am pt-13.5* ptt-29.2 inr(pt)-1.3* discharge physical exam: 07:35am blood wbc-8.4 rbc-3.35* hgb-10.0* hct-30.9* mcv-92 mch-29.7 mchc-32.2 rdw-15.0 plt ct-186 07:35am blood plt ct-186 07:35am blood glucose-117* urean-37* creat-1.7* na-141 k-3.9 cl-106 hco3-27 angap-12 07:35am blood calcium-8.4 phos-2.7 mg-2.0 pertinent micro/path: 7:25 am serology/blood **final report ** helicobacter pylori antibody test (final ): negative by eia. (reference range-negative). pertinent imaging: 1:38 pm chest (portable ap) clip # reason: eval for ngt position medical condition: 80 year old man with ugib reason for this examination: eval for ngt position final report indication: 80-year-old man with upper gi bleed. evaluate for ng tube position. comparison: pa and lateral chest radiograph from . technique: two portable chest radiographs were provided. findings: ng tube is difficult to visualize; however, appears to be coursing below the diaphragm likely within the stomach. the patient is status post median sternotomy. there is no focal consolidation, pleural effusion, or pneumothorax. the cardiac size appears enlarged, but unchanged from the prior exam. osseous structures are intact. impression: ng tube tip likely within the stomach. the study and the report were reviewed by the staff radiologist. ecg study date of 12:25:22 pm atrial fibrillation with a mean ventricular rate of 91. diffuse non-specific repolarization abnormalities. no previous tracing available for comparison. read by: , intervals axes rate pr qrs qt/qtc p qrs t 91 0 98 376/430 0 -3 130 ecg study date of 9:19:24 am sinus rhythm with premature atrial contractions. baseline artifact. poor r wave progression in leads v1-v4 of unclear significance. diffuse repolarization changes, cannot exclude anterolateral ischemia. clinical correlation is suggested. compared to the previous tracing of sinus rhythm has replaced atrial fibrillation, st segment changes have slightly improved. tracing #1 read by: das,saumya intervals axes rate pr qrs qt/qtc p qrs t 59 /454 36 -3 146 date: saturday, endoscopist(s): , md , md (fellow) patient: ref.phys.: , md birth date: (80 years) instrument: gif-h180 () id#: medications: midazolam 5 mg iv fentanyl 125 micrograms indications: gastrointestinal bleeding procedure: the procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. a physical exam was performed. the patient was administered moderate sedation. supplemental oxygen was used. the patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. careful visualization of the upper gi tract was performed. the vocal cords were visualized. the procedure was not difficult. the patient tolerated the procedure well. there were no complications. findings: esophagus: normal esophagus. stomach: mucosa: diffuse gastropathy was noted in the whole stomach. no evidence of active or recent bleeding. duodenum: lumen: the first part of the duodenum was mildly stenosed suggesting chronic duodenitis. the scope traversed the lesion without difficulty. mucosa: erythema and congestion of the mucosa were noted in the first part of the duodenum compatible with severe duodenitis. excavated lesions a single cratered non-bleeding 15 mm ulcer was found in the first part of the duodenum. there was evidence of recent bleed but no visible vessel, active oozing, or pigmented material. impression: diffuse gastropathy in the whole stomach ulcer in the first part of the duodenum stenosis of the first part of the duodenum erythema and congestion in the first part of the duodenum compatible with severe duodenitis otherwise normal egd to third part of the duodenum recommendations: continue iv ppi. would continue iv gtt for at least the next 24 hours continue to trend hcts q6-8h further plans per inpatient gi team additional notes: the attending was present for the entire procedure. the patient's home medication list is appended to this report. final diagnoses are listed in the impression section above. estimated blood loss = zero. no specimens were taken for pathology _ _ _ ______________________________ _________________________________ , md electronically signed by , md on 7:35:34 pm , md (fellow) electronically signed by , md (fellow) on 7:35:34 pm brief hospital course: reason for hospitalization: patient is an 80yo male with pmh of cad s/p cabgx3, copd and duodenal ulcer who presents with ugib and findings of duodenal ulcer on egd. active issues: #duodenal ulcer bleed: patient developed abdominal pain followed by several days of black tarry stools at home. he then presented to the ed when the volume of black, tarry stool became concerning to him. he underwent resuscitation with 1u prbc and crystalloid resuscitation and was transferred to the micu team. he experienced st changes on his ekg (see below) consistent with demand ischemia. egd revealed duodenal ulcer. he was continued on iv protonix gtt started in the ed. egd showed active oozing but no overtly bleeding ulcers. the most likely etiology of his bleeding was a bleeding duodenal ulcer from recen increased heavy nsaid use. once transferred to the floor, he was transitioned from iv protonix to po. he did not require additional units of prbcs, he was hemodynamically stable, with no recurrence of cardiac demand ischemia. he was asymptomatic at discharge, and was prescribed high dose po protonix . his h. pylori serologies were negative. # non-specific st-t wave changes on ecg: patient had this finding on presentation when he had some chest pressure. the troponing elevated to 0.04 to 0.08 in the interim. symptoms of chest pressure resolved. this likely represented demand ischemia coupled with arf leading to an acure elevation in troponin. his troponin plateaued, and he no longer had episodes of ischemia or chest pain once transferred to the floor. #a-fib: pt was fount to be intermittently in a-fib, no rvr. in order to rate control, we restarted his coreg at half his home dose (this was previously held due to gi bleed. it was started at half dose due to blood pressures running in the 100s-110s systolic). the pt remained hemodynamically stable. his primary care physician was to inform her of this new finding, and the chosen management. #frequent belching/heartburn: pt complained frequently of this. resolved with simethicone and tums. resolved by discharge. pt was discharged on these meds for symptomatic mgmt. chronic issues: #copd-stable. continued bronchodilators #cad- as above. held asa for gib. restarted asa at discharge given hx of cad and new onset paroxymal a fib. #hld-continued home statin. #htn: held antihypertensives in setting of ugib. restarted coreg at half of home dose (see above). #t2dm: held glipizide and was on insulin sliding scale. #gout: held allopurinol for arf. transitional issues: #gi recommended that the pt continue po protonix for at least one month and to d/c nsaids. a follow up egd is not necessary. #a-fib: pt was found to be in irregularly irregular rhythm without known history of a-fib. he did not have rvr. he was started on half his dose of home coreg. #antihypertensive regimen: all but coreg were held due to gib. coreg started at half dose. will need bp recheck in outpatient setting for further adjustment. #constipation: the pt was discharged on bowel regimen. medications on admission: allopurinol - allopurinol 300 mg tablet 1 tablet(s) by mouth once a day amlodipine - amlodipine 5 mg tablet 1 tablet(s) by mouth once a day carvedilol - carvedilol 25 mg tablet take 1 tablet by mouth twice a day fluticasone-salmeterol - advair diskus 250 mcg-50 mcg/dose for inhalation 1 inhalation(s) twice a day glipizide - glipizide er 5 mg tablet,24 hr extended release 1 tab(s) by mouth once a day for diabetes ipratropium-albuterol - combivent 18 mcg-103 mcg/actuation aerosol inhaler inhael 2 puffs four times a day as needed for short of breath pravastatin - pravastatin 80 mg tablet 1 tablet(s) by mouth once a day triamcinolone acetonide - triamcinolone acetonide 0.1 % topical cream apply to affected area twice a day discharge medications: 1. acetaminophen 650 mg po q6h:prn pain/fever 2. albuterol-ipratropium puff ih q6h:prn shortness of breath or wheeze 3. calcium carbonate 500 mg po qid:prn indigestion rx *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth four times daily disp #*120 tablet refills:*0 4. carvedilol 12.5 mg po bid hold for sbp<100 or rr<55 rx *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 5. docusate sodium 100 mg po bid:prn constipation rx *docusate sodium 100 mg 1 tablet(s) by mouth twice daily disp #*60 tablet refills:*0 6. fluticasone-salmeterol diskus (250/50) 1 inh ih 7. pantoprazole 40 mg po bid rx *pantoprazole 40 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 8. pravastatin 80 mg po daily 9. senna 1 tab po bid:prn constipation rx *sennosides 8.6 mg 1 tab by mouth twice daily disp #*60 tablet refills:*0 10. simethicone 40-80 mg po qid:prn dyspepsia rx *simethicone 80 mg 1 tab by mouth two times daily disp #*60 tablet refills:*0 11. allopurinol 300 mg po daily 12. glipizide xl 5 mg po daily 13. aspirin 81 mg po daily rx *aspirin 81 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 discharge disposition: home discharge diagnosis: primary diagnoses: 1. duodenal ulcer 2. anemia 3. demand ischemia of the heart 4. acute kidney injury secondary diagnoses: 1. chronic obstructive pulmonary disease 2. hypertension 3. hyperlipidemia 4. coronary artery disease 5. type 2 diabetes mellitus 6. gout discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , you were admitted to for bleeding from your upper gi tract. you had an endoscopy performed which showed an ulcer in your upper intestines (a duodenal ulcer). you were given blood to replace what you had lost. you also received a strong dose of antacid through your iv. your blood counts stabilized, and you improved. as part of your treatment, you will continue to take this antacid, known as pantoprazole, twice a day for the next month at least. you will also need to avoid taking over the counter pain medications such as advil/ibuprofen/motrin/aleve/excedrin. you should only take tylenol over the counter for pain from now on. we made the following changes to your medication list: stop advil/ibuprofen/motrin/aleve/excedrin stop amlodipine 5mg by mouth daily change carvedilol (coreg) from 25mg by mouth twice daily to 12.5mg by mouth twice daily **start pantoprazole 40mg by mouth twice a day start simethicone 80mg twice a day as needed for gas/belching start docusate 100mg twice a day as needed for constipation start senna 1 tab twice a day as needed for constipation start calcium carbonate 500mg up to 4 times daily as needed for heartburn start aspirin 81mg daily please be sure to follow up with your pcp at the appointment made below. followup instructions: department: - adult med when: wednesday at 11:15 am with: , md building: (, ma) campus: off campus best parking: free parking on site md Procedure: Other endoscopy of small intestine Diagnoses: Esophageal reflux Acute posthemorrhagic anemia Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of tobacco use Chronic kidney disease, Stage III (moderate) Osteoarthrosis, unspecified whether generalized or localized, site unspecified Obesity, unspecified Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Duodenitis, without mention of hemorrhage Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Other acute and subacute forms of ischemic heart disease, other Unspecified disorder of stomach and duodenum |
allergies: penicillins / cephalosporins attending: chief complaint: liver hematoma, acute anemia major surgical or invasive procedure: bronchoscopy x 2 thoracentesis mechanical ventilation intubation history of present illness: mr. is a 37-year-old male with past medical history significant for mental retardation, seizure disorder, prior dvts/pes on chronic warfarin, ileus, chronic aspiration with several aspiration realted pnas in the past who was admitted to from his group home on with lethargy and fevers. per osh report, patient had clean urine and blood cultures but cxr remarkable for a lll pna so he was placed on levaquin (patient allergic to cephalosporins/pcn) and required intubation for 5 days due to respiratory distress and hypoxia. he was extubated on but has required high flow facemask at 70-80% to maintain oxygen saturations above 90%. he was reintubated on and had a ct torso that revealed large intraparenchymal and subcapsular liver hematoma that is felt with likely active extravasation of iv contrast. on he was also noted to have hct drop from 31-->20. he was subsequently transferred to the surgical icu on . he underwent an hepatic angiogram by ir but was found not to have active bleeding thus not embolized. he has been managed conservately and has been hemodynamically stable. his hospital course has been complicated by presumed vap and bilateral pleural effusions that have been thought to contribute to his inability to wean from the vent. of note he has had a bronch on , bal with no growth and thoracentesis on with 750cc removed. he has been on vancomycin, aztreonam, tobramycin and metronidazole for presumed vap started on . . review of systems: (+) per hpi (-) unable to provide past medical history: -mental retardation -seizure disorder -prior dvts/bilateral pes (per osh records, idiopathic and unclear cause, patient does not have an ivc and he is on home warfarin) -gerd -uti with sepsis in -spastic quadraparesis / cortical blindness -h/o meningitis in childhood -urolithiasis -chronic constipation social history: patient lives in group home. mother and 2 sisters very involved with his care. from the area. no history of any tobacco, etoh or illicit drug use. family history: noncontributory physical exam: general: pale skin, intubated heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: crackles at left base, rhonchi anteriorly, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, tender to palpation , non-distended, bowel sounds present gu: foley in place ext: cool, well perfused, 2+ pulses, no clubbing, cyanosis or edema on discharge, afebrile, breathing comfortably with good saturations on room air, abdomen soft, non-distended, non-tender pertinent results: admission labs : wbc-19.7* rbc-3.26* hgb-10.3* hct-28.9* mcv-89 mch-31.7 mchc-35.6* rdw-16.7* plt ct-137* neuts-93* bands-1 lymphs-1* monos-5 eos-0 baso-0 atyps-0 metas-0 myelos-0 pt-16.1* ptt-31.2 inr(pt)-1.4* glucose-93 urean-8 creat-0.7 na-150* k-3.2* cl-110* hco3-28 angap-15 alt-1057* ast-2387* ld(ldh)-1864* alkphos-145* totbili-3.0* albumin-3.7 calcium-8.9 phos-2.7 mg-2.0 type- po2-107* pco2-36 ph-7.46* caltco2-26 base xs-1 comment-green top lactate-1.7 hypercoagulability workup: 02:22pm blood lupus anticoag-pos 02:22pm blood protcag-26* protsfn-51 02:22pm blood aca igg-pnd aca igm-pnd 08:42pm blood alpha-fetoprotein (afp) and afp-l3- low 02:22pm blood beta-2-glycoprotein 1 antibodies (iga, igm, igg)-pnd 02:22pm blood antithrombin antigen-85% (normal) 02:22pm blood factor v leiden-negative discharge labs : 06:35am blood wbc-15.5* rbc-3.62* hgb-11.6* hct-37.7* mcv-104* mch-32.1* mchc-30.8* rdw-21.1* plt ct-428 06:35am blood glucose-128 urean-12 creat-0.5 na-143 k-3.7 cl-110 hco3-21 06:35am blood calcium-8.5 phos-1.7 mg-2.0 microbiology: mrsa screen negative blood cultures negative urine culture negative vre swab negative sputum culture gram stain (final ): pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram positive cocci in pairs. respiratory culture (final ): sparse growth commensal respiratory flora. c diff negative thoracentesis gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. anaerobic culture (final ): no growth. bronchial washings: gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): squamous epithelial cells. no microorganisms seen. smear reviewed; results confirmed. respiratory culture (final ): commensal respiratory flora absent. yeast. 10,000-100,000 organisms/ml.. blood cultures negative monospot negative cmv igg antibody (final ): equivocal for cmv igg antibody by eia. 4 au/ml. reference range: negative < 4 au/ml, positive >= 6 au/ml. cmv igm antibody (final ): negative for cmv igm antibody by eia. greatly elevated serum protein with igg levels > mg/dl may cause interference with cmv igm results. cmv viral load non-detectable blood cultures negative bal gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): 10,000-100,000 organisms/ml. commensal respiratory flora. urine culture: yeast blood culture negative imaging: ekg: sinus tachycardia. early precordial qrs transition. modest st-t wave changes with what may be borderline short qtc interval. findings are non-specific. no previous tracing available for comparison. cxr: the tip of the endotracheal tube lies approximately 2.5 cm above the carina. nasogastric tube extends well into the stomach. left ij catheter extends to about the junction of the brachiocephalic vein and superior vena cava. cardiac silhouette is within normal limits. there is hazy opacification in the right hemithorax, consistent with layering effusion. some indistinctness of pulmonary vessels could reflect elevated pulmonary venous pressure. mild bibasilar atelectasis. right subclavian catheter tip is difficult to see, though it probably lies within the distal svc. liver/abdomen angiogram: selective arteriograms of the proper hepatic artery and two secondary hepatic arterial branches demonstrating marked vasoconstriction and displacement of vessels secondary to a large subcapsular hematoma with no angiographic evidence of active extravasation. therefore, no embolization was performed. ct abdomen/pelvis: 1. large intraparenchymal and subcapsular hematoma within the right lobe of the liver. in the absence of trauma, and a normal appearance to the liver parenchyma on exam one week prior, the etiology of this bleed is uncertain. multiphasic imaging demonstrates areas of active bleeding in the more inferior aspect of the subcapsular component of the right lobe of the liver as described. the left lobe of the liver appears unremarkable. 2. small-to-moderate amount of intermediate-density material within the abdomen and pelvis consistent with hemorrhagic fluid. 3. small bilateral pleural effusions, right greater than left with adjacent compressive atelectasis. 4. rectal wall thickening and perirectal fat stranding may result from chronic disimpaction. circumferential fatty thickening in the colonic wall may reflect chronic inflammatory changes. 5. bilateral hip dysplasia. abnormal configuration of thoracolumbar vertebral bodies may represent disuse. osteopenia. lenis: no evidence of dvt in either lower extremity. tte: the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). transmitral and tissue doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. no diastolic dysfunction, pulmonary hypertension or pathologic valvular disease. cta torso: 1. no change in the large, previously seen intraparenchymal and subcapsular hepatic hematoma. there is no evidence of active extravasation. an underlying mass within the parenchymal hematoma cannot be excluded. 2. moderate-sized bilateral pleural effusions with neighboring compressive atelectasis of the right and left lower lobes. an underlying infection within these regions cannot be excluded. 3. no evidence of pulmonary embolism. feeding tube conversion: successful conversion of a g tube to a gj tube, 22 french; the tube is ready for use. echo: positive bubble study. right-to-left shunt across the interatrial septum is seen at rest during bubble study. lenis: no dvt in bilateral lower extremity. ct abdomen/pelvis: 1. stable size of large right hepatic intraparenchymal and subcapsular hematomas. 2. foci of subcutaneous gas anterior to the lateral margin of the left rectus muscle. the findings are of unclear etiology. differential diagnosis would include iatrogenic causes perhaps related to manipulation of the patient's peg tube or other procedures and correlation for these recommended. in the absence of these, this finding can be seen in necrotizing fasciitis, although there are not necessarily other ct findings to suggest this diagnosis; however, clinical correlation in this region is recommended. 3. marked dilation of the rectosigmoid. 4. stable bilateral pleural effusions and compressive atelectasis. 5. mild thickening of the distal esophagus. correlation for esophagitis recommended. cta chest: 1. no acute central or segmental pulmonary embolism. no acute aortic pathology. 2. persistent moderate simple pleural effusions with moderate bibasilar atelectases. 3. grossly unchanged right intraparenchymal and subcapsular hepatic hematomas, incompletely evaluated in the current study. cxr: in comparison with the study of , there is little overall change. continued bilateral layering effusions with bibasilar atelectasis. prominence of mediastinal veins most likely represents the supine positioning. dilatation of the mid portion of the trachea is again seen, reflecting either preexisting tracheomalacia or recent intubation and cough overinflation. brief hospital course: this is a 37 year old male with mental retardation, seizure disorder, h/o pe/dvts, pna complicated by hypoxic respiratory failure requiring intubation, and liver hematoma. # hypoxic respiratory failure: hypoxic respiratory failure felt to be multifactorial in etiology, including aspiration pna compounded by bilateral pleural effusions, vap, volume overload and asd. he had a thoracentesis on the surgical service on with 750 cc fluid removal and bronch on and mini bal on . all cultures were negative. he was given an empiric course of vancomycin, aztreonam, tobramycin and metronidazole started on the sicu service for an 8 day course for presumed vap. he was diuresed daily to lasix 1 l net negative and was extubated on . an echo in work up for shunt revealed asd and was felt to have been playing a role in his hypoxemia. he also had several ctas throughout his hospitalization that were negative for pe. at time of discharge, he remained on room air with sats in the mid-upper 90s%. # fever: patient was febrile and spiking high grade temps with leukocytosis on broad spectrum antibiotics while in the intensive care unit. infectious disease was consulted and extensive culture data were negative. his fever was felt to be likely due to his hematoma and possibly drug fever given multiple abx. he self-defervsced and was afebrile for days prior to discharge. he continued to have a leukocytosis without signs of infection. his workup included search for dvt/pe which were negative. if patient develops fever or diarrhea, c diff should be considered given his recent antibiotic exposure but he did not have diarrhea while in the hospital and had a negative c diff earlier in the admission. # hepatic hematoma: he was found to have a hepatic hematoma on admisson but remained hemodynamically stable. patient received two units of prbcs to support his blood count. he was conservatively managed and angiogram did not show any active bleeding requiring embolization. per discussion with family, no aggressive interventions including drains/hepatectomy were persued. as mentioned, he was hemodynamically stable throughout hospital stay. # history of pe: anticoagulation with warfarin was held in setting of hematoma. hypercoaguable work up revealed lupus anticoagulant with all other tests normal except beta2 glycoprotein which is still pending. discussed possibility for ivc filter but given asd/hypercoaguable state, this was not felt to be a good long term solution. he had several ctas negative for pe. he was discharged on twice daily heparin subq shots and should not restart warfarin anticoagulation for at least two weeks. he has a follow-up appointment with his pcp scheduled to discuss this hospitalization and determine anticoagulation goals. # anemia: patient was anemic throughout his hospital stay. this was likely due to blood loss from his hepatic hematoma and poor nutrition evidenced by low prealbumin on admission. his mcv was elevated after switching from depakote to valproic acid syrup as below. folate and b12 levels were pending at time of discharge. # seizure disorder: he was continued on phenobarbitol and depakote initially but whole depakote pills were found in his stools prompting concern about absorption. he was changed to valproic acid syrup and had a therapeutic level prior to discharge. he was continued on phenobarbitol. patient has an appointment to establish care with an epilepsy specialist at later this month. # fen: due to chronic aspiration, his chronic g-tube was converted to gj tube on . he was seen by nutrition for tube feeding recommendations to maximize his nutritional status. dnr/dni per discussion with hcp, mother. medications on admission: -po warfarin / per inr level -depakote ( 625mg qam, 500mg daily at 2pm, 875mg qpm) -phenobarbitol 90mg qdaily -omeprazole 20mg qdaily -colace 100mg -miralax qdaily -milk of magnesia -tap water enema -atenolol 12.5mg daily -baclofen 10mg tid discharge medications: 1. atenolol 25 mg tablet sig: 0.5 tablet po daily (daily). 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) milliliter injection (2 times a day): inject 1 ml sub-cutaneous twice daily. disp:*5 10 ml vials* refills:*2* 3. phenobarbital 30 mg tablet sig: three (3) tablet po daily (daily). 4. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: ten (10) milliliters po qam (morning). disp:*2 bottles* refills:*2* 5. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: ten (10) milliliters po qpm (evening). 6. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: fifteen (15) milliliters po qhs (bedtime). 7. baclofen 10 mg tablet sig: one (1) tablet po three times a day. 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 9. bowel regimen please continue previous bowel regimen with milk of magnesia, daily tap water enemas and daily miralax. 10. docusate sodium 50 mg/5 ml liquid sig: ten (10) milliliters po bid (2 times a day). 11. syringe with needle (disp) 1 ml 25 x 1 syringe sig: one (1) syringe miscellaneous twice a day: please use 1 syringe for each 1ml sub-cutaneous heparin shot. disp:*100 syringes* refills:*2* discharge disposition: home with service facility: southeastern residential services discharge diagnosis: primary: hepatic hematoma pneumonia secondary: seizure disorder discharge condition: non-verbal, requiring total care discharge instructions: you were admitted to the hospital for lethargy and fevers. you were in the intensive care unit for close monitoring. your hospital course was complicated by severe pnuemonia requiring a breathing tube to support your breathing and you were found to have bleeding in your liver. you improved with antibiotics and were taken off of your warfarin blood thinners to allow your liver bleed to heal. please follow-up with your pcp . and see a neurologist regarding your seizure medications. the following changes were made to your medications: 1. stopped dekapote as you were not completely digesting it. 2. started valproic acid syrup to control your seizures. 3. stopped warfarin as you had a liver bleed. 4. started heparin shots twice daily to prevent blood clots. followup instructions: please follow-up with your pcp to discuss your anti-coagulation for your prior pe. you have an appointment scheduled on at 1pm at dr. office. you have an appointment to establish care with a seizure specialist at : department: neurology when: monday at 8:30 am with: dr. & dr. building: sc clinical ctr campus: east best parking: garage Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Fiber-optic bronchoscopy Thoracentesis Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Arteriography of other intra-abdominal arteries Replacement of tube or enterostomy device of small intestine Diagnoses: Esophageal reflux Iron deficiency anemia secondary to blood loss (chronic) Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Fever, unspecified Personal history of venous thrombosis and embolism Ventilator associated pneumonia Quadriplegia, unspecified Unspecified intellectual disabilities Other specified disorders of liver Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy |
allergies: meropenem attending: chief complaint: workup of fuo and pancreatic cyst major surgical or invasive procedure: ct-guided drainage and placement of a drain in a pancreatic pseudocyst packed rbc transfusion 1 unit packed red blood cell transfusion central venous line insertion history of present illness: patient is a 29-year-old man who had a very complicated medical course at for alcoholic pancreatitis in that required a prolonged icu stay, complicated by ards, , asystolic cardiac arrest, placement of a tracheostomy, and diffuse neurologic injury and cognitive impairment from complications and subsequent development of a seizure disorder. he presented to medical center on with chief complaint of fevers, nausea, vomiting, flank pain, and mild elevation of pancreatic enzymes. during his admission at , fever workup was negative. per report, his bandemia on day of discharge was 28% (with a white count of 14). he underwent ct of the abdomen that showed a multilobulated cystic lesion in the tail of the pancreas measuring 9.6 by 5 cm consistent with a pseudocyst. there was moderate peripancreatic inflammatory stranding. he continued to have fevers during the hospital stay to as high as 103.6. abdominal exam was reportedly benign throughout. inflammatory markers were elevated to crp of 368 and esr of 122. he was evaluated during the hospital admission by infectious diseases service, and they were reluctant to start antibiotics given that there was no clear source of infection and he remained clinically stable. the id consultants had recommended consideration of tapping the pancreatic pseudocyst visualized on ct scan. the patient was also seen by gastroenterology who favored starting empiric broad-spectrum antibiotics, although antibiotics were never started. the patient was then evaluated by neurology for his seizure disorder history (and the fact that he had recently started lamictal in early ); the neurology service had recommended to consider decreasing the dose of lamictal, as it could potentially be the cause of a drug-induced fever. additionally, the patient was seen by rheumatology who wanted to rule out an occult vasculitis - labs were sent for , anca and immunoglobulins, rf and complement. all of these studies are still pending at time of transfer. per the transfer summary notes, blood cultures from are still negative, and a urine culture from admission was likely contaminated. as above, he was never treated with antibiotics. prior to his transfer to , a discussion was held between patient's family and dr. , the intensivist at who took care of him during his admission in . the decision was made to transfer the patient to for further workup of the pancreatic lesion visualized on ct scan. ros: currently, patient denies chest pain, shortness of breath, nausea, headache, dizziness, abdominal/flank/back pain, or urinary complains. he feels okay. past medical history: - insulin dependent diabetes since - depression and anxiety - history of hemorrhagic pancreatitis in - history of asystolic arrest with resultant anoxic brain injury - history of seizure disorder on triple therapy social history: the patient lives with his family. his mother is a physiatrist and his father is a rheumatologist. his brother is a dermatologist. prior to the patient's admission in for severe pancreatitis, he was an engineer with a master's degree. the patient is not married and he is without children. his remote alcohol abuse history was significant for 5-6 years, drinking 6 mixed drinks daily with withdrawl symptoms. he used to smoke 1.5 ppd of cigarrettes. family history: mother with dm2. physical exam: afebrile, vss general: well-appearing indian man in no acute distress. heent: non-icteric sclera, moist mucus membranes. neck: supple, no lad. heart: rrr, normal s1/s2, lungs: clear bilaterally anterior fields. abdomen: soft, non-tender, no rebound or guarding. extremities: warm, well-perfused, without edema; patient is wearing braces over the shins for foot support. pertinent results: osh labs: : -wbc 16.3, 80% polys -hct 35.4 -mcv 78 -plt 398 -cre 1.1 -bun 12 -co2 27 - 89 -alb 4.1 -tbi 0.3 -alt 18 -ast 21 -lip 106 (uln 59) -esr 122 -ua >100 glu, sm blood, >300 pro, neg nit, neg leuks : -wbc 14.6, 28% bands -hct 28.0 -mcv 76 -plt 388 -cre 0.8 -bun 8 -co2 25 admission labs at : 10:59pm glucose-223* urea n-10 creat-0.9 sodium-127* potassium-4.1 chloride-92* total co2-23 anion gap-16 10:59pm alt(sgpt)-15 ast(sgot)-13 ld(ldh)-195 alk phos-132* amylase-82 tot bili-0.3 10:59pm lipase-125* 10:59pm albumin-3.4* calcium-8.5 phosphate-2.8 magnesium-1.7 10:59pm triglycer-156* 10:59pm osmolal-271* 10:59pm wbc-20.1*# rbc-3.95* hgb-9.9* hct-30.1* mcv-76* mch-25.2* mchc-33.0 rdw-13.3 10:59pm neuts-76.9* lymphs-18.3 monos-2.9 eos-1.2 basos-0.8 10:59pm plt count-566* 10:59pm pt-14.2* ptt-25.5 inr(pt)-1.2* . cxr pm preliminary report !! wet read !! r-ij tip at level of superior cavoatrial junction. lucency in right apex however no definite pleural line seen to suggest pneumothorax. otherwise stable radiograph; left effusion, atelectasis. . cxr am findings: the moderate left pleural effusion is unchanged. there is new elevation of the left hemidiaphragm with associated increase in the underlying gastric bubble. no right effusion is seen. the lungs are clear. the cardiac and mediastinal silhouettes are unchanged. there is no pneumothorax identified. . impression: 1. unchanged moderate left pleural effusion. 2. new elevation of the left hemidiaphragm. . . ct abdomen/pelivs final read: ct of the abdomen: the left hemidiaphragm is elevated, likely due to significant left lower lobe collapse. the spleen enhances homogeneously. in the left upper quadrant, there is a multiloculated pancreatic pseudocyst. a pigtail catheter enters from the left posterior approach with pigtail appropriately situated within the pseudocyst cavity. the dominant compartment has decreased moderately in size compared to one day prior, now measuring 7.9 x 2.9 cm, previously 10.2 x 5.2 cm. small foci of air within the superior aspect of the collection have likely been introduced by the pigtail catheter. there is no free air to suggest viscus perforation. the pseudocyst insinuates along the greater curvature of the stomach and extends inferiorly encompassing the body and tail of the pancreas. there are calcifications of the pancreatic head, consistent with the history of pancreatitis. no hyperdensity surrounding the pseudocyst to suggest hemorrhage. the left adrenal gland is again thickened as previously, likely reactive. . the liver, gallbladder, kidneys, and right adrenal gland are normal. the visualized small and large bowel loops are of normal caliber. there is no ascites. multiple small retroperitoneal lymph nodes are unchanged from prior exam and likely reactive. . there are no concerning lytic or sclerotic lesions. mild degenerative changes are seen at t8-9 with small anterior osteophytes. . impression: . 1. new moderate nonhemorrhagic left pleural effusion with significant atelectasis of the left lower lobe and lingula, causing elevation of the left hemidiaphragm. . 2. left pseudocyst pigtail drain in appropriate position, with moderate decrease in size of the pseudocyst. . osh studies: ct abdomen pelvis (): no report sent, but cd sent and uploaded. per discharge summary the report was significant for a multilobulated cystic lesion in the tail of the pancreas measuring 9.6 by 5 cm consistent with a pseudocyst. additionally there was moderate peripancreatic inflammatory stranding present. chest x-ray (): the heart is normal in size. the aortic contaours and mediastinal structures are normal in appearance. the lungs are clear with no active infiltrate, pulmonary vascular congestion, or pleural effusions. there is no acute osseaous pathology identified. impression: normal chest. electrocardiogram (): sinus tachycardia 123, na, ni, no ischemic changes. mri abdomen (): in the region of the distal body and tail of the pancreas, there is a thin-walled, multiloculated t2 hyperintense lesion measuring approximately 7.4 cm x 4.6 cm. within the lesion, there are multiple t2 hypointense foci, most likely represent debris. this lesion communicates with an additional t2 hyperintense lesion with a thick enhancing wall in the midline near the head of the pancrease measuring approximately 3 cm by 1.9 cm. this also has an enhancing internal septation. differential for this lesion includes pseudocyst versus cystic pancreatic neoplasm. admission labs: 10:59pm blood wbc-20.1*# rbc-3.95* hgb-9.9* hct-30.1* mcv-76* mch-25.2* mchc-33.0 rdw-13.3 plt ct-566* 06:15am blood wbc-16.3* rbc-3.82* hgb-9.6* hct-29.4* mcv-77* mch-25.0* mchc-32.5 rdw-13.3 plt ct-488* 08:35am blood wbc-18.4* rbc-3.68* hgb-9.5* hct-27.9* mcv-76* mch-25.7* mchc-33.9 rdw-13.3 plt ct-564* 10:59pm blood pt-14.2* ptt-25.5 inr(pt)-1.2* 10:59pm blood glucose-223* urean-10 creat-0.9 na-127* k-4.1 cl-92* hco3-23 angap-16 06:15am blood glucose-234* urean-9 creat-0.8 na-126* k-4.1 cl-92* hco3-23 angap-15 08:35am blood glucose-156* urean-7 creat-0.8 na-126* k-4.5 cl-91* hco3-21* angap-19 10:59pm blood alt-15 ast-13 ld(ldh)-195 alkphos-132* amylase-82 totbili-0.3 06:15am blood ld(ldh)-196 ck(cpk)-52 06:20am blood alt-13 ast-11 alkphos-130 amylase-47 totbili-0.4 05:48am blood alt-13 ast-11 totbili-0.2 10:59pm blood lipase-125* 06:20am blood lipase-41 10:59pm blood albumin-3.4* calcium-8.5 phos-2.8 mg-1.7 05:35am blood calcium-8.2* phos-3.2 mg-1.7 06:20am blood iron-12* 06:15am blood caltibc-163* hapto-580* ferritn-1547* trf-125* 06:20am blood caltibc-148* ferritn-1368* trf-114* 10:59pm blood triglyc-156* 10:59pm blood osmolal-271* cxr pa/lateral : findings: as compared to the previous radiograph, there is no relevant change. borderline size of the cardiac silhouette without pulmonary edema. small left pleural effusion with left basal atelectasis. no evidence of pneumonia, no pneumothorax. the previously placed right internal jugular vein catheter has been exchanged against a right tip line. the tip of the line projects over the inflow tract of the right atrium. ekg : sinus tachycardia with non-specific st-t wave abnormalities. compared to the previous tracing of no diagnostic interim change. ekg : sinus tachycardia with non-specific st-t wave abnormalities. compared to tracing #1 there is no change. ct abd/pelvis : impression: interval decrease in the size of pancreatic pseudocyst. pigtail drain previously inside the pseudocyst is no longer in the proper location with the coiled tail pulled against the posterior abdominal wall. micro: all blood/urine cultures negative c diff negative abscess: gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and chains. smear reviewed, possible short gram positive rods in chains. fluid culture (final ): this is a corrected report (). reported by phone to dr. @ 0955a, . streptococcus . sparse growth. identification performed by laboratories. previously reported as gram positive rod(s) (). anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): no fungus isolated. discharge labs: 08:28am blood wbc-11.5* rbc-3.64* hgb-9.3* hct-28.8* mcv-79* mch-25.6* mchc-32.4 rdw-14.4 plt ct-594* 06:06am blood glucose-97 urean-17 creat-1.0 na-135 k-4.4 cl-100 hco3-26 angap-13 08:28am blood glucose-139* urean-15 creat-1.0 na-136 k-4.6 cl-101 hco3-27 angap-13 08:28am blood calcium-9.8 phos-3.1 mg-1.7 07:35am blood tsh-4.0 06:21am blood cortsol-16.1 05:40am blood levetiracetam (keppra)-test 06:21am blood aldosterone-test 06:21am blood renin-test 02:29pm other body fluid amylase- 10:12am other body fluid organism referred for identification, aerobic bacteria-test name brief hospital course: 29-year-old man with a history of severe etoh pancreatitis complicated by anoxic brain injury and seizure disorder who was transferred from osh for evaluation of ongoing fevers, and found to have pancreatic pseudocyst with abcess. . # pancreatic pseudocyst with abcess: the patient presented to the with several weeks of subjective fevers, nausea, and vomiting and was found to have an enlarging pancreatic pseudocyst on ct abdomen/pelvis and was transfered to . on hd 3, patient had a percutaneous drain placed by ir with aspiration from the pseudocyst showing gram positive rods. the specimen was sent to the for speciation. while awaiting final speciation, he was treated with iv vancomycin and ampicillin-sulbactam. pancreatic drain fluid showed amylase >40,000 suggesting a communication between the pancreatic duct and the abcess cavity. pancreatic surgeons were consulted who recommended ercp to evaluate pancreatic duct morphology. ercp was not performed in house as there were concerns regarding the inflammation of the pancreas and risk of post-ercp pancreatitis. a repeat ct scan showed marked decrease in size of the psuedocyst with drain having been pulled out to the peritoneum. the drain was removed the following day by surgery. abscess specimen grew back strep , id the patient was to continue iv ceftriaxone for at least 5 weeks, full treatment to be guided by infectious disease. . # hyponatremia: the patient's sodium was 127 at time of transfer and trended down to 124. he trended down to a low of 119 and suffered two tonic-clonic seizures as described below. the hyponatremia was thought to be secondary to siadh. was initially corrected with hypertonic saline, then started on fluid restriction and tabs and sodium normalized. there was concern that sertraline was causing the hyponatremia, dosing was decreased. . # seizure disorder: the patient had 2 seizures in the setting of hyponatremia. this was corrected in the intensive care unit with hypertonic saline. neurology was consulted and did not recommend making any changes to the seizure regimen. once back on the general medicine floor, the patient had an episode of shaking leg movements, tachycardia to 170s that was concerning for seizure disorder, however neurology examined patient and did not think this was seizure disorder. . # tachycardia - the patient remained tachycardic during his hospitalization. ekgs revealed this to be a sinus tachycardia. cardiology was consulted and thought this was either related to inappropriate sinus tachycardia or anemia. the patient was not responsive to fluid boluses or blood transfusion. there was thought that the patient's pleural effusion may have been the cause of the tachycardia, however after speaking to interventional pulmonology and interventional radiology, they felt that the effusion was not large enough to cause this or tap. the patient was started on a low dose of metoprolol to control the heart rate. the effusion should be followed with x-rays to make sure it is not enlarging or becoming loculated which may be indicative of infection. . # nausea - the patient had chronic nausea during his hospitalization with some episodes of emesis. he was treated with anti-emetics, including standing compazine with zofran prn which did help. he was also started on a low fat diet and omemprazole to try and minimize his nausea. . # diabetes mellitus: was consulted to help control the patients diabetes. his regimen was changed to 42 units of lanuts in the morning, and recommended a new sliding scale that was provided. his blood sugar was well controlled on the new regimen. . # anemia: the patient's anemia was thought to be secondary to iron deficiency and anemia of chronic disease. he did receive a blood transfusion with appropriate rise in hematocrit. . # chronic cough - thought to be secondary to diaphragmatic irritation from psuedocyst. treated with anti-tussives. # emergency contact: brother . . # code status: full code. medications on admission: (per osh records) - acetaminophen 325-650 mg q6h prn - insulin aspart per sliding scale four times daily with meals - insulin glargine 29 units in the morning - carbamazepine 800 mg q12h - lamotrigine 50 mg q12h - levetiracetam mg q12h - sertraline 100 mg q12h - zofran 4 mg iv q8h prn (usually before seizure meds) discharge medications: 1. acetaminophen 325 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for pain. 2. carbamazepine 400 mg tablet sustained release 12 hr : two (2) tablet sustained release 12 hr po every twelve (12) hours. 3. lamotrigine 50 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po every twelve (12) hours. 4. levetiracetam 1,000 mg tablet : two (2) tablet po every twelve (12) hours. 5. prochlorperazine maleate 10 mg tablet : one (1) tablet po every six (6) hours as needed for nausea. :*60 tablet(s)* refills:*0* 6. insulin glargine 100 unit/ml solution : forty two (42) units subcutaneous qam. :*qs * refills:*2* 7. ceftriaxone 2 gram recon soln : two (2) grams intravenous every twenty-four(24) hours for 5 weeks: dosing will be adjusted per infectious disease doctors. :*qs * refills:*0* 8. metoprolol succinate 25 mg tablet sustained release 24 hr : one (1) tablet sustained release 24 hr po once a day. :*30 tablet sustained release 24 hr(s)* refills:*0* 9. zofran odt 4 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po every four (4) hours as needed for nausea. :*40 tablet, rapid dissolve(s)* refills:*0* 10. sertraline 25 mg tablet : three (3) tablet po once a day. :*90 tablet(s)* refills:*0* 11. humalog 100 unit/ml cartridge : per sliding scale subcutaneous four times a day. :*qs * refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: primary - pancreatic pseudocyst/abscess - hyponatremia - seizure disorder secondary - history of anoxic brain injury - history of hemorrhagic pancreatitis - seizure disorder discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , it was a pleasure taking care of you during your hospitalization. you were transferred to hospital for continued work up of your fevers. the infectious disease and neurology specialists were consulted to help with your case. the infectious disease doctors were concerned that the enlarging pancreatic pseudocyst seen on the imaging from the other hospital was infected so you underwent a ct-guided drainage of the pseudocyst. this revealed pus which grew a bacteria called strep . you were initially treated with broad spectrum antibiotics that were then narrowed to a single , ceftriaxone. you will need to take this antibiotic for a prolonged time, for at least 5 weeks. a repeat ct scan revealed significant decrease in the size of the pseudocyst. at your follow up visit with infectious disease, they will help guide the . you had 2 seizures while you were on the floors. these were due to your sodium level being too low. you went to the icu and were treated with hypertonic saline and tablets and your sodium normalized and you had no more seizures. neurology did not change your medication regimen. you had a sinus tachycardia that we were not able to find a cause for. we had the cardiologists see you and they thought this may have been due to anemia. we gave you a blood transfusion, however your heart rate did not improve. we started a medication called metoprolol which did help control your heart rate. you were able to ambulate without symptoms. because of your nausea and vomiting, we started a medication called omeprazole to help with this. medication changes: started ceftriaxone 2gm q24 hours for 5 weeks - this will be adjusted by the infectious disease doctors as needed tablets 1 gm by mouth three times a day metoprolol succinate 25 mg by mouth once daily omeprazole 20mg by mouth once daily increased lantus to 42 units subcutaneously every morning humalog - per provided sliding scale decreased sertraline to 75mg by mouth daily . please follow-up with your scheduled appointments. you will need to make appointments to follow-up with your outpatient neurologist and endocrinologist. if you do not hear from ercp in the next 1 week, please call and make an appointment. followup instructions: ercp will be in touch with you to an appointment in the next two weeks. your scheduled appointments include: name: church, address: , , phone: appt: at 1pm infectious disease provider: , md phone: date/time: 10:30 department: cardiac services when: tuesday at 1 pm with: , md building: sc clinical ctr campus: east best parking: garage department: surgical specialties when: friday at 10:30 am with: , md building: campus: east best parking: garage dr. should follow up with the pending aldosterone and renin to evaluate for hypoaldosteronism. please call your endocrinologist and neurologist to make follow-up appointments. Procedure: Drainage of pancreatic cyst by catheter Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Hyperpotassemia Anemia of other chronic disease Unspecified pleural effusion Abnormality of gait Nausea with vomiting Other specified cardiac dysrhythmias Anoxic brain damage Long-term (current) use of insulin Epilepsy, unspecified, without mention of intractable epilepsy Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Other disorders of neurohypophysis Acute pancreatitis Cyst and pseudocyst of pancreas |
allergies: meropenem attending: chief complaint: hematemesis major surgical or invasive procedure: endotracheal intubation central venous line hemodialysis line history of present illness: the patient is a 28 year old male with a history of alcohol abuse who walked into the ed with the complaint of hematemesis. the patient has been a significant drinker for 5-6 years, reporting drinking 6 mixed drinks a day, with tremulations on withdrawl, but no prior seizure. for the last week, he has felt increasing weakness and fatigue, and has become slightly disoriented and confused. he reports no head trauma. 3 days prior to presentation, he began to notice that he was coughing up blood and mild epigastric tenderness. these episodes were occuring 2-3 times per day. he additonally noted black tarry stools, but unable to quantify the number of bowel movements. with mild abdominal discomfort, nausea, and hematemesis, the patient was unable to tolerate a po diet, but continued to drink. his last drink was the night prior to presentation. . on arrival to the ed, vitals were 97.8, bp 53/palp, hr of 143. he was immediatly given 1unit of unmatched prbc, a cordis was placed, and he was given 3l of ns. his bp improved, but the patient remained tachycardic. he has a low grade temp of 100.1, and blood and urine cultures were went. with a wbc of 23, the patient was given cipro/flagyl. a ct scan and laboratory evaluation was consistent with acute pancreatitis and hepatitis. an ng tube was placed and lavaged, at first showing coffee-grounds, but then developing bright red blood, and an octreotide gtt was started. the patient was admitted to the micu for further manegment. . on arrival to the flor, the patient's vitals were 99.9, hr 132, bp 115/80, 94% on ra. . 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. no dysuria. denied arthralgias or myalgias. . past medical history: depression alcoholism social history: patient originally from western mass. works for a it computing company. not married and without children, lives with a roomate in . significant alcohol use for 5-6 years, drinking 6 mixed drinks daily with withdrawl symptoms. 1.5 ppd of cigarrettes, denies drug use. family history: mother with dm2. physical exam: vitals: t: 99.9 bp: 115/80 p: 132 r: 18 o2 95% ra general: alert, oriented, appears uncomfortable with ng tube with coffee grinds to clamp heent: scleral icterus, markedly dry mm with dry blood on lips neck: supple, jvp flat, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: tachycardic with normal rhytyhm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, mild ruq tenderness and luq tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. tremulous. . pertinent results: bronch cytology negative for malignant cells. pulmonary macrophages, bronchial epithelial cells, and inflammatory cells, including eosinophils. . ecg study date of 10:22:14 am baseline artifact. sinus tachycardia. otherwise, within normal limits. no previous tracing available for comparison. read by: , intervals axes rate pr qrs qt/qtc p qrs t 135 122 76 300/431 62 27 59 . liver/gallbladder u/s limited study demonstrating marked liver echogenicity, consistent with fatty infiltration, although more severe liver disease including significant hepatic fibrosis and cirrhosis cannot be excluded on this study. there is no intrahepatic biliary dilatation, and the common bile duct measures 4 mm. there is normal flow in the portal vein. . ct abdomen w/contrast study date of 10:52 am impression: 1. diffuse peripancreatic stranding which, in the setting of known alcohol use is likely indicative of pancreatitis. necrosis is difficult to quantify though there appears to be roughly 30-40% necrosis. 2. enlarged diffusely fatty infiltrated liver. 3. orogastric tube terminating in the duodenum. . chest (portable ap) study date of 11:08 am impression: low lung volumes with clear lungs. no free air noted under the hemidiaphragms. . ct head w/o contrast 1. diffuse loss of -white matter differentiation concerning for global hypoxia or edema with hypodensities in bilateral thalami. 2. no hemorrhage, mass effect, or herniation. 3. fluid seen in bilateral temporal subcutaneous tissue. near-complete opacification of bilateral mastoid, maxillary, frontal, and ethmoid sinuses. . ct torso w/ contrast 1. new multifocal airspace consolidation, suspicious for acute infiltrates. 2. diffuse colonic wall thickening, which could reflect colitis. 3. diffuse soft tissue edema. 4. peripancreatic stranding, in keeping with pancreatitis. extent of necrosis cannot be evaluated on a non-contrast exam. there are no new peripancreatic fluid collections. . cta chest w&w/o c&recons, non-coronary study date of 3:24 pm impression: 1. no evidence of pulmonary embolus. 2. interval worsening of the consolidation of the dependent portions of the bilateral upper and lower lobes, which may represent atelectasis; however, a superimposed infection cannot be excluded. 3. marked fatty infiltration of the liver. . ct head w/o contrast 1. interval improvement in the -white matter differentiation, overall, suggesting slow resolution of diffuse cerebral edema. 2. no hemorrhage, herniation or evidence of acute vascular territorial infarction. 3. persistent opacification of paranasal sinuses, nasal cavity and mastoid air cells, likely related to intubation and supine positioning. . ct torso w/contrast study date of 4:31 pm impression: 1. persistent atelectasis/consolidation in the dependent portions of the lungs bilaterally. ground-glass opacity in the dependent portions of the lungs is suggestive of edema. 2. diffuse fatty infiltration of the liver with areas of sparing about the gallbladder fossa. 3. persistent area of necrosis within the pancreas as described above, not significantly changed. minimally decreased peripancreatic fluid collection. resolution of the collection previously seen adjacent to the greater curvature of the stomach. 4. unchanged diffuse colonic bowel wall thickening for which an infectious etiology is not excluded. 5. increased attenuation of the splenic vein. the sma and smv is patent. no evidence of pseudoaneurysm. . ct sinus : 1. near-opacification of the nasopharynx, sphenoid sinuses and ethmoid air cells. moderate-to-severe left maxillary sinus disease. mild right maxillary sinus disease. non-pneumatized frontal sinuses. 2. persistent opacification of bilateral mastoid air cells and middle ear cavity. ct head : no acute intracranial abnormality. . eeg : this is an abnormal routine eeg due to three independent focal onset electrographic seizures in the right posterior quadrant without obvious clinical correlate. the background rhythm was slow and poorly modulated indicative of a moderate to severe encephalopathy. there was also recurrent sharp activity seen over the right posterior quadrant indicative of acute cortical and subcortical dysfunction . eeg : this is an abnormal video-eeg study because of severe diffuse background slowing and attenuation, and continuous periodic lateralized epileptiform discharges (pleds) in the right posterior quadrant. these findings are indicative of a severe encephalopathy and a highly potentially epileptogenic focal structural lesion in the right posterior quadrant. compared to the routine eeg yesterday, repetition rate of pleds has decreased and there are no electrographic seizures. . abd u/s : nondistended gallbladder, with lumen entirely replaced with echogenic material, likely sludge. no shadowing stones identified. no hyperemic thickened wall. . gallbladder scan : 1. non-visualization of the gallbladder but cannot evaluate for cholecyctitis in the setting of poor hepatic function. 2. tracer excretion into the bowel is observed, excluding common bile duct obstruction. . ct abd/pelvis : 1. persistent atelectasis/consolidation in the dependent portion of the lungs bilaterally. 2. diffuse fatty infiltration of the liver. 3. continued evolution of areas of necrosis within the pancreas. new fluid collection anterior to superior segment of the duodenum, 5.6 x 2.9 cm, and along pancreatic uncinate process, 2.2 x 1.9 cm. 4. delayed enhancement of the kidneys, with no excretion of contrast, and dense material within the gallbladder; these findings could suggest renal failure, if clinically correlated. 5. similar appearance of the colonic bowel wall, which could be due to bowel wall collapse; however, infectious etiology cannot be excluded. 6. similar appearance of increased attenuation of the splenic vein. no evidence of pseudoaneurysm. brief hospital course: 28 year-old male with a history of alcoholism presenting with acute hepatitis, pancreatitis, and ugib. # hematemesis: he presented with complaints of hematemesis and was started on a ppi drip and octreotide prior to egd. he was found to have a diulefoy lesion on endoscopy but no active bleeding. he had no recurrence of hematemesis during his hospitalization. # pancreatitis: his lipase was elevated on presentation to 1600 in the setting of alcohol abuse. he underwent a ct that demonstrated significant pancreatitis necrosis, but no clear phlegmon. because he became hypotensive, febrile, and developed a leukocytosis, he was thought to be septic or in shock secondary to pancreatitis and was started on meropenem and aggressive ivf repletion, along with levophed and phenylephrine. the surgical service was also consulted but found no evidence of an abscess or pseudocyst requiring surgical intervention. repeat ct abdomen showed fluid collections around his pancreas and duodenum but thought to be sterile per surgery and not sampled; id agreed with this. kept on broad spectrum antibiotics. pt likely to continue to spike fevers due to necrotizing pancreatitis. # sepsis: as noted above, he became hypotensive, febrile, and developed a leukocytosis shortly after admission. he required levpohed and phenylephrine initially but was eventually able to maintain normal perfusion pressure with levophed alone. no clear source of infection was initially identified but he was treated empirically with several different antibiotic regimens because of concerns about inadequate coverage, allergic drug reactions, or new possible sources of infection. possible sources of infection considered included pancreatitis, cellulitis, c. diff given colonic wall thickening seen on abdominal ct, line infections, endocarditis, and sinusitis but most likely source thought to be necrotizing pancreatitis. hida with persistent sludge but not thought to have cholecystitis requiring intervention. there was evidence of fluid collections around his pancreas and duodenum but thought to be sterile per surgery and not sampled. his antibiotic courses included meropenem (; may have contributed to eosinophilia per id); aztreonam 6(/3- ; metronidazole iv (, , , ); vancomycin iv (; may have contributed to eosinophilia per id); daptomycin ( -> increased dose on ); linezolid (); vancomycin po (, ); vancomycin pr (); micafungin (, ); and cipro (, ). he did have one bottle of blood cultures grow coagulase negative staph, otherwise no source was found. his fever curve and leukocytosis trended down and antibiotics were slowly weaned off. he continued to spike fevers requiring restarting of pressors a few times for accompanying hypotension. however, these were thought to be due to necrotizing pancreatitis and expected to continue for a while. decision made not to tap abd fluid collections as he would be at very high risk of bleeding. he has continued to have recurring low grade fevers, tachycardia and tachypnea without any identified source (blood, urine, sputum cultures; cxr. his fevers at discharge were felt to be centrally driven and not from any organism. # respiratory failure: he was intubated for hypercapnia on in the setting of recent egd and shortly after admission. he was managed with assist control/cmv and underwent tracheostomy placement on by the thoracic surgery service. he was noted to have blood oozing around trach site with clots suctioned from trach and oropharynx. he received ddavp x 2 for this. on pt had pea arrest clot plugging (see below). bedside bronch was done by thoracics who determined that trach appropriately sized. no evidence of dic. completed a 24-hour course of amicar per heme-onc recs. pt eventually weaned to trach mask with fio2 40%. he did require additional ddavp on for return of bloody secretions but bronched with no evidence of bleed. he is able to clear most secretions on his own requiring occasional suctioning. # pea arrest: on , he developed respiratory distress progressing to cardiac arrest with pea reportedly lasting minutes. he received compressions and atropine with return of spontaneous circulation. a large clot was suctioned from trach with resolution before arrival of code team. further respiratory issues were addressed as above. # renal failure: he went into renal failure a few days after admission that was thought to be atn in the setting of sepsis and hypotension. he required cvvh therapy afterward. he then had a tunneled hd line placed on and started hd once blood pressures stable off pressors. renal function improved and no longer required hd after . with cr. of 0.8 and good uop on discharge from micu. # seizures/intercerebral edema: he underwent a head ct that demonstrated loss of /white matter differentiation on . on the same day, he also developed eye twitching concerning for seizure activity. neurology was consulted and recommended starting keppra and hypertonic saline to treat his edema, which was thought to be secondary to both volume overload in the setting of ivfs and toxic-encephalopathy, likely secondary to elevated ammonia. his cerebral edema improved significantly over the next several days, as a follow-up head ct demonstrated significant improvement. he also underwent an eeg that was nondiagnostic for seizure activity. after several weeks he again was noted to have seizure-like activity with twitching of the mouth and eye deviation upward. he was initially thought to be withdrawing from benzodiazepines as this activity occured in the setting of weaning his midazolam gtt and he was treated with higher doses of benzos, which are being weaned with change of valium to 5mg qhs on with plan for 2wks at this dose before d/c'ing. after an eeg showed only seizures in the occipital lobe, his keppra dose was increased. he then underwent a repeat eeg that was negative for seizures. upper extremity tremors thought more consistent with clonus and thought to be more reactive in setting of waking up. # acute hepatitis: this was thought to be secondary to alcoholic hepatitis, with a ct scan showing extensive fatty infiltration. # alcoholism: patient describd history of withdrawal symptoms but not prior seizure. last drink was night prior to presentation. he was given thiamine, folate, and vitamin b12. he was started on a ciwa but received fentanyl and midazolam after being intubated. # hyperbilirubinemia: initially this was attributed to his alcoholic hepatitis and pancreatitis. however, it continued to rise in the setting of receiving tpn. the tpn was d/c'd and the bilirubin decreased. #. adrenal insufficiency: the patient developed profound eosinophilia and was persistently hypotensive despite adequate antibiotic coverage for sepsis. stim test showed 0, 30, 60 levels of 12->18->19, but he was started on high dose hydrocortisone anyway with decrease in his eosinophilia and decreased pressor requirement. the steroids were then slowly weaned off prior to discharge. ... ... ... in essence, hospital course has been complicated by respiratory failure (currently with a trach), cyclic fevers (no organism identified, felt to be centrally mediated from the brain), and anoxic brain injury (possibly from pea arrest) with limited but improving neuro status. his low grade fevers with tachypnea have not been related to an infection, but rather his brain injury, as assessed by the neurologists here and also due to the lack of an isolated microorganism. medications on admission: prozac discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 8-15 puffs inhalation q2h (every 2 hours) as needed for sob, cough, bronchospasm. 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) 5000 injection tid (3 times a day). 3. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 4. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever. 5. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 6. levetiracetam 100 mg/ml solution sig: one (1) 500 mg po bid (2 times a day). 7. diazepam 5 mg tablet sig: one (1) tablet po hs (at bedtime). 8. insulin please see attached insulin regimen discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary - diulefoy lesion - necrotic pancreatitis - hepatitis - respiratory failure - renal failure - cerebral edema/anoxic brain injury - seizures - likely colitis - adrenal insufficiency secondary - alcohol abuse - depression discharge condition: stable on trach discharge instructions: you were admitted with bloody emesis in the setting of alcohol abuse. you were intubated for an upper endoscopy, which showed a diulefoy lesion (ulcer). other studies also showed hepatitis and necrotic pancreatitis. you required reintubation for respiratory failure. you had multiple complications during your hospital stay, including cerebral edema, seizures, likely colitis, renal failure, adrenal insufficiency, and fevers which are centrally driven by the brain. a trach was placed as you still require ventilatory support, but the above issues are now stable. you are being transferred to a rehab for further care. the following changes were made to your medications: - tyleonol 650 mg every 6 hrs for fevers - albuterol inhaler every 2 hrs for wheezing - diazepam 5 mg by mouth at night for 2 weeks - famotidine 20 mg every 12 hours - lasix 40 mg daily - heparin 5000 units sq three times a day - insulin - keppra 500 mg twice a day please take all medications as prescribed. please call your doctor or 911 if you develop chest pain, difficulty breathing, change in mental status, dizziness, bleeding, severe pain, or any other concerning symptoms. followup instructions: please schedule follow-up with your pcp on discharge from rehab. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Arterial catheterization Other intubation of respiratory tract Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed biopsy of skin and subcutaneous tissue Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Thrombocytopenia, unspecified Other and unspecified noninfectious gastroenteritis and colitis Toxic encephalopathy Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Other convulsions Acute respiratory failure Cardiac arrest Anoxic brain damage Septic shock Cerebral edema Glucocorticoid deficiency Other and unspecified coagulation defects Acute pancreatitis Other and unspecified alcohol dependence, continuous Acute alcoholic hepatitis Dieulafoy lesion (hemorrhagic) of stomach and duodenum |
allergies: meropenem attending: chief complaint: seizure major surgical or invasive procedure: downsizing of trach peg placement picc history of present illness: the patient is a 28 year old male with a history of alcohol abuse who was recently discharged after an extended icu admission for pancreatits/hematemesis who during his hospital stay had a cardiac arrest and subsequent anoxic brain injury (see discharge summary). mri showed diffuse anoxic injury, and ct showed loss of /white matter differentiation. he began having seizure activity on and was treated with keppra. he also had an eeg that was nondiagnostic, and subsequent eeg that showed seizures in the occipital lobe. keppra was increased and seizures were controlled prior to d/c. . mr. was discharged to a rehab hospital where he was found to have what was believed to be two siezures yesterday and one today with persistent eye deviation to the right. he was given ativan, after which tremors reportedly stopped, and then transfer was arranged directly to the icu. past medical history: depression alcoholism pancreatitis s/p cardiac arrest tracheostomy anoxic brain injury social history: patient originally from western mass. works for a it computing company. not married and without children, lives with a roomate in . significant alcohol use for 5-6 years, drinking 6 mixed drinks daily with withdrawl symptoms. 1.5 ppd of cigarrettes, denies drug use. family history: mother with dm2. physical exam: vitals: t:100.5 p:120 r: 30 bp: 136/68 sao2: 100 % on 35% tm general: lying in bed, nad heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: lungs poor inspiratory effor bilaterally cardiac: tachy but regular abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp pulses bilaterally. skin: no rashes or lesions noted. neurologic: -mental status: arousable to stimuli. does not follow commands, appears to neglect right side. -cranial nerves: pupils 2-> 5mm bilaterally, blinks to threat. l eye gaze preference. face symmetric. -motor: hypertonic with diffuse myoclonus in upper extremities with any movements. able to grip bilaterally. -sensory: unable to test. -dtrs: tri pat ach l 3 3 3 2 1 r 3 3 3 2 1 plantar response was flexor bilaterally. -coordination: unable to test. -gait: unable to test. pertinent results: wbc 40.4, hb 9.2, hct 30.5, plt 732, mcv 95 n 52, b 2, l 37, m 5, e 3, ba 0, meta 1 hypochr 2+, anisocy 1+, poiklo 1+, macrocy 1+, microcy 1+, tear-dr 1+ na 145, k 3.1, cl 113, hco3 23, bun 19, cr 0.9, gluc 23 ca .8, mg 1.6, p 3.9 alt 26, ast 47, ap 125, ldh 243, tbili 1.1, alb 2.6 ck 29 pt 16.1, ptt 40.8, inr 1.5 fibrinogen 372 . micro: , , c. diff negative c. diff pending fecal cx: pending , bcx: pending ucx: sternotrophomonas maltophilia, bactrim sensitive . images: . cxr: persistent lower lung volumes. small to moderate left pleural effusion is unchanged. tracheostomy tube is in standard position. right picc remains in place with tip in the upper svc. no evidence of pneumothorax. bibasilar atelectasis are unchanged. cardiomediastinal contours are also stable ng tube tip is in the stomach. . leni: 1. no deep vein thrombosis in the right leg. 2. cyst in the right popliteal fossa which may have ruptured or contains hemorrhage. . ct abdomen w/ and w/o contrast: 1. interval enlargement of the pancreatic pseudocysts in the mid body, tail and head of the pancreas. 2. new - nonocclusive thrombus in the superior mesenteric vein extending to the junction of the splenic vein. 3. interval enlargement of fluid collection lateral to the antrum of the stomach. 4. unchanged colonic wall thickening. . mri head: no seizure focus identified. diffuse volume loss. resolution of previously noted hypoxic changes in the cortex. new changes in the pons and midbrain which could represent a central pontine myelinolysis/osmotic demyelination. . ekg: sinus tachycardia with nonspecific <1mm st depressions . ruq u/s-impression: 1. no deep vein thrombosis in the right leg. 2. cyst in the right popliteal fossa which may have ruptured or contains hemorrhage. the study and the report were reviewed by the staff radiologist. . -impression: no hemorrhage, mass, or fracture. atrophy likely secondary to global anoxic brain injury. would recommend mri. findings were discussed with at 9:55 a.m. on . . cta abd-impression: 1. no significant change in the appearance of numerous pancreatic pseudocysts, replacing the tail and distal pancreatic body, and also adjacent to the head of the pancreas and the gastric antrum. there are no new intra-abdominal fluid collections identified. the residual normal pancreatic tissue again demonstrates normal enhancement. there is no evidence for new inflammation involving this region. peripancreatic stranding persists. 2. redemonstration of diffuse hepatic steatosis. 3. minimal, if any, residual clot in the smv. the smv and splenic vein as well as the main portal vein, are patent, though a focal narrowing of the splenic vein is noted. 4. unchanged colonic wall thickening, nonspecific. the study and the report were reviewed by the staff radiologist. . eegimpression: this telemetry captured no pushbutton activations. routine sampling continues to show poorly organized and low attenuation background rhythm with frequent left occipital and posterior temporal discharges. seizure detection files showed one electrographic seizure. there was no clinical correlate. overall, this recording is unchanged compared to the previous 24 hours. . eeg-impression: this telemetry captured no pushbutton activations. routine sampling continues to show a poorly organized and low attenuation background. however, the left occipital discharges are less frequent and no runs were seen on routine sampling. seizure detection files showed one possible electrographic seizure with right sided body jerking. overall, there are less seizures on this recording compared to the previous 24 hours. . cxrthe tracheostomy tip is 6.7 cm above the carina. the right picc line tip is in the medial portion of right subclavian vein. there is no change in the high position of both hemidiaphragms and bibasilar atelectasis. the gastrostomy is projecting over its expected position in the left upper abdomen. no interval development of pneumothorax, pleural effusion, or pulmonary edema has been demonstrated. brief hospital course: 28 y/o male with an anoxic brain injury s/p cardiac arrest in the setting of necrotizing pancreatitis etoh who was recently d/c'd from to rehab/ltc. was seen by a neurologist at rehab after 2 seizures who in consultation with epileptology at decided patient to be transfered back to for further evaluation to include neurology consult and 24hr eeg. . # seizure: mr. has an anoxic brain injury and has had seizures treated with keppra. mri and eeg results as above. transfered to for neurology eval and presumptive 24hr eeg. it is possible that these seizures are from benzo withdrawal after the decrease in dose of the valium is possible but not probable and more likely a result of his anoxic brain injury. he remained on neurology service who performed a 24 hr eeg and keppra was continued. after development of wbc and fever he was transfered to medicine but recieved several other eegs including 24 hr eeg on which showed evidence of seizure activity. he was followed by the neurology service and placed on keppra and standing ativan. in addition, after witnessed tc seizures on he was loaded with dilantin and started on both po and iv regimens. his target dilantin levels were changed based on his albumin levels. currently, pt's target levels are between . pt is currently on 200mg tid po dilantin. intermittently, pt had been given iv fosphenytoin for loading doses. levels of dilantin should be continually monitored and pt should be given 500mg po dilantin as needed for when levels are below goal. he should be having levels two to three times a week for the first two weeks or so to make sure he remains therapeutic. his mental status seems related to seizure activity.. . # fevers/tachypnea/tachycardia: pt has had persistent fevers/tachypnea/tachycardia which were evaluated during the prior hospitalization. multiple blood/urine cx were initially negative and the sputum cx were thought to be colonization. eventually, pt grew multiple different colonies of pseudmonas and alcaligenes, including cephalosporin resistant pseudomonas. he was followed by the id service and treated with tobramycin and ceftazidime. this regimen will be completed on . in addition, there is some question of whether pt had an allergic rxn to meropenem, causing a blistering skin rash. he is to complete the above course. if he clinically worsens, meropenem could be considered, but likely should have another id consult due to the hx of a reaction. . # pea arrest: occurred at 02:30 on . patient was noted by housestaff to become increasingly bradycardic on tele. on evaluation, pt found nonresponsive with no bp or pulse. chest compressions initiated for pea arrest. pt with agonal breathing and suctioned by rt for copius secretions; respirations given through ambu bag. he developed a rhythm concerning for vfib; one 200j shock was delivered with subsequent rhythm of sinus bradycardia. femoral line placed. pt given 1 amp epinephrine and 1 amp bicarb with increase in hr to 150 and bp 180/132. fsbs 21, and pt received 1 amp d50. duration of pea arrest was 7 minutes. pt transferred to micu for further management. vs on transfer:bp 94/64, hr 112, o2sat 99%. - unclear etiology. mucous plugging likely given copious secretions, especially since he has had pea arrest in this setting before (during hospitalization 6/). possible presepsis in setting of pneumonia given leukocytosis and low grade temps. have been complicated by ams in setting of hypoglycemia. seizure with unwitnessed tonic clonic movements also a possibility, perhaps triggered by hypoglycemia. pe less likely with rapid recovery and as pt on heparin gtt, although subtherapeutic. . # neuro eval post-code: concern for herniation v. progression of anoxic brain injury v. bleed given posturing, roving eye movements, and weak corneal reflex in setting of hypertension to sbp 230s. does have seizure activity noted on eeg at admission typified by rue clonus and right gaze deviation which he did not exhibit after the code. his mental status slightly improved to where he would occasionally nod his head yes/no to questions. he appears to recognize his family. . # hypertension: baseline sbp 110s-140s. after he received epinephrine during the code was sbp sustained >200. also be related to clonic movements. received hydral 10mg iv and started on nitro gtt without effect. subsequently received 2 doses of ativan and hydralazine 20mg iv with improvement in sbp to 130. after this point, his blood pressure remained normotensive. . # hypoglycemia: fsg 90s-120s on stable dose of glargine. he had iatrogenic hypoglycemia to 20, likely continuation of glargine while tube feeds discontinued, and this occured around the time of the pea arrest as described above. could be also decreased in setting of infection. fs now stable on the attached regular insulin sliding scale. . # hypercalcemia: unclear etiology, ? bone turnover given low pth. patient recieved aggressive iv fluids and endocrine consult recommended calcitonin. he was also given iv bisphosphonate. his calcium levels improved. in addition, he was started on vitamin d. he should continue vitamin d twice weekly for 4 weeks and then have his level rechecked. . #hyponatremia - pt with persisent hyponatremia thought to likely be related to siadh from his neurologic issues and seizure activity. his medications and tube feeds were concentrated, he was placed on a fluid restriction. urine electrolytes were consistent with an siadh pattern. he did worsen with diuresis and should be closely monitored if lasix started. . # volume overload: pt was volume up during prior hospitalization and was on dialysis renal failure. he has had return of renal function and now is being diuresed with lasix 40mg po daily. he is currently autodiuresing. . # etoh/benzo withdrawal: continued valium taper. currently on ativan q6h but for seizure ppx. also has been getting folic acid/mvi/thiamine which we will continue. . # hypothyroidism - newly started on levothyroxine; should be continued at current dose and have a tsh checked in about 1.5 weeks. . # weakness - should continue pt daily. . # pancreatitis - patient has history of severe pancreatitis complicated by known necrosis and pseudocytst. were worried that he was having increasing pain and that it may have been the source of his fevers before his vap became apparent. ct scan was done showing no change, but surgery was reconsulted to see if it was surgical. he is not a candidate. by the time of discharge, his lipase was trending down and he had no apparent pain and was tolerating tube feeds. . # nutrition - had peg tube placed on , tolerating tube feeds at the time of discharge. continue with concentrated tfs secondary to hyponatremia. . # smv thrombus - patient had known smv thrombus found incidentally on ct scan during prior hospitalization. had been anticoagulated on heparin gtt until we tried to bridge him with coumadin. had difficulty maintaining therapeutic level and had an interaction with dilantin. thought he would benefit best from lovenox injections for the long run until more stabalized on antiseizure medication. medications on admission: -albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 8-15 puffs inhalation q2h (every 2 hours) as needed for sob, cough, bronchospasm. -heparin (porcine) 5,000 unit/ml solution sig: one (1) 5000 injection tid (3 times a day). -famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). -acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever. -furosemide 40 mg tablet sig: one (1) tablet po daily (daily). -levetiracetam 1000 mg po bid -diazepam 5 mg tablet sig: one (1) tablet po hs (at bedtime). -insulin (glargine 40units qhs) -metoprolol 25mg po/ng tid -mvi daily -folic acid 1mg daily -thiamine 100mg daily -ranitidine 150mg daily -omeprazole 20mg discharge medications: 1. multivitamins tablet, chewable sig: one (1) ml po daily (daily). 2. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q2h (every 2 hours) as needed for sob/wheezing. 4. acetaminophen 160 mg/5 ml solution sig: one (1) po q6h (every 6 hours) as needed for fever, pain. 5. insulin regular human 100 unit/ml solution sig: as directed injection asdir (as directed). 6. enoxaparin 100 mg/ml syringe sig: one (1) subcutaneous q12h (every 12 hours). 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 2x/week (mo,th). 9. dextromethorphan poly complex 30 mg/5 ml suspension, sust.release 12 hr sig: ten (10) ml po q12h (every 12 hours) as needed for cough. 10. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 11. phenytoin 125 mg/5 ml suspension sig: 200mg po tid (3 times a day). 12. famotidine 20 mg tablet sig: one (1) tablet po twice a day. 13. keppra 1,000 mg tablet sig: two (2) tablet po twice a day. 14. lorazepam 1 mg tablet sig: one (1) tablet po every six (6) hours. 15. ceftazidime 2 gram recon soln sig: one (1) recon soln injection q8h (every 8 hours) for 5 days: to end on . 16. tobramycin sulfate 40 mg/ml solution sig: one (1) injection q48h (every 48 hours) for 3 doses: to end on . 17. dilantin kapseal 100 mg capsule sig: five (5) capsule po as directed: to be given daily if dilantin level not in range. 18. percocet 5-325 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain. discharge disposition: extended care facility: & rehab center - discharge diagnosis: anoxic brain injury depression alcoholism pancreatitis s/p pulseless electrical activity cardiac arrest tracheostomy discharge condition: stable. discharge instructions: you were admitted for change in mental status, seizures, as well as complications of your severe pancreatitis. while you were here, you were treated for a pseudomonal ventilator associated pneumonia and were followed by the infectious disease service. in addition, you were noted to have seizures for which you were followed by the neurology service and were started on antiepileptic medications. you were seen by the surgical service as well to evaluate for your severe pancreatitis and pseudocysts. you had the placement of a trach tube which was down-sized. in addition, you underwent placement of a peg tube in the or. . you will need to have these issues further treated at rehab. . please take all your medications as prescribed and follow up with the appointments below. . please return to the hospital for seizures, vomiting, fevers, or any other changes or concerns. followup instructions: you will need to follow up with the following specialties . 1.neurology 2.general surgery 3.endocrine 4.primary care physician 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 Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Replacement of tracheostomy tube Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Urinary tract infection, site not specified Unspecified septicemia Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Other convulsions Depressive disorder, not elsewhere classified Sepsis Acute respiratory failure Pneumonia due to Pseudomonas Cardiac arrest Anoxic brain damage Cerebral edema Encephalopathy, unspecified Ventilator associated pneumonia Acute vascular insufficiency of intestine Acute pancreatitis Cyst and pseudocyst of pancreas Other and unspecified alcohol dependence, continuous Hypercalcemia Hypoglycemia, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: right upper lobe cancer major surgical or invasive procedure: right upper lobectomy with chest wall resection/reconstruction with goretex mesh, flex bronch () via right thoracotomy. history of present illness: the patient is an 85-year-old gentleman with a biopsy-proven cancer of the right upper lobe with invasion of the chest wall. his staging workup including a cervical mediastinoscopy was negative, and he was brought to the operating room today for resection. past medical history: cva with residual l arm numbness, dementia, likely vascular etiology adenocarcinoma of colon, dx'd , surgery sch'd for anemia (on iron & b12 supplementation now) copd/asthma with chronic cough hyperlipidemia bph s/p turp hiatal hernia hand surgeries b/l h/o tb infxn in childhood social history: retired teacher. widower. has dementia with stm deficits. daughter ( , ) is health care proxy. distant 30 pk-yr smoking history (quit 43 yrs ago), no etoh. patient is a vegetarian. family history: mother-stroke in 70s, father-tb pna, sister died of cardiac cause physical exam: general: frail appearing male in nad. vs: 98.2, 72, 140/82, 18, 94% on ra heent: unremarkable chest: cta bilaterally, right thoracotomy incision healing well w/o redness or drainage cv: rrr s1, s2 abd: soft, nt, nd, +bs extrem: no c/c/e neuro: intact but basline level of anxiety pertinent results: 04:26pm blood wbc-13.3*# rbc-3.85* hgb-11.6* hct-34.0* mcv-88 mch-30.3 mchc-34.3 rdw-13.0 plt ct-293 05:56am blood wbc-10.8 rbc-3.53* hgb-10.7* hct-30.8* mcv-87 mch-30.3 mchc-34.8 rdw-13.0 plt ct-254 09:32am blood wbc-7.0 rbc-3.27* hgb-9.6* hct-28.3* mcv-87 mch-29.2 mchc-33.8 rdw-13.2 plt ct-173 03:33pm blood wbc-8.0 rbc-3.11* hgb-9.3* hct-26.7* mcv-86 mch-29.8 mchc-34.7 rdw-13.2 plt ct-169 02:47am blood wbc-11.8* rbc-3.42* hgb-10.4* hct-30.0* mcv-88 mch-30.5 mchc-34.8 rdw-13.3 plt ct-197 02:15am blood wbc-9.6 rbc-3.49* hgb-10.7* hct-29.9* mcv-86 mch-30.7 mchc-35.9* rdw-13.2 plt ct-198 01:00am blood wbc-9.7 rbc-3.49* hgb-10.4* hct-30.2* mcv-87 mch-29.8 mchc-34.5 rdw-13.4 plt ct-229 06:05am blood wbc-8.4 rbc-3.63* hgb-10.9* hct-31.8* mcv-87 mch-30.0 mchc-34.3 rdw-13.4 plt ct-252 05:30pm blood wbc-8.5 rbc-3.57* hgb-10.7* hct-30.6* mcv-86 mch-29.9 mchc-34.9 rdw-13.6 plt ct-286 08:10am blood wbc-8.8 rbc-3.80* hgb-11.2* hct-32.8* mcv-86 mch-29.4 mchc-34.1 rdw-13.7 plt ct-321 06:35am blood wbc-9.9 rbc-3.72* hgb-11.3* hct-32.7* mcv-88 mch-30.4 mchc-34.6 rdw-14.1 plt ct-359 09:21am blood pt-14.6* ptt-36.5* inr(pt)-1.3* 04:26pm blood glucose-127* urean-12 creat-0.9 na-138 k-4.3 cl-106 hco3-23 angap-13 10:23pm blood glucose-141* urean-12 creat-0.8 na-138 k-4.5 cl-110* hco3-20* angap-13 02:15am blood glucose-125* urean-12 creat-0.9 na-136 k-4.8 cl-106 hco3-23 angap-12 05:56am blood glucose-121* urean-11 creat-0.8 na-138 k-4.7 cl-109* hco3-24 angap-10 09:32am blood glucose-120* urean-11 creat-0.7 na-138 k-4.3 cl-111* hco3-24 angap-7* 03:33pm blood glucose-113* urean-11 creat-0.7 na-137 k-4.2 cl-109* hco3-23 angap-9 02:47am blood glucose-133* urean-12 creat-0.7 na-139 k-4.3 cl-109* hco3-25 angap-9 02:15am blood glucose-107* urean-15 creat-0.8 na-136 k-3.7 cl-105 hco3-24 angap-11 01:00am blood glucose-119* urean-17 creat-1.0 na-133 k-3.5 cl-100 hco3-25 angap-12 06:05am blood glucose-93 urean-15 creat-1.0 na-134 k-3.5 cl-98 hco3-25 angap-15 07:40am blood glucose-91 urean-14 creat-0.8 na-131* k-3.4 cl-95* hco3-27 angap-12 05:30pm blood glucose-113* urean-15 creat-0.9 na-132* k-3.4 cl-97 hco3-27 angap-11 08:10am blood glucose-112* urean-9 creat-0.8 na-132* k-3.6 cl-98 hco3-26 angap-12 06:35am blood glucose-114* urean-9 creat-0.9 na-136 k-4.5 cl-102 hco3-25 angap-14 01:40pm blood glucose-114* urean-12 creat-1.0 na-137 k-4.7 cl-105 hco3-24 angap-13 04:26pm blood ck(cpk)-770* 04:26pm blood ck-mb-9 ctropnt-<0.01 10:23pm blood ck(cpk)-1179* 10:23pm blood ck-mb-14* mb indx-1.2 ctropnt-<0.01 05:56am blood ck(cpk)-1158* 05:56am blood ck-mb-12* mb indx-1.0 ctropnt-<0.01 03:33pm blood ck(cpk)-843* 03:33pm blood ck-mb-8 ctropnt-<0.01 brief hospital course: pt was admitted on and taken to the or for right thoracotomy for right upper lobectomy, with chest wall resection and reconstruction w/gortex mesh. chest tube placed to suction at the time of surgery w/moderate amount of serosanguinous drainage. a paravertebral epidural was placed at the time of sugery. , pt remained intubated and was admitted to the sicu. had brief episode of hypotension and required ivf and pressors. pod#1 extubated without difficulty. geriatric consult obtained for pain control management; pt remained on epidural. cardiology was consulted for rapid afib; started on amiodarone drip w/ good response. received 1u prbc for hct drop. pod#2 chest tubes placed to water seal. infiltrate seen on cxr; started on iv zosyn. advanced to clear diet. epidural removed, switched to po pain meds and po amiodarone. pod#3 episode of rapid afib; started on iv amiodarone and esmolol. converted to sr and started on po lopressor and po amiodarone. gentle diuresis. advanced to full liquid diet with fluid restriction for hyponatremia. pod#4 chest tubes draining moderate amount of pleural fluid. intermittent afib. rebolus w/ iv amiodarone and oral dose increased to 400mg amiodarone. pod#5 eval by pt, who recommended rehab. remains in and out of afib. chest tube output decreasing but remains moderate. pod#6 pain medication increased per geriatric team recommendation. pod# chest tube drainage decreased, and chest tube was removed on pod#9 w/stable cxr. medications on admission: combivent 90mcg 2puffs q 4, lopressor, roxicodone, plavix 75', proscar 5', protonix 40', zocor 20', mvi discharge disposition: extended care facility: house rehab discharge diagnosis: rul tumor invading 4th-5th ribs, now s/p rulobectomy with chest wall resection/reconstruction with goretex mesh / flex bronch () . pmh: tia, copd, colon ca, sleep apnea, hyperchol, hiatal hernia psh: turp, hand surgery, deviated septum, cyto (bladder stone removal) partial colectomy discharge condition: deconditioned discharge instructions: call dr. office if you develop chest pain, shortness of breath, fever, chills, redness or drainage from your incisions or any symptoms that concern you. you may shower on friday. after showering, remove your chest tube site dressing and cover the area with a clean bandaid daily until healed. no tub bathing for 4 weeks. take a mild stool softener while you are on narcotic pain medication. followup instructions: you have a follow up appointment with dr. on thursday 10:30am on the clinical center . please arrive 45 minutes prior to your appointment and report to the radiology for a chest xray. Procedure: Fiber-optic bronchoscopy Other repair of chest wall Division or crushing of other cranial and peripheral nerves Regional lymph node excision Other lobectomy of lung Diagnoses: Pneumonia, organism unspecified Other iatrogenic hypotension Esophageal reflux Atrial fibrillation Secondary malignant neoplasm of other specified sites Peripheral vascular disease, unspecified Other persistent mental disorders due to conditions classified elsewhere Personal history of malignant neoplasm of large intestine Malignant neoplasm of other parts of bronchus or lung Chronic obstructive asthma, unspecified Unspecified hereditary and idiopathic peripheral neuropathy Anemia in neoplastic disease |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sob major surgical or invasive procedure: inferior vena cava catheter placement with imaging followed by inferior vena cava filter. history of present illness: pt is a 85yom ex-smoker w/ rul nsc lung ca w/ chest wall invasion (poorly diff sq cell ca, t3 n0, stage iib), s/p rul lobectomy, r chest wall resection (ribs ), rml wedge resection, chest wall reconstruction w/ goretex graft . he was readmitted with hypotension and dyspnea and was found to have a pe and recurrent, non-malignant pleural effusion. he was started and coumadin and discharged to rehab on . he was last seen in clinic . at that time his rehab was noted to be coming along very slowly. he was able to able to walk for short periods of time with assistance, though he continued to be oxygen dependent at all times. today he was transferred from rehab to the ed for c/o increased dyspnea and left-sided changes pain. he reports the pain has been ongoing for the past week. denies previous episodes. pain in over the left chest with radiation to the l axilla. no arm, neck, or jaw pain. pain worse with deep inspiration. has been coughing for about the same time period with grey, "clumpy" sputum. denies fever or chills. has been walking less. feels progressively worse since last been seen in clinic 3 weeks ago. past medical history: cva with residual l arm numbness, dementia, likely vascular etiology adenocarcinoma of colon, dx'd , surgery sch'd for anemia (on iron & b12 supplementation now) copd/asthma with chronic cough hyperlipidemia bph s/p turp hiatal hernia hand surgeries b/l h/o tb infxn in childhood social history: retired teacher. widower. has dementia with stm deficits. daughter ( , ) is health care proxy. distant 30 pk-yr smoking history (quit 43 yrs ago), no etoh. patient is a vegetarian. family history: mother-stroke in 70s, father-tb pna, sister died of cardiac cause physical exam: physical exam: temp: 97.5 hr: 82 bp: 110/56 rr: 32 o2 sat: 100% nrb general all findings normal wn/wd nad aao abnormal findings: heent all findings normal nc/at eomi perrl/a anicteric op/np mucosa normal tongue midline palate symmetric neck supple/nt/without mass trachea midline thyroid nl size/contour abnormal findings: respiratory all findings normal cta/p excursion normal no fremitus no egophony no spine/cvat abnormal findings: tender over l chest r chest incision well healed. nontender. cardiovascular all findings normal rrr no m/r/g no jvd pmi nl no edema peripheral pulses nl no abd/carotid bruit abnormal findings: gi all findings normal soft nt nd no mass/hsm no hernia abnormal findings: gu deferred all findings normal nl genitalia nl pelvic/testicular exam nl dre abnormal findings: neuro all findings normal strength intact/symmetric sensation intact/ symmetric reflexes nl no facial asymmetry cognition intact cranial nerves intact abnormal findings: ms all findings normal no clubbing no cyanosis no edema gait nl no tenderness tone/align/rom nl palpation nl nails nl abnormal findings: lymph nodes all findings normal cervical nl supraclavicular nl axillary nl inguinal nl abnormal findings: skin all findings normal no rashes/lesions/ulcers no induration/nodules/tightening abnormal findings: psychiatric all findings normal nl judgment/insight nl memory nl mood/affect abnormal findings: pertinent results: wbc-12.1* rbc-3.20* hgb-8.3* hct-25.9* plt ct-216 wbc-13.7*# rbc-3.44* hgb-9.0* hct-28.3* plt ct-209 wbc-10.1# rbc-4.22*# hgb-11.0* hct-34.1* plt ct-244 glucose-72 urean-16 creat-0.7 na-134 k-4.0 cl-104 hco3-23 glucose-106* urean-22* creat-1.2 na-129* k-4.4 cl-99 hco3-26 glucose-111* urean-14 creat-0.9 na-133 k-4.4 cl-100 hco3-26 pt-31.0* ptt-40.2* inr(pt)-3.2* pt-32.4* ptt-48.0* inr(pt)-3.4* pt-32.9* inr(pt)-3.4* pt-31.4* ptt-150* inr(pt)-3.2* pt-25.7* ptt-38.0* inr(pt)-2.5* cxr: multiple surgical clips in the right thorax, with volume loss, diffuse opacification, basilar consolidation, moderate right pleural effusion which appears to be somewhat loculated. there is patchy consolidation of the right mid lung zone as well. fluid is seen at the right lung apex as well. the left lung, there is evidence of interstitial disease as well. cta: 1. new bilateral pulmonary emboli involving the left lobar, and both segmental and subsegmental arteries. left lower subsegmental pulmonary emboli may be chronic. no evidence of heart strain. 2. stable right loculated pleural effusion and consolidative process at the right lung base. 3. stable mediastinal lymphadenopathy. brief hospital course: mr. is a 85 year-old male admitted with sob. a chest cta showed bilateral segmental pulmonary embolism. a vascular surgery consult was obtained and an ivc filter was placed. blood cultures and urine cultures were positive for e.coli, the patient refused antibiotic therapy. pt was transfered out of the icu in , palliative care was consulted, pt was made cmo. a morphine drip was initiated for pain control, on at 1131 am the patient expired. the case was not refered to the medical examiner, an autopsy was not requested by the family. medications on admission: 1. plavix 75 mg daily 2. protonix 40 mg daily 3. combivent 18 mcg-103 mcg 2 puffs inh q4hrs prn wheezing/sob 4. mvi daily 5. vitamin e 400 unit daily 6. proscar 5 mg daily 7. simvastatin 20 mg daily 8. cyanocobalamin 500 mcg daily 9. oxycodone 5 mg daily discharge medications: expired discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Interruption of the vena cava Angiocardiography of venae cavae Diagnoses: Urinary tract infection, site not specified Unspecified septicemia Personal history of malignant neoplasm of bronchus and lung Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Sepsis Other persistent mental disorders due to conditions classified elsewhere Other and unspecified hyperlipidemia Personal history of malignant neoplasm of large intestine Chronic obstructive asthma, unspecified Hematuria, unspecified Other pulmonary embolism and infarction |
allergies: patient recorded as having no known allergies to drugs attending: addendum: patient was readmitted for volume overload and hypotenision likely secondary to diastolic heart failure. discharge disposition: extended care facility: house md Procedure: Thoracentesis Thoracentesis Diagnoses: Unspecified pleural effusion Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Iatrogenic pneumothorax Iatrogenic pulmonary embolism and infarction Malignant neoplasm of other parts of bronchus or lung Other postprocedural status Chronic obstructive asthma, unspecified Acute diastolic heart failure Emphysema (subcutaneous) (surgical) resulting from procedure Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Secondary malignant neoplasm of bone and bone marrow Vascular dementia, uncomplicated Anemia in neoplastic disease Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity Suicidal ideation Major depressive affective disorder, recurrent episode, moderate |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea, hypotension major surgical or invasive procedure: :transthoracic ultrasound. thoracentesis on the right side 1.5l : transthoracic ultrasound. thoracentesis on the right side 1l history of present illness: 85yom ex-smoker w/ rul nsc lung ca w/ chest wall invasion (poorly diff sq cell ca, t3 n0, stage iib), s/p rul lobectomy, r chest wall resection (ribs ), rml wedge resection, chest wall reconstruction w/ goretex graft by dr . pt discharged to rehab and returns to ed today due to hypotension noted at rehab. past medical history: cva with residual l arm numbness, dementia, likely vascular etiology adenocarcinoma of colon, dx'd , surgery sch'd for anemia (on iron & b12 supplementation now) copd/asthma with chronic cough hyperlipidemia bph s/p turp hiatal hernia hand surgeries b/l h/o tb infxn in childhood social history: retired teacher. widower. has dementia with stm deficits. daughter ( , ) is health care proxy. distant 30 pk-yr smoking history (quit 43 yrs ago), no etoh. patient is a vegetarian. family history: mother-stroke in 70s, father-tb pna, sister died of cardiac cause physical exam: vs: t 97.4 hr: 52 sr bp: 105-120/60 sats: 96% 4l wt; 74 kg general: lying in bed no apparent distress neck: supple no lymphadenopathy card: rrr resp: bibasilar crackles, no wheezes gi: benign extr: warm no edema incison: right thoracotomy site well healed neuro: non-focal pertinent results: wbc-6.7 rbc-3.25* hgb-9.9* hct-29.1* plt ct-248 wbc-7.4 rbc-3.27* hgb-9.8* hct-29.4* plt ct-244 wbc-11.3* rbc-4.03* hgb-12.1* hct-35.6* plt ct-389 neuts-87.2* lymphs-9.0* monos-3.2 eos-0.5 baso-0.1 pt-16.1* inr(pt)-1.4* pt-15.8 inr(pt)-1.4* pt-16.9* inr(pt)-1.5* pt-16.8* ptt-78.1* inr(pt)-1.5* glucose-100 urean-9 creat-0.8 na-132* k-4.7 cl-100 hco3-25 glucose-99 urean-11 creat-0.7 na-133 k-4.8 cl-99 hco3-26 glucose-109* urean-12 creat-0.7 na-131* k-4.1 cl-100 hco3-25 glucose-85 urean-11 creat-0.8 na-136 k-3.9 cl-105 hco3-23 glucose-120* urean-18 creat-1.1 na-137 k-4.4 cl-106 hco3-22 calcium-9.4 phos-2.7 mg-1.9 chest ct : impression: 1. large multiloculated nonhemorrhagic right pleural effusion, decreased slightly since . 2. right chest wall graft intact. no associated abscess. 3. moderate pulmonary edema increased. 4. right bronchial stump intact. 5. stable reactive central adenopathy. 6. stable moderate sliding hiatus hernia. 7. no new emboli in large pulmonary arteries. subsegmental left lung emboli are all that remain. chest ct ; impressions: 1. multiple left-sided segmental and subsegmental pulmonary emboli. 2. post- operative changes on the right after right upper lobectomy including increasing fluid and small amount of residual air within the pleural space, and subcutaneous gas along the chest wall. rounded opacity in the right lung base could represent rounded atelectasis, although infection cannot be excluded. 3. new reticulation with ground-glass attenuation along the posterior left upper lobe could represent aspiration or infection. trace left pleural effusion. 4. large hiatal hernia. study : there is thrombus in the right cephalic vein which is a superficial vein, otherwise no thrombus is seen. duplex and color doppler of both lower extremities demonstrates thrombus within the peroneal veins only. :cytology. pleural fluid: negative for malignant cells. brief hospital course: : patient was admitted to sicu after ct showed multiple segmental & subsegmental left pulmonary emboli involving both lobes, as well as a loculated r pleural effusion, a heparin bolus was given, followed by a drip, together with zosyn for possible pneumonia. : a pleural tap produced 1.5 l of transudative fluid : the patient was triggered fro transient hypoxia, resolved spontaneously on 4 l n/c o2. r pleural effusion found to be recurring. : coumadin 3 given. : the patient had an acute desaturation with sinus tachycardia, likely a chf exacerbation, he received iv lasix and lopressor and was transferred back to icu. cultures of pleural fluid were negative, so the patient's antibiotics were discontinued. a foley was replaced and the patient given additional lasix with good response. the patient also expressed suicidal ideation to the nursing staff. : patient returned to floor, continued to receive coumadin and heparin drip. psychiatric consultant recommended starting citalopram and changing seroquel to standing, both of which were done. : a chest ct was done to further evaluate the loculated right pleural effusion. no further treatment was warrented at this time. he was converted from heparin to lovenox. his coumadin was restarted with a goal inr 2.0-2.5 for pulmonary embolism. he will remain off plavix while on coumadin. his foley was removed and he voided without difficulty. he continued to do well and was discharged to rehab on . medications on admission: albuterol/atrovent nebs, omeprazole 20 mg daily, amiodarone 400mg daily, plavix 75mg daily, finasteride 5mg daily, heparin 5000units sq tid, lopressor 25mg tid, oxycontin 20mg , oxycodone 5mg prn discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 7. oxycodone 20 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po q12h (every 12 hours). 8. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 9. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily). 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 11. quetiapine 25 mg tablet sig: 0.5 tablet po bid (2 times a day) as needed. 12. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 13. enoxaparin 80 mg/0.8 ml syringe sig: one (1) subcutaneous q12h (every 12 hours): goal inr 2.0-2.5 stop when inr 2.0. 14. quetiapine 25 mg tablet sig: 0.5 tablet po qhs (once a day (at bedtime)) as needed for sleep. 15. warfarin 1 mg tablet sig: three (3) tablet po dose to maintain inr 2.0-2.5. 16. zocor 20 mg daily discharge disposition: extended care facility: house discharge diagnosis: left pulmonary embolus, right loculated effusion right upper lobe squamous cell ca invading 4th-5th ribs (t3n0), s/p rulobectomy with chest wall resection/reconstruction with goretex mesh/flex bronch () dementia, likely vascular etiology anemia hyperlipidemia hiatal hernia bph s/p turp, known distal urethal stricture discharge condition: deconditioned discharge instructions: call dr. office if experience: -fever > 101 or chills. -increased shortness of breath, cough or chest pain. followup instructions: follow-up with dr. :00am on the clinical center, . report to the 4th radiology department for a chest x-ray 45 minutes before your appointment. coumadin follow-up with his pcp . . has been notified and agreed. follow-up with psychriatry for newly started psychiatric medications. Procedure: Thoracentesis Thoracentesis Diagnoses: Unspecified pleural effusion Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Iatrogenic pneumothorax Iatrogenic pulmonary embolism and infarction Malignant neoplasm of other parts of bronchus or lung Other postprocedural status Chronic obstructive asthma, unspecified Acute diastolic heart failure Emphysema (subcutaneous) (surgical) resulting from procedure Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Secondary malignant neoplasm of bone and bone marrow Vascular dementia, uncomplicated Anemia in neoplastic disease Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity Suicidal ideation Major depressive affective disorder, recurrent episode, moderate |
allergies: oxycodone attending: chief complaint: s/p fall, right subdural hematoma major surgical or invasive procedure: right craniotomy for subdural evacuation history of present illness: this is a 85 year old female on aspirin/coumadin for atrial fibrillation who is status post presumed mechanical fall on . she attempted to stand from a seated position and fell onto her right side. she presents from hospital where she had a head ct that was consistent with subdural hematoma with midline shift. the patient was given 1 unit of fresh frozen plasma and transferred here for further evaluation and treatment. while in the ed, the patient became nauseous with increasing headache and a repeat head ct was performed. the patient was given an additional unit of ffp/profiline 9, and vitamin k. the patient was loaded with dilantin. the patient's son was present and stated that his mother refused to go to the hospital yesterday, but this morning she was lethargic and confused so he brought her to hospital. he also stated the she was a full code. the patient proceeded to become lethargic and stopped following commands while in the emergency department. past medical history: afib on coumadin chf cad vertigo htn left hip orif social history: lives at home, has son named who is the hcp. family history: unknown physical exam: on admission: gen: eyes open spontaneously, smiling, sitting up in bed comfortable, nad. heent: pupils: eoms: intact neck: supple. extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, not place or date language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout except right deltoid- - difficult mobility. pronator drift- patient unable to perform given decreased mobility sensation: intact to light touch bilaterally. toes downgoing bilaterally on discharge: aox3 to person, place, month and year follows commands easily. left upper and lower extremities 4+/5 right sensation intact to light touch pertinent results: 12:00pm pt-13.7* ptt-25.7 inr(pt)-1.3* 04:31pm pt-11.9 inr(pt)-1.1 07:31pm pt-11.2 ptt-24.8* inr(pt)-1.0 03:04am blood pt-10.5 ptt-23.4* inr(pt)-1.0 12:00pm ctropnt-<0.01 05:46pm ck(cpk)-193 05:46pm ck-mb-5 ctropnt-<0.01 03:04am blood ck(cpk)-612* 03:04am blood ck-mb-18* mb indx-2.9 ctropnt-<0.01 head ct findings: again visualized is a hyperdensity along the inner table of the skull on the right ranging from anterior to the right frontal lobe to the right parietal lobe, consistent with an acute subdural hematoma. this hemorrhage measures 14 mm in maximal dimension from the inner table of the skull and demonstrates mass effect on adjacent sulci and the right frontal and parietal lobe with stable leftward shift of normally midline structures by 8 mm. no new foci of hemorrhage are identified. a hypodensity region is again noted in the right frontal lobe, and may represent an infarction of indeterminate age. confluence of periventricular white matter hypodensities. bilateral basal ganglia calcifications are again identified. no acute fractures are noted. there is mild sphenoidal mucosal thickening as well as mild opacification of the right maxillary air cells. otherwise, the remainder of the visualized paranasal sinuses and mastoid air cells are clear. impression: 1. stable appearance of acute right subdural hematoma, ranging from anterior to the right frontal lobe to posterior to the right occipital lobe measuring approximately 14 mm in maximal dimension from the inner table of the skull. there is continued stable leftward shift of normally midline structures by 8 mm. new foci of hemorrhage is identified. continued followup is recommended. 2. hypodense region in the right frontal lobe is again noted and may represent an infarction of indeterminate age, versus a confluence of periventricular white matter hypodensity. chest xray findings: frontal and lateral views of the chest were obtained. there is no focal consolidation or pneumothorax. blunting of the left posterior costophrenic sulcus may represent a tiny pleural effusion or scarring. prominent diffuse interstitial markings suggest underlying chronic lung disease. the heart is mildly enlarged. mediastinal silhouette and hilar contours are within normal limits. degenerative changes seen in the shoulders bilaterally. no displaced rib fracture is identified. a wedge compression deformity in the lower thoracic/upper lumbar spine is of unknown chronicity. aortic calcifications are better seen on the prior study. impression: 1. no acute intrathoracic process. 2. wedge compression deformity in the lower thoracic/upper lumbar spine of unknown chronicity. correlate with exam. head ct findings: the patient is status post right craniectomy with interval evacuation of the right subdural hemorrhage. the subdural cavity has been replaced by air. there is persistent 8 mm leftward shift of normally midline structures. a small left parafalcine hemorrhage layering along the left tentorium is more apparent than prior studies. no new intraparenchymal hemorrhage is identified. hypodensity in the right frontal lobe is unchanged and may represent an infarction of indeterminate age versus confluence of periventricular white matter hypodensity. mild mucosal thickening is seen in the right sphenoid sinus. the mastoid air cells and middle ear cavities are clear. impression: 1. post-surgical changes after right craniectomy with stable 8 mm leftward shift of normally midline structures. 2. small left parafalcine subdural hemorrhage. pelvis xray findings: there are no old films available for comparison. this is a single ap view of the pelvis. there is diffuse osteopenia, which somewhat limits evaluation. there is an old healed left hip fracture with an intramedullary rod and screw with associated deformity of the left femoral head and new bone formation extending into the soft tissues. no new fracture is identified, but osteopenia limits this assessment. ct head there is reaccumulation of fresh subdural hematoma along the right convexity. new right parietal lobe intraparenchymal hemorrhage surrounded by edema : cxr: findings: tip of the nasogastric tube is in the mid-to-lower stomach with the side hole just distal to the esophagogastric junction. little change in the heart and lungs when compared to the study of this date. : video swallow evaluation: technique: oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. multiple consistencies of barium were administered. findings: barium passes freely through the oropharynx and esophagus without evidence of obstruction. there was, however, deep penetration and aspiration with nectar and honey-thick barium. there was residual barium with all thicknesses, most pronounced with pudding thickness barium. impression: penetration and aspiration with nectar and honey-thick barium. residual barium with all thicknesses. for details of the examination as well as recommendations, please refer to speech and swallow division note in online medical record. the study and the report were reviewed by the staff radiologist. dr. . dr. brief hospital course: 85f who presented to an osh after a fall, on coumadin, ct showed a r sdh and she was transferred to . on initial examination, her exam was stable, however, she decompensated while in the er and required to go to the or emergently. she was intubated. intraoperatively, the patient did well, and post-operatively was taken to the icu where she was later extubated. post-op imaging was stable with expected post-op changes. there were no issues overnight. the patient remained in afib. on , the patient was more awake and alert. her exam was improved from the day prior. she remained in the icu for monitoring. her dilantin level corrected was 19.1 and one dose was held. on she remained neurologically stable. her dilantin level was high again, two doses of dilantin were held. she was ready for transfer to the floor so that she can work more aggressivly with pt and ot. on her mental status continued to improve. dilantin level remained high and so she was switched to keppra for seizure prophylaxis. she was seen and evaluated by physical therapy and occupational therapy who felt that she would benefit from acute rehab. overnight on into she became tachycardic to the 130s. metoprolol dosing was increased to 50 and then to 75 on . on this day she was noted to have decreased strength on the left and had pupil asymmetry, l>r. ct head showed a new right sdh and new right iph but improvement in mls. stroke neurology was consulted and did not feel that this was a hemorrhagic conversion of ischemic stroke. she continued to aspirate on repeat speach and swallow evaluation on . we discussed the need for ngt or dobhoff placement. she wishes tohold off until monday. on , she was tolerating water and taking meds without issues. on , patient was seen to have more overall generalized weakness. she was also seen to desat with o2 at 89%. respiratory was called and patient was placed on 2l o2 and saturation was improved. a cxr was ordered to evaluate for pna and a ngt was placed for medication and food administration. she was started on ciprofloxacin for a uti on . video swallow evaluation was performed on and demonstrated moderate-severe pharyngeal dysphagia primarily characterized by risk of aspiration with all po intake due to swallow initiation delay, reduced laryngeal valve closure, and residue mixing with secretions. she was maintained on strict npo status. at the time of discharge on she was tolerating a regular diet, afebrile with stable vital signs. medications on admission: preadmission medications listed are correct and complete. information was obtained from family/caregiver. 1. warfarin 5 mg po daily16 2. aspirin 81 mg po daily 3. furosemide 20 mg po daily 4. calcium carbonate 500 mg po bid 5. digoxin 0.125 mg po daily 6. folic acid 1 mg po daily 7. metoprolol tartrate 25 mg po bid 8. omeprazole 20 mg po daily 9. meclizine 12.5 mg po daily:prn vertigo discharge medications: 1. calcium carbonate 500 mg po bid 2. digoxin 0.125 mg po daily 3. folic acid 1 mg po daily 4. metoprolol tartrate 25 mg po bid 5. warfarin 5 mg po daily16 6. acetaminophen 325-650 mg po q6h:prn pain headache 7. artificial tears preserv. free 1-2 drop both eyes prn dry eye 8. ciprofloxacin hcl 500 mg po q12h duration: 3 days 9. heparin 5000 unit sc tid 10. lansoprazole oral disintegrating tab 30 mg po daily 11. levetiracetam 1000 mg po bid 12. multivitamins 1 tab po daily 13. potassium chloride 40 meq po bid duration: 24 doses hold for k > 4.5 14. phosphorus 500 mg po bid 15. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. discharge disposition: extended care facility: - discharge diagnosis: subdural hematoma with compression cerebral edema intraparenchymal hemorrhage dysphagia delirium urinary tract infection discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: craniotomy for subdural hematoma dr. ?????? 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. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? you were on a medication such as coumadin (warfarin) and aspirin 81 mg qd, prior to your injury, you may safely resume taking this on . ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: follow-up appointment instructions ?????? please call ( to schedule an appointment with dr. , to be seen in 4 weeks. ?????? you will need a ct scan of the brain without contrast. Procedure: Incision of cerebral meninges Enteral infusion of concentrated nutritional substances Arterial catheterization Other repair of cerebral meninges Central venous catheter placement with guidance Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Hypopotassemia Alkalosis Cerebral edema Long-term (current) use of anticoagulants Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Fall from other slipping, tripping, or stumbling Disorders of magnesium metabolism Other alteration of consciousness Pseudomonas infection in conditions classified elsewhere and of unspecified site Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Dysphagia, pharyngeal phase |
allergies: penicillins attending: chief complaint: chest pain major surgical or invasive procedure: intubation s/p extubation central line placement picc arterial line history of present illness: mr. is a 66yo m with history of copd on 2l home o2 and hypertension who presented to his pcp's office with 12 days of non-radiating substernal chest pain and worsening shortness of breath. he felt this pain may have been his gerd but did not improve with tums. at (his pcp's office), he was noted to be look weak and an ekg was concerning for ? new anterior-lateral changes. in the ed, initial vs were: 98, 84, 136/88, 18, 96% 2l. on arrival to er, ekg was nsr without st changes, and labs were significant for trop of 0.31, platelets of 9, leukocytosis to 35 with 88% "other" cell types and hematocrit of 21. repeat ekg was still non-ischemic and cardiology felt his troponins were not due to active ischemia. given his platelets, there were no plans for intervention. heme/onc was consulted to review his smear given concern for acute leukemia. patient was given one sublingual nitro and started on morphine for pain control. he was moving very little air on exam and felt to be having a copd exacerbation. he was given solumedrol, ceftriaxone, azithromyin, cefepime and albuterol/ipratropium nebs. patient was transferred to the icu for further management. at time of transfer, vitals were 98.7, 93, 150/68, 20, 94% 3l nc. in the icu, he endorses having had chest pain for the past couple weeks that he felt was heartburn and epigrastric pain. over this time period, he has also had some generalized weakness and cough productive of blood tinged sputum. he feels his scattered arm bruises are related to tripping and falling a few days ago. past medical history: # pneumonia that was slow to resolve, requiring 2-3 months of abx # copd with 2l home o2 # history of asbestos exposure # psoriasis # hyperlipidemia # arthritis # hypertension # depression # venous insufficiency social history: he is married and has a daughter who is his hcp. previously smoked but quit a number of years ago. he occasionally drinks alcohol but denies iv drug use. family history: mother had unspecified mental illness and had a coronary artery bypass. his father with unknown cancer died at the age of 83. physical exam: icu exam on admission - vitals: t: 97.6 bp: 130/71 p: 102 r: 14 o2: 92% 4l nc general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: very limited air movement bilaterally but clear to auscultation without wheezes, rales, or rhonchi cv: regular rate and rhythm, distant s1 + s2, no murmurs, rubs, gallops abdomen: obese, soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly appreciated gu: no foley ext: scattered upper extremity ecchymoses, r>l mild, 1+ pitting edema, warm, well perfused, 2+ pulses, no clubbing or cyanosis icu exam on transfer - general: very somnolent but arousable (rn & daughter state not a change from baseline), a+o x 2 (name, hospital) heent: sclerae anicteric, perrl, eomi neck: supple lungs: scattered bibasilar crackles cv: regular rate and rhythm, distant s1 + s2, no murmurs, rubs, gallops abdomen: obese, soft, non-tender, distended, normal bowel sounds no hsm. right sided abd ecchymosis which is stable from prior exam gu: foley in place ext: l>r upper extremity edema, scattered upper extremity ecchymoses, trace pitting edema, warm, well perfused, 2+ pulses neuro: l sided hemiparesis from known iph pertinent results: admission labs: wbc-38.9* rbc-2.49* hgb-7.5* hct-20.3* mcv-82 mch-30.3 mchc-37.1* rdw-15.8* glucose-214* urea n-22* creat-0.6 sodium-131* potassium-3.8 chloride-91* total co2-28 anion gap-16 alt(sgpt)-52* ast(sgot)-70* ld(ldh)-661* alk phos-85 tot bili-0.9 lactate-1.3 ck(cpk)-739* ck-mb-70* mb indx-9.5* ctropnt-0.55* fibrinoge-158 d-dimer-8889* lipase-25 discharge labs: 12:00am blood wbc-3.2* rbc-3.65* hgb-10.9* hct-30.8* mcv-84 mch-29.9 mchc-35.5* rdw-15.9* plt ct-79* 12:00am blood neuts-25* bands-0 lymphs-40 monos-6 eos-0 baso-0 atyps-0 metas-0 myelos-0 other-29* 06:00am blood pt-14.3* ptt-31.2 inr(pt)-1.2* 06:00am blood plt ct-105* 12:00am blood gran ct-810* 12:00am blood glucose-138* urean-19 creat-0.5 na-134 k-3.7 cl-99 hco3-23 angap-16 12:00am blood alt-29 ast-24 ld(ldh)-353* alkphos-82 totbili-1.4 12:00am blood albumin-3.6 calcium-8.7 phos-3.6 mg-1.8 uricacd-3.3* studies: neoplastic blood date of karyotype: 47,xy,+8,t(15;17)(q22;q21.1) only two metaphase cells were obtained and analyzed from this specimen. this limited/ incomplete study may not rule out mosaicism at a level that is standard for such an analysis. two cells contained an extra copy of chromosome 8 (trisomy 8) and a translocation of chromosomes 15 and 17. this translocation is associated with pml-rara fusion and is a characteristic finding in acute promyelocytic (m3) leukemia. ----------------interphase fish analysis, 100-300 cells------------------- nuc ish(pml,rara)x3(pml con rarax2) fish evaluation for a pml-rara rearrangement was performed on nuclei with the lsi pml/rara dual color, dual fusion translocation probe ( molecular) for pml at 15q22 and rara at 17q21.1 and is interpreted as abnormal. rearrangement was observed in 89/100 nuclei, which exceeds the normal range (up to 1% dual rearrangement) for this probe in our laboratory. a pml-rara rearrangement is found in most acute promyelocytic leukemias (fab m3). this test was developed and its performance determined by the cytogenetics laboratory as required by the clia ' regulations. it has not been cleared or approved by the u.s. food and drug administration. this test is used for clinical purposes. flow cytometry: results: three color gating is performed (light scatter vs. cd45) to optimize blast yield. abnormal cells comprise 82% of total gated events. b-cells comprise 6% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens. t-cells comprise 57% of lymphoid-gated events, express mature lineage antigens, and have a normal helper-cytotoxic ratio of 1.04 (usual range in blood 0.7-3.0). cell marker analysis demonstrates that the majority of the cells isolated from this peripheral blood express myeloid associated antigens (cd13, cd33 (bright), cd15 (bright, subset), express cd64, cd71, lack b and t cell associated antigens, are cd10 (callaa) negative, and are negative for cd34, hla-dr, cd14, cd41, cd11c, cd56 and glycophorin a. immunophenotypic findings consistent with involvement by acute myeloid leukemia. lack of cd34 and hla-dr promyelocytic differentiation. however, correlation with concurrent cytogenetic findings is recommended for further characterization. . imaging: echocardiogram conclusions the left atrium is elongated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is moderate to severe global left ventricular hypokinesis, with some regional variation (the anterior septum, anterior free wall, and apex appearing more hypokinetic than the other walls) (lvef = 30 %). right ventricular chamber size is normal. with severe global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the ascending aorta is moderately dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , contractile function of both ventricles is now significantly reduced. ct head w/o contrast 6:31 pm impression: large intraparenchymal hemorrhage in the right frontal lobe, with surrounding vasogenic edema and local mass effect. a hypodense lesion with smaller hemorrhagic component is also seen in the right occipital lobe, with two additional non-hemorrhagic hypodense lesions seen in the left cerebellar hemisphere and the right parieto-occipital cortex. given the multifocality of these lesions, and history of malignancy, these may represent metastases with associated hemorrhage. an alternate consideration is multiple infarctions, some hemorrhagic, likely embolic. mri with and without contrast would be helpful for further evaluation. mri brain 3:27 pm conclusion: multiple acute areas of infarction, many with hemorrhage. the distribution suggests emboli from a proximal source, most likely cardiac. 5-6 mm anterior communicating artery aneurysm. the location of the hemorrhages does not imply prior bleeding from this aneurysm. within the limits of an adequate but not optimal mra examination, no other intracranial vascular abnormalities are detected. echocardiogram at 1:30:32 pm conclusions: no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no mass/thrombus is seen in the left atrium or left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with anterior hypokinesis. no masses or thrombi are seen in the left ventricle. rv hypokinesis is seen. there are complex (>4mm) atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is small vegetation (4mm) on the mitral valve attached to the posterior leaflet on the . mild to moderate (+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. impression: small vegetation of the mitral valve. complex, non-mobile atheroma of the aortic arch. mild regional lv systolic dysfunction. ct head 8:28 pm impression: 1. no interval change since , with unchanged appearance of right frontal parenchymal hematoma with associated edema, local mass effect and stable degree of leftward shift of normally-midline structures. 2. hypodense lesions in the right occipital and parietal occipital cortex appear grossly unchanged but are not further characterized on this motion- degraded study. left upper extremity ultrasound: 1:45 pm findings: grayscale and doppler son of right subclavian vein was performed and shows normal compressibility, flow, and augmentation. grayscale and doppler son of left subclavian, left internal jugular, left axillary, left brachial, left basilic, and left cephalic veins were performed. the left internal jugular vein shows normal flow and augmentation. there is abnormal flow in the left subclavian vein, left axillary vein, and left basilic vein. hypoechoic foci consistent with clots are also clearly visualized in the left basilic and left axillary veins. these findings are consistent with an upper extremity thrombus in the left subclavian vein, left axillary vein, and left basilic vein. brief hospital course: 66 yo man h/o severe emphysema who presented with a new diagnosis of apml and nstemi with ef 30%, s/p intubation with extubation on , found to have large iph, multiple strokes, and endocarditis. # apml: mr. was diagnosed with apml by peripheral smear, flow cytometry, and pcr of the blood. he was treated with atra and hydroxyurea initially and when his wbc was <10k, his hydroxyurea was stopped. he also received steroids initially for prophylaxis of atra syndrome and this was gradually weaned. he was monitored for tumor lysis and dic and transfused blood products prn to keep his fibrinogen >100 and inr <1.5. his platelet goal was initially 20k but this was increased to 100k after his intraparenchymal hemorrhage. # nstemi with new heart failure (ef 35%): mr. initially presented to his pcp's office with chest pain. he had elevated troponins on admission with no st or t wave changes on ekg, c/w nstemi. we trended his troponins which plateaued at 3.50. his first echo showed moderate to severe global left ventricular hypokinesis, with some regional variation (the anterior septum, anterior free wall, and apex appearing more hypokinetic than the other walls) and lvef = 30 %. he was monitored on telemetry and had no significant arrhythmias. given his concurrent iph (see below), antiplatelet & anticoagulant agents are contraindicated and he was medically managed with nitrates, beta-blockers, low-dose ace-i and a statin. repeat echo on showed a persistent small vegetation of the mitral valve, complex, non-mobile atheroma of the aortic arch, and mild regional lv systolic dysfunction (ef 45%). # intraparenchymal hemorrhage: on the morning of , it was noted that mr. was not moving his l arm. ct head showed a large intraparenchymal hemorrhage in the right frontal lobe, with surrounding vasogenic edema and local mass effect. a hypodense lesion with smaller hemorrhagic component was also seen in the right occipital lobe, with two additional non-hemorrhagic hypodense lesions seen in the left cerebellar hemisphere and the right parieto-occipital cortex. mri/a on revealed multiple areas of acute infarction, many with hemorrhage, with a distribution that suggests emboli from a proximal source, likely cardiac. unclear etiology for embolism ?????? blood cultures are negative to date to assess for bacteremia. tee showed aortic plaque that could be potential embolic source. mra showed a 5-6mm communicating artery aneurysm as well. neurosurgery had no plans for intervention. neurology was consulted & recommended eeg which showed a diffuse encephalopathy pattern and a focal area with epileptogenic potential, but no electrographic seizures. all antiplatelet/anticoagulant agents were held. dic labs were stable, with a platelet count goal of >100k. he was able to be extubated on and pt/ot was consulted for help managing/recovering from his stroke. he continued to suffer from mood lability on the floor and intermittently refused his medications. neurology continued to follow him. eeg was repeated and did not show any seizure activity, just a diffuse encephalopathy. haldol 0.5mg iv was used prn for mood stabilization as he refused. # respiratory distress/hypoxia: on presentation, he was hypoxic and required oxygen support by nasal cannula (up to 6l). it was felt to be multifactorial, with his underlying emphysema, acute systolic heart failure, pulmonary edema, and pneumonia contributing. following his iph, he was intubated for airway protection on with successful extubation on . bronchoscopy on showed edematous airways with friability but no frank blood. bal grew yeast (it was initially reported as mold, concerning for aspergillus, but galactomannan/glucan were normal and it was re-read as yeast). he is s/p 8 day course of cefepime and levofloxacin for his pneumonia. following extubation, he was maintained on his home copd medications and was maintaining stable o2 sats on room air. # culture-negative endocarditis: echo on showed a small vegetation on mitral valve. unclear if this is infectious versus malignant. added vancomycin (d1=) for mrsa endocarditis coverage and started ceftriaxone (d1=). had abdominal ct which did not show any infectious source. per id, 6 week course of antibiotics recommended. # lue edema: lue>rue edema, of hand and arm. patient had picc placed in left arm and his edema was concerning for dvt. given his recent iph, anticoagulation was not an option. left upper extremity u/s done on to r/o dvt was negative. edema and pain persisted, so a repeat lue u/s was done on and showed extensive dvt of the l subclavian, axillary and basilic vein. the picc line was removed on and a peripheral iv was placed. on , the family expressed a desire to transfer his care to . dr. the inpatient hematologic malignancy team who accepted the patient in transfer. medications on admission: albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 puffs inhaled four times daily as needed for shortness of breath bupropion hcl 150 mg tablet sustained release - 1 tablet(s) by mouth twice a day clobetasol - 0.05 % ointment - apply to affected areas x up to 2 weeks per month: avoid face and folds ; may wrap with saran to areas as directed diazepam - 5 mg tablet - 1 tablet(s) by mouth twice a day as needed fluticasone-salmeterol - 250 mcg-50 mcg/dose disk with device - 1 puff inhaled every 12 hours; rinse mouth well after each use furosemide - 40 mg tablet - 1 tablet(s) by mouth daily hydrochlorothiazide - 25 mg tablet - 1 tablet(s) by mouth daily oxygen - - 2l by nasal cannula continuously during sleep and with any exertion room air sat 87% with minimal exertion documented potassium chloride - 10 meq capsule, sustained release - 1 capsule(s) by mouth daily sildenafil - (not taking as prescribed) - 100 mg tablet - 1 tablet(s) by mouth as needed simvastatin - 40 mg tablet - 1 tablet(s) by mouth daily tiotropium bromide - 18 mcg capsule, w/inhalation device - 1 puff inh daily verapamil - 240 mg cap,24 hr sust release pellets - 1 cap(s) by mouth daily acetaminophen - (otc) - 500 mg tablet - 2 tablet(s) by mouth twice a day as needed aspirin - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth daily discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). 3. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 4. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day). 5. senna 8.8 mg/5 ml syrup sig: one (1) tablet po bid (2 times a day). 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily). packet 7. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 8. isosorbide mononitrate 20 mg tablet sig: one (1) tablet po bid (2 times a day). 9. fluticasone 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). 10. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 11. tretinoin (chemotherapy) 10 mg capsule sig: five (5) capsule po bid (2 times a day). 12. ipratropium bromide 0.02 % solution sig: one (1) inhalation inhalation q6h (every 6 hours). 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 or wheezing. 14. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours). 15. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush . 16. bupropion hcl 100 mg tablet sig: one (1) tablet po bid (2 times a day). 17. ceftriaxone 2 gm iv q24h start: in am start on morning of 18. vancomycin 1000 mg iv q 8h d1= 19. haloperidol 0.5 mg iv bid:prn agitation 20. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 21. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 22. lantus 100 unit/ml cartridge sig: eighteen (18) units subcutaneous at bedtime. 23. humalog 100 unit/ml cartridge sig: 2-10 units subcutaneous qachs: according to sliding scale. . discharge disposition: extended care discharge diagnosis: primary: acute promyelocytic leukemia stroke with intracranial hemorrhage non st elevation mi endocarditis, culture negative delerium chronic obstructive pulmonary disease discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , you were admitted with an nstemi, new diagnosis of apml, stroke with ich and endocarditis. you were treated with atra and antibiotics. you are being transferred to for further care per your request. dear mr. , you were admitted with an nstemi, new diagnosis of apml, stroke with ich and endocarditis. you were treated with atra and antibiotics. you are being transferred to for further care per your request. followup instructions: you will need to follow up with a hematologist on discharge. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Arterial catheterization Closed [endoscopic] biopsy of bronchus Removal of other device from thorax Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Adrenal cortical steroids causing adverse effects in therapeutic use Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Obstructive chronic bronchitis with (acute) exacerbation Depressive disorder, not elsewhere classified Paroxysmal ventricular tachycardia Acute respiratory failure Defibrination syndrome Cerebral aneurysm, nonruptured Acute and subacute bacterial endocarditis Hypoxemia Diarrhea Cerebral embolism with cerebral infarction Acute systolic heart failure Accidents occurring in residential institution Drug-induced delirium Other psoriasis Unspecified intracranial hemorrhage Anemia in neoplastic disease Venous (peripheral) insufficiency, unspecified Personal history of contact with and (suspected) exposure to asbestos Arthropathy, unspecified, site unspecified Acute myeloid leukemia, without mention of having achieved remission Neoplasm of uncertain behavior of brain and spinal cord Dysphagia, unspecified Other secondary thrombocytopenia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: gastric outlet obstruction. major surgical or invasive procedure: 1. esophagogastroduodenoscopy and injection of pylorus with 200 units of botox. 2. bronchoscopy and bronchoalveolar lavage. history of present illness: this is a 53 year old lady well know to the thoracic surgery service. she underwent a minimally invasive esophagectomy on . her hospital course was complicated by enterobacter aspiration pneumonia for which she required intubation. she was discharged home on in good condition on po augmentin (now day ). yesterday the patient noticed that the j-tube was clogged and this morning went to the ed where they were not able to unclog it. the patient also felt progressively short of breath and she initially attributed it to anxiety. she reports cough productive of clear sputum and pleuritic chest pain upon coughing and reports a fever earlier at home. her sob failed to improve during the course of the morning and mrs herself contact dr. who then advised her to come to the ed for further evaluation and treatment. physical exam: vs: t: 98.0 hr:: 92 sr bp: 134/78 sats: 94% ra general: 53 year-old female who appears well heent: normocephalic, mucus membranes moist neck: supple no lymphadenopathy card: rrr resp: clear breath sounds gi: bowel sounds positive, abdomen soft, j-tube site clean extr: warm no edema neuro: awake, alert oriented pertinent results: 09:00am blood wbc-8.3 rbc-2.95* hgb-9.3* hct-28.3* mcv-96 mch-31.5 mchc-32.8 rdw-16.2* plt ct-865* 06:10am blood wbc-16.6* rbc-2.86* hgb-9.2* hct-27.6* mcv-96 mch-31.9 mchc-33.2 rdw-16.3* plt ct-888* 01:15pm blood wbc-15.9* rbc-3.27* hgb-10.4* hct-30.9* mcv-94 mch-31.9 mchc-33.7 rdw-16.4* plt ct-969* 01:15pm blood glucose-108* urean-13 creat-0.6 na-133 k-6.3* cl-93* hco3-28 angap-18 bronchoalveolar lavage right lobe bal. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): commensal respiratory flora absent. enterobacter aerogenes. 10,000-100,000 organisms/ml.. gram negative rod #2. ~1000/ml. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): fungal culture (preliminary): yeast. :sputm mucous plug endotracheal. gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (preliminary): commensal respiratory flora absent. enterobacter aerogenes. sparse growth. gram negative rod #2. rare growth. enterobacter aerogenes | cefepime-------------- <=1 s ceftazidime----------- 16 i ceftriaxone----------- 16 i ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s brief hospital course: mrs was transferred to ed from on for gastric outlet obstruction and respiratory distress requiring non-rebreathe and febrile to 101. she was transferred to the tsicu. aggressive pulmonary toilet, nebs, iv antibiotics vanco and zosyn were started. an ngt was placed. she improved and was transfer to the floor on with an ngt, j-tubes. events: she was taken to the operating for esophagogastroduodenoscopy and injection of pylorus with 200 units of botox. bronchoscopy and bronchoalveolar lavage with large amount of secretions removed. she was monitored in the pacu and transfer to the floor in stable condition. pulmonary: left thoracentesis for 800 ml by interventional pulmonology. with aggressive pulmonary toilet, nebs, incentive spirometer her oxygenation improved to with saturations of 94% ra. gi: ppi & bowel regime. the ngt was clamped following pylorus botox injection for 24 hrs, she remained asymptomatic, cxr no esophageal dilatation seen therefore was removed. nutrition: seen by nutrition. tube-feeds were continued jevity full strength 90 ml x 18 hrs. sips were started then advanced to clears on . chest-films: followed by serial films for esophageal dilation id: vano and zosyn were continued. once bal cultures grew enterobacter and sensitive to cipro she was converted to a 10 day course. renal: normal renal function. endocrine: insulin sliding scale to maintain bs < 150. disposition: continued to tolerate a clear liquid diet. ambulated in the halls independently. she was discharged to home with vna on medications on admission: 1. oxycodone 5 mg/5 ml solution sig: teaspons po q8h as needed for pain. 2. amoxicillin-pot clavulanate 400-57 mg/5 ml suspension for reconstitution sig: two (2) teaspoons po twice a day for 7 days. 3. lorazepam 0.5 mg tablet sig: one (1) tablet po every twelve (12) hours as needed for anxiety. 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 6. home oxygen 2-3 liters via nasal cannula, continuous discharge disposition: home with service facility: vna discharge diagnosis: gastric outlet obstruction discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: call dr. office if you experience: -fevers > 101 or chills -difficult or painful swallowing. -chest or back discomfort. -early fullness feeling feeding tube: -flush with warm water before, after and mid-day to prevent clogging -keep head of the bed elevated at all times activity -shower daily -walk frequently followup instructions: provider: , md phone: date/time: 10:00 on the clinical center, chest x-ray radiology 30 mintues before your appointment Procedure: Enteral infusion of concentrated nutritional substances Thoracentesis Injection or infusion of other therapeutic or prophylactic substance Closed [endoscopic] biopsy of bronchus Endoscopic excision or destruction of lesion or tissue of stomach Diagnoses: Unspecified pleural effusion Pneumonitis due to inhalation of food or vomitus Attention to gastrostomy Personal history of malignant neoplasm of esophagus Acquired hypertrophic pyloric stenosis Attention to other artificial opening of digestive tract |
allergies: no known allergies / adverse drug reactions attending: chief complaint: esophageal cancer major surgical or invasive procedure: : 1. esophagectomy with intrathoracic anastomosis. 2. buttressing of intrathoracic anastomosis with pericardial fat. 3. esophagogastroduodenoscopy. history of present illness: the patient is a woman with locally-advanced esophageal cancer. she underwent chemoradiation therapy. she presents for esophagectomy. past medical history: none social history: smoker with 34 pack year smoking history occupation: cvs supervisor marital status: married lives w/ family, husband with family history: mother- diagnosed at 81 with rectal cancer father- died of mouth cancer at age 67 physical exam: vs: t: 98.4 hr: 98 sr bp: 110-120/60 sats: 93 1 l ambulating ra 86% wt: 53.9 kg general: 53 year-old female in no apparent distress heent: normocephalic, mucus membranes card: rrr resp: decrease breath sounds with bibasilar crackles gi: bowel sounds positive, abdomen soft non-tender incision: r vats & abdomen clean dry intact, no erythema, j-tube site clean neuro: awake, alert oriented, walks independently pertinent results: wbc-11.7* rbc-2.97* hgb-9.7* hct-27.6 plt ct-657* wbc-14.0* rbc-2.93* hgb-9.4* hct-26.9 plt ct-375 wbc-8.2 rbc-2.73* hgb-8.8* hct-27.0 plt ct-327 glucose-136* urean-28* creat-0.5 na-142 k-4.8 cl-101 hco3-31 glucose-150* urean-18 creat-0.7 na-143 k-4.0 cl-109* hco3-23 bronchial washings rll/bronchial lavage. final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). smear reviewed; results confirmed. respiratory culture (final ): commensal respiratory flora absent. enterobacter aerogenes. >100,000 organisms/ml.. enterobacter aerogenes | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s cxr: : the lower lung opacities, all remain unchanged as are the bilateral pleural effusions. both upper lungs are aerated with no new areas of opacities. heart size is normal. the persisting bilateral lower lobe opacities may represent atelectasis/pneumonic consolidation secondary to aspiration. the right subclavian line is terminating into the mid svc. cct: : no evidence of main, lobar or segmental pulmonary embolism. complete occlusion of the left lower lobe bronchus from secretions with atelectasis of the left lower lobe. low-density areas are within the atelectatic left lower lobe suggestive of a pneumonic consolidation. moderate left pleural effusion. dilated and fluid filled neoesophageus causing compressive atelectasis of the adjacent lung. possibility of distal obstruction is suspected. mild pneumomediastinum, minimal right sided pneumothorax and subcutaneous emphysema along the right chest wall which are likely post-procedure related. esophagus : no evidence of leak. however, delay in gastric emptying of barium from the stomach into the duodenum with retention of barium within the distal stomach. brief hospital course: mrs. was admitted following esophagectomy with intrathoracic anastomosis. buttressing of intrathoracic anastomosis with pericardial fat. esophagogastroduodenoscopy. she was extubated in the operating room transfer to the tsicu for further monitoring with right chest tube, jp, ngt, foley and epidural for pain. she was transfused 2 units of prbc for hct of 23>31. she transferred to the floor pod 2. events: developed respiratory distress requiring non-rebreathe. she was transfer to the sicu requiring intubation. the chest film revealed a dilated esophagus likely secondary to pylorus spasm. ngt was placed with 900 cc of drainage. bedside bronchoscopy with suction of multiple mucus plugs. on she was taken to the operating room for esophagogastroduodenoscopy and balloon dilation of pylorus to 20 mm. over the next few days her respiratory status improved. she was successfully extubated with oxygen saturations of 92-94% on 4 l via nasal cannula. the ngt was removed on . she transfer to the floor. a clear liquid diet was initiated and advanced to fulls slowly. id: cultures were sent. sputum culture was positive for enterobacter aerogenes pan-sensitive. on she was started on 2 week course of cefepime 2 gms which was changed to augmentin. respiratory: aggressive pulmonary toilet, nebs, incentive spirometer. on pod 5 she was noted to have acute episodes of back pain thought to be muscle spasm, that was accompanied by an increasing oxygen requirement from 3lnc up to 6l & nrb. a ct was done to look for pe but thus was negative. her respiratory status improved but required supplemental oxygen 1-2 liters. ambulating oxygen saturation 86% on room air, 2l 93%. she was discharged home with supplemental oxygen. drains: right chest and jp with minimal drainage, both were removed without complication. card: sinus rhythm 60-70's without ectopy. bp stable 110-130's. gi: ppi, bowel regime continued. pt had bowel movements following surgery. ngt was removed pod 5. swallow study on was negative for anastomose leak. nutrition: replete was started pod 1 titrated to goal 90 ml x 18 hours as recommended by the dietician. on she was started on a clear liquid titrated to fulls slowly. renal: she had normal renal function. electrolytes were replete as needed. daily weights were stable. the foley was removed with good urine output. pain: epidural with pca dilaudid. she transition to po roxicet via j-tube with good control. disposition: she was seen by physical therapy and deemed safe for home. she was discharged on with oxygen, vna and her family. she will follow-up with dr. as an outpatient. medications on admission: oxycodone 5mg prn (uses occasionally at night) docusate protonix 40mg po bid zofran prn albuterol prn (hasn't used in past few years) discharge medications: 1. oxycodone 5 mg/5 ml solution sig: teaspons po q8h (every 8 hours) as needed for pain. disp:*400 teaspons* refills:*0* 2. amoxicillin-pot clavulanate 400-57 mg/5 ml suspension for reconstitution sig: two (2) teaspoons po twice a day for 7 days. disp:*150 ml* refills:*0* 3. lorazepam 0.5 mg tablet sig: one (1) tablet po every twelve (12) hours as needed for anxiety. disp:*10 tablet(s)* refills:*0* 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 6. home oxygen 2-3 liters via nasal cannula, continuous pulse dose for portability dx: esopahgeal cancer, pneumonia 7. zofran odt 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. disp:*6 tablet, rapid dissolve(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: esophageal cancer (s/p chemotherapy & xrt) asthma gerd discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: call dr. office if you experience: -fevers > 101 or chills -increased shortness of breath, cough or chest pain -your incisions develop drainage -difficult or painful swallowing -nausea (take anti-nausea medication) or vomiting -increased abdominal pain pain -acetaminophen 650 mg every 6-8 hours as needed for pain -oxycodone liquid teaspoon every 4-6 hours as needed for pain acitivity -shower daily. wash incision with mild soap & water, rinse pat dry -no tub bathing, swimming or hot tubs until incision healed -no driving while taking narcotics -take stool softner with narcotics -walk 4-5 times a day for 10-15 minutes increase to a goal of 30 minutes daily medication -augmentin (antibiotic) through . -keep the head of your bed elevated. place a wood wedge or foam wedge under the mattress. followup instructions: follow-up with dr. 10:00 on the clinical center chest x-ray radiology 30 mintues before your appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Total esophagectomy Endoscopic dilation of pylorus Removal of intraluminal foreign body from stomach and small intestine without incision Diagnoses: Other iatrogenic hypotension Esophageal reflux Tobacco use disorder Unspecified pleural effusion Asthma, unspecified type, unspecified Atrial flutter Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Pneumonitis due to inhalation of food or vomitus Loss of weight Mechanical complication due to other implant and internal device, not elsewhere classified Other symptoms referable to back Tachycardia, unspecified Malignant neoplasm of other specified part of esophagus Other specified disorders of esophagus Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Foreign body in respiratory tree, unspecified Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation Status of other artificial opening of gastrointestinal tract Dysphagia, unspecified Pylorospasm |
allergies: no known allergies / adverse drug reactions attending: chief complaint: sah major surgical or invasive procedure: : cerebral angiogram with coiling history of present illness: this is an 81f who presents with six hours of headache, chest pain, left face pain, and left neck pain associated with "heart pounding" after getting out of the shower found to have a sah on ct scan of head. she denies any weakness, speech slurring, or changes in vision or hearing. she reports that her pain was associated with left neck and arm tingling as well as a 30 second, witnessed syncopal episode where she fell backwards onto her bed (no head strike). she immediately regained conciousness without any residual neurologic deficits. ed course: after transport by ems to ed, she was found to have st depression in leads ii, iii. she received nitroglycerin and aspirin relief of chest pain to . past medical history: a fib on coumadin, h/o breast cancer (not active), h/o lumpectomy (5 years ago), htn, hld, hypothyroidism, osteopenia social history: pt. retired from clerical work at and now lives with her daughter. she has two children. she denies any tobacco, alcohol or illicit drug use. family history: mother and father thought to have had htn, but patient is unsure. no family history of cad, dm or hyperlipidemia. physical exam: vitals: 98 91 146/97 16 99% heent: pupils: 2 to 1.5 mm bil eoms intact neck: supple. extrem: warm and well-perfused. neuro: mental status: cooperative with exam, normal affect. orientation: aox3 language: fluent with good comprehension. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 2 to 1.5 mm bilaterally, brisk response. visual fields intact iii, iv, vi: extraocular movements intact bilaterally without nystagmus or diplopia. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline with no fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. no pronator drift d t b grasp i q h gc ta sensation: intact to light touch throughout upper and lower extremities coordination: normal on finger-nose-finger upon discharge: aox3, , with full motor, nonfocal exam pertinent results: ct head w/o contrast left-sided subarachnoid hemorrhage centered over the left side of the suprasellar cistern with associated effacement. given the quantity of hemorrhage, this likely reflects a sentinel bleed of a left internal carotid artery terminus or left middle cerebral artery bifurcation aneurysm. cta head w&w/o c & recons 4 x 4 x 5 mm saccular aneurysm with a 2-mm neck, projecting posteriorly from the supraclinoid left internal carotid artery distal to the ophthalmic artery origin. fusiform enlargement of the left internal carotid artery at the level of the aneurysm. this aneurysm is the likely source of the left-sided subarachnoid hemorrhage. cta head : impression: 1. no evidence of vasospasm is identified. the internal carotid artery adjacent to the coil pack is mildly limited due to coil pack artifact. 2. there are scattered vague foci of hypodensity within the periventricular and subcortical white matter which are stable compared with the prior study and likely represent the sequela of chronic small vessel ischemic disease. lenis : negative for dvt in ble brief hospital course: this is an 81 y/o f on coumadin for a-fib presents to the ed s/p chest pain. while being evaluated for chest pain, she also complained of headache. ct head was done which revealed a l sah in which a cta was immediately recommended. cta showed l ica aneurysm and patient was admitted to neurosurgery and taken to icu for q1h neuro checks. cardiology was consulted and determined that patient has unstable angina and will continue to monitor patient while in hospital. she was taken to angiogram for coiling of the l ica anuerysm. angiogram was successful, her l ica was coiled and patient brought to icu. she was extubated and on post op exam found to be nonfocal. she was placed on aspirin and her blood pressure was liberalized to 100-200. on she was lethargic in the early am but a ct was stable and she was brighter in pm. cardiac enzymes were not trending up. she had no chest pain. she was on a cear diet. on , patient remained nonfocal on examination. a u/a was sent and some bacteria was observed. her foley was removed and patient oob with assistance.she remained stable in the icu and had no evidence of neurological decline. a repeat ct-angiogram on revealed no evidence of new sah or infarct or gross evidence of vasospasm. she was transferred to floor in stable condition. she was evaluated by pt and they recommended rehab. on she complained of leg aches, although they appeared muscular in nature, we did ble lenis to evaluate and were negative. now dod, she is afebrile, vss, neurologically stable and pain is well controlled. she is set for discharge home in stable condition and will f/u with dr. accordingly. medications on admission: coumadin 5 mg qd, levothyroxine 100 mcg qd, anastrozole 1 mg qd, atenolol 25 mg qd, diltiazem cd 180 mg qd discharge medications: 1. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. diltiazem hcl 60 mg tablet sig: one (1) tablet po qid (4 times a day). 5. senna 8.6 mg tablet sig: 1-2 tablets po daily (daily). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 8. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po q6h (every 6 hours) as needed for head ache. 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. discharge disposition: extended care facility: at discharge diagnosis: sah l ica aneurysm 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: 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 emergency room! followup instructions: please follow up with dr. in 4 weeks. this appointment can be made by calling . - you will need a brain mri/mra ( protocol) prior to appointment. Procedure: Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Intermediate coronary syndrome Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Personal history of malignant neoplasm of breast Subarachnoid hemorrhage Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Disorder of bone and cartilage, unspecified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: small bowel obstruction major surgical or invasive procedure: none history of present illness: mr. is an 87 year old male with a h/o parkinsons disease who presented to hospital today with a small bowel obstruction with pneumatosis coli indicative of bowel necrosis and respiratory failure requiring intubation who was transferred to for surgical evaluation. upon surgical evaluation, his overall condition was poor and he was deemed to be a very high risk surgical candidate. his ph at the outside hospital had been 6.93. his family reached a decision of dnr but several family members were to arrive prior to initiating comfort measures only. past medical history: parkinson disease recurrent utis frequent falls with old c1 fractures, shoulder injury, and prior left hip fracutre prostate cancer s/p prostectomy social history: patient lives at home with his wife does not drink, smoke, use iv drugs family history: non-contributory physical exam: vitals: 96.8, hr 120, 100/59, rr 24, saturation 92% general: sedated, intubated, unresponsive to verbal stimuli cardio: tachycardic without murmurs pulmonary: ctab anteriorly abdominal exam: extremely rigid extremities: no edema pulses: 2+ radial, carotids bilaterally pertinent results: 09:24pm type-art temp-36.6 po2-182* pco2-41 ph-7.14* total co2-15* base xs--14 intubated-intubated comments-green top 09:24pm glucose-136* lactate-5.7* k+-4.3 08:48pm lactate-6.2* 08:41pm urea n-42* creat-2.1* 08:41pm estgfr-using this 08:41pm lipase-59 08:41pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 08:41pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 08:41pm wbc-26.8* rbc-5.14 hgb-14.8 hct-47.0 mcv-92 mch-28.7 mchc-31.4 rdw-14.6 08:41pm pt-12.6* ptt-26.3 inr(pt)-1.2* 08:41pm plt count-268 08:41pm plt count-268 08:41pm fibrinoge-470* imaging from outside hospital includes ct abdomen and pelvis: ??????marked gaseous distension of entir colon with prominent fecal density??????pneumatosis of the ascending colon with gas extending into the smv and reaching the peripheral portal vein branches in the liver, worrisome for necrotic bowel.?????? brief hospital course: 87 year old male presents with severe acidemia, respiratory failure, small bowel obstruction, and pneumatosis coli indicative of visceral necrosis. as the patient was not a surgical candidate, medical prognosis was poor. following visits from concerned family members, and following discussion with patients' wife ), patient care was transistioned to focus care on comfort. patient expired quietly at 2:20 am on with many family members at the bedside. organ bank notified. attending notified. pcp . admitting and medical examiner notified. medications on admission: expired discharge medications: expired 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 Diagnoses: Acidosis Unspecified essential hypertension Unspecified septicemia Severe sepsis Personal history of malignant neoplasm of prostate Depressive disorder, not elsewhere classified Acute respiratory failure Septic shock Do not resuscitate status Dementia in conditions classified elsewhere without behavioral disturbance Acute vascular insufficiency of intestine Unspecified intestinal obstruction Dementia with lewy bodies Other specified disorders of intestine |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral thigh pain and left sided foot drop major surgical or invasive procedure: l3-l5 lateral lumbar interbody fusion followed by l3-s1 laminectomy and fusion with l5-s1 transforaminal lumbar interbody fusion. history of present illness: 50- year-old female with a progressive and disabling syndrome of degenerative scoliosis as well as spinal stenosis. this did cause a syndrome of back and leg pain which did interfere with her ability to walk. she underwent a prolonged and progressive and multimodal course of conservative care, but despite this, her symptoms were not relieved. due to the progressive nature of syndrome, the history of this disorder, the refractory nature of the syndrome, and the severity of symptoms, she did elect to undergo surgical treatment. physical exam: avss well appearing, nad, comfortable bue: silt c5-t1 dermatomal distributions bue: /tri/bic/we/wf/ff/io bue: tone normal, negative , 2+ symmetric dtr bic/bra/tri all fingers wwp, brisk capillary refill, 2+ distal pulses ble: silt l1-s1 dermatomal distributions ble: ip/qu/hs/ta/gs//fhl/per except left ta and 0/5 ble: tone normal, no clonus, toes downgoing, 2+ dtr knee/ankle all toes wwp, brisk capillary refill, 2+ distal pulses pertinent results: 07:20pm glucose-215* urea n-15 creat-0.5 sodium-140 potassium-4.0 chloride-104 total co2-23 anion gap-17 07:20pm estgfr-using this 07:20pm calcium-9.0 phosphate-3.9 magnesium-1.7 07:20pm wbc-17.9* rbc-4.59 hgb-14.9 hct-43.3 mcv-94 mch-32.6* mchc-34.5 rdw-13.8 07:20pm plt count-185 brief hospital course: patient was admitted to the spine surgery service and taken to the operating room for the above procedure. refer to the dictated operative note for further details. the surgery was without complication and the patient was transferred to the pacu in a stable condition. teds/pnemoboots were used for postoperative dvt prophylaxis. intravenous antibiotics were continued for 24hrs postop per standard protocol. initial postop pain was controlled with a pca. diet was advanced as tolerated. the patient was transitioned to oral pain medication when tolerating po diet. was removed on pod#2. physical therapy was consulted for mobilization oob to ambulate. hospital course was otherwise unremarkable. on the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. discharge medications: 1. acetaminophen 650 mg/20.3 ml solution sig: one (1) po q8h (every 8 hours). 2. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). 3. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). discharge disposition: extended care facility: hospital - discharge diagnosis: lumbar spinal stenosis with adult degenerative scoliosis discharge condition: stable, alert and oriented, tolerating pos. discharge instructions: you have undergone the following operation: lumbar decompression with fusion immediately after the operation: - activity: you should not lift anything greater than 10 lbs for 2 weeks. you will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - rehabilitation/ physical therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. you can walk as much as you can tolerate. o limit any kind of lifting. - diet: eat a normal healthy diet. you may have some constipation after surgery. you have been given medication to help with this issue. - brace: you may have been given a brace. this brace is to be worn when you are walking. you may take it off when sitting in a chair or while lying in bed. - wound care: remove the dressing in 2 days. if the incision is draining cover it with a new sterile dressing. if it is dry then you can leave the incision open to the air. once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. do not soak the incision in a bath or pool. if the incision starts draining at anytime after surgery, do not get the incision wet. cover it with a sterile dressing. call the office. - you should resume taking your normal home medications. - you have also been given additional medications to control your pain. please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. you can either have them mailed to your home or pick them up at the clinic located on 2. we are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. in addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - follow up: o please call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o at the 2-week visit we will check your incision, take baseline x-rays and answer any questions. we may at that time start physical therapy. o we will then see you at 6 weeks from the day of the operation and at that time release you to full activity. please call the office if you have a fever>101.5 degrees fahrenheit and/or drainage from your wound physical therapy: ambulation with assistance, gait training, stair climbing. treatments frequency: 2-3 times a week followup instructions: follow up in 2 weeks with dr in clinic. please call to make an appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Lumbar and lumbosacral fusion of the anterior column, posterior technique Closed [endoscopic] biopsy of bronchus Excision of intervertebral disc Excision of intervertebral disc Lumbar and lumbosacral fusion of the anterior column, anterior technique Other repair and plastic operations on spinal cord structures Insertion of interbody spinal fusion device Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Fusion or refusion of 4-8 vertebrae Insertion of recombinant bone morphogenetic protein Diagnoses: Pneumonia due to other gram-negative bacteria Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Ventilator associated pneumonia Other acquired deformities of ankle and foot Spinal stenosis, lumbar region, without neurogenic claudication Other kyphoscoliosis and scoliosis Accidental puncture or laceration of dura during a procedure |
allergies: no known allergies / adverse drug reactions attending: chief complaint: altered mental status major surgical or invasive procedure: lumbar puncture endotracheal intubation history of present illness: history of present illness: mr. is a 56 year old cantonese-speaking man with history of hypertension and delusional disorder who presented from home after being found unresponsive by family, not responding to voice but protecting airway and with pulses intact. family found him in bed this morning, thought he was sleeping in but then noted that he was not responding to them, so they called ems. fingerstick was about 100. . pcp states that he is usually not delusional during clinic visits, though neice states that he is quite delusional and paranoid accusing his sister of things at home. last mental health clinic visit was on ; next scheduled on . at the last visit, psychiatrist did not report any delusional behavior in the clinic note. pcp has no knowledge of narcotics for this patient. last seen by pcp by pcp for gout attack. patient had been complaining of chest pain in the spring, missed scheduled ett in , missed a few times, now rescheduled for 8/. . in the ed, patient was noted to have rectal temp of 99.8, tachycardic to 140s-150s with stable blood pressures. he responded to noxious stimuli in the ed. pupils were noted to be constricted bilaterally, symmetric and responding to light. patient was given narcan 0.4mg with no response. he was intubated for mental status. head ct showed no acute intracranial process. ct torso showed lower lobar opacification (left greater than right), likely atelectasis though cannot rule out potential aspiration on left. no additional acute intrathoracic, abdominal, or pelvic process was noted in the preliminary read to explain the patient's circumstance. lp was done in the ed which was unremarkable. blood cultures were drawn. patient was given 1l of ns. he was given a dose of vancomycin and levofloxacin. vitals in the ed prior to micu transfer were as follows: 79 166/98 14 100% peep 5 vt 500 rr 12 fio2 40%. . in the icu, patient was intubated and sedated with propofol. propofol was stopped, and patient became agitated. given a dose of narcan again on arrival to icu to which he appeared to respond. . review of systems: unable to obtain due to altered mental status. past medical history: hypertension delusional disorder - on medications gout latent tuberculosis - s/p treatment last year x6 months social history: lives with elderly mom and sister. moved from 17yrs ago. receives disability and retirement benefits. retired from working at restaurant. - tobacco: quit smoking 17 yrs ago - alcohol: none - illicits: none family history: mother with bad diabetes. father died at 40 y/o from sudden cardiac death physical exam: admission physical exam: vitals: t: 95.8 bp: 124/77 p: 129 r: 14 o2: 99% cmv fio2 40%, vt 500 general: intubated and sedated heent: sclera anicteric, difficult to assess oropharynx neck: no jvd lungs: good air movement bilaterally, mild ronchi at bases cv: regular rhythm, rapid rate, no murmurs appreciated abdomen: soft, non-tender, very mildly distended, old well healed vertical scar llq gu: foley in place draining large amounts of clear yellow urine ext: warm, well perfused, 2+ pulses, no peripheral edema discharge physical exam: vitals:98.7 126-154/72-94 74-84 16-18 96-98%ra gen: aox3, pleasant in nad lungs: ctab, no w/r/r cv: rrr, no m/r/g abd: s/nt/nd, +bs, no hsm ext: no edema, wwp, swelling over right big toe improved neuro: grossly intact pertinent results: labs: on admission 02:58pm blood wbc-8.7 rbc-4.90 hgb-15.6 hct-43.5 mcv-89 mch-31.9 mchc-35.9* rdw-13.0 plt ct-167 02:58pm blood neuts-72.2* lymphs-20.2 monos-4.9 eos-2.3 baso-0.4 02:58pm blood glucose-126* urean-18 creat-1.4* na-143 k-3.6 cl-106 hco3-24 angap-17 02:58pm blood alt-48* ast-24 ld(ldh)-153 alkphos-62 totbili-0.7 04:16am blood ck(cpk)-77 02:58pm blood ctropnt-<0.01 02:58pm blood calcium-9.4 phos-3.0 mg-2.1 02:55am blood vitb12-608 02:55pm blood ammonia-17 02:58pm blood osmolal-294 02:55am blood tsh-0.27 07:32pm blood asa-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 11:30am blood type-art po2-92 pco2-32* ph-7.50* caltco2-26 base xs-1 09:02pm blood type-art temp-37 po2-79* pco2-35 ph-7.45 caltco2-25 base xs-0 intubat-not intuba 03:04pm blood glucose-119* lactate-2.3* na-144 k-3.7 cl-103 calhco3-24 03:10pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-neg 03:10pm urine color-straw appear-clear sp -1.011 08:37am urine blood-lg nitrite-neg protein-100 glucose-tr ketone-40 bilirub-neg urobiln-neg ph-6.5 leuks-tr 08:37am urine color-red appear-hazy sp -1.023 03:10pm urine rbc-<1 wbc-<1 bacteri-none yeast-none epi-0 08:37am urine rbc->182* wbc->182* bacteri-none yeast-none epi-0 08:37am urine hours-random creat-218 na-173 k-46 cl-102 uric ac-84.5 03:10pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg 04:50pm cerebrospinal fluid (csf) wbc-1 rbc-1* polys-0 lymphs-61 monos-39 . other labs: 02:55am blood vitb12-608 06:55am blood %hba1c-6.1* eag-128* 06:55am blood triglyc-186* hdl-47 chol/hd-4.2 ldlcalc-115 02:55am blood tsh-0.27 vitamin b1 (thiamine), blood 109 hbv viral load (final ): hbv dna not detected. . on discharge: 06:30am blood wbc-7.5 rbc-5.04 hgb-15.7 hct-45.3 mcv-90 mch-31.1 mchc-34.6 rdw-13.2 plt ct-245 06:30am blood glucose-100 urean-26* creat-1.4* na-141 k-4.8 cl-101 hco3-30 angap-15 06:30am blood alt-147* ast-71* ld(ldh)-242 alkphos-72 totbili-0.2 . imaging head ct: no acute intracranial process . ecg: sinus tachycardia. non-specific st-t wave changes. compared to the previous tracing there is no change. . ct chest/abd/pelvis: 1. left greater than right lower lobar opacification likely reflects atelectasis, although an element of aspiration, particularly on the left, cannot be excluded. 2. no additional acute intrathoracic, abdominal, or pelvic process to explain the patient's circumstance . eeg: this is an abnormal eeg due to a disorganized background with fairly. consistent with a moderate encephalopathy. the potential causes include but a metabolic, infectious, or sedative consistent with common causes of encephalopathy include medications, infections, disturbances . mri head: punctate area of slow diffusion in right medial temporal lobe medial to the temporal of right lateral ventricle. this likely represents a small area of ischemia . tte: no asd or left ventricular thrombus seen. mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. saline contrast study was technically suboptimal for exclusion of patent foramen ovale. if clinical suspicion of a pfo is high, consider a transesophageal study or transcranial dopplers . cta head/neck 1. head ct shows no evidence of hemorrhage or mass effect. the mra demonstrated infarct is not apparent on ct. 2. ct angiography of the neck demonstrates no vascular occlusion or stenosis. 3. ct angiography of the head demonstrates no evidence of vascular occlusion, stenosis or an aneurysm greater than 3 mm in size. brief hospital course: 46m cantonese-speaking man with history of delusional disorder presenting with unresponsiveness that gradually improved, so thought to be due to a seroquel overdose. . # altered mental status - patient was found at home unresponsive, with a pulse and breathing on his own. in the emergency department, the patient was found to have no acute process on head ct. the patient underwent lumbar puncture, that was negative. serum and urine tox were negative. pupils were noted to be constricted on presentation to the ed but the patient did not respond to narcan. patient had no signs of cirrhosis on abdominal ct, and ammonia level is 17. the patient was intubated out of concern for airway protection. the patient was transferred to the micu. the patient was given a second dose of narcan on presentation to micu after propofol was stopped, and became modestly more alert. he was extubated, as he was able to protect his airway. in the micu, the patient was noted to have continued miosis, a prolonged qt, tachycardia, and urinary retention, consistent with possible seroquel overdose. seroquel level was sent. over the next 48 hours, the patient's alertness gradually improved. he began to speak and open his eyes spontaneously. the patient was seen by neurology. he underwent eeg that showed no evidence of seizure. he also underwent brain mri which showed a small area of ischemia in the temporal lobe, though this did not seem to completely explain his initial presentation so medication effect still thought to be the primary explanation for patient's altered mental status. pt exhibited no focal neurological deficits on exam. he was transferred to the floor where his mental status continued to improve back to his baseline. . # ischemic stroke: pt was found to have a small ischemic stroke on brain mri. echo and cta of head and neck were negative. no focal neuro findings. stroke w/u showed only mildly elevated triglycerides and ldl, but no other risk factors. hba1c was 6.1. pt to f/u with neuro as an outpt. will need repeat mri brain in 8/. started on aspirin for secondary prevention. . # agitation - on transfer to the floor, pt became quite agitated, kicking at nursing and pulling at his foley. he briefly required four-point restraints, but eventually calmed down after 2.5mg zyprexa. cause of pt's agitation thought to be delirium due to recent administration of ativan in addition to the effect of seroquel withdrawal. pt had no further episodes of agitation for the remainder of his stay. . # fever - on day 1 of admission, the patient began to have intermittent fevers. blood cultures returned negative. urine culture returned negative. ed lumbar puncture showed no evidence of infection. the patient underwent repeat cxr that showed mild edema. pt subsequently developed an acute gout flare near his right toe, which was thought to be the most likely source of his fever. he remained afebrile for the remainder of his stay. . # bilateral lower lobe opacifications - on admission, the patient was noted to have bilateral lower lobe opacifications on chest ct, left side worse than right side. the opacifications likely represented atelectasis, as patient was afebrile. patient given levofloxacin and vancomycin in the ed for potential aspiration. in the micu, antibiotics were held and patient was monitored for further signs of pneumonia. on the floor, pt's wbc count remained stable and he was afebrile. he did complain of some cough, but this was thought to be due to atelectasis so pt was encouraged to use an expectorant and incentive spirometry. . # - patient was admitted with cr 1.4 (baseline 1.1). etiology unclear, but likely related to toxic ingestion and pre-renal causes such as hypovolemia. patient's creatinine subsequently improved, though was 1.2-1.4 at time of discharge. will need to be followed at rehab, and fluid intake should be encouraged. if creatine trends up, contrast induced nephropathy would be on differential as patient received dye load for cta head/neck this admission. . # delusional disorder - chronic. patient continued to report occasional delusions during his admission but per his family these are his baseline. as patient's presentation likely due to overdose of home seroquel, his seroquel was initially held on admission but re-started prior to discharge. his initial seroquel level was still pending at the time of discharge. . # gout - acute flare over patient's right big toe. pt received 1.8mg colchicine and his allopurinol was held. prednisone and nsaids avoided in setting of pt's underlying psychiatric disorder and his recent gastritis, respectively. improved. . # rectal bleeding - pt reported minor amounts of blood in his stool. on exam, pt found to have external hemorrhoids. h/h remained stable throughout his admission. . # - pt's lfts to 100s elevated on sunday in the setting of recently increased statin dose. negative for hepatitis b. hepatitis c studies pending at the time of discharge. statin was decreased with hopes these values would continue to trend down. . transitional issues - patient's seroquel level pending at the time of discharge and needs to be followed up as possible explanations of his mental status - patient will need education about the importance of taking his medications regularly and only as prescribed - pt should follow-up with neurology in one month with a follow-up mri to evaluate her ischemic lesion - patient will need monitoring of lfts and renal function as outpatient medications on admission: seroquel 50mg qhs simvastatin 20mg daily allopurinol 100mg vit d 1000u omeprazole 20mg daily colchicine 0.6mg prn vitamin b12 250mg discharge medications: 1. outpatient radiology pt needs a repeat mri brain to evaluate his possible ischemic lesion seen on mri in 2. length of stay anticipated that pt needs acute rehab for <30 days 3. allopurinol 100 mg tablet sig: one (1) tablet po twice a day. 4. vitamin d 1,000 unit tablet sig: one (1) tablet po once a day. 5. aspirin 325 mg tablet sig: one (1) 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. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 8. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 9. quetiapine 50 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 10. colchicine 0.6 mg tablet sig: one (1) tablet po once a day as needed for gout. 11. vitamin b-12 250 mcg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: healthcare center - discharge diagnosis: (primary) toxic metabolic encephalopathy secondary to seroquel overdose cerebrovascular accident in right medial temporal lobe (secondary) delusional disorder gout gerd hearing loss discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , you were admitted to the hospital because your family could not wake you up one morning. we think it is because you took too much of a medicine called seroquel. this medicine is important to control your delusional disorder but can make you dangerously sleepy if you take too much. you initially had to be placed on a ventilator to help you breathe and sent to the intensive care unit for close monitoring, but you gradually woke up and returned to your normal personality. **it is very important that you take only the dose of seroquel that has been prescribed to you.** while you were here, you had an mri of your brain which showed an area concerning for a stroke. you were evaluated by the neurology team and started on aspirin. the neurology team did not feel the stroke was the cause of your unresponsiveness. you will need a repeat mri in for further evaluation. we also noted that some of your liver enzymes were elevated. this elevation may be due to an increase in one of your medications (simvastatin). we made the following changes to your medications while you were here: 1. started aspirin 325mg daily we did not make any other changes to your medications. please continue to take them as you have been doing. followup instructions: name: , md location: address: , , phone: appointment: wednesday at 10:30am name: , j. location: address: , , phone: appointment: wednesday at 1:45pm department: neurology when: friday at 10:00 am with: , md building: campus: east best parking: garage Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Diagnoses: Toxic encephalopathy Unspecified essential hypertension Acute kidney failure, unspecified Pulmonary collapse Poisoning by other antipsychotics, neuroleptics, and major tranquilizers External hemorrhoids with other complication Cerebral artery occlusion, unspecified with cerebral infarction Acute gouty arthropathy Delusional disorder Accidental poisoning by other specified tranquilizers Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Personal history of tuberculosis Physical restraints status |
allergies: no known allergies / adverse drug reactions attending: chief complaint: unresponsiveness. major surgical or invasive procedure: 1. endotracheal intubation 2. central venous line placement history of present illness: 84 yo male history of prior stroke with right facial droop, copd on home o2, osa on bipap, pulm htn, htn, mr, and chf with ef 50% who was sent in from the home after being found at 9pm with unresponsiveness and pinpoint pupils. fs was 108. he was non-responsive to narcan given by ems. in the ed, initial vs were: 96.8 176/80 48 100% on "20l". upon arrival to the ed, a right facial droop was noted and there was not a lot of history from the facility or ems so a code stroke was called. initially, he was able to open his eyes to sternal rub, so he was intubated for unresponsiveness and airway protection given concern for an evolving stroke. the ed noted a difficult and inferior intubation. he received atropine 0.5mg prior to intubation for bradycardia to the 30's. he was given fent/versed after intubation. no response to more narcan in ed. more information was then gathered. he had been at rehab for coughing leading to syncopal episodes and rehab after prior strokes. he was intermittently brady at the facility with bp 63/48. patient on alfa-2 eye drops for glaucoma with constrict pupils. portable cxr after intubation noted that the ett was low and was subsequently pulled back cms. a rij was placed for sbp of 80. repeat cxr was ordered. he was given levofloxacin for a uti. a cta of the head and neck was done to rule out stroke. neurology was consulted. neuro consult recs noted: cta attempted, contrast not perfused adequately. transcranial doppler (tcd) done on basilar artery showing flow to 110mm, makes clot unlikely. most recent vitals prior to transfer: afeb 47 103/61 500x14 50%x5. on arrival to the micu, pt is intubated and sedated. his vital signs were stable. of note, the patient's dry weight is 247-252lbs. the patient called his wife this morning to say "goodbye". he has been in the hospice section of nursing home for end stage chf. past medical history: - acs s/p cabg - prostate cancer s/p xrt c/b residual incontinence, condom cath qhs - severe right sided systolic failure - severe phtn (on 2-3lnc) - osa on home bipap - mult cvas w residual r-sided weakness and r-facial droop - recurrent syncope of uncertain etiology (potentially cough) - dm2 - htn - dvt - depression - mild dementia - s/p cataract surgery - internal hemorrhoids social history: married with 5 children, admitted to home for syncopal episodes and rehab. is in the hospice section because "the doctors told his heart is endstage" and for insurance reasons, but is still full code. wheelchair bound at baseline. retired bus driver. previous 20 year smoking history, quit >40 years ago. no etoh or illicit drug use. family history: mother had cancer, patient cannot recall diagnosis. physical exam: admission exam: vs: 58 124/78 general: intubated, sedate, obese, aa male heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: bradycardia, holosystolic murmur best heard at apex lungs: bibasilar crackles abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: foley with yellow urine ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis. trace to 1+ edema in b/l le's. neuro: full admission neuro exam documented in neurology consult stroke team note. baseline is r facial droop and arm weakness. on admission he is intubated and sedated, perrl. discharge exam: vs general: obese male in no acute distress heent: dy mucous membranes neck: supple, jvp not able to be appreciated cv: holosystolic murmur best heard at lower left sternal border, regular rate lungs: diffuse end-expiratory wheezing, poor air movement abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis. 1+ edema in b/l le's. neuro: full admission neuro exam documented in neurology consult stroke team note. baseline is r facial droop and arm weakness. pertinent results: labs on admission: 11:30pm blood wbc-7.1 rbc-5.20 hgb-14.4 hct-44.9 mcv-86 mch-27.6 mchc-32.1 rdw-14.9 plt ct-212 11:30pm blood pt-13.7* ptt-34.2 inr(pt)-1.3* 11:30pm blood urean-33* 11:39pm blood creat-1.9* 11:30pm blood alt-18 ast-35 alkphos-130 totbili-0.4 11:30pm blood lipase-28 11:30pm blood ctropnt-0.04* 05:57am blood albumin-2.3* calcium-7.7* phos-3.8 mg-1.7 11:40pm blood glucose-85 lactate-2.8* na-143 k-3.5 cl-93* calhco3-36* labs prior to discharge: 06:57am blood wbc-7.0 rbc-5.19 hgb-14.3 hct-44.6 mcv-86 mch-27.6 mchc-32.1 rdw-14.7 plt ct-184 06:57am blood glucose-87 urean-22* creat-1.5* na-147* k-3.8 cl-102 hco3-36* angap-13 06:57am blood calcium-8.6 phos-3.4 mg-2.1 urine site: not specified **final report ** urine culture (final ): gram positive bacteria. >100,000 organisms/ml.. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. blood culture blood culture, routine-pending blood culture blood culture, routine-pending reports: cxr: 1. et tube ends 2.5 cm above the carina, and could be withdrawn a few cm for optimal positioning. 2. moderate pulmonary edema. right upper lobe paramediastinal consolidation, which may represent acute infection or asymmetric edema. cta head and neck: ct head demonstrates no hemorrhage. mild changes of small vessel disease. ct angiography of the head and neck was unsuccessful and no diagnostic ct angiographic information is obtained. exuberant calcifications are seen in the aortic arch and the neck vessels. pleural parenchymal changes are seen in both lungs. - of note contrast extravasated from the iv tubing. cxr: endotracheal tube has been repositioned, now terminating about 5.2 cm above the carina. heart remains enlarged. rapid improvement in pulmonary edema, which is nearly resolved. more confluent opacity in right upper lobe is also improving, but difficult to fully assess due to patient rotation. calcified pleural plaques are present, indicative of prior asbestos exposure. brief hospital course: 84yo m pmhx cva, severe osa, phtn, and chf w chronic 2l o2 requirement admitted with unresponsive episode, etiology uncertain, family not wishing to pursue further workup, being transferred back to nursing facility without a clear etiology to the episode. active issues: # syncope: pt presented w unresponsive episode of unclear etiology; given history of multiple utis, initially thought to be toxic metabolic picture, however no clear source of infection with all cultures negative. initially was intubated in setting of episode, but was quickly extubated without residual acute respiratory issues. he was started empirically on vancomycin and cefepime, which were stopped when cultures returned negative. considered cardiac or neurologic cause; neurologic thought to be unlikely given normal ct head; discussion was had with family who agreed that no further workup was desired at this time. patient was stable and discharged back to rehab. chronic issues: # diastolic chf / phtn/ osa patient w severe osa, severe r-sided chf, phtn, dlco 50% (), without signs of exacerbations on this admission. patient was continued on home bipap. continued home torsemide, asa, lisinopril, metoprolol, isosorbide # chronic pain continued home tylenol # psych / dementia continued home citalopram, ropinirole, donepezil # glaucoma continued brimonidine transitional issues: -pt was full code for this admission after multiple discussions, although family expressed desire to focus on symptom directed care with hospice at rehab medications on admission: - tylenol prn - asa 325mg qd - celexa 20mg qd - docusate 200mg qd - iron supp 325mg qd - lisinopril 20mg qd - metoprolol succinate er 25mg qd - torsemide 20mg qd - brimonidine tartrate 0.15% eye drops - potassium chloride 10mg er qd - isosorbide mononitrate sr 30mg qhs - ropinirole hcl 2mg qhs - donezepil 5mg qhs - senna 8.6mg qhs discharge medications: 1. acetaminophen oral 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. citalopram 20 mg 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. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 6. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 7. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 8. torsemide 20 mg tablet sig: one (1) tablet po daily (daily). 9. brimonidine 0.15 % drops sig: one (1) drop ophthalmic q8h (every 8 hours). 10. potassium chloride 10 meq tablet extended release sig: one (1) tablet extended release po once a day. 11. isosorbide mononitrate 30 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 12. ropinirole 1 mg tablet sig: two (2) tablet po qpm (once a day (in the evening)). 13. donepezil 5 mg tablet sig: one (1) tablet po hs (at bedtime). 14. senna 8.6 mg tablet sig: one (1) tablet po at bedtime as needed for constipation. discharge disposition: extended care facility: care & rehab center - discharge diagnosis: primary: encephalopathy secondary: pulmonary hypertension discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: mr. , it was a pleasure taking care of you during your hospitalization at . you were admitted after having an episode of unresponsiveness at your nursing facility. you were monitored and were stable. after discussion with your family, we agreed that no further work-up will be conducted at this time. you are now safe for discharge back to your home. please note the following medication changes: none followup instructions: please have your nursing facility schedule an appointment with your primary care physician . within the next two weeks. department: cardiac services when: monday at 11:30 am with: dr. building: sc clinical ctr campus: east best parking: garage Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Fiber-optic bronchoscopy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Other chronic pain Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Personal history of malignant neoplasm of prostate Aortocoronary bypass status Other chronic pulmonary heart diseases Unspecified glaucoma Depressive disorder, not elsewhere classified Other specified cardiac dysrhythmias Other late effects of cerebrovascular disease Personal history of venous thrombosis and embolism Encephalopathy, unspecified Other disorders of muscle, ligament, and fascia Restless legs syndrome (RLS) Other late effects of cerebrovascular disease, facial weakness Chronic combined systolic and diastolic heart failure Dementia, unspecified, without behavioral disturbance |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall from stairs with scalp laceration and left occipital condyle fracture major surgical or invasive procedure: 1) repair of scalp laceration 2) repair of epicanthal fold laceration history of present illness: 20 year old male, prisoner, found down after fall down 10 steps, seen on video camera, with a gcs of 7 in the field. he was intubated prior to arrival, and sedated. there was an obviuous scalp laceration and epicanthal fold laceration but no other associated injuies noted. past medical history: psychiatic disorder - unknown social history: incarcerated family history: unknown physical exam: aao x3, flat affect, nad in cervical collar, diffuse ecchymoses of the right face and head rrr no mrg, intermittent tachycardia with stress cta b/l no rrw soft, nt, nd, no masses no cce pertinent results: imaging: ct head: no bleed, no fx, large r subgalean hematoma ct cspine: l occipital condyle fx ct torso: neg, tls no fx cta head/neck: hypoplastic l vertebral a w/o evidence of dissection brief hospital course: patient was admitted to the trauma icu where he was kept under custody for the entirety of his stay. all radiographic findings were negative other than the left occipital condyle fracture. he was seen by orthopaedic spine for this and a cervical collar was recommended. plastic surgery was consulted and repaired his epicanthal fold laceration. he did well, and was extubated hd 1 after neurological exam improved. by hd 2 he was cleared for discharge to the infirmary of his prior incarceration facility. medications on admission: zyprexa, lexapro discharge medications: 1. erythromycin 5 mg/g ointment sig: one (1) ophthalmic qid (4 times a day). 2. olanzapine 2.5 mg tablet sig: two (2) tablet po daily (daily). 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 4. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). discharge disposition: extended care discharge diagnosis: 1) traumatic brain injury 2) left occipital condyle fracture. 3) scalp laceration and ecchymosis 4) epicanthal fold laceration discharge condition: stable discharge instructions: ***patient will be discharged to infirmary at the facility at which he is incarcerated*** return to er if: - persistent temperature > 101.4 - severe abdominal pain, nausea or vomiting - persistent diarrhea - changes in mental status, consciuousness or neurological exam - changes in vision followup instructions: 1) plastic surgery clinic - call for appt is weeks 2) orthopaedic spine: dr. - call to schedule appointment in 4 weeks 3) trauma clinic - if needed for suture removal ( Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Linear repair of laceration of eyelid or eyebrow Closure of skin and subcutaneous tissue of other sites Diagnoses: Anemia, unspecified Open wound of scalp, without mention of complication Accidental fall on or from other stairs or steps Laceration of skin of eyelid and periocular area Unspecified psychosis Closed fracture of base of skull with cerebral laceration and contusion, with concussion, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sudden onset of l arm and leg weakness major surgical or invasive procedure: intubation at osh on for concern of airway protection history of present illness: the pt is a year-old right-handed woman with a history of htn, hld, hypothyroidism and remote hx of lupus who presents with an episode of dizziness on , found to have a l cerebellar infarct, now with acute onset of face arm and leg weakness. according to her family and notes, for much of last week the patient seemed much sleepier than usual, and spent a significant amount of time in bed. she was napping all day on , and when she awoke from her nap at 5pm, she was complaining of dizziness, and was also noted to be slurring her speech. by some reports she also had a cold sweat and was complaining of being too weak to walk. she was taken to , where she was admitted and underwent evaluation for possible stroke. exam initially was only notable for end gaze nystagmus, and slight ataxia. she had an mri that day, which showed a new left cerebellar infarct. mra at that time had a significant amount of artifact, but no obvious intracranial abnormalities. on , she was just finishing lunch at 1pm when she was noted to have sudden onset of left facial droop, and left arm and leg weakness. neurology was called again, and she was found to have an nihss of 7. discussion was had with the family about the possibility of tpa, however given her known subacute cerebellar infarct, the decision was made not to give tpa. she was intubated at that time for airway protection, as she was noted to be choking on her saliva, and arrangements were made to transfer her to past medical history: - lupus (remote - primary manifestation was joint pains) - oa - htn - hld - hypothyroidism - dementia - hx of shingles - prior presumed tia in - presented with dysarthria, but declined admission for further evaluation - s/p left mastectomy - s/p bladder surgery - s/p hysterectomy - s/p carpal tunnel repair (left) social history: reportedly lives alone but has several caregivers who help take care of her. no reported etoh or smoking history. family history: no known history of strokes physical exam: neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: some wheezing. crackles at bases bilaterally. bowel sounds evident in frontal left field cardiac: rrr, nl. s1s2, grade ii systolic murmur abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: 1+ pitting edema bilatteraly, 2+ radial, dp pulses bilaterally. skin: no rashes or lesions noted. neurologic: -mental status: knows she is in a hospital. says the year is . can name high frequency objects. -cranial nerves: pupils 1.5-1mm bilaterally. has right 6th nerve pasly. intact corneals and gag. slight left facial droop. -motor: right: delt, biceps, triceps ; ip 4-/5, hamstring left: deltoid 3-/5, biceps , tricep ; ip , hamstring 3-/5 -dtrs: tri pat ach l 3 3 3 2 1 r 2 2 2 2 1 plantar response was flexor on right, extensor on left. pertinent results: 09:26pm glucose-125* urea n-12 creat-0.8 sodium-139 potassium-3.3 chloride-100 total co2-31 anion gap-11 09:26pm alt(sgpt)-12 ast(sgot)-24 ck(cpk)-191 alk phos-63 tot bili-0.6 09:26pm ck-mb-5 ctropnt-<0.01 09:26pm urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-tr wbc;8.5 urine culture pending mri/mra brain: findings: when compared to the mri, there has been interval development of numerous acute infarcts. the largest is in the right posterior cerebral artery territory involving the inferomedial right temporal lobe. a second new acute infarct involves the lateral aspect, right thalamus. other new small foci of restricted diffusion within the right cerebellar hemisphere, posterior left cerebellar hemisphere, medial left temporal lobe, and inferior right occipital lobe are also new compared to . these infracts show mildly increased signal on t2-weighted and flair sequences. there has been expected maturation of the now subacute left pica territorial infarct within the inferomedial left cerebellar hemisphere. on dwi, this infarct shows "pseudonormalization," centrally, with slight interval increase in signal on adc map. more peripherally, the infarct maintains low signal on adc map. this infarct also remains hyperintense on dwi, flair, and t2-weighted images. this infarct shows increased flair- and t2-hyperintensity when compared to the more recent infarcts. there is also more vasogenic edema within this infarct with loss of normal gyri and sulci. none of these infarcts show loss of signal on susceptibility-weighted images to suggest hemorrhage. the ventricles, cisterns, and sulci otherwise show symmetric, age-related prominence. underlying sequelae of chronic microvascular disease are similar to the prior mri with subcortical, centra semiovale, and periventricular hyperintensity on flair and t2-weighted images. the patient is status post bilateral lens surgery. a mucus-retention cyst within the right maxillary sinus, a right mastoid effusion, and fluid within the aerated left petrous apex are all unchanged since prior examinations. a small focus of susceptibility artifact within the posterior left frontal lobe subcortical white matter likely corresponds to a small hyperintense focus seen on the ct and may represent a small calcification. mra head: the time-of-flight mri of the head is limited by motion artifact. within this limitation, and correlating with the contrast enhanced mra of the neck which extedned to the circle of , there is no significant luminal irregularity and no flow- limiting stenosis. the left vertebral artery is dominant. the basilar artery is mildly tortuous. the p1 segments have normal caliber bilaterally. no posterior communicating arteries are identified. the intracranial internal carotid arteries show no apparent flow-limiting stenosis. the right a1 segment is dominant, supplying the majority of the left and right a2 segments. a small, likely hypoplastic a1 segment is patent. the anterior communicating artery is not well seen. there is normal symmetric arborization of the middle cerebral arteries bilaterally. there is no intracranial aneurysm. mra neck: contrast-enhanced mra of the neck reveals no significant luminal irregularity and no flow-limiting stenosis. apparent mild narrowing of the left vertebral artery may be artifactual, or may represent mild stenosis. the dominant left vertebral artery has otherwise normal course and caliber. the right vertebral artery has normal course and caliber. bilaterally, the common, proximal external and cervical internal carotid arteries have normal course and caliber. impression: 1. interval (compared to mri) development of numerous acute infarcts involving multiple vascular territories, suspicious for central/embolic infarcts. 2. interval expected maturation of the left pica territory infarct. 3. no evidence of hemorrhagic transformation. brief hospital course: icu course: the patient was admitted to the icu, after having been intubated at an outside hospital after concern that she was choking on her sailva. her exam on admission was notable for a r eye abducens palsy and l arm and leg paresis that improved during her stay in the icu. she was extubated without difficulty on her 2nd day. blood pressure was stable in the 110-130s systolic with one episode of hypotension to the 90s likely secondary to propofol. after extubation patient was interacting with the team, and following commands. her family noted her memory deficits to be at baseline which were mostly semantic memory issues. her l arm improved to and l leg improved to 3/5 strength as well. she had a tte to look for cardioembolic source, of which none was found. mri showed patent posterior circulation with no issues. she was started on aggrenox but because the pills had to be crushed she was switched to plavix. patient had a speech/swallow study w/ video assitance and was noted to have aspiration with thin liquids. nectar thick was adequate. patient was transferred to floor after being stable for 3 days. on the neruomedicine floor the patient was hemodynamically . had lasix for slight fluid overload. had as outpatient a prn lasix dose of unknown amount. had a slight leukocytosis that developed and was found to have minor pna and uti. she was started on iv ceftriaxone 1gm qday for total of seven days. speech and swallow reevaluted and stated there was no evidence of aspiration on current regiment. on repeat chest x-ray it was noted that there was an overlying gastric bubble overlying the heart that was probably related to a hiatal hernai. there was no problems with bowel movements. her blood glucose checks were stable and insulin sliding scale was dinscontinued. she was transferred to an extended rehabilitaion facility for further management. culture results will be relayed to the facility. medications on admission: medications at home: - celexa 10mg qday - dyazide 37.5/25 - imdur 30mg qday - levothyroxine 25mcg/day - atenolol tablet - lasix prn - aspirin 325mg - calcium w/vitamin d 600mg tid - glucosamine/chondroitin 500/400 - leg cramp pills - magnesium 100mg daily - preservision 1 capsule - tylenol prn - vitamin b complex daily discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fever. 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 5. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 6. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 7. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 8. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po twice a day. 9. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 11. ipratropium bromide 0.02 % solution sig: one (1) inhalation q8h (every 8 hours) as needed for wheezing. 12. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback sig: one (1) intravenous q24h (every 24 hours) for 5 days: total duration 7 days. will need 5 more days. 13. sodium chloride 0.9 % intravenous 14. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 15. famotidine 20 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: newbridge on the - discharge diagnosis: primary - multiple acute infarcts in diffrent vascular distributiosn including the cerebellum and thalamus. - uti - pneumonia secondary - lupus (remote - primary manifestation was joint pains) - oa - htn - hld - hypothyroidism - dementia - hx of shingles - prior presumed tia in - presented with dysarthria, but declined admission for further evaluation - s/p left mastectomy - s/p bladder surgery - s/p hysterectomy - s/p carpal tunnel repair (left) discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admited after a transfer from . you were initially seen there after developing dizzyness and vomiting with dysarthria. you then developed trouble with left arm and leg weakness. you were intubated for airway protection and sent to the intensive care unit for closer observation. you had an uncomplicated course and you were extubated. you were then transferred to the floor for further observation. you were started on aggrenox but then you were changed to plavix because of swallowing difficulties. you had a speech and swallow evaluaiton and you were recommended a soft diet with nector thick liquids. you developed a left lower lobe pneumonia nad a urinary tract infection and you were started on treatment for this with i.v antibiotics (ceftriaxone). you had imaging of your brain which showed that you had multiple strokes. you have been seen by physical thearapy and you will continue with physical therapy. you were asked to be dnr/dni (do not resucitate/ do not intubate) followup instructions: clinic: dr , . date/time: at 2:30 pm. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Systemic lupus erythematosus Urinary tract infection, site not specified Unspecified essential hypertension Unspecified acquired hypothyroidism Sixth or abducens nerve palsy Other persistent mental disorders due to conditions classified elsewhere Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Cerebral embolism with cerebral infarction Hemiplegia, unspecified, affecting unspecified side |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: general malaise, chest heaviness major surgical or invasive procedure: s/p metronic sensis pacemaker in left cephalic vein. history of present illness: 80yof w/ a h/o paf (on dronedarone) and hypertension, recently discharged from , represented to the ed this morning with general malaise, chest heaviness, and self-reported bradycardia. . the patient had been hospitalized from for new onset atrial fibrillation and was started on dronedarone for rhythm control. the patient was also started on warfarin in addition to her home metoprolol succinate and norvasc. the patient was discharged home without complication. . the patient represented to the ed early in the am of with atrial fibrillation with rvr (120s). patient was rate controlled in the ed with 10mg iv dilt then 60mg po dilt and 5mg iv dilt and was ultimately discharged home on diltiazem xr 120mg daily. once she got home, she took her home medications (metoprolol, norvasc, dronedarone) and developed generalized fatigue and noted her pulse to be in the 30s, prompting her to return to the ed. . in the ed, she presented with an inital heart rate in the 40s, with her systolic blood pressure in the 80s. she complained of fatigue, malaise, and chest discomfort. she received asa, calcium, glucagon and zofran. pacer pads were placed in the er. she was started on peripheral dopamine at 10mcg. pt continued to feel nauseated and was transferred to ccu. . on review of systems, she 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. s/he denies recent fevers, chills or rigors. 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, syncope or presyncope. ros positive as above. past medical history: 1. cardiac risk factors: hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: -pacing/icd:none 3. other past medical history: mild ar and mild mr. palpitations associated with atypical cp. htn gerd hepatitis b ckd s/p l nephrectomy social history: worked as ob/gyn in , lives with husband, daughter very involved. -tobacco history:none -etoh: none -illicit drugs:none family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: general: nad. mood, affect appropriate. oriented x 3 heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: jvp of 12cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. ii/vi sm at apex. no thrills, lifts. no s3 or s4. lungs: crackles 2/3 up bilaterally abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ dp 2+ pt 2+ pertinent results: admission labs: 12:28am blood wbc-5.6 rbc-4.35 hgb-13.6 hct-40.6 mcv-93 mch-31.3 mchc-33.6 rdw-13.4 plt ct-292 12:28am blood neuts-63.3 lymphs-30.6 monos-4.4 eos-1.5 baso-0.2 10:45am blood pt-26.1* ptt-39.7* inr(pt)-2.5* 12:28am blood glucose-114* urean-17 creat-1.2* na-130* k-7.7* cl-96 hco3-23 angap-19 10:45am blood alt-31 ast-36 ck(cpk)-75 alkphos-67 totbili-0.4 12:28am blood ck(cpk)-191 12:28am blood ck-mb-2 12:28am blood ctropnt-<0.01 10:45am blood ck-mb-notdone 10:45am blood ctropnt-<0.01 10:45am blood calcium-8.3* phos-3.9 mg-2.2 ----------------- discharge labs: 05:55am blood wbc-7.7 rbc-3.10* hgb-9.8* hct-28.4* mcv-92 mch-31.5 mchc-34.3 rdw-13.3 plt ct-222 05:55am blood pt-22.7* ptt-33.9 inr(pt)-2.1* 05:55am blood glucose-96 urean-18 creat-1.0 na-135 k-4.4 cl-101 hco3-26 angap-12 04:03am blood albumin-3.5 calcium-7.6* phos-4.1 mg-1.9 ----------------- studies: . admission ekg: rate 30. p waves out and regular, qrs narrow and regular. p-p interval longer than r-r interval. there is a pac with normal qrs following the p wave, and the pr interval was normal. this ekg indicates that sinus rate is lower than junctional escape rate, and avn conduction is normal. this is consistent with sick sinus syndrome. . tte : the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. . compared with the prior study (images reviewed) of , the bradycardia is more profound and the estimated pa systolic pressure is higher. the severity of mitral and aortic regurgitation are similar. . cxr : findings: ap portable view of the chest obtained. multiple overlying wires limit the evaluation. there is no definite change from prior study with grossly clear lungs bilaterally. cardiomediastinal silhouette appears essentially stable. no pneumothorax or pleural effusion is seen. impression: no acute interval change. somewhat limited evaluation. . cxr : impression: recommend repeat chest radiograph in four hours to determine stability of new left deep sulcus which raises possibility of pneumothorax post icd placement. brief hospital course: 80 y/o f with paf and hypertension presenting with bradycardia, likely manifestation of sick sinus syndrome. . # rhythm: patient presented with bradycardia, hr 30s-40s. she was started on dopamine in the ed. presentation ecg was consistent with sick sinus syndrome with normal av conduction (see admission ekg description in the results section). on admission to ccu, temp wire was placed after 2u ffp was given for inr of 2.6. her symptoms of dizziness, malaise and nausea resolved after the temp pacing wire was put in. dopamine was weaned off overnight. the next morning, her inr was 2.0, so she underwent pacemaker placement on . patient tolerated the procedure well without complications. patient was discharged home with dronedarone and warfarin. . # pump: patient received 4l ns bolus in ed for hypotension. on admission to ccu, she was volume overloaded on exam with signs of l sided heart failure from aggressive fluid resusitation. patient was initially on 6l nc. echo on showed preserved systolic function. she received one dose of 20mg iv lasix, to which she put out close to 3l urine. her respiratory symptoms significantly improved afterwards. she was satting well on room air, and her lung exam was clear on discharge. . # coronaries: no known history of cad. patient had no angina or anginal equivalents during this hospital stay. . # ckd: patient s/p l nephrectomy for rcc three years ago. basline cr ~1.0. admission cr 1.2, likely pre-renal etiology secondary to hypotension. it returned to baseline the next day. . # hepatitis b: diagnosed > 10 years ago, unclear mode of transmission. hepbsag pos, eab pos, eag neg, viral load ~3000 . patient was seen in the liver clinic in , and was recommended against liver bx and treatment given low viral load and lack of clinical symptoms. . # prophylaxis: patient's inr was therapeutic. . # code: full (confirmed with patient). . # comm: daughter, , at (home), (office). medications on admission: toprol 50mg daily dronedarone norvasc 5mg daily diltiazem 120mg xl daily ***started in ed, script not filled protonix warfarin 5mg daily discharge medications: 1. dronedarone 400 mg tablet sig: one (1) tablet po bid (2 times a day). 2. multivitamin tablet sig: one (1) tablet po daily (daily). 3. acetaminophen extra strength 500 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for fever, headache. 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. warfarin 5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 6. cephalexin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 2 days. disp:*6 capsule(s)* refills:*0* 7. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 8. multi-day tablet sig: one (1) tablet po once a day. 9. calcium 500 + d 500 mg(1,250mg) -400 unit tablet, chewable sig: one (1) tablet, chewable po twice a day. 10. outpatient lab work check inr on and call results to dr. at 11. metoprolol succinate 50 mg tablet sustained release 24 hr sig: 0.5 tablet sustained release 24 hr po once a day. tablet sustained release 24 hr(s) discharge disposition: home with service facility: vna discharge diagnosis: sick sinus syndrome discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you had a pacemaker for sick sinus syndrome, a slow heart rate. there were no complications from this pacemaker. please follow the activity restrictions outlined in the discharge instructions. you will need to take antibiotics for the next two days to prevent an infection at the pacer site. do not remove the pacer dressing for 3 days. you can then take off the pacer guaze dressing but keep the tape strips intact. until then, do not shower or bathe in a tub. you will be seen in the device clinic in 1 week to check the pacer function and look at the site. if you notice any bleeding, increasing bruising or pain at the pacer site, please call the device clinic. you will see dr. tomorrow and need to check your inr on friday . . medication changes: 1. discontinue metoprolol 2. take tylenol for any discomfort at the pacemaker site. 3. get your inr checked on friday . 4. take cephalexin for 2 days as a precaution against infection from the pacemaker. followup instructions: cardiology: provider: clinic phone: date/time: 9:30 provider: , m.d. phone: date/time: 3:00 . primary care: , j. phone: date/time: thursday at 10:15am. please get your inr checked on friday . . provider: , md phone: date/time: 9:00 Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Diagnoses: Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Chronic kidney disease, unspecified Sinoatrial node dysfunction Personal history of malignant neoplasm of kidney Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta |
allergies: codeine attending: chief complaint: altered mental status, suicide attempt major surgical or invasive procedure: icu stay with intubation to protect airway history of present illness: 37 yo m with pmh of dm ( insulin dosing) who presented to the ed after reportedly being found injecting heroin in the bathroom at . brought in by ems, initial fs 300s. in the ed, initial vs were temp:98.8 hr:106 bp:88/72 resp:12 o(2)sat:92. physical exam with somnolence awakening to voice and diffuse ronchi throughout. labs concerning for renal failure with cr 2.4 and wbc 12.7 with 19 bands. cxr with diffuse right sided process. patient was given naloxone, ondansetron, levofloxacin 750mg iv, vancomycin 1g, haldol 5 mg iv, lorazepam 2 mg iv x 4. blood cultures were obtained prior to antibiotics. patient then became more combative and was refusing antibiotics or further lab draws when awake, but quickly become more somnolent with decreased respiratory rate. given concern for poor respiratory status with risk of the patient not protecting his airway, he was intubated. right external jugular line was then placed. repeat cxr revealed worsening of the process involving his right lung. given 5 l (6th hanging) with sbp 95 so femoral line was placed to start vasopressors. on propofol gtt on transfer (initially given midazolam 5mg / fentanyl 200 mg but patient still agitated, not sedated). . upon arrival to the micu, patient is intubated and sedated. past medical history: per omr, cannot obtain further patient intubated diabetes - insulin dependent polysubstance abuse recent overdose: per mother 2 weeks prior on xanax 3 suicide attempts in last 3 months - cut wrists, twice od on xanax depression ingrown toenails social history: unable to obtain, patient is intubated per mother he recently had his marriage break-up. also had his girlfriend die of a heroin overdose approximately 1 month prior. previously director at department of youth services; but started using drugs about 7 years prior following a car accident. - tobacco: active use - alcohol: no per mother - : heroin, possibly percocet family history: noncontributory physical exam: admission physical: vitals: 102 (pr), 82, 92/53, 12, 98 on 100 fio2 general: sedated, intubated heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad, rij in place lungs: course with ronchi on r side, no wheezes or rales cv: tachycardic, regular, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge physical: vs: 99.3, 144/90, 67, 18, 97%ra general: slightly jittery, breathing comfortably heent: mmm, op clear, neck supple, jvd normal lungs: slight crackles in right lower lobe, otherwise clear to auscultation cv: s1s2, rrr, no m/r/g abd: soft, nt, nd, +bs, no rebound, no guarding, no organomegaly ext: wwp, 2+ peripheral pulses pertinent results: tte (complete) done at 1:58:07 pm the left atrium is mildly dilated. the estimated right atrial pressure is 10-15mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. there is a moderate sized (0.8cm2) mass in the left ventricular tract (clip ), which is a possible vegetation. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. impression: mild symmetric left ventricular hypertrophy with normal biventricular systolic function. a possible vegetation is present in the left ventricular outflow tract, recommend transesophageal echocardiography to further assess shoulder (ap, neutral & axillary) trauma left study date of 10:46 am findings: no previous images. the acromioclavicular and glenohumeral joints are well maintained. no evidence of acute bone or joint space abnormality. visualized portion of the left lung is clear. tee (complete) done at 2:52:14 pm no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no valvular masses or vegetations identified. cbc 05:10am blood wbc-8.2 rbc-3.57* hgb-10.6* hct-31.0* mcv-87 mch-29.8 mchc-34.3 rdw-13.1 plt ct-263 05:10am blood wbc-9.0 rbc-3.61* hgb-10.3* hct-30.4* mcv-84 mch-28.7 mchc-34.1 rdw-12.9 plt ct-240 05:45am blood wbc-9.0 rbc-3.72* hgb-11.0* hct-31.1* mcv-84 mch-29.6 mchc-35.3* rdw-12.8 plt ct-221 03:25pm blood wbc-15.5* rbc-3.75* hgb-11.3* hct-32.2* mcv-86 mch-30.2 mchc-35.2* rdw-12.9 plt ct-228 06:30am blood wbc-15.3* rbc-3.38* hgb-10.2* hct-29.7* mcv-88 mch-30.3 mchc-34.4 rdw-13.3 plt ct-214 08:12am blood wbc-12.0* rbc-3.35* hgb-10.4* hct-30.2* mcv-89 mch-31.1 mchc-35.1* rdw-13.2 plt ct-197 07:10pm blood wbc-12.7* rbc-4.17* hgb-12.9* hct-37.1* mcv-89 mch-30.8 mchc-34.7 rdw-13.4 plt ct-243 chemistry 05:10am blood glucose-185* urean-21* creat-0.7 na-135 k-3.9 cl-101 hco3-27 angap-11 05:10am blood glucose-218* urean-12 creat-0.7 na-136 k-3.8 cl-103 hco3-25 angap-12 05:45am blood glucose-218* urean-11 creat-0.7 na-135 k-3.8 cl-103 hco3-24 angap-12 03:25pm blood glucose-195* urean-12 creat-0.7 na-137 k-3.2* cl-103 hco3-25 angap-12 06:30am blood glucose-121* urean-15 creat-0.9 na-140 k-3.6 cl-108 hco3-25 angap-11 03:58am blood glucose-203* urean-29* creat-1.5* na-138 k-4.3 cl-107 hco3-24 angap-11 07:10pm blood glucose-288* urean-35* creat-2.4*# na-133 k-5.4* cl-98 hco3-22 angap-18 iron studies 06:30am blood caltibc-166* ferritn-193 trf-128* hepatitis studies 06:30am blood hbsag-negative hbsab-negative hbcab-negative 06:30am blood hcv ab-negative tox screen 07:10pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-pos barbitr-neg tricycl-neg brief hospital course: 37 yo m with pmh of polysubstance abuse and diabetes, presenting with heroin overdose and decreased respiratory rate, intubated in the ed for continued poor respiratory effort combined with combativeness and inability to protect airway. # respiratory failure: patient was intubated in the emergency department for inability to protect airway and combativeness and transferred to the icu. patient was found to have a pneumonia most likely from aspiration on chest x-ray. he was initially started on vancomycin and unasyn for concerns of aspiration and mrsa. he was extubated without incident on , was found to be stable on room air, and transferred to the general medicine floor for further managment. cxr repeated on the floor continued to show rml/rll infiltrate. sputum cultures showed pansensitive coagulase positive staph. once possibility of vegetation/endocarditis was ruled out with tee, he was switched to levofloxacin to complete treatment of his aspiration pneumonia. on discharge he has improved breath sounds and saturating well on room air. # leukocytosis: patient has multiple possible sources including aspiration pneumonia and recent iv drug abuse. blood cultures continue to show no growth to date. sputum culture grew pansensitive coag negative staph. tte was concerning for a possible vegetation in the lvot, but tee showed that there was no evidence of vegetation/endocarditis. patient was transitioned to levofloxacin, and did well on it, no longer spiking fevers and with normalization of white cell count. # ams: patient presented with decreased alertness on arrival secondary to toxic ingestion and heroin use. patient received narcan and was monitored carefully for withdrawal symptoms. patient is currently at his baseline. # suicidial ideation: per communication with ed physicians, patient intermittently endorsed suicidal ideation with possible intentional heroin overdose. he continued to endorse these thoughts after extubation once the patient was lucid. psychiatry saw the patient and sectioned him as he was a danger to himself. psych agreed that he needs inpatient level of care. patient is being discharged to a psychiatric facility for further management. # polysubstance abuse: patient reports heroin and vicodin use. social work and psychiatry were involved. he was monitored on ciwa scale for benzo withdrawal, but did not show any withdrawal symptoms. patient was on dilaudid prn for pain but this was tapered down. patient was agreeable to transfer to psych facility and with coming off of dilaudid on discharge. #. left shoulder pain - patient says he ran his shoulder into a doorframe prior to admission. plain films show no evidence of fracture. his pain is managed using naproxen and tylenol as needed. # renal insufficency: patient has an unclear baseline creatinine, but was found to have a creatinine of 2.4 on admission. this improved to normal ranges with iv fluids. # diabetes mellitus, type i: it is unclear what patient was taking at home for diabetes control. while admitted patient was maintained on glargin insulin 20 units qhs with a humalog sliding scale. medications on admission: insulin - unclear dosing discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 2. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. polyethylene glycol 3350 17 gram/dose powder sig: seventeen (17) grams po daily (daily) as needed for constipation. 6. levofloxacin 250 mg tablet sig: three (3) tablet po daily (daily) for 3 days. 7. naproxen 250 mg tablet sig: two (2) tablet po q8h (every 8 hours) as needed for pain. 8. lantus 100 unit/ml solution sig: twenty (20) units subcutaneous at bedtime. 9. humalog 100 unit/ml solution sig: per sliding scale units subcutaneous qac and qhs: please dose according to sliding scale. discharge disposition: extended care discharge diagnosis: primary diagnosis: respiratory failure secondary to heroin overdose suicide attempt with heroin overdose secondary diagnosis: depression diabetes - insulin dependent polysubstance abuse recent overdose: per mother 2 weeks prior on xanax 3 suicide attempts in last 3 months - cut wrists, twice od on xanax discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: you were admitted to for heroin overdose. during this admission you were admitted to the icu and intubated because of respiratory failure. you were also found to have an aspiration pneumonia for which you were treated with antibiotics. psychiatry saw you on this admission and they recommend that you get further care at a psychiatric facility. your medications have changed, please take only the medications as listed below. acetominophen 325-650 mg every 6 hours as needed for pain and fever docusate sodium 100 mg twice a day lantus insulin 20 units at night humalog insulin sliding scale before meals and bedtime levofloxacin 750 mg daily for 3 day naproxen 500 mg every 8 hours as needed for pain nicotine patch 21 mg daily miralax 17 g daily as needed for constipation senna 1 tablet daily if you experience chest pain, shortness of breath, or any other worrisome symptoms, please return to the emergency room followup instructions: please follow up with your primary care physician, . () in weeks once you have been discharged from the psychiatric facility. you will need a repeat chest x-ray. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Diagnoses: Tobacco use disorder Acute kidney failure, unspecified Depressive disorder, not elsewhere classified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Long-term (current) use of insulin Methicillin susceptible pneumonia due to Staphylococcus aureus Iron deficiency anemia, unspecified Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics Opioid abuse, continuous Poisoning by heroin Pain in joint, shoulder region Shock, unspecified Sedative, hypnotic or anxiolytic abuse, continuous |
allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with bare metal stent placement to svg-lad/d1 graft history of present illness: 80 year old male with history of cad s/p cabg (svg->lad-d1, svg->om rplb), a-fib on coumadin, cva presenting with new onset chest pain. pain had been occuring since yesterday morning. improved slightly with one sl ntg but was worse this am. he reports that the pain started when he was having a bowel movement, no associated sob, n/v, or diaphoresis. this pain did not feel like when he had his prior stents or cabg--at those times he did not have chest pain at all. in the ed, initial vitals were temp: 98.6 hr: 90 bp: 144/82 resp: 18 o(2)sat: 98 normal. labs and imaging significant for ekg with st depressions in lateral leads. cardiology was consulted and they recommended a heparin gtt and nitro gtt for ongoing chest pain. however, after about 1 hour, he was still having chest pain and a posterior lead ecg with 1 mm ste in v5, and 1/2 mm ste v4. thus, he was taken to the cath lab. in the cath lab, he had deployment of a bms to the svg-lad near the 1st diag. also administered metoprolol 12.5 mg, aspirin 325 mg, and lisinopril 5 mg. on arrival to the floor, patient is chest pain free. no compliants. review of systems on review of systems, he denies any prior deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, 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 chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: + hypertension 2. cardiac history: -cabg: -percutaneous coronary interventions: , 3. other past medical history: - embolic stroke in after pci c/b hemorrhagic conversion after receiving tpa - psoriasis - hypothyroid - afib social history: retired, lives with his wife. is a doctor . -tobacco history: none -etoh: none -illicit drugs: none family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. his son does have cad and is s/p mi with stent placement in his 50s. physical exam: admission physical exam: vs: t=afebrile, bp 154/85, hr 45, rr 10, o2 sat 97% 2lnc general: wdwn m in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 5 cm. cardiac: irrr, 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. extremities: no c/c/e. no femoral bruits. right groin with dressing c/d/i, no ecchymoses. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ radial 2+ left: dp 2+ radial 2+ . discharge physical exam: vs: tm 98.0 tc 97.3 bp 114-129/63-76 hr 51-97 rr 18 general: wdwn m in nad. mood, affect appropriate. heent: mmm, op clear neck: supple without appreciable jvd sitting up at 60 degrees. cardiac: irregularly irregular rhythm, normal s1, s2. no m/r/g lungs:nonlabored, ctab. abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. holds left arm in contracture. left leg in brace with decreased strength skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: admission labs: 08:20am blood wbc-4.9 rbc-4.46* hgb-13.5* hct-42.2 mcv-95 mch-30.4 mchc-32.1 rdw-15.0 plt ct-191 08:20am blood neuts-56.9 lymphs-30.9 monos-3.7 eos-7.7* baso-0.9 08:20am blood pt-19.5* ptt-37.8* inr(pt)-1.8* 08:20am blood glucose-104* urean-9 creat-0.9 na-142 k-4.6 cl-108 hco3-25 angap-14 08:20am blood ck(cpk)-76 08:20am blood ck-mb-4 08:20am blood ctropnt-0.03* 08:20am blood calcium-9.3 phos-3.2 mg-2.1 . cxr : ap and lateral views of the chest: patchy left mid lung lower opacities are best seen on the frontal view. heart size is top normal, slightly enlarged from . there is no pleural effusion or pneumothorax. sternotomy wires and cabg clips are again noted. small bowel appears minimally distended. hypodensities overlying the area of the gallbladder may represent cholelithiasis. impression: 1. patchy mid left lung lower opacities could be pneumonia in the correct clinical setting, otherwise, may represent atelectasis. 2. cholelithiasis. 3. slight small bowel distension. . cath : preliminary report - diffuse instent restenosis < 50% to lcx - lad: proximally occluded - lcx: no significant disease - rca: known occluded - svg-ramus-om: normal, provides collaterals to lad - svgy to lad and d1: proximally thrombotic occlusion, stent placed . tte : left atrium: dilated la. right atrium/interatrial septum: moderately dilated ra. left ventricle: normal lv wall thickness and cavity size. mild regional lv systolic dysfunction. doppler parameters are indeterminate for lv diastolic function. no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. focal calcifications in ascending aorta. normal aortic arch diameter. aortic valve: mildly thickened aortic valve leaflets (3). no as. mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. mild to moderate (+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. mild to moderate +] tr. normal pa systolic pressure. pulmonic valve/pulmonary artery: pulmonic valve not visualized. no ps. physiologic pr. pericardium: no pericardial effusion. regional left ventricular wall motion: conclusions the left atrium is dilated. the right atrium is moderately dilated. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with hypokinesis of the distal anterior wall, anteroseptum and of the apex. the distal inferior wall is probably mildly hypokinetic also. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: regional left ventricular systolic dysfunction consistent with cad (distal lad distribution). mild aortic regurgitation. mild to moderate mitral regurgitation. brief hospital course: principlereason for admission mr. is an 80 year old male with history of coronary artery disease (cad) status post cabg and pci who presented with chest pain x 24 hours with ekg showing st depressions in v3-v4 and posterior ekg with elevations. he underwent stenting with bare metal stent (bms) to svg/lad-d1 with resolution of his chest pain. . # non-st elevation myocardial infarction: his posterior leads showed st elevations and he was taken to the cath lab with successful deployment of bare metal stent (bms) to svg/lad-d1 via access in his right groin. he was monitored in ccu overnight and has been chest pain free since intervention. he had a transthoracic echo post-mi which showed apical hypokinesis in the lad territory but preserve ejection fraction at 45-50% and no diastolic dysfunction. he was started on plavix 75 mg daily and his atorvastatin was increased from 20 mg daily to 80 mg daily. lastly, his atenolol was converted to metoprolol in house and the dose was decreased to metoprolol succinate 12.5 mg daily due to pauses on higher doses. his discharge regimen was: asa 325 mg daily, plavix 75 daily, metoprolol succinate 12.5 mg daily, atorvastatin 80 mg daily, lisinopril 5 mg daily. # atrial fibrillation (afib): patient has afib and is on warfarin and atenolol at baseline. on admission he was subtherapeutic at 1.8 so he was bridged with heparin drip while his warfarin was restarted at home dosing 1 mg daily. on discharge, his inr was 2.5. he will have inr draw qweekly and followed by pcp, . . for rate control, his atenolol was changed to metoprolol. he was having several second pauses so the dose was down titrated to metoprolol succinate 12.5 mg daily. metoprolol was held day prior to discharge due to pauses and transient hypotension, which was fluid responsive, but was restarted when he was noted to increase his hr asymptomatically to 140's with exertion. # hypertension: the patient's bp was stable during his admission although slightly elevated at 150s early in his stay. he did develop transient asymptomatic hypotension day prior to admission which was fluid responsive. his goal bp is <140/80. he was continued on lisinopril 5 mg daily. metoprolol was dosed as above. by discharge his blood pressures were well controlled. chronic issues: # history of embolic stroke with hemorrhagic conversion: his afib was managed as above to prevent further strokes. he was also continued on keppra 500 mg daily for seizure prophylaxis. he was seen by physical therapy for his left hemiparesis and contractures and they felt that he was well compensated to go home. # hypothyroid: continued home levothyroxine 75 mcg daily. # psoriasis: continued clobetasol and desonide creams. . transitional issues: - please monitor his inr weekly and adjust the dose of warfarin as needed - please continue to monitor systolic blood pressures medications on admission: warfarin 1 mg daily lisinopril 2.5 mg qam asa 81 mg qam atorvastatin 20 mg qpm keppra 500 mg qpm atenolol 25 mg qpm levothyroxine 75 mcg qam clobetasol oint dovonex desonide cream discharge medications: 1. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. 2. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablets* refills:*0* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. levetiracetam 500 mg tablet sig: one (1) tablet po once daily at 4 pm. 5. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 6. clobetasol 0.05 % ointment sig: one (1) appl topical (2 times a day). 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. aspirin 81 mg tablet, effervescent sig: one (1) tablet, effervescent po once a day. 9. metoprolol succinate 25 mg tablet extended release 24 hr sig: 0.5 (one half) tablet extended release 24 hr po once a day. disp:*15 tablet extended release 24 hr(s)* refills:*2* 10. dovonex topical 11. desonide topical discharge disposition: home with service facility: homecare discharge diagnosis: primary diagnosis non-st elevation myocardial infarction hypertension 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 mr. , it was a pleasure taking care of you while you were here at . you were admitted to the hospital because you had chest pain. your ekg showed some changes in the electrical pattern of your heart, which indicated an impaired blood flow. thus, you underwent a procedure called cardiac catheterization to place a stent in your heart and open up the blood flow. your stent was placed in the bypass graft leading to your lad artery. after the procedure you did well and your chest pain resolved. the following changes were made to your medications: medications started: 1. plavix (blood thinner since you have the stent in your artery) 2. metoprolol succinate (toprol xl) a 25mg tablet daily (total 12.5mg) medications changed: 1. atorvastatin- increased from 20mg a day to 80mg a day medications stopped: 1. atenolol (blood pressure medicine similar to metoprolol) **continue taking your baby aspirin (81mg) by mouth once a day** follow-up needed for: 1. inr - make sure to have your inr checked the morning of your doctors with dr next week. it is also very important that you keep the follow-up appointments listed below. you should bring your medications to each so your doctors update their records and adjust the doses as needed. it was a pleasure taking care of you in the hospital! followup instructions: name: , l. location: healthcare - address: , , phone: : friday 11:45am Procedure: Insertion of non-drug-eluting coronary artery stent(s) Left heart cardiac catheterization Coronary arteriography using a single catheter Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Subendocardial infarction, initial episode of care Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Other complications due to other cardiac device, implant, and graft Epilepsy, unspecified, without mention of intractable epilepsy Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Other psoriasis Nonspecific low blood pressure reading Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Coronary atherosclerosis of unspecified bypass graft |
allergies: codeine attending: chief complaint: 16' fall off ladder major surgical or invasive procedure: none history of present illness: 66m fell off ladder, struck left side, with + loc. past medical history: hyperchol, htn social history: non-contributory family history: non-contributory physical exam: gen: nad neuro: a&ox3, ambulatory chest: ctab rrr abd: s/nt/nd ext: wnl pertinent results: 05:48am blood wbc-12.9* rbc-3.98* hgb-11.6* hct-33.0* mcv-83 mch-29.2 mchc-35.2* rdw-13.9 plt ct-253 05:48am blood plt ct-253 02:33am blood phenyto-7.9* 08:00pm blood phenyto-16.1 05:32am blood phenyto-16.3 05:48am blood phenyto-13.3 06:18am blood phenyto-13.2 brief hospital course: this is a 66 year old gentleman who was admitted with a 15' fall off a ladder, with positive loss of consciousness. he underwent a chest x-ray which showed no injuries. a ct of his head showed right frontal intraparenchymal hemorrhage with contusion, small bilateral subdural hemorrhages, and a large left frontal subgaleal hematoma. a ct of his cervical spine showed no injuries. on ct imaging of his torso, three vessel coronary artery disease involving the lad was observed, as were multiple renal cysts consistent with polycystic kidney disease, particularly in combination with his elevated serum creatinine. no injuries were identified however. plain films of his left shoulder and elbow showed a proximal humeral fracture. neurosurgery was consulted and recommended admission to icu with q1h neurochecks, serial head ct scans, and dilantin for seizure prophylaxis. orthopedics recommended a sling for comfort mr. was admitted to the trauma intensive care unit were he was monitored closely including q1h neuro checks, and was started on dilantin for seizure prophylaxis. on hd2, the patient was seen by physical therapy and occupational therapy. he was transferred to the floor, and in the course of the day became increasingly ataxic, dysarthric, and confused. a repeat ct of his head showed no interval changes, and neurology was consulted. they felt that the most likely cause of his symptoms was dilantin toxicity, recommended holding his dilantin and checking serial levels. they also suggested mri/mra of head and neck to rule out aneurysm, vertebral artery dissection or stroke. the patient became repeatedly agitated in ct, requiring two attempts to obtain the mri, as a result the mra of the neck was not done. mr right frontal hemorrhagic contusion and bilateral frontoparietal subdural hygromas, with frontal and right parietal subdural hematomas. no infarctions were seen. these findings in combination with the patient's improved mental status, dysarthria and ataxia prompted neurology to recommend cancelling the mra neck. at this time, the patient is stable, ready for discharge, and has been cleared by physical therapy. ot recommended home ot and 24 hour supervision. the family stated they would provide 24 hour supervision and would get vna/ot on monday. they adamantly stated they wished to take him home, and he is therefore discharged . medications on admission: lipitor 20, budeprion 150', lisinopril 20', fluoxetine 40' discharge medications: 1. bupropion 150 mg tablet sustained release sig: one (1) tablet sustained release po qam (once a day (in the morning)). 2. fluoxetine 20 mg capsule sig: two (2) capsule po daily (daily). 3. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 4. metoprolol tartrate 25 mg tablet sig: tablet po twice a day. disp:*60 tablet(s)* refills:*0* 5. phenytoin 50 mg tablet, chewable sig: tablet, chewables po please take two each morning, one at noon, two each evening. for 2 days. disp:*10 tablet, chewable(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: subdural hematoma, intraparenchymal hemorrhage, proximal humeral fracture, polycystic kidney disease discharge condition: good discharge instructions: you were admitted with a fracture of the humerus (the bone in your upper arm) and small amounts of blood in your head. please return to the emergency department or call for any of the following *new nausea/vomiting *excessive sleepiness or inability to wake up *new dizziness *new shortness of breath, chest pain *fever 101.4 f or greater *any other symptoms of concern on your ct scans we also found changes in your kidneys that suggest polycystic kidney disease, and coronary artery disease in three arteries in your heart. you should discuss these findings with your primary care physician. followup instructions: follow up with dr. , behavioral neurology in weeks after discharge for follow up of your traumatic brain injury. call for an appointment. followup with dr. in 8 weeks his number is (, please schedule a head ct at the same time as your appointment. followup with ortho trauma in weeks their number is ( followup with trauma clinic as needed, our number is ( md, Procedure: Closure of skin and subcutaneous tissue of other sites Diagnoses: Unspecified essential hypertension Accidental fall from ladder Home accidents Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration Polycystic kidney, unspecified type Open wound of elbow, without mention of complication Other closed fracture of upper end of humerus |
allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: pulmonary embolism intergluteal hematoma intracranial hemorrhage major surgical or invasive procedure: inferior vena cava filter placement history of present illness: ms. is a 79 year-old woman transferred from the hospital emergency department. she was recently living at rehab after a prior hospitalization at starting . at that time she sufferred intraventricular hemorrhage and interglutteal hemorrhage in her r iliacus muscle, leading to hct drop requiring 4 units prbc and icu level care. she stabilized and was transferred to rehab. . this morning, ms. was found cool, diaphoretic, and vomitting, followed by unresponsiveness. she was taken to the . there she was found to have extensive bilateral pulmonary emboli with rv dilatation (rv:lv ratio 2:1) as well as evidence of apiration. she received levofloxacin and ctx. she was transferred to ed. . on arrival, vs t 99.4, hr 110, bp 110/74, rr 22, o2 sat 82% on ra, 95% on 6l. she is on nc 4-6l now. given recent bleed, cardiac surgery was called and doesn't want to intervene. she was not heparinized due to recent bleed vs currently: 98, 113/72, 20, 96.3, 95% on 5 l nc past medical history: dementia/ alzheimer's disease hypothyroidism sensory motor neuropathy unsteady gait s/p multiple falls joint pain/arthropathy colitis osa social history: she lived with her husband and was independent in adls prior to transfer to rehab after her recent hospitalization. she denies etoh, tobacco. she is unwilling to provide further history. family history: noncontributory physical exam: vs: t 98, hr 92, rr 17, bp 125/61, o2 95% on 5l gen: crabby, reluctant to accept exam, appropriately conversational but only oriented x 2 (person, ) heent: perrl, mucosa moist resp: clear bilaterally cv: rv heave, prominent neck vein pulses, no murmurs abd: soft, nontender, pelvic ecchymoses extending around r flank and into buttocks ext: trace bilateral pitting edema skin: ecchymoses on pelvic, flank, buttocks neuro: oriented x 2, perrl, cn 2-12 intact rectal: deferred pertinent results: 01:13am ph-7.34* comments-green top 01:13am glucose-170* lactate-2.7* na+-138 k+-4.3 cl--100 tco2-27 01:13am freeca-1.18 01:10am urine blood-sm nitrite-neg protein-75 glucose-neg ketone-neg bilirubin-sm urobilngn-1 ph-6.5 leuk-tr 01:10am urine rbc-* wbc- bacteria-few yeast-none epi-0-2 01:05am ctropnt-0.15* 01:05am wbc-15.6* rbc-3.54* hgb-10.9* hct-32.8* mcv-93 mch-30.7 mchc-33.2 rdw-15.3 01:05am neuts-94.3* lymphs-2.1* monos-3.4 eos-0.1 basos-0.1 01:05am plt count-255 01:05am pt-13.7* ptt-23.0 inr(pt)-1.2* . cxr: there is mild cardiomegaly. bibasilar opacities left greater than right are consistent with areas of atelectasis. superimposed infection cannot be totally excluded. there is no pneumothorax or pleural effusion. . lenis: 1. thrombus in the left deep femoral vein at junction with superficial femoral vein, extending proximally in the common femoral vein for approximately 1 cm. 2. thrombus in one of the peroneal veins in the right calf. 3. non-visualization of peroneal veins in left calf. . head ct: impression: 1. previously visualized right occipital hemorrhage is no longer visualized. 2. ethmoidal and bilateral maxillary (greater on the left than the right) mucosal thickening. 3. evidence of old left frontal infarct as well as chronic small vessel ischemic disease. brief hospital course: mrs. was a 79 year-old woman with recent intracranial and intramuscular bleed on who presented from hospital with saddle pulmonary embolism. . # pulmonary emboli: she was found to have sub-massive pulmonary embolism on ct scan. she was initially admitted to the icu for additional monitoring. she was hemodynamically stable on admission and required 5l oxygen via nc to keep oxygen saturation above 93%. given her recent large intergluteal and smaller intracranial bleed, anticoagulation was witheld initially. cardiac surgery was consulted and did not advise an invasive procedures at that time. lower extremity ultrasound revealed extensive bilateral dvts. to protect her lungs from further embolic trauma, an ivc filter was placed. a tte demonstrated a dilated r ventricle without conclusive evidence regarding intracardiac shunt. cardilogy was consulted and determined that catheter-based embolectomy was not indicated. neurosurgery was alos consulted and determined that anticoagulation would be safe, however anticoagulation was withheld started due to concern for further intramuscular bleeding. her hematocrit was closely monitored and remained stable. in addition, general surgery was contact to determine stability of intragluteal bleed (that occured .) it was determined that her intragluteal bleed was stable and anticoagulation was initiated with weight based iv heparin without bolus on hospital day 3 (.) she was therapeutic on heparin iv and was started on coumadin on hospital day 4. she was maintained therapeutic on iv heparin until her coumadin was therapeutic for greather than 24 hours and then iv heparin was discontinued on hospital day 8. she remained therapeutic on coumadin for the remained for her admission. . she was also evaluated by phsical therapy and it was determined that she would benefit for physical rehabilitation after discharge. . # intracranial hemorrhage: she was evaluated by neurosurgery and determined to be stable for anticoagulation from a neurosurgical standpoint. a ct scan performed on revealed resolution of right occipital hemorrhage. she will continue to follow with neurosurgery as an outpatient. . # intergluteal hematoma: her intramuscular bleed was monitored with serial hematocrit checks that remained stable. there were no findings to suggest that her hematoma was not resolving. . # dementia with possible acute encephalopathy: her mental status waxed and waned, but was at baseline per her family. her namenda and donepazil were continued. she seldom became agitated in the evening and responded well to re-orientation in these circumstanses. she rarely required 2.5 mg of olanzapine for agitation that was not responsive to re-orientation. . # colitis: sulfasalazine was continued. . # hypothyroidism: levothyroxine was continued. . # communication: hcp is , cell , patient and daughters - (), daughter , and daughter medications on admission: neurontin 100 aricept 5 mg daily namenda 5 daily levoxyl 25 mcg daily omeprazole 20 daily calcium /vitamin d 600/400 mg sulfasalazine 500 tid discharge medications: 1. gabapentin 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. donepezil 5 mg tablet sig: one (1) tablet po hs (at bedtime). 3. memantine 5 mg tablet sig: one (1) tablet po daily (). 4. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. sulfasalazine 500 mg tablet sig: one (1) tablet po tid (3 times a day). 7. calcium 600 + d(3) 600-400 mg-unit tablet sig: one (1) tablet po twice a day. 8. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm: please check inr tomorrow . patient will be continued on warfarin for at least 3 months please verify with pcp to appropriate stop date. discharge disposition: extended care facility: house nursing and rehab ctr discharge diagnosis: pulmonary embolism intergluteal hematoma intracranial hemorrhage discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were tranfered to the for a clot that was found in your lungs. this clot made it difficult for you to breath. you had also had bleeds in your head and back from a prior injury on . you were evaluated and treated by the medicine service. when you arived, you could not receive blood thinning medication because of your head and back bleeds; instead you received a vein filter to protect your lungs form further clots. after further studies, your head and back bleeds were determined to be stable with the help of the neurosurgery and general surgery service. it was determined that you could safely reveive blood thinning medication to treat the blood clots in your lungs. your blood clots were treated with the appropriate medications and your breathing improved. the following changes were made to your outpatient medications: 1. you were started on coumadin 3mg daily, this medication need monitoring and adjustment at least every three days until your dose is stable. no other changes were made to your outpatient medications. please take your medications as prescribed and keep your outpatient appointments. followup instructions: department: radiology when: wednesday at 10:00 am with: cat scan building: cc clinical center campus: west best parking: garage department: neurosurgery when: wednesday at 11:00 am with: , md building: lm campus: west best parking: garage **you will need a referral from your primary care doctor for this appointment. please call your pcp to obtain this before your appointment. the fax number for this doctor if needed is .** Procedure: Interruption of the vena cava Angiocardiography of venae cavae Diagnoses: Other and unspecified noninfectious gastroenteritis and colitis Obstructive sleep apnea (adult)(pediatric) Unspecified acquired hypothyroidism Abnormality of gait Acute respiratory failure Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Other pulmonary embolism and infarction Delirium due to conditions classified elsewhere Acute venous embolism and thrombosis of deep vessels of distal lower extremity History of fall Arthropathy, unspecified, multiple sites |
allergies: spironolactone / prilosec attending: chief complaint: abdominal pain, hypotension major surgical or invasive procedure: : ercp with sphicterotomy and sphincteroplasty history of present illness: 67 yo m with copd on 2l home o2, chf, afib not on coumadin, pacemaker, dm2 presenting with abdominal pain. he had 3 episodes of abdominal discomfort over the past couple of months, each lasting for hours, associated with yawning, and without any clear association with meals. the patient developed severe abdominal pain during dinner last night at around 9 p.m. when he tried to get up, he became dizzy and had to lie down. he had one episode of non-bloody emesis and presented to hospital for further evaluation. . the patient reports abdominal pain as his primary symptoms, but hospital records, dyspnea was his chief complaint there. at hospital, the patient was found to be hypotensive to the 70s. his blood pressure rapidly improved with iv fluids. labs showed creat 1.2, dbili 0.6, tbili 1.3, ast 182, alt 137, amylase 1819, lipase >3000, troponin t 0.02 (neg), wbc 22, hct 46.5, plt 271 inr 0.96, digoxin 1.06, u/a neg. abg 7.36/69/74 on 2l nc. ct chest/abdomen with iv contrast showed non specific gallbladder wall thickening, mild to moderate fluid and stranding around the pancreas, no pe. the patient was given unasyn, flagyl, levalbuterol, methylprednisolone 125 mg iv, zofran, and fentanyl, and was transferred to for further management. . at , initial vital signs were 98.1 75 133/65 20 99% 2l. labs were notable for wbc 18.9, cr 1.5, alt 202, ast 289, ap 202, lipase 2527, lactate 1.2. abdominal ultrasound showed gallbladder filled with stones, with limited assessment of gallbladder wall due to stones, equivocal son signs due to diffuse abdominal tenderness, and a cbd that was dilated to 8 mm. surgery was consulted and recommended ercp, iv fluids, antibiotics, with likely cholecystectomy in the future. he was given morphine 4 mg iv and unasyn 3 gm iv. . on transfer to the icu, vital signs were 127/54, 76, 20, 99% 3l nc. he has 2 18-gauge peripheral ivs for access. . on arrival to the icu, the patient complaind of abdominal pain. he denies nausea, but has had a total of 2 episodes of non-bloody emesis, one at home and one in the ed. he had a soft bm this a.m. he had some shortness of breath initially but now feels that his breathing is at baseline. past medical history: chf - details unclear copd (2l home o2) dmii a-fib (not on coumadin) s/p pacemaker s/p appendectomy 12 years ago s/p bilateral inguinal hernias "bright's disease" at age 5 social history: prior etoh abuse, now <1 drink/week; never had alcoholic pancreatitis; quit smoking just under 4 years ago family history: non-contributory physical exam: admission exam: . general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated lungs: poor air movement throughout, minimal basilar rales, no wheezes or rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: quiet bowel sounds present, mildly distended, diffusely tender, especially in ruq and epigastrium, +guarding, especially in areas of maximal tenderness. ? signs gu: foley ext: warm, well perfused, trace bilateral le edema neuro: a+ox3. cn ii-xii intact. moving all extremities. . pertinent results: admission labs: 04:50am blood wbc-18.9* rbc-4.50* hgb-14.6 hct-43.0 mcv-95 mch-32.5* mchc-34.1 rdw-12.9 plt ct-218 04:50am blood neuts-95.6* lymphs-2.9* monos-1.3* eos-0.1 baso-0.2 04:50am blood pt-10.7 ptt-26.0 inr(pt)-1.0 04:50am blood glucose-207* urean-27* creat-1.5* na-139 k-5.2* cl-96 hco3-34* angap-14 04:50am blood alt-202* ast-289* alkphos-202* totbili-1.5 04:50am blood lipase-2527* 04:50am blood albumin-4.1 12:32pm blood calcium-9.1 phos-3.5 mg-2.4 05:19am blood lactate-1.2 microbiology: blood cultures no growth, urine cultures no growth, and c.difficile negative imaging: abdominal ultrasound: 1. thick walled contracted gallbladder filled with stones and sludge. no evidence of acute cholecystitis. 2. dilated common bile duct measuring 8 mm. 3. pancreas not visualized due to overlying midline bowel gas. cxr: in comparison with the study of , the patient has taken a better inspiration. continued enlargement of the cardiac silhouette without definite pulmonary vascular congestion. probable small effusions on the lateral view. some increased opacification at the left base medially is consistent with atelectatic change. pacer device remains in place. discharge labs: 06:05am wbc-11.1* rbc-3.09* hgb-9.8* hct-29.2* mcv-95 plt ct-240 glucose-59* urean-12 creat-0.9 na-143 k-3.7 cl-98 hco3-43* angap-6* brief hospital course: 67 yo m with copd on 2l home o2, chf, dm2, pacemaker, presents with shortness of breath and abdominal pain, with laboratory data and imaging studies concerning for gallstone pancreatitis. # pancreatitis: likely related to gallstones. cbd diameter of 8 mm is concerning for obstruction. ercp and surgery were consulted in emergency department, and patient underwent ercp with sphincterotomy/sphicteroplasty and removal of 8 stones and sludge. he was started and continued on unasyn for abdominal flora. he was started on ivf for his pancreatitis and his pain was controlled with dilaudid prn. following ercp he did well and had improved abdominal pain. his pain was controlled and he tolerated clear liquids well without nausea or emesis. following discharge from rehab he should follow-up with the acs service for a outpatient cholecystectomy. # post pancreatitis ileus the patient had significant abdominal distention following his transfer out of the icu without abdominal pain. an bowel regimen was started and he began to move his bowels. his diet was slowly advanced and he tolerated a regular diet prior to discharge. #persistent leukocytosis the patients peak wbc was 34k and gradually trended down. on the patient's empiric unasyn was stopped due to no obvious source of infection. his wbc continued to slowly trend down. # copd: patient is currently without respiratory distress, and he says his breathing is at baseline. however, he appears mildly dyspneic. he was placed on tiotropium and advair and his respiratory status stablized. on the day of discharge his serum hco3 was elevated, likely reflecting increased co2 retention in the setting of increased oxygen via nasal cannula the previous day in response to some subjective dyspnea in the absence of hypoxia. his supplemental o2 should be titrated to o2 saturation in the low 90s given his copd. # guaiac positive stools, anemia: patient's hct slowly trended down from admission in the setting of aggressive volume repletion. as he has recently established care with a new pcp his baseline hct is unknown. he was noted to have guaiac positive stools, but did not have any episodes of melena. he will need outpatient work-up including colonoscopy when he has recovered from his acute illness. # chf: in the setting of pancreatitis, patient requires aggressive hydration and his volume status was monitored given pt's history of chf. he was clinically monitored for fluid overload and his home furosemide, lisinopril and coreg were initially held in setting of pancreatitis and recent episodes of hypotension. a tte was done on the floor which revealed a normal ef and moderate pulmonary hypertension. his home medications were resumed once he was transitioned to po intake and tolerating diet without pain or gi symptoms. he had borderline low blood pressures, and so his lisinopril is currently at 5mg, decreased from his home regimen of 10mg. # dm2: his glipizide was held in the hospital and he was covered with sliding scale insulin. glipizide was resumed at discharge. # atrial fibrillation: patient was continued on home digoxin with good rate control, but his carvedilol was initially held in the setting of recent hypotension. patient was not on anticoagulation as outpatient, and was not started on systemic anticoagulation given possibility of repeat procedures. he was continued on aspirin. transition of care issues: 1. will need outpatient acs surgery follow-up regarding cholecystectomy timing. 2. follow up with pcp weeks following d/c from rehab 3. patient will need outpatient evaluation of his guaiac positive stools; he reports that he has never had a colonoscopy. medications on admission: ranitidine 150 mg coreg 3.125 mg digoxin 0.125 mg daily atrovent inhaler, as directed humalog 75/25 30 units qam and 20 units qpm albuterol inhaler albuterol nebs glipzide 5 mg mg oxide 400 mg combivent inhaler 2 puffs 3-4 times daily lisinopril 10 mg daily lasix 40 mg . (otc meds also on med list from , unable to verify with pharmacy) aspirin 81 mg daily thiamine 100 mg daily multivitamin 1 tab daily klor-con 40 mg daily discharge medications: 1. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 2. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. polyethylene glycol 3350 17 gram powder in packet sig: one (1) powder in packet po daily (daily) as needed for constipation. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. bisacodyl 10 mg suppository sig: one (1) suppository rectal 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. 8. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 9. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 10. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 11. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 12. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) inhalation inhalation (2 times a day). 13. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 14. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 15. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed for nasal congestion. 16. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 17. 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. 18. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 19. outpatient lab work please check a cbc and chem 7 in two to three days to ensure improvement in hco3 and stability of hct. discharge disposition: extended care facility: livingcenter - discharge diagnosis: gallstone pancreatitis ileus copd chf atrial fibrillation discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you intially presented to with abdominal pain and shortness of breath and you were transfered to for further management of pancreatitis and hypotension in the setting leukocytosis. imaging studies showed gallbladder edema and multiple stones. you had an ercp where multiple stones were removed. your course was complicated by an ileus, which slowly resolved. you were re-started on your home lasix and your respiratory status was stable on your home oxygen requirement of 2l. you were noted to have trace blood in your stools and you should undergo further evaluation as an outpatient which will likely include a colonoscopy. followup instructions: 1) follow up with pcp weeks after discharge from rehab 2) follow up with acs for timing of cholecystectomy Procedure: Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Pancreatic sphincteroplasty Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Other and unspecified alcohol dependence, in remission Chronic airway obstruction, not elsewhere classified Acute on chronic diastolic heart failure Other chronic pulmonary heart diseases Personal history of tobacco use Alkalosis Long-term (current) use of insulin Paralytic ileus Cardiac pacemaker in situ Nonspecific abnormal findings in stool contents Hyperosmolality and/or hypernatremia Abdominal pain, epigastric Other specified hypotension Acute pancreatitis Leukocytosis, unspecified Vomiting alone Calculus of gallbladder and bile duct without cholecystitis, with obstruction Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] |
allergies: keppra attending: chief complaint: sepsis major surgical or invasive procedure: right ij placement history of present illness: ms. is an 87yo f with a h/o meningioma resected x 2 (15 & 30yrs ago), vp drain in place, h/o sz, who presented to with at least 1 day of fevers and confusion. history is gleened from records as she is intubated and sedated. she saw her pcp , where she reportedly collapsed and was hypotensive and unresponsive. she was taken to the ed, where she had a temperature of 102.3 f, bp in the 90s down to the 80s, hr in the 90s, and she was intubated for airway protection. she was given peripheral dopamine in the ed there, which unfortunately infiltrated her antecubital fossa bilaterally. . she was admitted to the icu, where her wbc went from 8.7 on to 56.4 on with 41 bands. 2/2 blood cultures are growing gnr and her urine is growing lactose fermenting gnrs. she also had tbili of 3.0 (2.8 before transfer), an alp of 396 --> 220, alt 419 --> 311, ast 509 --> 287, amylase 641, and lipase 3811. a ct abdomen showed dilation of her cbd and intrahepatic ducts. gi was consulted who felt she had cholangitis due to biliary obstruction. she was started on ceftriaxone, levo, and vanc. id was consulted who recommending covering for urospesis and aspiration pna, and flagyl was added when the obstructed picture arouse. the dopamine was changed to norepi and rapidly weans in the micu. she was levo, ceftaz, and flagyl by transfer. she is being transfered to for possible since that is not done at on the weekends. . other results from are notable for a bicarb dropping from 27 on to 18 on , a lactate of 5.4 trending down to 2.6, and ce bump of troponin to 0.17 trending down to 0.08 (peak 0.17 at 0100 on ), cpk of 299 trending down to 211 (peak 299 at 0100 on ), and ck-mb which peaked at 5.1 at noon on the day of transfer. her increased cardiac enzymes were thought to be due to demand ischemia. her ekg was noted as no acute changes. . she was also given 5mg of iv vitamin k and 5mg po for inr 1.6. her hct dropped from 42 to 32 during her stay, felt hemodilution. . she had an eeg for her loc, which showed no seizure activity. ct head is reported as no acute change and meningioma and slit-like ventricles. neurology there recommended starting keppra. it was noted that she refused a shunt replacement a few years ago. . prior to transfer, her mechanical ventilation was psv15/5, fio2 35%, and small lung volumes. abg prior to transfer on psv 15/5 30% fio2 tv 400 was 7.40/24/325/14.3. micu events significant for: on am she underwent showing biliary ostruction but no cholangitis. while intubated she remained obtunded, not following commands. blood cultures from showed klebsiella resistant to ampicillin and pan-sensitive e coli. she was changed from keppra back to tegretol, associated with significant improvement in her mentation. she was then extubated but had copious respiratory secretions requiring frequent suctioning. also received ivf for pleural effusion. code status after discussion with patient's daughter was also changed to dnr/dni. . patient is very difficult to communicate with currently, as she is hypophonic and polish is her primary language. she however seems to understand english. her main complaint is that she "wants her ring and watch now." i spoke with her daughter , who states that her mother is much improved today in terms of alertness and is uncomfortable due to her pressure sore on her back. review of systems: unable to obtain past medical history: meningioma s/p resection x 2, drain in place seizure on carbamazepime hx of oophorectomy hx of pelvic fracture social history: former head and neck surgeon in poland. lives with daughter. tobacco or etoh. family history: nc physical exam: admission: gen elderly female with severe facial droop, edentulous vs 98.8 143/76 93 20 93% ra heent unable to examine due to collapse of oral tissues, hypophonic neck ecchymoses on left neck, no cervical lad, no obvious jvd cv rr no mrg pul decreased bs at bases, no rales extremities 1+ edema in hands/arms, 2+ in feet, pneumoboots on neuro limited due to cooperation but grossly intact strength and sensation in upper extremities with coordination of hands intact enough to try to remove my wedding band, moves lower extremities skin bandaged sacral ulcer with erythema and small area of skin breakdown without discharge or odor pertinent results: 10:31pm urine blood-tr nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-sm urobilngn-neg ph-5.5 leuk-neg 10:31pm urine color-yellow appear-clear sp -1.041* 10:31pm pt-17.9* ptt-35.6* inr(pt)-1.6* 10:31pm plt count-174 10:31pm neuts-96.8* lymphs-1.5* monos-1.4* eos-0.1 basos-0.2 10:31pm wbc-31.4* rbc-3.60* hgb-11.3* hct-33.3* mcv-93 mch-31.4 mchc-33.9 rdw-13.7 10:31pm tsh-1.6 10:31pm albumin-2.9* calcium-8.3* phosphate-2.5* magnesium-1.8 10:31pm ck-mb-4 ctropnt-<0.01 10:31pm lipase-16 10:31pm alt(sgpt)-321* ast(sgot)-224* ck(cpk)-60 alk phos-185* amylase-45 tot bili-2.1* 10:31pm estgfr-using this 10:31pm glucose-119* urea n-16 creat-0.6 sodium-138 potassium-3.5 chloride-110* total co2-18* anion gap-14 11:04pm freeca-1.24 11:04pm o2 sat-97 11:04pm glucose-119* lactate-1.6 k+-3.2* 11:04pm type-art temp-36.7 peep-5 o2-50 po2-95 pco2-27* ph-7.44 total co2-19* base xs--3 intubated-intubated ct head osh: 1. no acute hemorrhage or extra-axial fluid collection 2. essentially stable appearance of the left cerebellopontine mass since 3. interval resolution of the ventricular dilatation. slit-like appearance of the ventricles suggests possible csf hypotension. 4. mastoid sinus disease. . ct abd/pelvis osh: marked intrahepatic and extrahepatic biliary ductal dilatation without a focal lesion within the pacrease or near the ampulla. tiny focus of air seen adjacent to the ampulla could represent a duodenal diverticulum however a perforated duodenal ulcer cannot be completely excluded. large focus of extraluminal air seen adjacent to small bowel within the right inguinal hernia (most likely represents air within the bladder secondary to a foley catheter). bilateral lower lob consolidation or atelectasis with small bilateral pleural effusions. 05:10am blood wbc-11.7* rbc-2.87* hgb-9.0* hct-26.3* mcv-92 mch-31.2 mchc-34.1 rdw-14.8 plt ct-391 05:10am blood glucose-114* urean-13 creat-0.3* na-143 k-3.9 cl-111* hco3-27 angap-9 06:00am blood alt-39 ast-30 alkphos-185* totbili-0.6 04:23am blood alt-34 ast-27 alkphos-167* totbili-0.5 10:31pm blood lipase-16 10:31pm blood ck-mb-4 ctropnt-<0.01 04:23am blood albumin-2.8* calcium-8.1* phos-2.8 mg-2.1 06:00am blood caltibc-238* vitb12-1870* folate-9.3 ferritn-215* trf-183* 10:31pm blood tsh-1.6 micro: blood culture blood culture, routine-pending inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient stool clostridium difficile toxin a & b test-final inpatient swab r/o vancomycin resistant enterococcus-final inpatient mrsa screen mrsa screen-final inpatient mrsa screen mrsa screen-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient sputum gram stain-final; respiratory culture-final {yeast} inpatient : impression: a small zenker's diverticulum was found after examination with a gastroscope. successful intubation of the esophagus with a duodenoscope over a guidewire and with direct visual laryngoscopy. duodenoscope. the major papilla appeared prominent and was bludging. a single non-bleeding periampullary diverticulum with small opening was found at the major papilla. cannulation of the biliary duct was performed with a sphincterotome after a guidewire was placed. contrast medium was injected resulting in complete opacification. a moderate diffuse dilation was seen at the main duct with the cbd measuring 13-14 mm. there were no filling defects or strictures seen. a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. dark, clear bile drainined from the common bile duct after the sphincterotomy was performed. there was no sludge or pus seen. a 7cm by 10fr plastic biliary stent was placed successfully with excellent drainage of dark, clear bile after it was placed. recommendations: the findings of the are consistent with biliary obstruction, but not cholangitis. her obstruction may be due to papillary stenosis or a periampullary lesion. this could first be evaluated with mrcp as an outpatient. she will need a repeat in weeks for stent removal and possible sphincterotomy. brief hospital course: ms. is a 87 yo female with pmh of meningioma and seizure disorder who presented to on with urosepsis. she developed question of cholangitis and was transferred to icu for . . . # klebsiella and e coli septicemia, hypotension, uti, biliary obstruction, clinical cholangitis - this improved on broad spectrum antibiotics and she was narrowed to cipro monotherapy, following an () to relieve obstruction (s/p stent). gi recommended outpatient mrcp. she was extubated on . she will complete a 2 week course of antibiotics from her first negative culture (day 1: ). - converted cipro to oral (tolerating po's) will complete . - outpt follow up to remove biliary stent; scheduled . . #. cardiac: the patient ruled in for a type ii nstemi due to demand ischemia in the setting of hypotension and sepsis with positive troponins. there were no significant ekg changes. this was managed medically. if clinically appropriate, could consider outpatient cardiology evaluation; will defer to outpt providers. . #. seizure disorder: her imaging is stable from ; eeg did not show seizure. she was initiated on keppra at while intubated; this preceipated mental obtundation and was discontinued. keppra was added to allergy list. tegretol was initially held d/t dysphagia and was restarted on . - contin tegretol . # dysphagia: the patient failed speech and swallow evaluations on and . the patient and her daughter were strongly against ogt or ngt for enteral feedings. tpn was started as a temporary measure on with the understanding that this would only be continued for a maximum of a few weeks in hopes that the patient would regain swallowing function in the interim as she continued to recover from her critical illness. repeat s+s eval on revealed ongoing intermittent aspiration of her baseline ground solids and honey thickened liquids, consistent with or better than her previous baseline. pt and daughter accept risk of aspiration with resuming oral diet. pt had been found to have oral thrush and this was treated aggressively to maximize chance to tolerate oral diet (see below). pt received several days of tpn, now discontinued. - resumed ground solids, and honey-thickened liquids - pills crushed in puree. - encourage oral intake. . # oral thrush - fluconazole iv x 5 days; completed - received nystatin oral swabs as well . #. meningioma: baseline per radiology. . # acute renal failure: she suffered acute renal failure while critically ill; this resolved as she recovered hemodynamic stability with iv fluids. . # hoarseness/hypophonia - the patient developed hypophonia following extubation; suspect this was from mechanical ventilation. there was concern for unilateral vocal cord paralysis; thus ent was consulted. limited fiberoptic exam demonstrated normal vocal cord mobility. . # hemangioma, obstructive hydrocephalus s/p vp shunt - radiologic findings of possible overshunting but unclear if this is acute. patient prior to this hospitalization was clear-headed, communicative, and at baseline. given improvement in mental status and stability radiographically of the meningioma, doubt that this is clinically significant. also, at time of admission to , lp was considered given mental status change, but neurosurgery evaluation there indicated that there would be significant risk with the mass. her previous neurosurgeons are at . . # groin fungal rash: daughter had been refusing to allow use of antifungal creams. wound care d/w dtr, and now consenting. - clotrimazole cream . # code status: dnr/dni . dispo: to home with services today; declining rehab medications on admission: medications on transfer: lansoprazole 30mg qday keppra iv 500mg q 12 hrs levoflozacin 500mg iv ceftriaxone 2g q 12 hours flagyl 500mg iv q 8 hrs discharge medications: 1. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day): apply to red areas on groin. disp:*1 tube* refills:*2* 2. carbamazepine 100 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 3. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day). 4. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily) as needed for constipation: may purchase over the counter as miralax. 5. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 1 days. disp:*2 tablet(s)* refills:*0* 6. senna 8.8 mg/5 ml syrup sig: 10 ml po at bedtime as needed for constipation. disp:*1 bottle* refills:*0* 7. artificial tears drops sig: gtt ophthalmic prn as needed for dry eyes: may purchase over the counter. discharge disposition: home with service facility: caregroup vna discharge diagnosis: primary: septicemia cholangitis secondary: 787.20 dysphagia, unspecified secondary diagnosis: 424.1 aortic stenosis-insufficiency secondary diagnosis: 428.31 heart failure, (b1) acute diastolic secondary diagnosis: 707.20 ulcer, pressure secondary diagnosis: 285.9 anemia, unspecified secondary diagnosis: 599.0 urinary tract infection, bacterial discharge condition: severe facial droop, dysarthric level of consciousness:alert and interactive activity status:out of bed with assistance to chair or wheelchair discharge instructions: you were admitted with overwhelming infection. you required life support in the intensive care unit. you are now recovering well. you will complete a course of antibiotics tomorrow. you had difficulty swallowing after you were extubated. a repeat swallow evaluation on showed that you still aspirate some food, but you have decided to accept these risks and continue to eat. followup instructions: md: specialty: internal medicine/ pcp date/ time: thursday, , 1:30pm location: , phone number: ______________________________ provider: 2 (st-4) gi rooms date/time: 11:30 provider: , md phone: date/time: 11:30 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Endoscopic sphincterotomy and papillotomy Endoscopic insertion of stent (tube) into bile duct Diagnoses: Subendocardial infarction, initial episode of care Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Sepsis Candidiasis of mouth Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Benign neoplasm of cerebral meninges Pressure ulcer, lower back Other septicemia due to gram-negative organisms Acute diastolic heart failure Septicemia due to escherichia coli [E. coli] Obstruction of bile duct Presence of cerebrospinal fluid drainage device Pressure ulcer, stage II Dermatophytosis of groin and perianal area Dysphagia, unspecified Malnutrition of mild degree Diverticulum of esophagus, acquired |
allergies: no known allergies / adverse drug reactions attending: chief complaint: aortic intramural thrombus major surgical or invasive procedure: none history of present illness: 75 m presents from osh with concern for aortic dissection seen on ct abdomen. around 7 pm today he had sudden onset mid abdominal pain radiating to his back. pain was sharp, tearing . he denies having pain like this before. denies chest pain. his pain has resolved since he presented to . he did have 2 bouts of non-bloody, light brown emesis at the osh after getting pain medication. ct abdomen at demonstrates concern for an aortic dissection. a repeat ct torso was performed here. on review with radiology there is thrombus extending from just distal to the left subclavian artery and extends to the level of the sma. the mesenteric vessels (celiac, sma, and renal arteries) are not involved. past medical history: pmh: depression, gerd, hld, prior smoker (quit over 20 yrs ago) psh: tonsillectomy social history: sh: lives with wife at home. retired, used to work for airlines. quit smoking over 20 years ago. family history: mother - died age 32 after appendix surgery father - t2dm an died of lung ca sibs - 3 brothers - 2 with dm and depression, 1 half sister died at 16 of leukemia children - 3 sons and 1 daughter - recent diagnosed with bone marrow disorder initially felt to be sle physical exam: gen: nad, aox3 neck: no bruits cvs: rrr no m/r/g abd: s/nt/nd no bruits heard le: no lle pulse: femoral palpable bilaterally. dopplerable dp bilaterally and palpable pt bilaterally neuro exam: ms - pt repeats any phrases asked to him, and then will mumble incomprehensibly when asked orientation questions. pt is uncooperative with further questioning, but will follow some simple commands, like "lift your arm" cn - perrl 2.5-->1.5, eomi, tongue midline, no facial droop motor - pt is uncooperative with formal strength testing, but is easily antigravity in his ue's bilaterally, and is in grip bilaterally. in his rle, he is antigravity at the hip and knee and can also bend his knee and foot off the bed, so is at least throughout. in his lle, he is unable to lift his leg off of the bed or bend his knee in the plane of the bed, but can wiggle his toes and very minimaly flex and extend his foot at the ankle. reflexes - pt has intact and symmetrical reflexes in ue's. his r patellar reflex is 1, and he is otherwise without reflexes in his le's. his l toe is now upgoing, and his r is mute. sensory - pt is uncooperative with sensory exam, and responds "yes" to if he feels very sensation even when examiner is not touching him. gait - deferred. pertinent results: 08:28am blood wbc-11.1* rbc-4.01* hgb-12.2* hct-36.2* mcv-90 mch-30.5 mchc-33.7 rdw-14.1 plt ct-194 03:51am blood glucose-115* urean-24* creat-0.8 na-139 k-3.8 cl-102 hco3-31 angap-10 02:03am blood alt-44* ast-46* ld(ldh)-186 alkphos-48 amylase-65 totbili-2.9* dirbili-1.1* indbili-1.8 03:51am blood calcium-8.5 phos-2.7 mg-2.1 09:52am urine color-straw appear-clear sp -1.008 urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg urine rbc-1 wbc-1 bacteri-few yeast-none epi-0 cerebrospinal fluid (csf) wbc-1 rbc-43* polys-24 lymphs-68 monos-8 cerebrospinal fluid (csf) glucose-96 11:03 am csf;spinal fluid source: lp. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. findings: interval placement of a right-sided central venous catheter with tip in the distal superior vena cava. there is a widened mediastinum and rightward bowing of the trachea, correlating with aortic intramural hematoma evident on ct. cardiac and hilar contours are normal. minimal bibasilar atelectasis evident. minimal blunting of the right costophrenic angle likely reflects small right pleural effusion. no pneumothorax identified. impression: right-sided triple-lumen catheter with tip terminating in the distal svc. no pneumothorax. stable widened mediastinum correlating with known aortic intramural hematoma. small right pleural effusion. viral culture (preliminary): no virus isolated. cta: medialization of the common carotid arteries is noted. the partially imaged vertebral arteries are patent. similar to the prior examination, there is extensive intramural hematoma, beginning just beyond the level of the left subclavian origin and extending along the descending thoracic aorta. the overall extent of intramural hematoma in the descending thoracic aorta appears similar to the prior examination. active contrast extravasation into the intramural hematoma at the aortic arch (2:40), now currently measures 25 x 17 mm, increased since the previous examination (11 x 8mm previously). however, the extent of aortic caliber and intramural hematoma is little changed. above the diaphragmatic hiatus at approximately the level of t10 is an 11 x 5 mm new focus of contrast within the intramural hematoma. the diameter of the aorta at this level, however, is unchanged. intramural hematoma extends to the upper abdominal aorta. the celiac artery, superior mesenteric artery, and bilateral renal arteries (note is made of two right renal arteries) are all patent. contrast opacification in the upper abdominal aorta has increased compared to the study. the infrarenal abdominal aorta is normal in caliber and there is little intramural thrombus. the iliac arteries, common, internal, and external are normal in caliber. chest: new small bilateral pleural effusions with bibasilar dependent atelectasis are present. apical emphysema is present. the heart appears normal without pericardial effusion. no pathologically enlarged lymph nodes are present in the axilla, hilum, or mediastinum. a 9-mm nodule is present in the left lobe of the thyroid. abdomen: the spleen, adrenals, and pancreas appear normal. numerous gallstones are present in the gallbladder with minimal wall hyperenhancement which may suggest chronic inflammation, but this is little changed from the prior study. the enhancement of the liver appears homogeneous without arterial enhancing lesions. the kidneys enhance symmetrically without hydronephrosis. bilateral hypodense lesions which are too small to characterize are present. an exophytic cyst arising off the upper pole of the right kidney is unchanged. no free air or free fluid is present. a portacaval lymph node measures 14 mm (2:135) unchanged. stomach and abdominal loops of bowel appear normal. pelvis: the small amount of simple fluid is present in the deep pelvis, new. otherwise, bowel loops appear normal. the bladder is decompressed with a foley catheter. the prostate is enlarged measuring 5.7 cm in transverse dimension. bilateral fat-containing inguinal hernias are present. bone windows: degenerative changes are present in the thoracolumbar spine and at the right hip, but no suspicious bone lesions are present. impression: 1. intramural thrombus of the thoracic aorta. while the diameter of the aorta and the extent of intramural thrombus appears similar, there is one area of increased contrast extravasation into the intramural hematoma at the level of the aortic arch, and a new area of contrast extravasation into the hematoma at the level of t10. stable patency of the mesenteric vessels with stable abdominal aortic intramural hematoma. 2. no specific findings to explain the patient's parasthesia noting lack of spinal artery delineation by this type of study. a spinal mri may be helpful to further evaluate for spinal cord abnormalities including dedicated mr angiography of spinal vessels if clinically indicated. 3. new bilateral non-hemorrhagic pleural effusions with dependent atelectasis. 4. cholelithiasis. gallbladder findings may be due to chronic cholecystitis. 5. small amount of new ascites fluid in the pelvis, which could be due to third spacing. 6. medialized common carotid arteries. 7. left thyroid nodule. ct scan head: findings: this study is markedly limited secondary to patient motion. there is no definite intracranial hemorrhage, edema, shift of normally midline structures, hydrocephalus, or acute large vascular territorial infarction. the assessable aspects of the paranasal sinuses are clear. impression: markedly limited study secondary to patient motion. no definite acute intracranial process. liver us findings: the liver is normal in echogenicity and contour. no focal liver lesion is seen. the portal vein is patent with hepatopetal flow. no intra- or extra-hepatic biliary dilation is seen. the cbd measures 5 mm. the gallbladder contains stones and sludge. no wall thickening or pericholecystic fluid is seen. son sign was negative. the spleen is not enlarged, measuring 10.1 cm. no free fluid is seen. the pancreas is not well assessed due to overlying bowel gas. impression: cholelithiasis without specific signs to suggest cholecystitis. echo: the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). there is a moderate resting left ventricular outflow tract obstruction. 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 systolic anterior motion of the mitral valve leaflets. physiologic mitral regurgitation is seen (within normal limits). the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: small lv cavity size with hyperdynamic lv systolic function. consequently the mitral leaflets and chordae are pulled towards the hypertrophied upper septum during systole and a moderate lvot gradient develops. there is no lvh seen. mild aortic regurgitation. brief hospital course: the patient was admitted to the vascular surgery service on , with aortic intramural thrombus. to note pt is not an operable candidate. went to the cvicu with strict blood pressure control. was initially put on esmolol drip. iv hydration was started. cardiac surgery was also consulted. neuro: hd # 3 pt had new found parapalegis. lumbar drain was placed with goal icp less then 15. neurology was consulted for paralysis. he was uncooperative with examination he was usually agitated and did not follow commands. his examination was overall very limited. however, cn:ii-xii seemed to be gossly intact. he was moving his arms/hands well. he barely moved his toes in response to painful stimulation of the left leg. he had better movement in the right leg, but more detailed examination was limited. dtrs were 1+ in the arms & difficult to elicit in the legs. toes were mute. sensory examination could not be performed due to agitation & non-cooperation. pt neuro status did not improve while in the hospital. his lumbar drain was removed. he has appropriate folloe up. probable cause of paralysis is spinal infarct. cv: the patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. pt had strict bp contraol. initially pt on esmolol drip with a map < 90. hd # 3 with new onset paralysis. we changed the parameters with a new map greater then 100. neo initially to elevate bp. once his bp was stabalized he was transitioned to po medications. on dc he will be on lopresser 50 . pulmonary: the patient was stable from a pulmonary standpoint; vital signs were routinely monitored. gi: initially pt was made npo/ngt for gastric distention on ct scan. once the gastric distention was resolved pt diet was, which was tolerated well. he was also started on a bowel regimen to encourage bowel movement. pt did have us which showed cholelithiasis. gerd prophylactic with pantoprazole. hd # 4 his diet was advanced. pt was also started on megestrol acetate to increase appetite. pt has had kub - lots of stool. bowel regime. yhis has been an ongoing problem since admission. gu: pt recieved foley catheter. hd #7 foley was removed. he vailed voiding trial. foley put back in. started on flomax. can dc foley at rehab. endocrine: riss with goal of 150, this ssi was dc'd. bs stable on dc id: the patient's temperature was closely watched for signs of infection. prophylaxis: the patient received subcutaneous heparin during this stay, also had boots. at the time of discharge on pod#8 the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, voiding without assistance, and pain was well controlled has appropriated follow-up. medications on admission: none discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 3. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. olanzapine 5 mg tablet sig: one (1) tablet po bid (2 times a day). 7. megestrol 400 mg/10 ml (40 mg/ml) suspension sig: one (1) po daily (daily). 8. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 9. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 10. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for breakthrough pain. 11. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 13. flomax 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po once a day. 14. polyethylene glycol 3350 17 gram powder in packet sig: one (1) powder in packet po daily (daily) as needed for constipation. 15. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po once (once): prn for constipation. discharge disposition: extended care facility: hospital - discharge diagnosis: large type b aortic dissection extending from the left subclavian to the level of the sma with new significant leg weakness and sensory deficit concerning for spinal cord infarction discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: pt with new paraparesis (left much greater than right). his presentation is suggestive of a spinal cord ischemia/infarct. pt is a non operable candidate. pt is dnr / dni. pt may complain of pain. this is normal for this entity. followup instructions: provider: , md phone: date/time: 10:15 you have an appointment with dr . hrs. building, . please call . when pt gets to rehab facility, to confirm and give dr office your phone number. Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Intracranial pressure monitoring Magnetic removal of embedded foreign body from cornea Diagnoses: Other iatrogenic hypotension Esophageal reflux Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Hypoxemia Do not resuscitate status Dissection of aorta, thoracoabdominal Paraplegia Other alteration of consciousness Embolism and thrombosis of thoracic aorta Other specified retention of urine Cerebral thrombosis with cerebral infarction Other musculoskeletal symptoms referable to limbs Vascular myelopathies |
allergies: codeine attending: chief complaint: chief complaint: abdominal pain, nausea. reason for micu admission: hypotension to sbp 80s. major surgical or invasive procedure: none. history of present illness: this patient is a very nice 86-year-old woman with history of aaa (4.8 cm), with plans for aaa repair at hospital next week, who was in her usual state of health until yesterday afternoon when, after donating blood for her upcoming surgery, she developed lower abdominal pain with nausea. at hospital, she underwent ct /pelvis with findings concerning for ischemic colitis, which is why she was transferred to . in the ed, initial vital signs were tm 101.2, hr 82, bp 132/79, rr 24, satting 97% on 2l by nasal cannula. cxr showed no infiltrate. ekg with normal sinus rhythm, no ischemic changes. ct scan from osh was reviewed by our radiologists and showed thickening of the descending and sigmoid colon with sparing of the splenic flexure and rectum, concerning for ischemia. notably, her hematocrit was 27.7 down from 38 on the previous day (at hosp). her lactate was 1.1. other labs were notable for alt 80 and ast 134 with tbili of 0.4 and inr of 1.1. white count was 7.7 with normal lipase. creatinine was 1.2 (down from 1.4 at hospital yesterday). on exam, patient was noted to have left lower quadrant tenderness and bright red blood per rectum. she was hypotensive to sbp 80s, and was volume rescucitated with 1l ivf and 1u prbcs. urine output was reportedly 250cc. she was given zosyn 4.5 mg iv x1, morphine 4 mg iv x1, zofran 4 mg iv x1, and tylenol 1 gm x1. she was then admitted to the icu for further treatment. prior to admission, patient was seen by both vascular surgery and general surgery. they recommended for cipro/flagyl, transfusion, serial hematocrits and lactates. vascular also wanted cta to evaluate for bowel wall thickening, which would be highly suggestive of ischemic colitis (cta is more specific for this finding). at time of admission to the icu, patient had hypotension to sbp 80s. otherwise, says that abdominal pain has improved. she feels overall "much better" than yesterday. mild nausea, no vomiting. no chest pain or shortness of breath. she does endorse lightheadedness when sitting. no urinary symptoms. no headache. no respiratory complaints. past medical history: past medical history: --abdominal aortic aneurysm, 4.8 cm, currently undergoing evaluation for repair --peripheral vascular disease --coronary artery disease --hypertension --hypercholesterolemia --hyperglycemia (patient denies diabetes diagnosis) --history of dilated intrahepatic and extrahepatic pancreatic ducts, s/p ercp --temporal arteritis, on chronic low-dose prednisone past surgical history: --s/p cholecystectomy --s/p appendectomy --s/p hysterectomy --s/p left lung lobectomy for ?cancer --s/p exploratory laparotomy and loa/ileal segment resection in for volvulus and sbo social history: - tobacco: remotes history, <25 pk-yrs total - alcohol: denies - illicits: denies family history: non-contributory. physical exam: vitals: t: currently afebrile, bp: 114/40, p: 76, rr 18, 97% 2l general: elderly woman, frail appearing, in no apparent distress heent: perrla, non-icteric sclera, dry mm neck: supple, no lad lungs: clear bilaterally posterior fields cardiovascular: rrr, normal s1/s2 abdomen: mild llq tenderness without rebound or guarding, negative sign, active bowel sounds rectal: red blood on exam glove (per ed examination) extremities: warm, well-perfused, non-edematous pertinent results: labs at admission: 05:40am blood wbc-7.7 rbc-2.95* hgb-9.2* hct-27.7* mcv-94 mch-31.3 mchc-33.3 rdw-14.0 plt ct-118* 05:40am blood neuts-87.1* lymphs-8.8* monos-3.4 eos-0.3 baso-0.4 05:40am blood pt-13.0 ptt-28.6 inr(pt)-1.1 05:40am blood glucose-152* urean-26* creat-1.2* na-141 k-4.4 cl-110* hco3-24 angap-11 05:40am blood alt-80* ast-134* alkphos-98 totbili-0.4 05:40am blood totprot-4.8* 03:21pm blood calcium-7.0* phos-3.6 mg-1.6 05:40am blood cortsol-21.4* 05:49am blood lactate-1.1 labs at discharge: . micro data: . blood culture blood culture - no growth to date blood culture blood culture - no growth to date stool clostridium difficile toxin a & b test- pending mrsa screen mrsa screen-pending inpatient stool fecal culture-pending; campylobacter culture-pending; clostridium difficile toxin a & b test- negative urine urine culture- negative mrsa screen mrsa screen-final - positive blood culture blood culture - positive {streptococcus species}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final emergency blood culture blood culture - positive {streptococcus species}; aerobic bottle gram stain-final . imaging results: . cta/p: 1. thickening of the descending and sigmoid colon as described in the prior study without definite evidence of complicaions of mesenteric ischemia. given the patient's clinical presentation this remains a likely consideration and direct visualization should be considered for definitive evaluation and exclusion of inflammatory and infectious processes which also can produce wall thickening. 2. marked dilatation of the common bile duct, intrahepatic biliary system and pancreatic duct with possible mass of the duodenum at the ampulla. consider direct visualization by ercp or endoscopic ultrasound for further evaluation. 3. marked atherosclerotic vascular disease including the patient's known abdominal aortic aneurysm measuring 4.8 cm unchanged in appearance from the prior study with irregular plaque throughout its course as well as stenosis of the origins of the celiac artery, sma, and right renal artery. 4. occlusion of the right common iliac artery just inferior to the aortic bifurcation with reconstitution prior to the iliac bifurcation. high-grade stenosis of the left common iliac artery just inferior to the bifurcation. 5. left protrusio acetabuli. . tte the left atrium is elongated. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. physiologic mitral regurgitation is seen (within normal limits). the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. . impression: suboptimal image quality. mild aortic regurgitation. aortic valve sclerosis without discrete vegetation (does not exclude). normal biventricular cavity sizes with preserved global and regional biventricular systolic function. brief hospital course: an 86-year-old woman presents with abdominal pain, nausea, fever to 101, brbpr, and hematocrit drop in setting of recent blood donation for upcoming aaa surgery. she likely suffered transient ischemic colitis and developed streptococcus bovis bacteremia. she was treated with antibiotic therapy with resolution of her presenting symptoms. she will be followed up in the outpatient setting by her gastroenterologist regarding the significance of streptoccocis bovis. # hypotension: this patient presented with brbpr and hematocrit drop from 38 to 28 in setting of recent blood donation. suspect hypotension is secondary to blood loss versus hypovolemia. other considerations include infection (febrile in the emergency ) versus adrenal insufficiency. blood pressure is fluid responsive (patient now s/p 1l in the ed and receiving 3rd liter currently). patient without altered mental status although uop and cvp are low, suggesting intravascular depletion. patient was resuscitated with ivf and received 2u prbcs in total. her blood pressure came up with these interventions, and her hematocrit stabilized at 30. on the second hospital day, she began having fevers and blood cultures grew gram positive cocci, for which she was treated empirically with zosyn. on hd 6 her streptococci speciated to streptococci bovis. # streptococci bacteremia: on hd 2, the patient developed fevers and blood cultures grew gram positive cocci. she was treated emprically with zosyn for five days. a tte was performed and was not significant for vegetations, making endocarditis less concerning. on hd 6, blood cultures further speciated to streptococci bovis. infectious diseases was consulted to assist with appropriate therapy. a tee was deemed not necessary given prior tte. she was continued on ceftriaxone and flagyl was added for a total of 2 weeks antibiotic therapy. she should have blood cultures two weeks after antibiotic therapy is finished to be sure her blood cultures are clear. vascular surgery should be avoided until blood cultures demonstrate resolution of the infection. - 14 days of ceftriaxone and flagyl - blood cultures 2 weeks after discontinuation of antibiotic therapy # asymptomatic cbd dilatation: ms was noted to have have marked dilation of her common bile duct on ct abdomen. on review of her previous history, she was found to have cbd in at hospital and underwent extensive work-up with mrcp and swallow endoscopy which was unrevealing. concern when streptococcus bovis grew out in blood cultures given biliary dilatation and association with malignancy, although seeding may likely have occured to ischemic colitis. ms. d inpatient mrcp/eus. the significance of streptoccocus bovis and its association with malignancy was explained to ms. who understood the discussion. it is important that she receive an outpatient workup, colonscopy as soon as her ischemic colitis completely resolves. colonscopy deferred in inpatient setting given ischemic colitis. - gi follow-up: colonscopy, ercp/eus # abdominal pain and bright red blood per rectum: suspect ischemic colitis given history of abdominal pain preceding brbpr in setting of blood loss from donation. other considerations: infectious colitis, aortoenteric fistula, diverticulitis. she underwent cta with findings indicative of ischemic colitis. her abdominal pain and nausea improved with volume resuscitation and blood transfusions. # anemia: as above, baseline hct in ?mid-30s (was 38 prior to admission). suspect that hematocrit drop was secondary to blood donation yesterday and gi losses from ischemic colitis. she received in total 2 units of prbcs during this admission with stabilization of her hematocrit at 30. # transaminitis: patient without ruq pain; sign negative on exam. patient with history of dilated intra- and extrahepatic bile ducts, consistent with ct findings from this admission. her transaminases were downtrending on by hd 2. the increase was felt to be secondary to shock liver. # hypertension: her amlodipine and atenolol were held initially due to hypotension and were restarted. # hypercholesterolemia and vascular disease: hher statin was held initially given the elevated transaminase. aspirin was also for concern of active gi bleeding. with respect to the abdominal aortic aneurysm, she has been scheduled for an appointment with her vascular surgeon for follow-up . # hypothyroidism: she was continued on her home dose of thyroid replacement. the offices of ms. primary care physician, . , gi physician, . and vascular surgeon were notified of her admission and discharge summaries were faxed to each physician. medications on admission: --prednisone 5 mg once daily --levothyroxine --atenolol --simvastatin --aspirin --amlodipine discharge medications: 1. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 3. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 4. simvastatin 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. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 7. avapro 300 mg tablet sig: one (1) tablet po once a day. 8. vitamin d 400 unit capsule sig: one (1) capsule po once a day. 9. citracal regular 250-200 mg-unit tablet oral 10. multivitamin tablet sig: one (1) tablet po once a day. 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 12. ceftriaxone in dextrose,iso-os 2 gram/50 ml piggyback sig: one (1) intravenous q24h (every 24 hours) for 8 days. disp:*8 syringe* refills:*0* 13. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 8 days. disp:*24 tablet(s)* refills:*0* discharge disposition: extended care facility: , discharge diagnosis: 1. transient ischemic colitis, streptococci bovis bacteremia 2. abdominal aortic anyeurism 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 for treatment of transient ischemic colitis and positive blood cultures for the bacterium streptoccocus bovis. it is likely that when you were giving blood prior to your triple a repair, you experienced decreased blood flow to your intestinal tract causing a transient decreased oxygen supply. you were started on antibiotic therapy. our gastrointestinal team was consulted to help evaluate treatment. on ct imaging of your abdomen on admission noted dilation of your pancreatic ducts. this dilatation was evaluated by your gastroenterologist previously. it is imperative that you follow up with your primary gastroenterologist after this hospitalization for further evaluation, as this particular bacteria is sometimes associated with a malignancy. you will likely need a colonoscopy in the future for screening purposes. in addition to your regular medications: please continue to take intravenous ceftriaxone and oral metronidazole for a total of 2 weeks. you will need to have blood cultures drawn two weeks after finishing antibiotic therapy. please follow up with your primary care physician regarding these lab tests. you should not pursue any vascular surgery until these blood cultures are negative. you were also started on pantoprazole for your abdominal pain and gi bleeding. please continue to take this medications until directed otherwise by your primary care physician or gastroenterologist. followup instructions: name: , p address: ., , phone: appt: at 1:30pm name: , md address: 100 center ste 107c, , phone: appt: we are working on an appt with you within the next two weeks. the office will call you at home with an apt. if you dont hear from them by tomorrow, please call them directly to book an appt. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Other iatrogenic hypotension Thrombocytopenia, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute and subacute necrosis of liver Acute kidney failure, unspecified Unspecified acquired hypothyroidism Personal history of malignant neoplasm of bronchus and lung Hypopotassemia Other and unspecified hyperlipidemia Bacteremia Other specified disorders of biliary tract Abdominal aneurysm without mention of rupture Hypovolemia Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus Acute vascular insufficiency of intestine |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: cardiac catheterization with balloon angioplasty of the left main coronary artery history of present illness: 67m with cad s/p cabg , pci with des to lmca (required iabp), copd, lung ca s/p resection, h/o vt s/p icd, hl, dm, af with ppm in place who presented today for elective c. cath after experiencing worsening chf symptoms at home. pt has severe ischemic cardiomyopathy with an ef of 25% from echo. after his cath his symptoms of dysnpea improved until approximately 6 weeks to 1 month ago. he noted increasing doe, now becoming winded walking to mailbox. has to sleep sitting up. notes he has gained 10lbs in the past week with increasing le edema. no cp, no palpitations. presented to cardiologist 4 days prior to admission, who increased his spironolactone and arranged for elective cath at today. in cath lab this evening pt was hypotensive peri-cath requiring dopamine. he was noted to have eccentric restenosis of his lmca --> lcx stent which was dilated to 4.0 with ballon angioplasty. his lima to lad graft remained patent. he was admitted to the ccu for monitoring in the setting of his persistent pressor requirement. . upon arrival to the floor the patient's bps were in the 80s on low dose dopamine. he complained of a headache, otherwise had no other complaints. denied any chest pain, shortness of breath, palpitations, groin pain. was able to lay flat in the bed comfortably. no lightheadedness. he was pleasant, alert and oriented. his wife and daughter were with him and corroborated that he had taken all of his medications that morning. past medical history: 1. cardiac risk factors:: diabetes +, dyslipidemia +, hypertension + 2. cardiac history: -cabg: , lima to lad, svg to ramus, svg to rca. -percutaneous coronary interventions: : occlusion of svg to ramus, and svg to rca. native rca occluded. 30% lmca lesion and 80% ramus lesion. l subclavian stenosis found and stented. : 70% ostial cm stenosis and 3vd with patent proximal left subclavian stent, patent lima to lad. had des placed lmca --> lcx, required. required aibp at the time. -pacing/icd: icd placed in for primary prevention, dr, a 6949 right ventricular lead. has ppm in place. 3. other past medical history: lung cancer, s/p rul lobectomy chemo/rads copd gout htn hyperlipidemia af home 02 (2l nc) prn social history: pt is a retired engineer, lives with wife in . -tobacco history: quit smoking: , 45 year smoking history -etoh: rare -illicit drugs:none family history: father had cabg in 60s, died at 81, mother with fatal mi at 71. physical exam: vs 97.2 75 (a-paced) 87/44 22 97% 3l nc general: middle aged man, lying flat, nad heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp to angle of mandible cardiac: regular rate/rhythm. 2/6 systolic murmur. lungs: unlabored breathing. no crackles. coarse expiratory wheezes throughout anterior and lateral fields. abdomen: soft, ntnd. no hsm or tenderness. extremities: 1+ ankle edema b/l. venous sheath in l groin, no hematoma, non-tender. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right:dp 1+ pt 1+ left: dp 1+ pt 1+ pertinent results: ***labs on admission*** 08:36pm wbc-7.6 rbc-4.04* hgb-12.6* hct-36.1* mcv-89 mch-31.3 mchc-35.0 rdw-15.0 08:36pm plt count-221 08:36pm pt-17.1* ptt-52.7* inr(pt)-1.5* 08:36pm glucose-127* urea n-18 creat-1.2 sodium-139 potassium-4.1 chloride-97 total co2-33* anion gap-13 08:36pm calcium-9.3 phosphate-3.4 magnesium-2.2 ...... ***labs during stay*** 04:46am blood wbc-6.5 rbc-3.95* hgb-12.3* hct-35.4* mcv-90 mch-31.2 mchc-34.8 rdw-15.1 plt ct-190 04:46am blood glucose-86 urean-15 creat-1.1 na-138 k-4.1 cl-97 hco3-35* angap-10 04:46am blood ck(cpk)-63 04:46am blood calcium-8.8 phos-4.0 mg-2.2 . ***imaging*** cxr findings: comparison is made to previous study from . pacemaker and median sternotomy wires are unchanged. there remains an enlarged cardiac silhouette. there is again seen some deformity of the right upper rib cage which is stable. scarring is seen within the right apex. there is no signs of overt pulmonary edema. there is likely small bilateral pleural effusions however these are unchanged since the previous study. . cath (prelim report, not logged on discharge) right dominant lmca: eccentric 70% re-stenosis in lm/cx stent lad: fills via lima lcx: no significant disease distal to stent rca: known occluded intervention: instent re-stenosis dilated with 4.0 cutting balloon and 4.0 nc balloon. . hemodynamics: ao 80/51 mean 63 pcw mean 15 pa 40/20 mean 29 rv 40/6 ra mean 10 brief hospital course: 67m with cad and severe ischemic cardiomyopathy presented for cardiac cath in the setting of worsening chf symtoms with balloon dilation of lmca stent, admitted to ccu for monitoring of his hypotension requiring pressors. . # pump: chronic systolic heart failure, ef 25% in . has icd in place. hypotensive to 70s in cath lab requiring dopamine. upon arrival to the ccu patient with persistent low dose requirement. per outpatient cardiologist and patient he tolerates sbps in 80s with minimal orthostasis. pt seems to be in class iii nyha heart failure at home, with worsening at home lately resulting in this presentation. patient was weaned off of pressors. initially held ace inhibitor in the setting of hypotension was restarted once pressures stabilized. patient was continued on outpatient digoxin. patient continued on aspirin and statin. patient was discharged on ace inhibitor at outpatient dose. atenolol was lowered given low blood pressure. . # coronaries: known cad, with occluded vein grafts, rca. patent lima to lad. lmca to cx ballooned on admission. pt's worsening symptoms potentially in setting of in-stent stenosis. patient was continued on asa. patient will require plavix for at least one year, ideally indefinitely. patient was continued on statin. initially held acei and bb tonight in the setting of hypotension. discussed medications for discharge with outpatient cardiologist and decided to discharge patient on decreased dose of atenolol given baseline hypotension. . # rhythm: pt has history of vt (without icd shocks) and af, has icd/ppm in place, currently a-paced at 75. patient is maintained as outaptient on quinidine which was continued through admission and on discharge. initially beta blocker held in the setting of hypotension restarted on discharge. patient is not on anti-coagulation as an outpatient even with history of atrial fibrillation and low ejection fraction. defer to outpatient cardiologist for this management. patient was dischaged on beta blocker, quinidine. . # copd: on home 02, per report has fairly severe disease, and has a history of rul lobectomy for lung ca. on admission patient had wheezing. patient was continued on home formeterol, fluticasone and given nebs of ipratropium, albuterol. patient not on long acting anti-cholinergic as outpatient, would consider outpatient addition of long acting anti-cholinergic. patient was continued on prn albuterol and supplemental oxygen. . # gout: pt complaining of increased pain similar to his gout pain in r foot. normally takes indomethacin at home, but holding in setting of recent cath. patient was given tylenol as needed to improve pain, but pain persistented. discussed case with rheumatology who suggested colchicine and prednisone for a few days and to avoid indomethacine given recent catherziation. . fen: regular heart healthy diet. fsbs iss prn. no ivf for chf/low ef . access: piv's . prophylaxis: hep sc, bowel regimen. . contact: wife, (home) (cell) . code: confirmed full medications on admission: aspirin 325mg daily flunisolide 250mcg 2 puffs atenolol 100mg daily rosuvastatin 40mg daily clopidogrel 75mg daily digoxin 125mcg mwf formoterol 12mcg 1 flunisolide nasal spray 29mcg 2 sprays furosemide 60mg daily lisinopril 2.5mg daily mom 50mcg 1 nasally ntg sl prn albuterol 1-2 puffs prn (pt states he uses ) quinidine 324mg qid spironolactone 25mg every other day alternating with 50mg discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. flunisolide 250 mcg/actuation aerosol sig: two (2) inhalation twice a day. 3. rosuvastatin 20 mg tablet sig: two (2) tablet po daily (daily). 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 5. digoxin 125 mcg tablet sig: one (1) tablet po 3x/week (mo,we,fr) as needed for heart failure. 6. formoterol fumarate 12 mcg capsule, w/inhalation device sig: one (1) inhalation twice a day. 7. flunisolide 29 mcg aerosol, spray sig: two (2) sprays nasal twice a day. 8. lasix 20 mg tablet sig: three (3) tablet po once a day. 9. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. 10. mom 50 mcg/actuation spray, non-aerosol sig: one (1) nasal twice a day. 11. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tables sublingual as needed. 12. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation as needed as needed for shortness of breath or wheezing. 13. quinidine gluconate 324 mg tablet sustained release sig: one (1) tablet sustained release po q6h (every 6 hours). 14. spironolactone 25 mg tablet sig: one (1) tablet po every other day: alternate with 50mg spironolactone. 15. spironolactone 50 mg tablet sig: one (1) tablet po every other day: alternate with 25mg spironolactone. 16. atenolol 50 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 17. prednisone 20 mg tablet sig: one (1) tablet po once a day for 2 days: take 1 tablet on monday and 1 tablet on tuesday . disp:*2 tablet(s)* refills:*0* 18. colchicine 0.6 mg tablet sig: one (1) tablet po twice a day for 2 days. disp:*3 tablet(s)* refills:*0* 19. mom 50 mcg/actuation spray, non-aerosol sig: one (1) nasal twice a day. discharge disposition: home discharge diagnosis: priamry: coronary artery disease, congestive heart failure . secondary: copd, lung cancer, atrial fibrillation discharge condition: stable vital signs, at baseline discharge instructions: you were admitted for elective cardiac catheterization. at catheterization you were found to have a partial blockage which we opened with a baloon angioplasty. your blood pressure was low after the procedure and you were observed overnight in the ccu. you blood pressure returned to your previous baseline. . please continue to take your medications as ordered. the following changes were made: - decrease atenolol to 50mg po daily - 3 days of steroids and colchicine in the setting of acute gout flare . please continue to take your plavix (clopidogrel). this medication is very important for keeping the arteries of your heart open. . please attend your follow up appointments. . please weigh yourself every morning and call your doctor if you gain more than 3lbs in 1 day or 5lbs in 1 week. . please adhere to 2000mg sodium diet. . please call your doctor or come to the nearest emergency room if you experience chest pain, shortness of breath, swelling, loss of consciousness, palpitations, bleeding, or other concerning symptoms. followup instructions: please make an appointment to see your cardiologist dr. within 2 weeks of discharge. you can reach him at (. in addition, you should follow up with your primary care physician . ( with 2 weeks of discharge. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Other and unspecified coronary arteriography Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Coronary atherosclerosis of autologous vein bypass graft 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 bronchus and lung Chronic kidney disease, unspecified Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Chronic systolic heart failure Other complications due to other cardiac device, implant, and graft Automatic implantable cardiac defibrillator in situ Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Chronic obstructive asthma, unspecified Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Chronic total occlusion of coronary artery Other dependence on machines, supplemental oxygen Acquired absence of organ, lung |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypotension major surgical or invasive procedure: right ij cvl placement intubation bronchoscopy lung biopsy via repeat bronchoscopy history of present illness: mr. is a 68 year-old male with cad s/p cabg , copd on home o2, prior lung cancer (s/p rul lobectomy), vt s/p icd, hyperlipidemia, type ii diabetes mellitus, and atrial fibrillation who was transferred from outside hospital for management of hypotension. patient presented to on the afternoon of his admission on with sytolic blood pressures in the 70's. he was intubated, given ivf, started on levophed and dopamine, given broad spectrum antibiotics, decadron and nebulizers. he was then sent to ed for further evaluation. . per the patient's wife he was recently admitted to for a copd exacerbation requiring icu admission but he had not needed intubation. he was discharged on a lengthy prednisone taper. following discharge he remained short of breath, wheezy, and continued to have a productive cough at home. he also developed neck pain and shoulder pain over day prior to this presentation. on he became febrile to 101.1f. he saw his pulmonologist in clinic and was prescribed another course of antibiotics. then, on the way home from this appointment he was complaining of feeling worse weakness. when patient and wife arrived at home he was too weak to even stand up and fell to the ground exiting the car. his wife activated 911. . when patient arrived to ed, his pressors had been tapered to solely levophed and systolics were in the 80's. he was started back on neosynephrine, bolused a total of 5 liters, and started on heparin gtt given concern for pulmonary embolism. he was also given a dose of cefepime and tamiflu along with solumedrol 125mg iv x 1. he had atrial fibrillation with rvr to the 170's and bp again dropped to 70's. at this point levophed was weaned down. notably ecg showed st depressions in v1-v4 which appeared similar to prior tracings. he was seen by the cardiology fellow who suggested amiodarone if atrial tachycardia recurs. patient transferred to micu for further management. . please see hospital course details below for icu course summary. past medical history: -type ii diabetes -coronary artery disease: cabg done in , lima to lad, svg to ramus, svg to rca. additional pci : des placed lmca --> lcx, required. required aibp at the time. ventricular tachycardia: icd placed in for primary prevention ( dr, a 6949 right ventricular lead. has ppm in place) -lung cancer, s/p rul lobectomy chemo/rads -copd, on home oxygen -gout -hypertension -hyperlipidemia -atrial fibrillation social history: patient is a retired engineer, lives with wife in ma. prior to this admission the patient was needing more supervision as he easily gets confused and was often disoriented. he smoked 1ppd for nearly 45 years and quit in . rare etoh use and no prior illicit drug use. family history: father had cabg in 60s, died at 81, mother with fatal mi at 71. physical exam: admission physical exam: general: intubated, sedated heent: nc/at, perrl, op clear neck: supple, no lad lungs: anterior lung fields clear to auscultation bilaterally, no wheezes or crackles heart: tachycardic, s1/s2 present, no murmurs abd: +bs, soft, non-tender, non-distended ext: no lower extremity edema, warm, well perfused skin: right wrist erythema with raised circular lesion . no discharge exam: patient was pronounced dead on at 4:20pm. pertinent results: admissions labs: . 08:44pm urine rbc-* wbc-0-2 bacteria-occ yeast-none epi-0-2 08:44pm urine blood-mod nitrite-neg protein-25 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 08:44pm urine color-straw appear-clear sp -1.011 08:44pm plt smr-low plt count-140* 08:44pm pt-13.2 ptt-27.9 inr(pt)-1.1 08:44pm hypochrom-1+ anisocyt-normal poikilocy-occasional macrocyt-normal microcyt-normal polychrom-normal ovalocyt-occasional 08:44pm neuts-92* bands-5 lymphs-0 monos-3 eos-0 basos-0 atyps-0 metas-0 myelos-0 08:44pm wbc-21.0* rbc-3.67* hgb-11.0* hct-32.9* mcv-90 mch-29.9 mchc-33.4 rdw-15.7* 08:44pm calcium-7.4* 08:44pm ctropnt-0.06* 08:44pm ck-mb-5 probnp-4087* 08:44pm alt(sgpt)-19 ast(sgot)-26 ck(cpk)-179 alk phos-50 tot bili-0.9 08:51pm glucose-167* lactate-1.0 na+-130* k+-4.4 cl--95* tco2-25 08:51pm comments-green top 10:39pm type-art rates-16/4 tidal vol-450 o2-100 po2-366* pco2-56* ph-7.24* total co2-25 base xs--4 aado2-306 req o2-56 intubated-intubated vent-controlled 11:30pm type-art po2-108* pco2-52* ph-7.25* total co2-24 base xs--4 . . . microbiology studies: 6:35 pm catheter tip-iv source: femoral line. wound culture (final ): no significant growth . blood culture, routine (final ): staph aureus coag +. final sensitivities. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s . 10:04 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): commensal respiratory flora absent. staph aureus coag +. sparse growth. of two colonial morphologies. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s 4:51 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. . 2:40 pm bronchoalveolar lavage / **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~/ml commensal respiratory flora. . urine culture (final ): no growth. urine culture (final ): no growth. urine culture (final ): no growth. . blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. ============================================== imaging: tte : the left atrium is elongated. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe regional left ventricular systolic dysfunction with thinned inferolateral and inferior wall akinesis/dyskinesis and anterolateral hypokinesis. overall left ventricular systolic function is severely depressed (lvef= 25 %). the right ventricular free wall is hypertrophied. 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. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. an eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild to moderate pulmonary artery systolic hypertension. the pulmonic valve leaflets are thickened. there is a trivial/physiologic pericardial effusion. there is an anterior space which most likely represents a promient fat pad. compared with the prior study (images reviewed) of , the severity of mitral and aortic regurgitation has increased. regional left ventricular systolic function may be slightly worse. no vegetations identified. if clinically indicated, a transesophageal echocardiographic examination is recommended to evaluate for endocarditis. ------ tee : no valvular or lead vegetations seen. mild to moderate aortic regurgitation. moderate mitral regurgitation. complex (>4 mm, non-mobile) atheroma in the descending aorta and aortic arch. depressed biventricular systolic function. . cxr: markedly abnormal radiograph with no comparison available. endotracheal tube is slightly high. consider advancement by 2.5 cm for optimal placement. there is a right upper chest thoracoplasty which results in significant distortion of the normal anatomy. patchy foci of opacity, particularly in the lateral left lung may represent foci of pneumonia or aspiration. . cxr: bibasilar atelectasis and bronchiectasis persist, left greater than right. small layering left pleural effusion is unchanged. there is no pulmonary edema. right upper thoracoplasty changes are noted. monitoring and support devices are stable in course and position. there is no pneumothorax. multiple calcified gallstones are seen in the right upper quadrant. . cxr : changes of right upper lobectomy and thoracoplasty are present. there is persistent bibasilar atelectasis, left greater than right. a small left pleural effusion is unchanged. mild cardiomegaly is stable. mediastinal clips and median sternotomy wires are well aligned. a right picc terminates at the cavoatrial junction. a left chest wall pacemaker has leads in the right atrium and ventricle. a dobbhoff tube courses into the abdomen and beyond the film. there is no pneumothorax. calcified gallstones are again noted in the right upper quadrant. . cxr: changes of right upper lobectomy and thoracoplasty are again seen. there is persistent bibasilar atelectasis, left greater than right. no focal consolidation is appreciated. probable small bilateral layering effusions are present. the cardiomediastinal and hilar contours are normal. monitoring support devices are unchanged in course and position. a right picc is indistinctly seen at the level of the clavicle. there is no pneumothorax. calcified gallstones are noted in the right upper quadrant. . cxr: in comparison with the study of , there is little change. monitoring and support devices remain in place. continued increased sharpness of the left hemidiaphragm, consistent with improved aeration at the left base.nevertheless, there are continued low lung volumes and bibasilar atelectatic changes. . cxr: as compared to the previous radiograph, there is no relevant change. the minimal further improvement of ventilation in the region of the pre-existing retrocardiac and left basal opacity. otherwise, unchanged appearance of the lung parenchyma, the cardiac silhouette and the chest wall. . cxr: pulmonary edema previously, it is gone now. multiple foci of atelectasis in the left lung are stable. heart is borderline enlarged. new feeding tube with the wire stylet in place ends in the stomach. gallstones noted in the right upper quadrant. transvenous right atrial pacer and right ventricular pacer leads follow their expected courses. no pneumothorax. small left pleural effusion or pleural thickening is longstanding. . lung pathology from fna / biopsy with bronchoscopy lul : lung (left upper lobe), fine needle aspirate: positive for malignant cells, consistent with squamous cell carcinoma. . admission ct imaging: chest/abd/pelvis report ct of the chest without contrast: there is a small left-sided pleural effusion. the patient is status post right upper and right middle lobectomies. there is a small right-sided pleural effusion and small areas of loculated fluid near the apex. there is bibasilar atelectasis. right chest wall deformity is present from prior thoracotomy. there are prominent coronary artery calcifications. a small linear area of fat density is noted along the left ventricle, consistent with fatty deposition. the patient has a pacemaker with leads in right atrium and ventricle. there is a left subclavian stent. the endotracheal tube ends approximately 4.0 cm above the carina. patient is status post sternotomy and cabg. ct of the abdomen without contrast: the non-contrast appearance of the spleen, adrenal glands, stomach, and intra-abdominal loops of bowel are within normal limits. the liver demonstrates a small area of pneumobilia in the left lobe of the liver. there are multiple, calcified gallstones within the gallbladder. the common bile duct and pancreas are within normal limits. the kidneys are slightly small bilaterally. there are prominent renal vascular calcifications. there is no retroperitoneal or mesenteric lymphadenopathy. there is no free air or free fluid. there is a small fat-containing umbilical hernia. an ng tube ends within the stomach. . ct of the pelvis without contrast: the rectum, prostate, and intrapelvic loops of bowel are within normal limits. a foley catheter is noted within a decompressed bladder. there is no free air or free fluid. there is no pelvic or inguinal lymphadenopathy. the patient is status post placement of right femoral venous line, which ends in the right iliac vein just prior to the bifurcation. areas of stranding and small foci of air within the right groin are likely due to recent line placement. there is dense calcification of the abdominal and pelvic arterial vasculature. bone windows: no concerning osseous lesions are identified. mild degenerative changes are noted most prominently in the lumbar spine. impression: 1. no acute intrathoracic or intraabdominal process. 2. status post right upper and right middle lobectomies with corresponding chest wall deformity. small areas of loculated fluid noted at the right lung apex. small left-sided pleural effusion. 3. cholelithiasis. . ========================================== ekgs: - rate 105, sinus tachycardia with ventricular premature beat versus aberrant conduction. -rate 80, atrial paced rhythm. right bundle-branch block. infero-posterolateral myocardial infarction of indeterminate age but may be old. diffuse st-t wave abnormalities are non-specific but clinical correlation is suggested. - rate 108, sinus tachycardia with rbbb, evidence of prior mi in lateral and inferoposterior distribution, similar to ekgs from 2/. . ========================================== last set of labs : 05:20am blood wbc-9.3 rbc-3.16* hgb-9.8* hct-30.7* mcv-97 mch-30.9 mchc-31.8 rdw-17.8* plt ct-319 05:20am blood glucose-253* urean-41* creat-1.7* na-146* k-4.4 cl-101 hco3-36* angap-13 05:20am blood calcium-9.1 phos-4.2 mg-2.5 . thyroid studies: 04:00am blood tsh-4.7* . drug monitoring: 04:11am blood vanco-20.9* 04:11am blood digoxin-0.2* brief hospital course: hypotension: patient was transferred from osh after presentation for weakness and pre-syncopal episode in his driveway witnessed by his wife. had notable systolic blood pressured in the 70s in ed at osh prior to transfer and he needed to be placed on both levophed and neosynephrine initially. hypotension likely due to his later established mrsa bacteremia and sepsis. ct done and no overt pulmonary emboli revealed to explain his marked hypotension. he was also ruled out for acute coronary syndrome given his prominent cardiac history and multiple risk factors. he also had rapid atrial fibrillation on day of admission which also contributed to poor cardiac output in setting of his already poor cardiac function with baseline ef of 35%. during his icu course he was weaned down to levophed alone and then slowly taken off pressor support completely with gentle fluid boluses for occasional low blood pressures which were predominantly limited to the setting of him requiring amiodarone boluses or iv metoprolol pushes when his atrial fibrillation episodes occurred throughout his icu stay. otherwise, blood pressures improved overall after patient had been adequately treated with iv vancomycin for his mrsa bacteremia and mrsa pneumonia. mrsa bacteremia: blood cultures from admission grew out mrsa. initially felt that his right hand cellulitis from recent iv placement may have been possible source. however, a sputum culture grew out mrsa within days of admission and his cxr had an area of patchy opacity in the lateral left lung on admission with was felt to represent foci of pneumonia vs. aspiration. during his hospital course he had immediate follow-up tte and tees which were both negative for vegetations. he was given a prolonged course of iv vancomycin starting on or mrsa bacteremia and mrsa pneumonia. he was followed by the id consult service. . respiratory failure: patient intubated at osh before transfer. he was extubated to bipap and required intermittent bipap for about 24 hrs following extubation. he continued to struggle with hypoxemia and shortness of breath and required re-intubation after additional hypercarbia developed on . treated with additional zosyn antibiotics for concern for additional aspiration pna which may have triggered need for his second intubation. he was given multiple iv lasix prn doses and even a lasix drip at times to help accomplish diuresis for his ongoing pulmonary edema which was also another factor felt to be contributing to his poor respiratory status. on had a bronchoscopy that showed area of small collapse in lul with question of recurrent lung cancer so interventional pulmonology team consulted and after holding plavix dose for about a week he had lung biopsy and repeat bronchoscopy which was consistent with malignant mass and pathology revealed squamous cell lung cancer. a formal oncology consult was deferred in setting of his very tenuous status in icu as team was waiting for patient to stabilize for formal consult and possible attempts for palliative radiation/medications but patient continued to clinically decline in icu. there were brief discussions for peg/tracheostomy placement but patient was able to be extubated successfully . he slowly declined again to the point of needing high flow face mask to maintain adequate oxygenation. patient and family changed code status to dnr/dni on and palliative care consult was called. overall, patient's persistent decline and respiratory failure felt to be combination of his underlying poor reserve with copd /prior lobectomy, recent pnas, recurrent lung cancer and pulmonary edema which lingered as well. he was made cmo on and passed away later that night. . copd exacerbation: initially treated more aggressively with steroids and standing nebulizers. copd flare up was attributed to persistent pneumonia. as above, respiratory failure required two intubations and multiple use of bipap and facemask at high flow to maintain oxygen saturations >88%. he continued to decline after second extubation and family and patient opted to be dnr/dni, then changed to cmo. . icu delirium: multifactorial and felt to be related to infection, steroids, and being in icu. patient was also noted to have recurrent lung cancer and brain metastasis is also possible although patient was never stable enough to pursue any additional mri or further workup for oncologic staging/management. notably, wife reported sun downing at home and issues with confusion for several months prior to admission. he was treated initially with olanzapine and then switched to standing haldol with good effect initially but he seemed to get more agitated so qhs zydis was combined with standing and prn haldol dosing. ekgs were monitored for qt changes. psychiatry was consulted and agreed with haldol therapy. unfortunately, his delerium worsened over the last few days of his icu course and he required soft restraints and additional doses of haldol with frequent re-orientation by staff. . rapid atrial fibrillation: patient had known atrial fibrillation in the past. during his icu course he had atrial flutter and fibrillation multiple times. likely triggers were sepsis, pressor use, and hypoxia. cardiology was consulted for additional guidance during his icu stay. patient's home regimen of quinidine stopped and he was loaded with iv amiodarone given his hemodynamic instability with rapid rhythm. patient followed by electrophysiology service. he was re-bolused with amiodarone for ongoing svt and later in hospital course metoprolol iv was added on a standing basis for additional control and worked well. . swallowing: failed speech and swallow. dobhoff placed for nutritional feedings. started on tf regimen. peg considered briefly but after goals of care discussion with family after recurrent lung cancer diagnosis and worse respiratory failure and progressive altered mental status the family wished to only keep patient comfortable and did not want any more surgeries. he was given dobhoff feedings up until day he expired. . esophagitis: thrush on admission with throat pain. treated with 7 day course of iv fluconazole for presumed esophagitis. resolved with therapy. . medications on admission: asa 325mg daily flucinolide 250mcg 2 puffs crestor 40mg daily plavix 75mg daily digoxin 125 mcg daily mwf floridil 12 mcg 1 lasix 40mg gabapentin 100mg levothyroxine 75mcg daily lisinopril 2.5mg daily proventil prednisone 10mg daily quinidine 324 mg qid spiriva 18 mcg daily spirinolactone 50mg daily discharge medications: no discharge medications to list . patient deceased, died on . discharge disposition: expired discharge diagnosis: patient deceased, passed away on discharge condition: patient deceased, passed away on discharge instructions: patient deceased, passed away on followup instructions: patient deceased, passed away on Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Closed [endoscopic] biopsy of bronchus Closed endoscopic biopsy of lung Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Long-term (current) use of steroids Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Severe sepsis 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 bronchus and lung Obstructive chronic bronchitis with (acute) exacerbation Aortocoronary bypass status Personal history of tobacco use Atrial flutter Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Pulmonary collapse Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of upper lobe, bronchus or lung Septic shock Cellulitis and abscess of upper arm and forearm Old myocardial infarction Cardiac pacemaker in situ Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Delirium due to conditions classified elsewhere Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Methicillin resistant Staphylococcus aureus septicemia Candidal esophagitis Other dependence on machines, supplemental oxygen Methicillin resistant pneumonia due to Staphylococcus aureus Acquired absence of organ, lung |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: cardiac catheterization stenting of the left main coronary artery history of present illness: 66 y/o man with h/o cad, s/p cabg in , s/p prior catheterization showing the lima-lad is the only remaining patent graft, s/p icd in for primary prevention against sudden cardiac death, and s/p right upper lobectomy for lung cancer in with adjunctive chemotherapy and radiation. he has done well over the past few years until about 2-3 weeks ago when his cardiologist, dr. , interrorgted his device and found he was having numerous episodes of vt (100 or so episodes without icd firing). his verapamil was discontinued, and he was started on quinaglute (did not start amiodarone due to lung issues). he returned and was found to have no vt. however, on he presented to with shortness of breath and orthopnea; he also stated that he has been increasingly dyspneic with exertion over the past few weeks. his blood pressure was down in the 80-90 systolic range and his bnp was in the 700's. he had lower extremity edema. he was admitted, had no biomarker evidence of mi, was diuresed, and underwent an echocardiogram yesterday showing an ef of 30% which was essentially unchanged, but he was found to have new 3+ mitral regurgitation and hypokinesis of the inferior wall. dr. had the patient transferred here for right and left heart catheterization. ros: he denies any prior history of stroke, tia, dvt, pe, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. past medical history: 1. hypertension 2. hyperlipidemia 3. cad, s/p cabg in (lima-lad, svg-ramus, svg-rca), s/p cath on found to have totally occluded svg-ramus and svg-rca. the native rca was totally occluded; he had a 30% left main lesion and a 80% ramus lesion. it was at this time he was found to have a lesion in his left subclavian and had a stent placed there. 4. cardiomyopathy/chronic lv systolic heart failure with ef of 30% s/p icd in . 5. lung cancer, s/p right upper lobectomy, chemo, & xrt 6. asthma 7. gout 8. diabetes mellitus social history: significant for 60 py smoking history, and the patient quit smoking in . there is no history of alcohol abuse. family history: there is a family history of cad: his father had an mi, mother had a cva. physical exam: gen: wdwn middle aged caucasian man in nad. oriented x3. mood, affect appropriate. vs: t 98.4 bp 107/69 hr 94 rr 18 o2sat 100% on 2 l/min nc heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no jvd. cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no murmurs, rubs or gallops. no thrills, lifts. chest: no chest wall deformities, scoliosis or kyphosis. respirations were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, ntnd. no hsm or tenderness. abdominal aorta not enlarged by palpation. no abdominal bruits. ext: no clubbing, cyanosis or edema. no carotid bruits. 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: admission labs: wbc-13.8* rbc-4.20* hgb-12.9* hct-38.9* mcv-93# mch-30.7# mchc-33.2 rdw-14.1 plt ct-203 neuts-87.1* lymphs-9.9* monos-2.9 eos-0.1 baso-0.1 glucose-136* urean-32* creat-1.4* na-137 k-4.2 cl-98 hco3-30 alt-24 ast-18 alkphos-74 totbili-0.3 dirbili-0.1 indbili-0.2 calcium-9.3 phos-3.7 mg-2.3 discharge labs: wbc-7.1 rbc-3.82* hgb-11.7* hct-35.3* mcv-92 mch-30.5 mchc-33.0 rdw-14.1 plt ct-217 pt-12.9 ptt-27.3 inr(pt)-1.1 glucose-97 urean-21* creat-1.2 na-138 k-4.1 cl-97 hco3-33* calcium-8.4 phos-3.3 mg-2.2 cxr no appreciable interval change. patient has had right upper lung and chest wall resection. there is mild scarring in the left mid lung unchanged over four years, no pleural effusion or pulmonary consolidation noted. heart size normal. transvenous right atrial pacer and right ventricular pacer defibrillator leads follow their expected courses unchanged and continuous from the left pectoral pacemaker. ecg 1:46:26 am sinus rhythm and paroxysmal atrial fibrillation with ventricular rate 143 bpm. the limb leads are misattached. there is evidence for prior inferoposterior and lateral myocardial infarction. right bundle-branch block. compared to the previous tracing of paroxysmal atrial fibrillation has appeared. otherwise, no apparent diagnostic interim change. cardiac catheterization 1. selective coronary angiography in this right dominant system revealed three vessel native coronary artery disease. the lmca was heavily calicified with ostial 70% stenosis and distal 40% stenosis; there was some pressure dampening when the lmca was engaged with the jl4 diagnostic catheter. the lad had proximal diffuse disease, was heavily calcified, and had competitive flow in the mid-lad; there were apical collaterals to the rca. the lcx was moderately calcified with a hazy origin stenosis of at least mild-moderate severity. a high om1 had diffuse severe disease after a proximal taper. there was a major patent om2. the om3/lpl was of modest caliber. the distal av groove cx supplied an atrial branch and faint collaterals to the rca. the rca had a proximal total occlusion with faint filling of ams. 2. selective venous conduit angiography was not performed as the svg's were known to be occluded. selective conduit arteriography revealed a patent lima arising adjacent to the thyrocervical trunk. the proximal left subclavian artery stent was patent, with a 20 mnhg gradient in the subclavian distal to the lima origin. the lima had a mild kinking mid graft and a mild anastomotic lesion; there was retrograde filling of a large diagonal and aterograde filling of the apical lad with collaterals to the rca. there was a 50% lesion at the origin of the vertebral artery. 3. abdominal aortography using an angled pigtail catheter just below the level of the renal arteries revealed no apparent renal artery stenosis. there was extensive distal abdominal aortic disease with plaque at the origin of the right iliac artery and a 60-70% stenosis at the origin of the left iliac artery. there was calcific atherosclerosis in both femoral arteries. the right femoral artery had been noted to be heavily calcified during arterial access. 4. resting hemodynamics revealed normal systemic blood pressure with sbp of 101 mmhg, elevated right and left sided filling pressures with rvedp of 13 mmhg and mean pcwp of 22 mmhg. there was pulmonary arterial hypertension with pasp of 45 mmhg. the cardiac index was preserved at 2.7 l/min/m2 (using an assumed oxygen consumption). echocardiogram the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is severely depressed (lvef= 25 %) with akinesis to dyskinesis of thinned inferior and infero-lateral walls. the basal septum moves best and the remaining segments are hypokinetic. there is no ventricular septal defect. with normal free wall contractility. the ascending aorta is mildly dilated. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are mildly thickened. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. an eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. pci 1. selective coronary angiography of this right dominant system demonstrated a severly diseased left main coronary artery extending into the proximal left circumflex and left main coronary artery. the mid to distal portion of the left anterior descending artery filled by a patent lima. the right coronary artery was not engaged. 2. successful prophylactic placement of an iabp via the left femoral artery for cardiogenic support during pci. 3. successful stenting of the left main coronary artery extending into the proximal left circumflex artery with a xience (3x23mm) drug eluting stent postdilated with a 3.5mm balloon. final angiography demonstrated no angiographically apparent dissection, no residual stenosis and timi iii flow throughout the vessel. 4. successful closure of the right femoral arteritomy site with a 6f mynx closure device. right knee x-rays right medial post-surgical clips projecting over the soft tissues. extensive vascular calcifications. subtle dot-like radiopaque particles projecting 6 cm caudal of the tibial head on the ap projection. minimal linear calcifications projecting into the joint space. there is no evidence of traumatic bone injury. brief hospital course: 66 y/o man with h/o cad, congestive systolic heart failure, and lung cancer with worsening dyspnea on exertion. history of numerous vt episodes on recent icd interrogation. # cad - known severe coronary artery disease. cardiac catheretizations this admission showed pcw 22 and lvedp 26 mm hg with preserved cardiac index. he had severe lmca and three vessel disease with patent proximal left subclavian artery stent and patent lima-lad. abdominal aortography showed extensive aortic and iliac disease, precluding using of the impella assist device. in consultation with dr. , the decision was made to proceed with high risk pci of the protected lmca with iabp support. this procedure was delayed for several hours due to arrhythmias (see below), but on , a xience des was placed in the lmca into the circumflex artery with right femoral arteriotomy closure using the mynx device and iabp secured in place in the left femoral artery. the patient was stable after the balloon pump was removed. he was continued on maximal medical management with aspirin, plavix, metoprolol, and rosuvastatin. # pump - has severe chronic systolic and diastolic left ventricular heart failure with recent acute exacerabtion with recent ef of 25% and akinesis to dyskinesis of thinned inferior and infero-lateral walls with slightly dilated lv wall. repeat echocardiogram here showed moderate eccentric mitral regurgitation, prompting the decision to revascularize the native circumflex in hopes of reducing papillary muscle ischemic dysfunction. his filling pressures were elevated at catheterization. lasix and spironolactone were continued, and captopril was decreased then changed to low dose lisinopril due to hypotension. # rhythm - has a pacer and icd. patient did have vt upon interrogation of icd prior to admission; unclear etiology for this, but likely secondary to ischemia. he had recurrent svt during this admission with hrs into 160s, mostly asymptomatic with relatively low bps which are now close to baseline. he was on an amiodarone drip for three days, but then switched back to quinidine, increased to qid instead of his prior dosing at tid. he triggered for atrial fibrillation with vr to 160 the night prior to discharge, however, he had not received his quinidine or metoprolol that evening. he was asymptomatic and his arrhythmia resolved after receiving these medications. he was evaluated by ep who felt that no further changes to his pacer/icd settings were needed at this time. they may consider ablation in the future if recurrent vt is originating from a scar. he is not anticoagulated at this time. this can be considered in the future if atrial fibrillation returns. his dose of metoprolol was increased on this admission. # dyspnea - the patient's dyspnea was likely multifactorial including past lobectomy, worsening heart failure, and asthma. he received ipratropium, fluticasone, salmeterol prn. the patient's dyspnea at rest resolved, however, he desaturated to 84% on room air with amublation the day prior to discharge and again on the of discharge, despite receiving extra lasix. he was discharged to home with oxygen and pulmonary rehab. he has not previously had home oxygen. # diabetes mellitus - the patient was placed on an insulin sliding scale with good blood sugar control. # knee pain - a few days prior to discharge, the patient developed a painful right knee. the patient was afebrile and the knee was not warm. it was felt that his knee pain was most consistent with a gout flare. he was given indomethacin for 24 hours with resolution of his knee pain. this medication was discontinued due to its potential to interfere with the antiplatelet effects of aspirin. he was discharged with a prescription for a prednisone burst-taper in the event that his symptoms recur. # mild acute renal function - the patient had a creatinine elevated to 1.4 on admission, likely due to hypovolemia and poor foward flow from chf. with pre-hydration prior to catheterization and judicious diuresis, his creatinine had returned to a baseline of 1.2 on the day of discharge. medications on admission: albuterol inhaler flunisolide 250 mcg, two puffs quinaglute 324 mg tid flovent inhaler foradil 12 mcg 1 inhaled captopril 25 mg crestor 40 mg daily aspirin 325 mg daily lasix 60 mg spironolactone 25 mg daily indomethacin 25 mg qid prn metoprolol 25 mg nasonex 50 mc 1 puff each nostril nitro sublingual prn verapamil 120 mg daily discharge medications: 1. prednisone 10 mg tablet sig: taper as outlined below tablet po once a day for 5 days: take 50 mg on day 1, then 40 mg on day 2, then 30 mg on day 3, then 20 mg on day 4, then 10 mg on day 5, then stop. disp:*15 tablet(s)* refills:*0* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. rosuvastatin 20 mg tablet sig: two (2) tablet po daily (daily). 4. spironolactone 25 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. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). disp:*30 tablet sustained release 24 hr(s)* refills:*2* 7. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* 8. quinidine gluconate 324 mg tablet sustained release sig: one (1) tablet sustained release po q6h (every 6 hours). disp:*120 tablet sustained release(s)* refills:*2* 9. furosemide 40 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*2* 10. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. albuterol 90 mcg/actuation aerosol sig: inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. flunisolide 250 mcg/actuation aerosol sig: one (1) inhalation twice a day. 13. foradil aerolizer 12 mcg capsule, w/inhalation device sig: one (1) inhalation twice a day. 14. nasonex 50 mcg/actuation spray, non-aerosol sig: one (1) nasal twice a day. 15. digoxin 125 mcg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 16. oxygen 2l continuous 17. please provide tubing for oxygen discharge disposition: home with service facility: nursing services discharge diagnosis: primary diagnoses: coronary artery disease, treated with drug-eluting stent deployment in the left main and circumflex coronary arteries acute on chronic left ventricular systolic and diastolic congestive heart failure secondary diagnoses: gout atrial fibrillation supraventricular tachycardia ventricular tachycardia diabetes mellitus prior lung cancer asthma hypoxemia acute renal failure mitral regurgitation discharge condition: stable, afebrile, sbps in 80s-100s, breathing comfortably on 2l o2. desats to 84% on room air with ambulation. discharge instructions: you were admitted to the hospital for worsening shortness of breath. it was thought to be due to your heart. you had a catheterization that showed an artery that needed a stent. you had another catheterization in which the stent was placed, and then you were monitored in the intensive care unit while you had a balloon pump helping your blood pressure stay high. you continued to have low oxygen saturations while walking, dropping to 84% and will need to go home with oxygen. you did well post cath. you had a few arrhythmias, so the electrophysiologists saw you and helped us adjust your medicines. the following changes were made in your medications: your captopril was stopped and changed to a lower dose of a similar medication called lisinopril. your metoprolol dose was increased to 100 mg daily. your diuretic was doubled to 60 mg twice daily. your quinidine was increased from three to four times daily (~ every 6 hours). you were also started on two new medications: clopidogrel 75 mg daily and digoxin 0.125 mg daily. you have been given prescriptions for these changes. you also developed knee pain which improved after a few doses of indomethacin. this may have been a gout attack, however, the indomethacin was stopped because it may interfere with aspirin. if your knee pain or other gout symptoms return, you should take a short course of a steroid medication called prednisone instead of indomethacin. you have been given a prescription for this should you need it. weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet. please call your physician or return to the hospital if you develop worsening shortness of breath, chest pain, fevers, swelling in your feet, or other concerning symptoms. followup instructions: provider: , md phone: date/time: 1:00 md, msc 12-339 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Coronary arteriography using a single catheter Implant of pulsation balloon Angiocardiography of right heart structures Angiocardiography of right heart structures 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 two vessels Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Gout, unspecified Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Asthma, unspecified type, unspecified Atrial flutter Paroxysmal ventricular tachycardia Automatic implantable cardiac defibrillator in situ Hypovolemia Chronic combined systolic and diastolic heart failure |
allergies: no known allergies / adverse drug reactions attending: chief complaint: nstemi major surgical or invasive procedure: : 1. repair of right subclavian artery laceration. 2. repair of right internal jugular vein laceration. 3. coronary artery bypass grafting x3 with left internal mammary artery to the left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the posterior descending coronary artery. 4. endoscopic left greater saphenous vein harvesting. history of present illness: 82 with pmh of htn who presents as a transfer from hospital for evaluation for cabg in setting of nstemi. per family she developed uri symptoms early in which lasted for several days but resolved. however, she did not feel "well" for rest of the month, and noted to have cough symptoms return 3 days pta which worsened to the point where she called emts yesterday after developing sob, and was brought to where she had cxr which was significant for pneumonia. treatment with iv levoquin initiated. she was intubated in the ed for resp distress and unresponsiveness. of note there was also a question of chf complicating her picture, and pt noted to have refractory hypotension requiring initiation of dopamine during admission. cardiac enzymes were followed and noted that tropi was trending up to >100 and ck mb of 73.3 with ekg with lateral st depressions. she was plavix loaded, given asa, and started on heparin ggt. she was taken to cath where she was found to have 90% ostial lesion 90% lad occlusion, and 80% distal rca with a widely patent lima visualized for bypass. during the procedure, she was noted to be hypotensive with sbps of 50s and in cardiogenic shock. balloon pump was placed at this time. she has been transferred to for evaluation of cabg for her critical 2vd. on transfer, she is on dopamine ggt at 20mcg/kg/min, fentanyl at 50mcg/hr, versed at 5mg/hr, and heparin ggt at 1200 u/ hr. pertinent labs on transfer: wbc: 14.7 hct: 36.1 plt: 289 na: 136 k: 3.9 bun: 28 cr: 1.6 ckmb: 58.5<--78.3 trop>100 inr: 1.2. abg on admission: 7.26/45/101 on admission she was intubated and sedated, unresponsive. vs: bp:115/35 hr: 78 o2: 100% on a/c tv: 400, peep: 5, rr: 20, fio2: 100% past medical history: 1. cardiac risk factors: -htn -hl 2. cardiac history: - percutaneous coronary interventions : 90% ostial lesion 90% lad occlusion, 80% distal rca, insignificant lcx plaquing, with a widely patent lima visualized for bypass. procedure complicated by cardiogenic shock. pcw of 24, and iabp placed, pulses dopplerable post-placement. . 3. other history -kidney stones -utis -s/p back surgery social history: per family, lives alone and independent with adls. tobacco, etoh history could not be obtained. family history: non-contirbutory physical exam: vs: bp:115/35 hr: 78 o2: 100% on a/c tv: 400, peep: 5, rr: 20, fio2: 100% general: intubated, sedated, non-responsive, on balloon pump heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple, unable to appreciate jvd cardiac: pmi located in 5th intercostal space, midclavicular line. balloon pump ascultated making it difficult to appreciate m/r/g. normal s1, s2. lungs: diffusely ronchorous, with bl crackles anteriorly with scattered wheezes abdomen: obese, soft, ntnd. no hsm or tenderness. extremities: 1+ edema to the mid shin b/l. 1+ dp/pt pulses. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: admission labs: 07:14pm blood wbc-13.0* rbc-3.79* hgb-11.2* hct-33.5* mcv-88 mch-29.5 mchc-33.5 rdw-14.0 plt ct-244 07:14pm blood pt-16.1* ptt-109.8* inr(pt)-1.4* 07:14pm blood glucose-160* urean-32* creat-2.0* na-133 k-4.4 cl-103 hco3-17* angap-17 07:14pm blood alt-29 ast-98* ld(ldh)-527* ck(cpk)-547* alkphos-83 amylase-276* totbili-0.7 07:14pm blood ck-mb-39* mb indx-7.1* ctropnt-3.86* 07:14pm blood albumin-3.2* calcium-8.5 phos-4.2 mg-1.7 cholest-132 09:34pm blood %hba1c-5.5 eag-111 07:14pm blood triglyc-102 hdl-57 chol/hd-2.3 ldlcalc-55 ldlmeas-65 08:11pm blood type-art po2-101 pco2-45 ph-7.26* caltco2-21 base xs--6 06:18am blood freeca-1.16 echo : the left atrium is normal in size. the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with anterior hypokinesis. the remaining segments appear to contract normally, though images are suboptimal (lvef = 40%). the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic valve leaflets are mildly thickened (?#). the study is inadequate to exclude significant aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is mild functional mitral stenosis (mean gradient 5 mmhg) due to mitral annular calcification. trivial mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. impression: mild regional left ventricular systolic dysfunction, c/w cad. cannot exclude hemodynamically-significant aortic stenosis. moderate pulmonary hypertension. echo : the left atrium is normal in size. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. calcific aortic valve disease with mild stenosis/mild regurgbitation. mild mitral regurgitation. mild pulmonary hypertension. compared with the prior study (images reviewed) of , anterior hypokinesis is no longer appreciated (prior study technically-suboptimal). 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. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. impression: preserved biventricular global systolic function. mild mitral regurgitation. mild aortic regurgitation. mild-moderate tricuspid regurgitation. abdm us : findings: the examination is markedly limited by patient body habitus and inability to position as well as bandage material. there is no gross evidence of intra- or extra-hepatic biliary dilation. the common hepatic duct measures 4 mm. the portal vein is patent with flow in the appropriate direction. the gallbladder is moderately distended. there is gallbladder wall edema. no gallstones are identified and there is no evidence of pericholecystic fluid. kidneys are echogenic. right kidney measures 10.4 cm. left kidney was difficult to visualize due to positioning. the spleen was also not adequately visualized due to positioning and bowel gas. impression: 1. markedly limited study. distended and edematous gallbladder without gallstones. gallbladder wall edema may result from a number of factors including congestive heart failure, hypoalbuminemia, but acalculous cholecystitis cannot be excluded by the ultrasound findings. if clinical suspicion warrants, then hida is recommended for further assessment. a page was sent to at 11:17 a.m. on to discuss these findings and results were discussed at 12:08 pm. 2. echogenic appearance of the right kidney suggestive of medical renal disease. left kidney poorly visualized. ct neck : findings: a cordis-type central venous access introducer sheath traverses the right external jugular and right internal jugular veins, following an oblique-inferior course with its tip at the take-off of the right subclavian from the brachiocephalic artery. there is an approximately 9-mm fascial interval between the right ij venous exit and the brachiocephalic arterial entry site. there is no evidence of organizing hematoma in the region, at either the skin entry or the site where the sheath traverses the internal jugular vein. extravasation cannot be assessed in the absence of intravenous contrast. an endotracheal tube has its tip 2.8 cm from the carina. the tip of the oro-enteric tube is not included in the imaging volume. there are bilateral pleural effusions, right greater than left and pleural seen in the oblique fissures bilaterally. there is thickening of the interlobular septae and ground-glass opacities consistent with pulmonary edema. evaluation of cervical lymph chain demonstrates no lymphadenopathy by imaging criteria. there are several nodules seen within the thyroid gland, the largest measuring 1.3 cm in the lower pole of its left lobe. there are multilevel degenerative changes of the spine seen with near-complete loss of disc space height between c2 and c3 as well as loss of disc space height between c4 and c5. there is no evidence of fracture. impression: 1. aberrant placement of the right-sided central venous introducer sheath, which traverses both the external jugular and internal jugular veins, with its tip within the right brachiocephalic artery at the origin of the right subclavian artery. 2. no evidence of signficant organizing hematoma in this location. 2. findings of chf, with mild pulmonary edema. comment: these findings concerning the aberrant arterial placement of this catheter were discussed with dr. (cardiology service) by dr. , at 1200h, and again by dr. , at 1230h, , who conveyed information regarding the traversal of the right internal jugular vein. brief hospital course: 82 yo female with pmh of htn, hl, presenting to osh with respiratory distress, intubated, hypotensive on pressors, found to have nstemi with tropi>100. cath showing significant 2vd, and complicated by hypotension intraprocedurally. transferred to for eval for urgent cabg. . # nstemi: pt initially presenting to osh with respiratory distress complicated by refractory hypotension requiring dopamine for pressor support likely nstemi. her enzymes were followed showing troponin >100 and cath significant for 2vd and requiring placement of balloon pump. bedside echo on admission showed ef of 35-40% with moderate regional left ventricular systolic dysfunction with basal and mid anterioseptal, anterior, anteriolateral, and apical hypokenesis. patient was continued on medical management with heparin ggt, asa 325, atorva 80. dopamine and levophed were weaned off over the course of 3 days. iabp remained in at one to one. echo showed a preserved ef 55%. patient was taken for cabg.... . # respiratory failure: patient remained intubated. oxygen was weaned down to 40% over the next 24 hours after arrival. initial cause of respiratory distress likely secondary to nstemi with resultant chf. as she began to spike fevers and cxr showed probable pneumonia, she was experically treated for pneumonia with vancomycin and zosyn. . # hypotension: on arrival to , patient was maxed out on dopamine 20mcg/kg/hr. initial pa catheter readings indicated a mixed picture of cardiogenic and distributive shock. patient's calculated svr then began to decrease, and echo showed globally normal lvef without major wall motion abnormalities. it was determined that she was in distributive/septic shock. she was weaned off dopamine, and transitioned to levophed. after 2 days on levophed, her maps remained > 60 and she was weaned off. . #. carotid artery: during replacement of pa catheter, cordis sheath was placed in the carotid artery. ct aorta showed no evidence of hematoma. patient was evaluated by vascular surgery and cardiac surgery. on the patient was brought to the operating room for sternotomy and removal of cordis sheath as well as coronary bypass grafting by cardiac and vascular surgery. please see the operative report for details. following the operation she was transferred to the cardiac surgery icu paralyzed and sedated in critical condition on multiple pressors and inotropes with an open chest. over the next several days she remained with an open chest on multiple pressors, she eventually developed acute renal failure and was begun on cvvhd. her condition continued to deteriorate and on pod 5 she was made comfort measures only. she expired on pod 5 with family present medications on admission: home medications: zetia 10mg po daily pravastatin 80mg po daily nadolol 40mg po daily diazide 37.5/25mg daily amlodipine 5mg po daily . transfer medications: fentanyl ggt versed ggt dopamine ggt azithromycin 500mg iv daily zosyn 2.25 g iv q6h heparin ggt at 1200 u/hr asa 325 metoprolol 5mg iv q6h simvastatin 80 mg daily insulin ss albuterol/ipratropium 10 puffs inh qid tylenol 650 mg pr q4h prn zofran 4mg iv q6h prn albuterol 10 puffs inh q2h prn discharge medications: expired discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Parenteral infusion of concentrated nutritional substances (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Hemodialysis Suture of vein Suture of artery Nonoperative removal of heart assist system Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Acute and subacute necrosis of liver Unspecified septicemia Severe sepsis Aortic valve disorders Accidental puncture or laceration during a procedure, not elsewhere classified Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Cardiogenic shock Septic shock Morbid obesity Accidental cut, puncture, perforation or hemorrhage during other specified medical care Acute systolic heart failure Body Mass Index 31.0-31.9, adult |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p motorcycle accident major surgical or invasive procedure: 1. exploratory laparotomy, hartmann's procedure, exploration of abdominal wall () 2. ultrasound-guided imaging for vascular access, contralateral first order arteriography with abdominal aortogram and pelvic runoff, left common iliac artery stent () 3. open reduction, internal fixation of anterior pelvic ring with symphysial plating () 4. incision and drainage of a portion of left thigh with vac dressing application () 5. fixation sacral fracture with 7.3 mm percutaneous sacroiliac screw () 6. inferior vena cava filter through the right femoral approach () history of present illness: patient is a 51-year-old male s/p motorcycle vs car accident, no loc, but found with unstable pelvis and bleeding around the perineum. brought in to er trauma bay via helicopter. injuries included open book midline sacrum pelvic fracture, rectal perforation tracking into the scrotum, multiple (right t2-t4 and l5) transverse process fractures, and focal dissection of the left common iliac at the bifurcation. past medical history: none social history: substance abuse hx: h/o etoh dependence in his 20's, one detox admission in . able to maintain sobriety through , when he elapsed. continued drinking until , and has been able to maintain sobriety since . denies h/o withdrawal seizures, or dt's. he reports experimentation with cocaine and mj, but denies active use. sh: born in ny, and later moved to nj to live with his grandfather after his parents divorced. he has one younger brother. pt was raised by his grandfather in nj. he has had long period of being estranged from his extended family as an adult, including his brother and mother. reports getting into many fights as a child through his adulthood. during the course of these altercations, pt reports sustaining multiple head injuries. pt also reports having sustained multiple concussions in the past while playing football in h.s, spitting his helmet x 3. legal: he reports multiple arrests for assault and battery. he was sent to state corrections facility for 6 months after arrest for domestic assault at house of correction, with 3 of those months spent in solitary confinement. he describes his life as a very violent one. denies access to weapons. education: pt did not complete h. s., but did get his ged, and then entered navy. after his service he started college (sat score 1280) with intention of studying engineering, but he ultimately dropped out. occupation: pt currently works in construction as a welder. reports having falling from ladder while at work, sustaining head injury at that time. family history: noncontributory physical exam: physical exam on admission: vs: hr 96, bp 144/92, rr 14, spo2 99ra gen: mild distress, c/o pain heent: peerl 3 to 2 bilaterally, airway intact, dry blood from nares bilaterally cv: rrr resp: ctab, thoracic cavity stable gi: abdomen distended, tender to palpation gu: no blood at meatus rectal: good rectal tone, gross blood at rectum ms: pelvis unstable, right hip externally rotated pertinent results: ct head: no intracranial hemorrhage or fx. tiny right occipital subgaleal hematoma. ct c-spine: nondisplaced r transverse process fx involving t2 through t4 on the right. ct torso: 1) extensive air dissecting around rectum, prostate and bladder base with apparent feculent air and fluid collection in anterior subcutaneous soft tissues of lower abdomen/upper pelvis on l tracking into medial l thigh. instillation of rectal contrast shows this is secondary to rectal perforation with contrast also tracking into scrotum. 2) fx's include gross pelvic diastasis with midline sacrum fracture. r transverse process fx's involve t2-4 and l5. anterior column r acetabular fx. 3) short segment dissection of l common iliac a. near bifurcation. 4) nonspecific small amount of fluid along r psoas, perhaps secondary to left adrenal injury vs other nonspecific retoroperitoneal injury. 5) hypovolemia. 6) gastric distension with fluid and debris in stomach and esopahgus-at risk for aspiration- in need of ng decompression. mri: mri sacrum: ? right s2 nerve crossing fx line?l5-s1 disc injury. ble u/s: no dvt fluoroscopy: single spot fluoroscopic image obtained intraoperatively without a radiologist present is submitted for review. there are midline skin staples. an ivc filter is seen in place to the right of midline, superior and at the level of the superior endplate of the l2 vertebral body. brief hospital course: patient was brought to the er trauma bay on with multiple injuries. he had several imaging studies done and was admitted to the trauma surgery team. he was initially started on unasyn and heparin sc. he went to the or for multiple procedures by several surgical services including an exploratory laparotomy, hartmann's procedure, exploration of abdominal wall by trauma; ultrasound-guided imaging for vascular access, contralateral first order arteriography with abdominal aortogram and pelvic runoff and left common iliac artery stent by vascular; and open reduction, internal fixation of anterior pelvic ring with symphysial plating by orthopedics. post-operatively, he remained intubated and sedated and went to the ticu for close monitoring while on pressors. on , he became hypovolemic and was resuscitated with 2l lr. he was also bronched, clearing up rul. echo was done showing no cardiac contusion. mri c and l spine. he was weaned off pressors. gentamicin was started. on , bedside incision and drainage of hematoma was done of a portion of left thigh with vac dressing application. he was switched from heparin sc to lovenox. cervical collar was removed. on , he was transfused 2u prbc for low hct with appropriate response. on , he went back to the or for fixation of the sacral fracture with 7.3 mm percutaneous sacroiliac screw. he also had a rash on his back and buttocks. on , he was extubated and started on a pca for pain control. gentamycin was discontinued. on , he was transferred to the floor and started on po pain meds and regular diet. he also had ble u/s done, which showed no dvt. his activity was changed from non-weight bearing to touchdown weight bearing by orthopedics. on , unasyn was discontinued. on , he went back to the or for ivc filter placement. his wound vac was also changed. lovenox was discontinued, and coumadin was started. at the time of discharge on , patient was doing well, pain controlled, tolerating regular diet. medications on admission: none discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 3. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day). 4. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm. discharge disposition: extended care facility: discharge diagnosis: s/p motorcycle accident 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 your incision sites, chest pain, difficulty breathing, shortness of breath, or anything else that is troubling you. * any serious change in your symptoms, or any new symptoms that concern you. other instructions: * your abdominal staples will be removed at your next follow-up appointment with dr. . * your jp drain output will be monitored daily. if it is draining less by your follow-up appointment with dr. , it may be removed. * your wound vac will be changed every 3 days until it is removed at your next follow-up appointment with dr. . * you will receive teaching for your ostomy care. it can be changed every 3 days or more often as needed. * your foley (urinary) catheter will stay in until your follow-up appointment with urology on . * you are allowed to do touchdown weightbearing on your lower legs bilaterally, as instructed by orthopedics. * you had an ivc (inferior vena cava) filter placed to prevent propagation of clots from your legs to your heart and lungs. you were also started on a small dose of coumadin (mini-coumadin), which helps keep your blood thin to prevent formation of clots. but you do not need to monitor your inr levels; your inr does not have to be at therapeutic levels because you already have an ivc filter in place. followup instructions: 1. follow-up with dr. in weeks. call his office at to schedule an appointment. 2. follow-up with urology on . call the office at to confirm your appointment. you will also have additional radiology studies (cystogram/urethrogram) performed on your bladder just prior to your appointment. 3. follow-up with dr. on at 10:10 am. you will also have additional imaging with in vascular (vascular lmob, nhb) just prior to your appointment at 9:30 am. call the office at to confirm your appointments. 4. follow-up with dr. . (orthopedics) in 2 weeks. call his office at to schedule an appointment. Procedure: Temporary colostomy Interruption of the vena cava Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Other bronchoscopy Incision of abdominal wall Aortography Other incision with drainage of skin and subcutaneous tissue Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Open and other sigmoidectomy Open reduction of fracture with internal fixation, other specified bone Repair of vertebral fracture Cranial or peripheral nerve graft Insertion of one vascular stent Procedure on single vessel Diagnoses: Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist Hypovolemia Closed fracture of lumbar vertebra without mention of spinal cord injury Closed fracture of sacrum and coccyx without mention of spinal cord injury Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum Dissection of iliac artery Injury to rectum, without mention of open wound into cavity Closed unspecified fracture of pelvis |
allergies: no known allergies / adverse drug reactions attending: addendum: discharge diagonises to clarify acute on chronic diastolic heart failure acute pulmonary edema resulting in acute respiratory failure preoperatively discharge disposition: home with service facility: home health & hospice md Procedure: Combined right and left heart cardiac catheterization Diagnostic ultrasound of heart Open and other replacement of aortic valve Aortography Percutaneous balloon valvuloplasty Diagnoses: Anemia in chronic kidney disease Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Acute on chronic diastolic heart failure Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Aortic valve disorders Other chronic pulmonary heart diseases Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Chronic kidney disease, Stage III (moderate) Retention of urine, unspecified Cardiac pacemaker in situ Unspecified accident Injury to bladder and urethra, without mention of open wound into cavity Hematuria, unspecified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: admission prior to percutaneous avr major surgical or invasive procedure: 1. percutaneous aortic valve replacement with a 29-mm corevalve device, model number mcs-p3-943, serial number . 2. balloon aortic valvuloplasty. 3. ascending aortography. history of present illness: m with critical as s/p balloon valvuloplasty , nyha stage iv diastolic chf, cad s/p cabg , tachy-brady s/p ppm , and ckd stage iii (baseline cr 2.2) admitted electively prior to percutaneous avr scheduled for tues . he has been having progressive dyspnea on exertion and can only walk a few steps before having to rest. he has no anginal symptoms. he has had worsening leg edema, orthopnea (sleeps in recliner), cough productive of clear sputum. no pnd, fevers, chills, weight loss, fatigue, poor appetite, palpitations. he reports that his symptoms are currently "much worse" than before his valvuloplasty in . . on arrival to the floor, patient is resting comfortably, no sob, does have cp in l sternum from a fall in the bathroom earlier this week (reproducible, not worse with inspiration, currently and improved from initial trauma). . 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. cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, syncope or presyncope. past medical history: critical as s/p balloon valvuloplasty nyha stage iv diastolic chf cad s/p cabg (lima-d1, svg-om1, svg-rpda, svg-1st rpl) tachy-brady s/p ppm ckd stage iii (baseline cr 2.2) htn pulmonary hypertension benign prostatic hypertrophy hypertension gerd history of remote gi bleed chronic back pain spinal fusion appendectomy social history: former pipe smoker. quit 20 years ago. no alcohol use. family history: there was no family history of premature coronary artery disease. physical exam: admission physical: physical examination: vs: tm 98, 133/69, 73, 18, 100% ra general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp at angle of jaw, 1x1cm mobile non-tender lymph node in l anterior cervical chain; carotid bruits b/l cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, muted s2. iii/vi systolic murmur peaking early, at rusb, radiating to carotids. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rales lower lung fields b/l, poor inspiratory effort abdomen: soft, ntnd. no hsm or tenderness. extremities: 2+ pitting edema to knees b/l skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: echo: conclusions the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. an aortic corevalve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. mild to moderate (+) aortic regurgitation is seen with an anterior perivalvular leak and minimal posterior jet of aortic regurgitation. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: well seated aortic corevalve prosthesis with normal gradient. mild-moderate perivalvular aortic regurgitation. mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. dilated ascending aorta. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. electronically signed by , md, interpreting physician 18:04 05:50am blood wbc-6.5 rbc-2.76* hgb-8.5* hct-25.1* mcv-91 mch-30.6 mchc-33.6 rdw-13.5 plt ct-183 05:50am blood urean-32* creat-1.7* na-132* k-4.2 cl-102 06:30am blood urean-31* creat-1.6* na-134 k-4.1 cl-103 03:55am blood glucose-94 urean-31* creat-1.6* na-133 k-4.0 cl-103 hco3-24 angap-10 brief hospital course: hospital course: m with critical as s/p balloon valvuloplasty , nyha stage iv diastolic chf, cad s/p cabg , tachy-brady s/p ppm , and ckd stage iii (baseline cr 2.2) admitted electively prior to percutaneous avr scheduled for tues . . active issues: # aortic stenosis: critical as s/p balloon valvuloplasty , nyha stage iv diastolic chf. symptoms progressing since valvuloplasty now with severe limitation of function. poor surgical candidate given age and prior cabg. pt admitted for percutaneous avr. pt diuresed gently with lasix given preload dependence. csurg was consulted and pre-op workup with panorex, ua/ucx, etc was completed. on hospital day 2, pt had flash pulmonary edema as lasix was held in the am. he was transferred to the ccu after morphine, lasix bolus, and on a non-rebreather. he was given diuril and lasix gtt, and produced good uop. he was transitioned from cpap to high-flow neb, and able to tolerate. on hospital day 3, he was taken for core valve. . # cad: s/p cabg in , has stable coronary artery and graft disease on cath in (prox cx 100% stenosis, prox rca 100% stenosis, all grafts widely patent. lima to first diagonal, svg to om, svg to first rpl, svg to rpda). pt's ekg's were unchanged, and pt had no chest pain during the admission. he was continued on asa 81mg. . # acute on chronic left ventricular diastolic dysfunction due to aortic stenosis: last ef 55-60% (). pt is currently in stage iv diastolic chf with severe limitation of function. pt presented with fluid overload on exam and by cxr. he was given cautious diuresis initially. however, as above, pt had flash pulmonary edema, and required transfer to ccu overnight for brief use of cpap, and diuresis with lasix and diuril. he was maintained on a fluid restricted, low sodium diet. . # tachy-brady s/p ppm : ep evaluation and interrogation of icd/ppm to determnine whether it needs to be suppressed during the valve procedure, which will involve rapid right ventricular pacing (up to 200 bpm) during balloon valvuloplasty and 110 bpm during valve placement. ep interrogated pacer and followed throughout hospital course. . # stage iii ckd: baseline cr 2.2. his cr was monitored, and was 2.1 prior to core valve replacement. . # htn: well-controlled on admission, with brief hypertension in setting of flash pulmonary edema. he was diuresed as above. . inactive issues: # gerd: continued on omeprazole. . # bph: continued doxazosin. . brief ccu course: patient was transferred to the ccu on a non-rebreather in severe respiratory distress and impending respiratory failure secondary to flash pulmonary edema, confirmed by chest xray imaging. he was started on bipap with improvement in his oxygenation and ventilation. his foley catheter became displaced during transfer necessitating removal and replacement with coude catheter with subsequent mild hematuria. the patient was diuresed with diuril and a lasix gtt once his catheter was in proper postion. he diuresed well, and was weaned off bipap within 3 hours to 50% face mask. the next morning he was taken to the or for his valve procedure. . the patient was brought to the hybrid room on where the patient underwent 1. percutaneous aortic valve replacement with a 29-mm corevalve device, model number mcs-p3-943, serial number . 2. balloon aortic valvuloplasty. 3. ascending aortography. with drs. , and . overall the patient tolerated the procedure well and post-procedurally was transferred to the cvicu in stable condition for recovery and invasive monitoring. post-procedure day 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. ep interrogated the ppm. beta blocker was initiated and the patient was gently diuresed toward the pre-procedure weight. the patient was transferred to the telemetry floor for further recovery. he did develop hematuria and urology was consulted. continuous bladder irrigation was initiated. he failed a void trial and he will be discharged home with a foley catheter. he is to follow-up with his local urologist within 5 days of discharge. the patient was evaluated by the physical therapy service for assistance with strength and mobility. the patient remained on the core valve pathway and had an echo and neuro evaluation prior to discharge. by the time of discharge on post-procedure day 6, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged home in good condition with appropriate follow up instructions. he will follow-up locally, in . medications on admission: furosemide 40 mgs twice daily. glucosamine sulfate 500 mgs daily. aspirin 81 mgs once daily. omeprazole (prilosec) 20 mgs once daily. doxazosin (cardura) 2 mgs once daily. salsalate 750 mgs three times daily. calcium-vitamin d (oscal d) 500 mgs twice daily. nitroglycerin patches (nitroglyn) 2% ointment. place 0.5 inches onto the skin 3 times daily. psyllium 5.8 g (metamucil), 1 packet twice daily polycarbophil (fibercon) 625 mgs at bedtime discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for temperature >38.0. 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 5. doxazosin 1 mg tablet sig: two (2) tablet po hs (at bedtime). disp:*60 tablet(s)* refills:*0* 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po daily (daily). disp:*60 tablet extended release(s)* refills:*0* discharge disposition: home with service facility: home health & hospice discharge diagnosis: stage 3 ckd,cad,as/ai,pulm htn,ppm,htn,bph<gerd discharge condition: alert and oriented x3 nonfocal ambulating, gait steady groin puncture site- healing well without erythema or drainage discharge instructions: see attached discharge instructions for transcatheter aortic valve implation followup instructions: urologist- dr. , , tuesday, 11:15am follow up with your pcp, , . within 2 weeks Procedure: Combined right and left heart cardiac catheterization Diagnostic ultrasound of heart Open and other replacement of aortic valve Aortography Percutaneous balloon valvuloplasty Diagnoses: Anemia in chronic kidney disease Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Acute on chronic diastolic heart failure Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Aortic valve disorders Other chronic pulmonary heart diseases Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Chronic kidney disease, Stage III (moderate) Retention of urine, unspecified Cardiac pacemaker in situ Unspecified accident Injury to bladder and urethra, without mention of open wound into cavity Hematuria, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache and left arm pain major surgical or invasive procedure: left heart cateterization, coronary angiogram redo sternotomy, coronary artery bypass grafts x 4(lima-lad, svg_dg, svg-om, svg-plv) history of present illness: this 67 year old white male with a history of vsd repair in was admitted with a nstemi. about one week ago patient was out walking his dog at night and felt a pressure in the back of his head. it went away on its own after about one hour. over the next week he had several of these episodes, always associated with walking. on the morning of admission he woke up with the pressure and it was much more severe, so he went to his doctor. his doctor thought he may have arthritis of his back and got a spine xr and prescribed cyclobenzeprine. that night, however, the patient continued to have the headache and then had pain radiate down his l arm into his axilla. he went to where he had labs drawn that showed troponin of 5.34 and ekgs that reportedly had no changes from prior but with baseline rbbb. he was given asa, plavix, lovenox, beta blocker, vicodin, and a liter of ns and then transferred to for cath. on arrival to the ed his vitals were: t:97.7 hr: 100 bp: 123/65 rr: 16 o2sat 96% on 2liters. he received 1mg dilaudid x 2 and remained chest pain/head pain free. past medical history: 1)type ii diabetes diagnosed in 2)gerd 3)hepatitis c - chronic 4)s/p vsd repair in the 5)hx of head and neck cancer (squamous cell ca of left palatine tonsil) diagnosed in s/p xrt and chemo with reportedly good results - all records at 6) s/p herniorrhaphy in 7) mediastinal lad possibly sarcoidosis as opposed to malignancy social history: social history is significant for smoking small cigars daily until . no etoh use currently. lives with wife and 17yo son who underwent foot surgery at chb in for congenital mal-formation of feet. no ivdu. works in marketing. family history: no h/o sudden cardiac death, congenital hd, dm, cad. father had leukemia in 30s. physical exam: admission vs t: 97.7 hr 91 bp 106/77 rr 18 o2 sat 100% 2l nc gen: wd thin middle aged male in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl. conjunctiva were pale, no pallor or cyanosis of the oral mucosa. neck: supple with no jvd. fullness of throat around trachea with no ttp, erythema, palpable masses. no lad. cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, increased s2. no m/r/g. no s3 or s4. chest: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, ntnd. no hsm or tenderness. ext: no c/c/e. pulses: right: dp 2+ left: dp 2+ discharge vs t 98.5 hr 84 sr bp 97/61 rr 18 o2sat 95% ra gen nad neuro a&ox3, nonfocal exam pulm cta-bilat cv rrr, no murmur. sternum stable, incision cdi abdm soft, nt/nd/+bs ext warm, 1+pedal edema bilat. left evh site cdi pertinent results: 08:18pm urine color-yellow appear-clear sp -1.029 08:18pm urine blood-mod nitrite-neg protein-tr glucose-250 ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 08:18pm urine rbc-* wbc- bacteria-few yeast-none epi-0 07:14pm ck-mb-60* mb indx-8.0* ctropnt-1.27* 03:00am ck-mb-45* mb indx-8.7* 12:45pm glucose-191* urea n-15 creat-0.7 sodium-130* potassium-4.6 chloride-100 total co2-21* anion gap-14 12:45pm alt(sgpt)-23 ast(sgot)-84* alk phos-48 tot bili-0.7 12:45pm albumin-3.4 12:45pm %hba1c-6.7* 12:45pm wbc-7.8 rbc-3.40* hgb-11.2* hct-29.9* mcv-88 mch-33.0* mchc-37.6* rdw-13.6 12:45pm plt count-178 12:45pm pt-13.3 ptt-34.2 inr(pt)-1.1 06:03am blood wbc-6.2 rbc-2.90* hgb-9.4* hct-25.2* mcv-87 mch-32.3* mchc-37.2* rdw-14.3 plt ct-144* 06:03am blood glucose-107* urean-20 creat-0.9 na-133 k-3.9 cl-96 hco3-26 angap-15 06:03am blood mg-1.7 echocardiography report , tte (complete) done at 10:10:38 am final referring physician information , c. division of immunology, 6 , status: inpatient dob: age (years): 67 m hgt (in): 63 bp (mm hg): 140/66 wgt (lb): 115 hr (bpm): 91 bsa (m2): 1.53 m2 indication: coronary artery disease icd-9 codes: 414.8 test information date/time: at 10:10 interpret md: , md test type: tte (complete) son: , rdcs doppler: full doppler and color doppler test location: west echo lab contrast: none tech quality: adequate tape #: 2008w053-: machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: 3.1 cm <= 4.0 cm left atrium - four chamber length: 5.1 cm <= 5.2 cm right atrium - four chamber length: 4.1 cm <= 5.0 cm left ventricle - septal wall thickness: 0.9 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 0.7 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.5 cm <= 5.6 cm left ventricle - ejection fraction: 20% to 30% >= 55% left ventricle - lateral peak e': *0.04 m/s > 0.08 m/s left ventricle - septal peak e': *0.05 m/s > 0.08 m/s left ventricle - ratio e/e': *16 < 15 aorta - sinus level: *4.0 cm <= 3.6 cm aorta - ascending: 3.4 cm <= 3.4 cm aortic valve - peak velocity: 0.9 m/sec <= 2.0 m/sec mitral valve - e wave: 0.7 m/sec mitral valve - a wave: 0.7 m/sec mitral valve - e/a ratio: 1.00 mitral valve - e wave deceleration time: 174 ms 140-250 ms tr gradient (+ ra = pasp): *33 mm hg <= 25 mm hg findings left atrium: normal la size. right atrium/interatrial septum: normal ra size. left ventricle: normal lv wall thickness. normal lv cavity size. severely depressed lvef. tdi e/e' >15, suggesting pcwp>18mmhg. transmitral doppler and tvi c/w grade ii (moderate) lv diastolic dysfunction. no resting lvot gradient. right ventricle: normal rv wall thickness. normal rv chamber size. focal apical hypokinesis of rv free wall. aorta: moderately dilated aortic sinus. focal calcifications in aortic root. normal ascending aorta diameter. focal calcifications in ascending aorta. no 2d or doppler evidence of distal arch coarctation. aortic valve: mildly thickened aortic valve leaflets (3). no as. mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. mild thickening of mitral valve chordae. calcified tips of papillary muscles. no ms. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets. normal tricuspid valve supporting structures. no ts. mild tr. mild pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. normal main pa. no doppler evidence for pda pericardium: no pericardial effusion. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions 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 severely depressed (lvef= 20-30 %) secondary to extensive apical hypokinesis, and dyskinesis of the true apex. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). transmitral doppler and tissue velocity imaging are consistent with grade ii (moderate) lv diastolic dysfunction. right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. the aortic root is moderately dilated at the sinus level. 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. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. electronically signed by , md, interpreting physician 10:42 , m 67 radiology report chest (pa & lat) study date of 5:55 pm chest (pa & lat) clip # reason: eval for pleural effusions medical condition: 67 year old man s/p cabg preliminary report !! pfi !! pfi: bilateral pleural effusion decreased, now small. left retrocardiac opacity increased, probably atelectasis. all tubes and catheters were removed. dr. dr. pfi entered: fri 10:44 am brief hospital course: patient admitted as transfer from outside hospital after ruling in for mi. transferred to for cardiac catheterization which revealed left main and 3 vessel disease. he was then referred to cardiac surgery for coronary artery bypass grafting. cardiac surgery course: following plavix washout, the patient was brought to the operating room on where he underwent redo sternotomy, coronary artery bypass grafting x 4 (lima->lad, svg->diagonal, svg->om1, svg->om3). please see operative note for further details. overall the patient tolerated the procedure well, and postoperatively was transferred to the cvicu in stable condition for invasive monitoring. pod 1 found the patient extubated, he was alert and oriented and breathing comfortably. he was neurologically intact and hemodynamically stable, on no inotropic or vasopressor support. the patient was transferred to the step down unit on pod 2 where he continued to progress. chest tubes and pacing wires were discontinued without complication. the physical therapy service was consulted, and the patient made improvements in strength and balance. by the time of discharge on pod 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. he was discharged home with visiting nurses on . medications on admission: metformin 500mg aspirin 81mg daily lisinopril 5mg daily simvastatin 10mg daily omeprazole 40mg daily cyclobenzaprine 10mg 1-2 tabs by mouth prn muscle spasm in back/neck (started ) magnesium 30mg orally twice daily ranitidine 150mg daily fluticasone 2 sprays each nostril daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 3. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). disp:*60 capsule, delayed release(e.c.)(s)* refills:*0* 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 6. simvastatin 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 7. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day. disp:*60 capsule, sustained release(s)* refills:*2* 9. toprol xl 25 mg tablet sustained release 24 hr sig: 0.5 tablet sustained release 24 hr po once a day. disp:*15 tablet sustained release 24 hr(s)* refills:*2* 10. 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 acute systolic heart failure s/p coronary artery bypass grafts s/p ventricular septal defect noninsulin dependent diabetes mellitus s/p herniorrhaphy hepatitis c h/o throat carcinoma discharge condition: good discharge instructions: no driving for 4 weeks no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming report any weight gain more than 2 pounds a day or 5 pounds a week report any drainage from, or redness of incisions report any fever greater than 100.5 no lotions, powders or creams to incisions take all medications as directed followup instructions: clinic in 2 weeks dr. (in 4 weeks dr. () in 2 weeks dr. () in weeks patient to call for appointments Procedure: Venous catheterization, not elsewhere classified (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Transfusion of packed cells Diagnoses: Other iatrogenic hypotension Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Chronic hepatitis C without mention of hepatic coma Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified 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 Accidents occurring in residential institution Combined systolic and diastolic heart failure, unspecified Personal history of malignant neoplasm of other sites |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with drug eluting stent to right coronary artery history of present illness: 64 y/o female with dm2, htn, hyperlipidemia and no significant family history who presented from hospital with chest pain. patient states that she experienced several seconds of substernal/epigastric pain without radiation that resolved spontaneously shortly after waking. the pain was associated with diaphoresis and with subsequent weakness. patient states that the pain then recurred so she asked her son to take her to hospital. the patient's son states that she had several episodes of chest pain approximately 1 year ago; and, the patient's daughter states that her mother was complaining of a discomfort in her chest approximately 1-2 days prior to her presentation to hospital. the patient states that she has never had chest pain like this before. she denies any strenuous activity during the onset of pain but states that she had been walking up and down stairs. patient reported diaphoresis and weakness as above, but denied any associated shortness of breath, dizziness/lightheadedness. she states that she was initially without nausea but vomited upon arrival to the ed following receipt of morphine. . on arrival to ed, initial vs were t 97.7, hr 64, bp 130/79, rr 16, and so2 100% on ra. patient received ntg x2 and asa 324 mg with reported relief of pain. she then received morphine 2 mg iv with subsequent nausea and vomiting, for which she received pepcid 20 mg iv and zofran 4 mg iv. ekg reportedly initially to show twis. ces were ck 2416, mb 24.6, and tr-t 0.020. repeat ekg revealed tw flattening/inversions in v4-v6, ii, iii, avf. repeat ces were ck 1838, mb 37.6, and tn-t 0.084. patient was transferred to for cardiac catheterization. she was started on atorvastatin 80 mg prior to transfer. . patient initially admitted to inpatient cardiology service but triggered for ekg changes. patient received cardiac catheterization that revealed a totally occluded rca, with subsequent lesions in pda, mid-circ, and two in lad. a des was placed to the rca. patient received atropine for bradycardia. she was transiently hypotensive during the procedure but responded to small ns boluses. patient was then transferred to the ccu with recommendation of ct surgery consultation. . on review of systems, she denied 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 denied recent fevers, chills or rigors. she denied exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: + diabetes, + dyslipidemia, + hypertension 2. other past medical history: - uterine fibroids - vitamin d deficiency - cataracts - gerd social history: -retired, lives with son - history: none -etoh: none -illicit drugs: none family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death. physical exam: on admission: vs: t 98.4, bp 101/58, hr 55, rr 16, so2 97% on 3l general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl. neck: supple with jvp of 2 cm above the sternal angle. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities. unlabored respirations. ctab. abdomen: s/nt/nd, bs+ extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: osh labs: na: 136, k 3.2, cl 101, hco3 28, bun 15, cr 0.6, glucose 169 ast 50, alt 68 ck 2416, ck-mb 24.6, trop: 0.020 wbc: 6.6, hct 38.6, plt 356 . labs (): . 6.3>34.7<317 . 136/103/16 ----------<229 4.6/25/0.7 . ca:8.5, mg:2.6, p:4.0 . pt:13.8, ptt:44.3, inr:1.2 . alt:107, ast:176, ap:73, tb:0.9, alb:3.9, ldh:508 . ck:2468, mb:132, mbi:5.3, trop-t: 2.00 other pertinent labs: 11:12am blood %hba1c-7.3* eag-163* 11:12am blood vitb12-863 folate-16.1 11:12am blood triglyc-99 hdl-45 chol/hd-3.3 ldlcalc-82 11:12am blood ck-mb-103* mb indx-4.1 ctropnt-2.40* 05:50pm blood ck-mb-66* mb indx-3.0 ctropnt-1.54* discharge labs: 10:45am blood wbc-5.0 rbc-3.22* hgb-11.5* hct-34.1* mcv-106* mch-35.9* mchc-33.8 rdw-12.3 plt ct-249 10:45am blood glucose-196* urean-11 creat-0.8 na-141 k-4.5 cl-103 hco3-30 angap-13 07:10am blood alt-126* ast-134* ck(cpk)-1533* alkphos-69 totbili-1.0 ekgs: ekg (, hospital): nsr @ 68 bpm, normal axis, normal intervals, twi in ii, iii, avf, v5, v6, and tw flattening in v4. . ekg#1 (, 21:30): sinus bradycardia @ 50, normal axis, normal intervals, 1 mm ste in iii, v1, v2 . ekg#2 (, 00:15): nsr @ 73, ? 1 mm ste in iii, v1, v2 . ekg#3 (, 08:00): sinus rhythm. probable inferior myocardial infarction of indeterminate age, possibly acute/recent/in evolution. cannot exclude myocardial ischemia. clinical correlation is suggested. since the previous tracing of no significant change. tte (): the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with basal inferior hypokinesis. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. brief hospital course: 64 y/o female with iddm, htn, and hld who presented with substernal chest pain with ekg and enzymes changes consistent with stemi. . #. stemi s/p pci: patient was transferred from hospital for cardiac cath for his stemi. he underwent cath which showed multivessel disease (report from interventional service, full report pending at time of discharge) with des placed in the rca. integrelin gtt was continued for 18 hours post cath. he was started on plavix 75 mg daily and aspirin was increased to 325 mg daily. his pravastatin was discontinued and he was started on atorvastatin 80 mg daily. he was discharged on these medications as well as losartan 25 mg and metoprolol succinate 25 mg daily with his blood pressure and heart rate at goal on this new regimen. a plan was made to arrange for an outpatient stress mibi for further evaluation for potential cabg given multi-vessel disease. dr. will get in touch with the patient regarding this. the patient was instructed to continue her aspirin and plavix until otherwise instructed by dr. . . #. hypertension: patient was normotensive on arrival to the floor. patient's outpatient records and medications she is actually taking were inconsistent. patient has documented ace-i cough. she was started on losartan 25 mg and metoprolol was added as above. at time of discharge she was normotensive on this regimen. . #. hyperlipidemia: patient with ldl of 126 on . per review of patient records, patient was subsequently changed to pravastatin 40 mg daily. her ldl on check here was 82, hdl 45. she was started on atorvastatin 80 mg daily in the peri-stemi period. this can be adjusted as necessary in the outpatient setting. . #. diabetes (iddm): patient's last a1c was 8.0 on . a1c on recheck in house was improved at 7.3 she was continued on her home insulin regimen and an iss. . #. gerd: started famotidine. medications on admission: per pt report: 1. insulin nph 5 units qam and 15-20 units qpm 2. pravastatin 40 mg qhs 3. amlodipine 5 mg daily 4. vitamin d 1000 units daily per atrius records: 1. insulin nph 5 in am, 15 in pm 2. pravastatin 40 mg daily 3. avapro hct 100/25 daily 4. amlodipine 10 mg daily discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): do not stop taking unless dr. tells you to stop. disp:*30 tablet(s)* refills:*11* 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for heartburn. disp:*60 tablet(s)* refills:*0* 4. metoprolol succinate 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:*2* 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. nph insulin human recomb 100 unit/ml suspension sig: five (5) units subcutaneous once a day. 7. nph insulin human recomb 100 unit/ml suspension sig: fifteen (15) units subcutaneous once a day: before dinner. 8. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po once a day. 9. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet sublingual as directed as needed for chest pain. disp:*25 tablets* refills:*0* 10. outpatient lab work please check chem-7 and lft's on and call results to dr. , e. phone: fax: 11. losartan 25 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: st elevation myocardial infarction hypertension diabetes mellitus type 2 discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms , it was a pleasure taking care of you. . you were transferred to due to concern for heart attack. upon arrival to the hospital you continued to have chest pain and the decision was made to proceed directly to cardiac catheterization which demonstrated occlusion of several coronary vessels. a stent was placed in a vessel, the right coronary artery, to open the artery. you were started on aspirin and plavix (clopidogrel) which act to keep the stent from closing. you should not stop taking these medicines or miss unless dr. tells you to. you will be contact by dr. office regarding a follow up appt and an appt for a stress test in the near future. do not return to work until after this appt and testing. no lifting more than 10 pounds for one week. no pools or baths, you can shower and change the band aid if you want. activity per your physical therapy prescription. . changes to your medications: increase aspirin to 325mg daily start taking plavix 75 mg daily with the aspirin to prevent the stent from clotting off and causing another heart attack. stop taking pravastatin, take atorvastatin instead to lower your cholesterol stop taking prilosec, take famotidine as needed for your heartburn stop taking avapro hct, start taking losartan twice daily for your high blood pressure. stop taking amlodipine start taking metoprolol to lower your heart rate and help your heart recover from the heart attack followup instructions: name: , e. location: address: , , phone: appt: at 1:40pm name: , location: address: , , phone: appt: dr office will call you at home with an appt. if you dont hear from them by tomorrow afternoon, please call them directly to book a follow up appt. Procedure: Coronary arteriography using two catheters 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: Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia Long-term (current) use of insulin Acute myocardial infarction of inferolateral wall, initial episode of care Unspecified cataract Unspecified vitamin D deficiency |
allergies: heparin agents attending: chief complaint: hypoxemic respiratory failure, acute renal failure major surgical or invasive procedure: dialysis catheter placed for cvvh history of present illness: 83m with hx of schf (ef 40%), cki (baseline cr ~2 at presentation at osh), former smoker with 30 pack year history, presents from an osh with hypoxemic respiratory failure and acute kidney injury. . the patient originally presented on to osh with 3 weeks of hemoptysis associated with intercurrent wheezing, weight loss, and dyspnea. symptoms were not responsive to antibiotics or low dose steroid therapy. 8 pound weight loss in past month also noted, with chills. per the patient's son, mr. has had a dry cough for about a year, and is bothered by chronic lower extremity claudication. a chest film on showed diffuse, primarily lower interstitial infiltrates without pleural effusions, with upper lung zone hyperlucency. a ct chest on showed diffuse bilateral interstitial, primarily ground-glass appearing interstitial infiltrates; bronchiectatic changes were also noted. pleura was focally, intermittently thickened. small right pleural effusion was noted. no lymphadenopathy was noted. . he presented for outpatient bronchoscopy on , with bal of lingula and transbronchial biopsy of the right middle . his vitals on presentation were 97.9 f, hr 69, rr 26, 170/75, o2 sat 87% on room air. post-procedure, his oxygenation declined, requiring 6 liters n/c and then a nrb to maintain sats in the high 80s. a post-procedure radiograph showed development of dense infiltrate in the rml. oxygenation remained poor, the patient became tachypneic, and was admitted. 100% o2 on a nrb did not improve o2 sats, and the patient was intubated for hypoxic respiratory failure. . while at the osh the pathology from the trans bronichial biopsy was sent to another osh, which was intepreted as consistent with boop. serologic , anca, rf negative. in the icu, an a-line and left subclavian were placed. mild transaminitis resolved in days. the patient subsequently received solumederol 0.5gm for a number of days, which did not improve bilateral infiltrates. he developed azotemia with bun of 200. the patient subsequently underwent repeat ct scan that revealed evidence of large bilateral effusions with worsening infiltrates. vent settings prior to transfer ac 550 x 25 10 peep 40% fi02. pt with klebsiella in sputum, has remained afebrile. steroids were tapered in setting of azotemia. diuresis was then attempted in setting of systolic chf, ef 40%. , block beta-blockade, coag (-) staph from a-line (since discontinued) was also noted during his course. . bal results at osh: path specimen was sent to , interpreted as having characteristic features of boop with branching of fibrous tissue surrounded by organizing alveolar inflammation and scattered eosinophils. differential: 32 lymph, 63 polys, numerous rbcs . while in transit the patients vent settings were adjusted to tv 500. t time increased from 0.6 to 1. he was paralyzed with rocuronium 63mg then 100mg. he received a total of 4mg of ativan and 150mcg of fenantyl. . upon arrival to the the patient is intubated, sedated and paralyzed. unable to assess futher review of systems. additional history provided by son noted above. no recent history of n/v/d/f or pnd/orthopnea. past medical history: chronic systolic chf (40%) chronic kidney injury (baseline cr) type ii dm pad htn mi s/p 6 angioplasties, one stent in ' ?cvd s/p right cea macular degeneration social history: widowed, lives alone on in . educator, continues to teach literature to adults. 30 pack year smoking history, quit in . no h/o tb or asbestos exposure. servings of etoh a week family history: mother and father with type ii dm, gout, cad, died in age 80s. physical exam: t= 96.6 bp= 147/71 hr= 90 rr= 19 o2= 99 % on peep 10, fio2 40% general: pleasant, elderly male sedated, in nad heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. dry mm. op clear. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . jvp= 1-2 cm above angle of jaw lungs: ctab, good air movement biaterally anteriorly abdomen: nabs. soft, nt, nd. no hsm. significant scrotal edema extremities: 2+ edema in le bilaterally, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: paralyzed, sedated pertinent results: 07:19pm type-art peep-10 o2-40 po2-60* pco2-36 ph-7.48* total co2-28 base xs-3 -assist/con intubated-intubated 07:29pm pt-13.0 ptt-30.6 inr(pt)-1.1 07:29pm plt count-138* lplt-3+ 07:29pm neuts-94.5* lymphs-1.9* monos-3.4 eos-0 basos-0.1 07:29pm wbc-20.8* rbc-3.07* hgb-8.7* hct-27.5* mcv-90 mch-28.2 mchc-31.5 rdw-16.0* 07:29pm osmolal-382* 07:29pm albumin-3.0* calcium-8.1* phosphate-5.9* magnesium-3.8* 07:29pm ck-mb-6 ctropnt-0.56* 07:29pm alt(sgpt)-109* ast(sgot)-69* ld(ldh)-430* ck(cpk)-269 alk phos-102 tot bili-0.9 07:29pm estgfr-using this 07:29pm glucose-248* urea n-185* creat-2.2* sodium-152* potassium-4.1 chloride-111* total co2-26 anion gap-19 09:22pm urine mucous-rare 09:22pm urine hyaline-4* 09:22pm urine rbc-66* wbc-2 bacteria-few yeast-none epi-<1 09:22pm urine blood-mod nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 09:22pm urine color-yellow appear-clear sp -1.013 09:22pm urine osmolal-516 09:22pm urine hours-random urea n-1019 creat-28 sodium-50 potassium-9 chloride-21 portable chest film: no previous images. the endotracheal tube tip lies approximately 4 cm above the carina. right picc line terminates near the origin of the svc. there is enlargement of the cardiac silhouette with prominence of pulmonary vessels consistent with vascular congestion. retrocardiac opacification is consistent with atelectasis and probable effusion. there are some patchy areas of opacification bilaterally that could represent superimposed pneumonia. nasogastric tube extends to the stomach. ct chest without contrast: 1. left ventricular enlargement, moderate pulmonary edema, moderate nonhemorrhagic bilateral pleural effusions, could be related to severe coronary atherosclerosis and some aortic valvular stenosis. 2. small right middle hematoma. 3. moderate emphysema. 4. severe atherosclerosis involving coronaries, proximal head and neck and abdominal arteries. no aneurysm. 5. large exophytic right renal cyst. 6. anemia. tte : the left atrium is dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is moderate global left ventricular hypokinesis (lvef = 30-35%). the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with moderate global lv hypokinesis. mild mitral regurgitation. mild pulmonary artery systolic hypertension. repeat tte : compared with the prior study (images reviewed) of , mitral regurgitation and rv dimensions/function are better appreciated, although these findings do not actually appear substantially difference. the rest of the findings are also similar repeat tte : compared with the prior study (images reviewed) of , no definite change. rv function remains moderately depressed ct head: 1. no acute intracranial hemorrhage or acute vascular infarct. 2. encephalomalacia in the right occipital indicating old right pca infarct. 3. sequelae of chronic small vessel ischemic disease. 4. opacification of scattered mastoid air cells, bilaterally. note added in attending review: the region of cystic encephalomalacia with volume loss involves the posterior right parietovertex rather than the occipital , se. this likely represents remote posterior mca branch embolic or, alternatively, "watershed" infarction, though there is no other evidence of the latter. also noted are likely chronic lacunes in the right caudate and bilateral lentiform nuclei. ruq ultrasound: 1. no intra- or extra-hepatic biliary ductal dilatation 2. gallbladder sludge without evidence of acute cholecystitis. 3. small amount of perihepatic fluid. 4. right pleural effusion eeg: impression: this is an abnormal portable eeg due to severe suppression of the background activity with only occasional diffuse theta/delta activity seen. this suggests a severe encephalopathy secondary to medications, toxic/metabolic disturbances, or infection. anoxia is also a possible etiology. no epileptiform discharges or electrographic seizures were seen during this recording. there is no evidence of non-convulsive status epilepticus in this recording. given the severity of this eeg, continuous eeg or repeat routine eeg in a few days may provide additional information. mr : 1. area of encephalomalacia involving the right middle cerebral artery territory consistent with a chronic infarct. there is no evidence of an acute infarct, mass or acute hemorrhage. 2. areas of white matter hyperintensity are a nonspecific finding, but likely represent the sequela of chronic microangiopathy given the patient's age. cxr : ap supine chest radiograph: there is increased patchy opacity bilaterally which likely represents fluid overload as there is fluid noted within the fissure on the right. an endotracheal tube with its tip 3.6 cm above the carina, a nasogastric tube and a right picc which terminates near the left brachiocephalic vein/upper svc are unchanged since hours prior. the heart size is normal. there is no pneumothorax. the lower cp angles are not imaged. cxr : pulmonary edema has improved throughout the right lung and in the upper portion of the left. moderate right pleural effusion, however, has increased and the heterogeneous opacification in the left mid lung could be residual edema or pneumonia. heart size is normal. et tube is in standard placement and the right picc line ends just before the junction of the brachiocephalic veins and a nasogastric tube passes below the diaphragm and out of view. no pneumothorax. right ue u/s: impression: no evidence of left upper extremity dvt lower extremity u/s: 1. partially occlusive thrombus involving the right common femoral vein extending to the superficial femoral vein. 2. no evidence of left lower extremity dvt /24/10 11:56 pm sputum site: endotracheal **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): budding yeast with pseudohyphae. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. yeast. moderate growth. klebsiella pneumoniae. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 8 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s 7:53 am sputum site: endotracheal source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): budding yeast with pseudohyphae. respiratory culture (final ): commensal respiratory flora absent. yeast. sparse growth. gram negative rod(s). rare growth. 4:51 am blood culture site: a line **final report ** blood culture, routine (final ): staphylococcus, coagulase negative. isolated from one set only. sensitivities performed on request.. 3:03 pm blood culture source: line-right dl picc. blood culture, routine (pending): 7:21 am urine source: catheter. heme specimen 0658s is used for culture interpret results with caution. **final report ** urine culture (final ): yeast. 10,000-100,000 organisms/ml.. brief hospital course: assessment and plan: 83m with schf (ef 40%), presenting from osh with acute hypoexmic respiratory failure with evidence of boop, unexplained hemoptysis and acute on cki. . # acute hypoxemic respitatory failure: the patient presented from an osh with vent setting of 10 peep, 40% fi02. differential of failure included boop, chf, anca-associated vasculitis e.g. goodpasture's syndrome, and ventilator associated pneumonia. there was no evidence of emphasematous changes on recent imaging to suggest obstructive physiology. continued solumedrol with taper, received multiple days of solumedrol at hospital. treated klebsiella sputum with piperacillin-tazobactam initially, converted to cipro. the patient initially improved with this regimen, but decompensated during his course, with a hypotensive episode that was likely due to a gastrointestinal hemorrhage. with serial chest films, there was a question of development of an aspiration pneumonia, with progressive focal consolidation in the right lung base. the patient was covered broadly for aspiration pneumonia with courses of vancomycin, cefepime, and flagyl, for a 10 day course. volume overload, likely due to left heart failure and steroid therapy, was managed with continuous -venous hemodialysis. the patient's respiratory failure stabilized following these interventions, and he was able to tolerate minimal ventilatory support. however, full wean off the ventilator failed due to profound weakness, likely from steroid and icu-induced myopathy. the patient thus was scheduled to undergo a tracheostomy which was placed and patient required ongoing ventilator support. given the grim prognosis for all of his medical issues he was made cmo in the hospital. . # gi bleed: on , the patient was noted to be hypotensive, requiring pressor support with levophed, then dopamine. this was weaned quickly. ng lavage brought back coffee grounds, and guaiac was positive. the patient then had persistent brbpr for several days. he received many units of packed red blood cells. he also received fresh frozen plasma and vasopressin. colonoscopy and egd were deferred given tenous clinical status. with improvement in the patient's thrombocytopenia, the gi bleed resolved. following transfer for tracheostomy, the patient's gi bleed recurred and he underwent a rigid scope by surgery; he was found to have ischemic colitis but felt to be a poor operative candidate. a decision was made not to do aggressive treatments/transfusions and ultimately he was made cmo. . # cad s/p angioplasty, stent x 1: troponin elevated, ck and mb normal. given recent history of hemoptysis and possible rml hemorrhage, renal insufficiency, and no significant ecg changes from admission to osh, will defer anti-platelet and anti-coagulation at this time. will continue to trend and continue asa 325 mg daily. statin therapy was held in the setting of his transaminitis. the patient had an acute onset of hypotension during his course, requiring levophed, replaced by dopamine, for a short period of time. ecg showed worsening ischemia with deepened st depressions in avl and i. troponin was also positive. it was thought that the gi bleed, likely lower in etiology, was the inciting event for the patient's ischemia. . #. acute on chronic kidney injury: ddx includes prerenal azotemia (poor forward flow, intravascular depletion), intrinsic, post-renal. although now with signs of fluid overload, bun of 200. no signs of acidosis, hyperkalemia to sugest urgent emergeny need for dialysis. pt may require hd vs cvvh given azotemia. patient was initially managed with iv diuresis, which proved difficult in setting of gi bleed. following stabilization of gi bleed, the patient received hemofiltration during cvvh, with some volume removed. his creatinine improved but then as the above issues deteriorated his creatinine worsened given the family and patients desire not to do aggressive fluids/blood transfusions. . # transaminitis- initially mildly elevated with unknown etiology. right upper quadrant ultrasound was unremarkable. lfts worsened significantly in setting of gi bleed, hypotension, with shock liver. resolved with improvement in cardiac output and resolution of gi bleed. . # altered mental status- patient was initially unresponsive for days despite lack of sedative medications. eeg was unremarkable. ct head was unremarkable. his mental status cleared following cvvh and improvement in renal function/azotemia. . #. chronic systolic chf: pt with last known ef of 40%. upon transfer appearred to be clinically hypervolemic with likely intravascular depletion. diuresis initially unsuccessful. tte as above showed some systolic dysfunction. hypervolemia due to systolic failure was managed by cvvh, which initially was limited by gi bleed. . # heparin-induced thrombocytopenia antibody positivity- serotonin release assay was negative. however, the patient was found to have a thrombus in the common femoral vein, and argatroban was started per hematology. he underwent an ivc filter for the clot. . overall after much discussion with the family and the patient, he was made comfort measures only. the patient passed with the family at his bedside. there was no need for an autopsy and the family declined. . medications on admission: medications (on transfer): amlodipine 5 mg po bid lipitor 10 mg daily chlorhexadine oral care lasix 40 mg iv bid sc heparin 5000 units tid combivent 6 puffs q6h solu-medrol 60 mg iv daily mvi protonix 40 mg iv daily zosyn 2.25 grams q6h (started ) insulin gtt fentanyl 50 mcg q1h prn lorazepam 1 mg q1h prn . medications (home) lantus 40 units sc qam asa 325 mg daily lipitor 10 mg daily lisinopril 20 mg daily hctz 25 mg labetalol 100 mg prilosec 20 mg daily iron sulfate 325 mg mvi glucosamine 500 mg daily allopurinol 100 mg daily cilostazol 100 mg discharge medications: . discharge disposition: expired discharge diagnosis: respiratory failure ischemic colitis vap hit cad acute on chronic renal failure discharge condition: death Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Interruption of the vena cava Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Arterial catheterization Laryngoscopy and other tracheoscopy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Bronchoscopy through artificial stoma Rigid proctosigmoidoscopy Angiocardiography of venae cavae Removal of other device from thorax Diagnoses: Hyperpotassemia Coronary atherosclerosis of native coronary artery Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute and subacute necrosis of liver Unspecified septicemia Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Peripheral vascular disease, unspecified Percutaneous transluminal coronary angioplasty status Chronic kidney disease, 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 specified cardiac dysrhythmias Cardiac arrest Old myocardial infarction Macular degeneration (senile), unspecified Other emphysema Pressure ulcer, lower back Infection and inflammatory reaction due to other vascular device, implant, and graft Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Hyperosmolality and/or hypernatremia Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Ventilator associated pneumonia Acute vascular insufficiency of intestine Acute on chronic systolic heart failure First degree atrioventricular block Critical illness myopathy Coma Heparin-induced thrombocytopenia (HIT) Dependence on respirator, status Pressure ulcer, stage II Cyst of kidney, acquired Other specified alveolar and parietoalveolar pneumonopathies |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p mvc, foreign body in esophagus major surgical or invasive procedure: intubation/sedation endoscopy history of present illness: 40m unknown pmh presents after mvc as unrestrained driver. . per social work note from ed --- "per ems report +loc, there were no visible skid marks on the road & pt's car went head on into tree. there was concern that crash might have been intentional. however, pt was confused & not arousable in the ed to clarify details. pt became agitated, threatening & hitting staff, so he was intubated. police at the scene reported to ems that they thought they recognized pt from court earlier in the day. there is a question as to whether pt was the same man from court who had a restraining order taken out against him by brother. this information has not been confirmed. identification for pt has not been confirmed either. police took the license in patient's possession. the license listed dob , , , ma. police & ems could not confirm that it was pt's license. car was also registered to ." . in the ed, vitals 60, 110/64, 100% on a/c 550x14/5/100%. on exam, no trauma injuries. gcs 7 or 8 initially. labs normal, only notable for tox screen positive for benzos. thought he was clearly intoxicated from something though. given tetanus shot, haldol, ativan. intubated for agitation on propofol. ct chest revealed foreign body in esophagus (?coin or battery). gi consulted and thought that most likely a coin based on appearance, plan to get xray in am to see if it has cleared and if not then scope at that time. admit micu. past medical history: none social history: lives with mother (never lived independently), unstable relationship. father passed away one year prior. denies etoh, intermittent marijuana. family history: mother with depression pertinent results: ct head : findings: there is no intracranial hemorrhage. there is no mass effect, edema, or infarction. ventricles and sulci are normal in size and configuration. there is no fracture. visualized paranasal sinuses are normally aerated. impression: no acute intracranial process. ct c spine : findings: there is no fracture or cervical spine malalignment. there is a 2.0-cm metallic round foreign body in the mid esophagus, only partially imaged on this examination. prevertebral and paraspinal soft tissues are otherwise unremarkable. endotracheal tube and nasogastric tube are in place. visualized outline of the thecal sac appears normal, but please note that ct is unable to provide intrathecal detail comparable to mri. impression: 1. no cervical spine fracture or malalignment. 2. 2.0-cm metallic round foreign object in the mid esophagus, possibly a coin or battery. cxr : impression: 1. low lung volumes. 2. 2.0 cm metallic foreign object in the expected location of the mid- esophagus, confirmed on concurrently performed torso ct. endoscopy impression: ulcers in the upper third of the esophagus a us quarter in the upper third of the esophagus (foreign body removal) otherwise normal egd to second part of the duodenum ct chest: impression: 1. no acute traumatic injury in the chest, abdomen, or pelvis. 2. two ingested round metallic foreign objects, one in the mid esophagus, and the second in the cecum. these likely represent ingested coins, or possibly batteries. ct abdomen/pelvis : impression: 1. no acute traumatic injury in the chest, abdomen, or pelvis. 2. two ingested round metallic foreign objects, one in the mid esophagus, and the second in the cecum. these likely represent ingested coins, or possibly batteries. brief hospital course: 40 year old male presents after motor vehicle crash/likely suicide attempt as unrestrained driver, found to have foreign body in esophagus and cecum, intubated for agitation. # suicide attempt: pt with h/o suicide attempt in the past. living with his mother who also had recent suicide attempt per psych history. he is on sertraline 50mg outpatient which was restarted hd 2. psychiatry felt that he needed inpatient admission to psychiatric facility for further management of suicidality, disordered thinking. # s/p mvc: the patient was found intoxicated in a motor vehicle wreck as an unrestrained drive. no fractures/significant trauma on exam or full body ct imaging. the event was thought to be a suicide attempt and psychiatry followed the patient while admitted. the patient was intubated for agitation and airway protection and successfully extubated . the patient was transferred to the floor in stable condition. # foreign body ingestion: two coins were found in cecum and esophagus respectively on routine ct imaging. endoscopy was performed after failed glucagon trial to remove the esophageal coin. per gi, coins do not pose harm to patient. they recommended proton pump inhibitor twice daily for two weeks. he was placed on an aggressive bowel regimen. # benzodiazepine intoxication/altered mental status: the patient was found with a toxicology screen positive for benzos. he was agitated in the ed concerning for withdrawal, but no clinical signs of withdrawal later on. he was intubated for airway protection then extubated once stable. psychiatry was consulted and recommended standing haldol & ativan in the short term with psychiatric placement pending on discharge. he had no further episodes of agitation after hd1. medications on admission: sertraline discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po every twelve (12) hours. 2. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. haloperidol 1 mg tablet sig: 2.5 tablets po tid (3 times a day). 5. lorazepam 1 mg tablet sig: one (1) tablet po tid (3 times a day). 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 9. haloperidol 2.5 mg iv q2h:prn agitation page micu intern if administered 10. haloperidol decanoate 50 mg/ml solution sig: one (1) intramuscular tid (3 times a day) as needed for agitation. 11. lorazepam in normal saline 100 mg/100 ml solution sig: one (1) intravenous tid (3 times a day) as needed for agitation. discharge disposition: extended care facility: caritas discharge diagnosis: primary: suicide attempt foreign body ingestion disordered thinking discharge condition: stable discharge instructions: you were admitted for a suicide attempt by motor vehicle. you were not found to have any significant trauma on ct scans of your body. you were initially intubated due to agitation. you were extubated without any problems. were found to have coins in your stomach and colon. one coin was retrieved on endoscopy and the other was in your colon. these should not harm you and should pass with regular bowel movements. you were transferred to a psychiatric facility for further management of your psychiatric illness. if you should have fever/chills, abdominal pain, chest pain/shortness of breath, you should present to the emergency department. you should take your medications as directed. followup instructions: you should establish primary care near your home once your psychiatric condition has stabilize and you are discharged from your psychiatric admission. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other endoscopy of small intestine Insertion of endotracheal tube Removal of intraluminal foreign body from esophagus without incision Diagnoses: Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents Poisoning by benzodiazepine-based tranquilizers Other specified cardiac dysrhythmias Accidents occurring in other specified places Foreign body in intestine and colon Foreign body accidentally entering other orifice Street and highway accidents Ulcer of esophagus without bleeding Suicide and self-inflicted poisoning by other and unspecified solid and liquid substances Toxic effect of ethyl alcohol Foreign body in esophagus Unspecified nonpsychotic mental disorder Suicide and self-inflicted injury by crashing of motor vehicle |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: trauma; injuries include l axillary a active extravasation right pneumothorax pubic rami fractures left scapula fx l lower extremity: fracture of proximal tibia and fibula. fracture of mid fibula. fracture at the distal tibia. r lower extremity: fracture of distal tibia and fibula. multiple fx of the face mult rib fractures l anterior ribs ; r anterior ribs , multiple areas of hemorrhagic contusions, most notably in the left parietal lobe and left anterior temporal lobe. multiple foci of diffuse axonal injury, most notably in the corpus callosum and in the mid brain - pontine junction. subdural hemorrhage, right greater than left and along the falx. intraventricular hemorrhage. near-complete obliteration of the cerebellar csf space and the foramen magnum with tonsils in the foramen magnum. major surgical or invasive procedure: exploratory laparotomy. operation performed: 1. access of left common femoral artery. 2. third-order catheterization of left circumflex brachial artery. 3. left axillary arteriogram. 4. coil embolization of left circumflex brachial artery. 5. evacuation of hematoma left shoulder. 6. perclose closure of left common femoral arteriotomy. history of present illness: 66y f w/ injuries as aforementioned presents as polytrauma s/p pedestrian vs. motor vehicle past medical history: stroke (?residual) bipolar disorder social history: lives alone, not married, 2 sisters, long time smoker, social etoh family history: non-contributory physical exam: refer to trauma admission assesment pertinent results: 11:55am blood wbc-10.8 rbc-2.83* hgb-8.8* hct-27.3* mcv-96 mch-31.2 mchc-32.3 rdw-13.2 plt ct-227 04:20pm blood wbc-5.5 rbc-3.49* hgb-10.7* hct-30.0* mcv-86 mch-30.8 mchc-35.8* rdw-15.3 plt ct-74* 02:57am blood wbc-5.6 rbc-3.59* hgb-10.9* hct-29.4* mcv-82 mch-30.5 mchc-37.2* rdw-15.7* plt ct-186 09:13am blood hct-30.3* 11:55am blood pt-14.8* ptt-37.5* inr(pt)-1.3* 04:20pm blood pt-21.7* ptt-55.6* inr(pt)-2.0* 03:37pm blood plt smr-very low plt ct-52*# 09:34pm blood pt-14.5* ptt-28.4 inr(pt)-1.3* 03:21am blood plt ct-135* 05:55pm blood glucose-144* urean-13 creat-1.0 na-155* k-3.3 cl-113* hco3-27 angap-18 09:13am blood glucose-221* urean-22* creat-1.3* na-157* k-3.7 cl-122* hco3-27 angap-12 05:55pm blood calcium-9.9 phos-5.1* mg-1.4* 09:13am blood calcium-8.6 phos-3.9 mg-2.1 09:40am blood osmolal-334* 11:55am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 02:31pm blood type-art po2-446* pco2-37 ph-7.33* caltco2-20* base xs--5 03:04pm blood type-mix po2-397* pco2-48* ph-7.23* caltco2-21 base xs--7 intubat-intubated 03:30am blood type-art temp-36.7 rates-/22 tidal v-320 peep-5 fio2-40 po2-112* pco2-43 ph-7.44 caltco2-30 base xs-5 intubat-intubated 12:07pm blood glucose-165* lactate-2.2* na-140 k-3.7 cl-111 calhco3-19* 03:34pm blood glucose-186* lactate-4.4* na-147 k-4.2 cl-106 06:00pm blood lactate-4.8* 11:05am blood glucose-164* lactate-2.8* brief hospital course: pt admitted via trauma bay. was emergently taken to the operating room after ct scan demonstrated active extravasation form a left axillary vessel. after control of the vessel was obtained the patient remained hemodynamically unstable and exploratory laparotomy was performed to evaluate for abdominal hemorrhage. this exploration was negative. post-operatively the patient was taken to the trauma icu. the neurosurgical team was consulted as well as orthopedic surgery. laboratory results demonstrated a elevation of serum sodium. urine osmolaity was checked and diabetes insipidus was diagnosed, ddavp and free water therapy was initiated along with q2 hours sodium checks. a mri of the head was obtained, the results of which were aforementioned. after continued discussion with neurosurgery it was determined that the patients neurologic injuries were such that recovery was unlikely. a discussion with the family was had and it was decided to withdraw support. the patient was started morphine and versed drips and was terminally extubated. she expired shortly thereafter. the family was notified as well as the medical examiner who accepted the case. discharge medications: expired discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired md, Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Exploratory laparotomy Other incision with drainage of skin and subcutaneous tissue Suture of vein Other endovascular procedures on other vessels Arteriography of other specified sites Diagnoses: Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Traumatic pneumothorax without mention of open wound into thorax Bipolar disorder, unspecified Other and unspecified coagulation defects Closed fracture of other facial bones Diabetes insipidus Closed fracture of pubis Closed fracture of eight or more ribs Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged [more than 24 hours] loss of consciousness, without return to pre-existing conscious level Dissection of other artery Open fracture of upper end of fibula with tibia Hypothermia not associated with low environmental temperature Closed fracture of glenoid cavity and neck of scapula |
allergies: morphine attending: chief complaint: seizure major surgical or invasive procedure: right craniotomy for resection history of present illness: ms. is a64 y/o female who was in usual good state of health, awoke this morning, exercised and then was found by her husband at approximately 10:30am to be confused with some left sided weakness. she was progressively worsening, he activated ems. she reportedly had tonic clonic seizure in ambulance en route to and seized again while there. she received 1gram dilantin and ativan and has had no further seizure activity. husband notes return of left arm and leg weakness over past several hours but remains with facial weakness. ct and mri done. she had small right frontal meningioma found incidentally in and today's ct compared with that shows marked enlargement to 4 x 5 cm mass. past medical history: hypercholesterolemia, bilat knee , left foot surgery, excision r groin lipoma, peripheral neuropathy r>l that is currently being worked up as outpt social history: quit smoking 31 yr ago (1ppdx 10yr). wine per day, no recreational drugs family history: father: had h/o benign brain tumor, deceased emphysema/heart failure mother: deceased cva sister: lung ca dx'd last year son/daughter: a and w physical exam: physical examination on admission: o: t:98.3 bp: 114/76 hr:79 r18 o2sats 99 ra gen: wd/wn, comfortable, nad.closing eyes and sleepy at times but easily arousable heent: pupils: bilat eoms full with lateral nystagmus neck: supple. abd: soft, nt extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. recall: objects at 5 minutes. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 6mm to 4 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 with slight weakness throughout left face. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch bilaterally. physical examination on discharge: gen: wd/wn, comfortable, nad.closing eyes and sleepy at times but easily arousable heent: pupils: bilaterally. eoms full with lateral nystagmus. neck: supple. abd: soft, nt extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested. ii: pupils equally round and reactive to light, 4mm to 3 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and with slight weakness throughout left face. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout with the exception of the right deltoid which was unable to be assessed secondary to h/o a rotator cuff injury. no pronator drift. sensation: intact to light touch bilaterally. wound is clean, dry and intact without edema, erythema or discharge. staples are in place. pertinent results: cta head w&w/o c & recons 1. hyperdense 4 cm right frontal extra-axial mass, most likely a meningioma. 2. apparent 6-mm dilatation of the cavernous right ica, versus an artifact of tortuosity. this may be clarified on the pending curved reformat images. an addendum to this report will be issued. 3. no enlargement of the right aca or mca branches to suggest significant contribution to the right frontal mass from these vessels. however, the arterial supply to the mass would be best assessed by a conventional angiogram, if indicated. 4. short-segment complete or near-complete occlusion of the superior sagittal sinus at the level of the right frontal mass. cta chest w&w/o c&recons, non-coronary 1. no pulmonary embolism. 2. left ventricular hypertrophy with possible aortic root dilatation. recommend evaluation with echocardiogram. ct head w/o contrast 1. stable examination with right frontal extra-axial mass likely representing meningioma, with stable degree of mass effect. 2. no interval hemorrhage or acute infarct evident. mri of the brain with and without contrast 1. status post right frontal craniotomy and resection of the right frontal mass lesion. residual blood products are visualized in the surgical bed and minimal residual edema, with no evidence of abnormal enhancement to suggest residual mass lesion. 2. small amount of subdural fluid and subarachnoid hemorrhage noted at the surgical region, with no evidence of significant mass effect, likely related with recent surgical procedure. no diffusion abnormalities are detected to suggest acute or subacute ischemic changes. 09:35pm glucose-112* urea n-9 creat-0.8 sodium-141 potassium-4.2 chloride-107 total co2-27 anion gap-11 09:35pm estgfr-using this 09:35pm calcium-8.8 phosphate-3.1 magnesium-2.1 09:35pm phenytoin-14.5 09:35pm wbc-7.6 rbc-3.99* hgb-12.7 hct-38.0 mcv-95 mch-31.8 mchc-33.4 rdw-12.8 09:35pm plt count-221 09:35pm pt-10.6 ptt-27.4 inr(pt)-1.0 brief hospital course: 64 y/o female found down with new left-sided weakness and seizure presents with right frontal brain lesion. she was admitted the neurosurgery for further neurosurgical evaluation. she was evaluated and was nonfocal on examination, but with some short term memory loss. cta of head was done to look at vasculature for or planning. on , patient was seen to have a seizure in the am, was also seen to be tachypenic and tachycardic. keppra was added to the dilantin and a level was checked. ct chest was ordered to rule out pe which was negative. neurology was consulted. on , no further seizure activity was seen, but dilantin level was not , dilantin was increased. she had an mri head for the or. on , patient was taken to the or. intraoperatively, she received platelets and magnesium, potassium and calcium were repleted. she was taken to the icu for close monitoring. she was started on a dexamethasone taper. on , she was transferred to the floor on telemetry for concern for seizures. she receivd a dilantin bolus and the keppra was increased. on , a dilantin level was obtained which was 18.2. on , ms. was neurologically intact on examination and her incision was clean, dry and intact with staples in place. medications on admission: lipitor 20mg daily. discharge medications: 1. atorvastatin 20 mg po daily 2. docusate sodium 100 mg po bid rx *docusate sodium 100 mg 1 capsule(s) by mouth twice daily disp #*15 capsule refills:*0 3. oxycodone (immediate release) 5-10 mg po q4h:prn pain hold rr < 12 rx *oxycodone 5 mg tablet(s) by mouth every four (4) hours disp #*30 tablet refills:*0 4. pantoprazole 40 mg po q24h rx *pantoprazole 20 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*1 5. levetiracetam 1500 mg po bid rx *levetiracetam 750 mg 2 tablet(s) by mouth q12 hours disp #*60 tablet refills:*1 6. dexamethasone 2 mg po q6 duration: 24 hours rx *dexamethasone 2 mg 1 tablet(s) by mouth please refer to additional instructions. disp #*5 tablet refills:*0 discharge disposition: home discharge diagnosis: right frontal lesion pending pathology results. 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. ?????? dressing may be removed on day 2 after surgery. ?????? your wound was closed with staples. 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. ?????? you have been discharged on keppra (levetiracetam), you will not require blood work monitoring. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: follow-up appointment instructions: ??????please return to the office in days(from your date of surgery) for removal of your staples and a wound check. this appointment can be made with the physician assistant or practitioner. please make this appointment by calling . if you live quite a distance from our office, please make arrangements for the same, with your pcp. ??????please call ( to schedule an appointment to see dr. and the brain clinic, to be seen in weeks. ??????you will not need a ct scan of the brain prior to this appointment. Procedure: Excision of lesion or tissue of cerebral meninges Diagnoses: Pure hypercholesterolemia Benign neoplasm of cerebral meninges Cerebral edema Unspecified hereditary and idiopathic peripheral neuropathy Other specified paralytic syndrome Other conditions of brain Generalized convulsive epilepsy, without mention of intractable epilepsy |
allergies: lamictal / sensipar / lithium / abilify attending: chief complaint: esrd and s/p failed kidney transplant here for living unrelatd kidney transplant major surgical or invasive procedure: living unrelated renal transplant history of present illness: patient is a 74-year-old man with end-stage renal disease due to lithium toxicity. he underwent an unsuccessful renal transplant in . after completing his workup and being found an acceptable candidate, he has now been selected for a non-directed living donor. past medical history: pmh: esrd, htn, h/o lithium toxicity, glaucoma, eczema, treated for bipolar disorder after emigrating to u.s from where he witnessed some violence. has been stable. psh: eye surgery, lue avf social history: married with 4 children, 9 grandchildren. smokes <1 pack per day x 50 years. no etoh. per s.w. noted:treated for bipolar disorder/ developed some psychiatric problems while living in and feels that living in war-torn environment helped to induce these symptoms of constant stress and worry. since relocating to the us in his mood has been much more stable. he is followed by dr. , a psychiatrist, has been seeing the patient since . family history: parents deceased. physical exam: vs: 97.9, 98, 117/42, 19, 92% on 4l n/c (post op) general: resting comfortably, no nausea/vomiting, pain well controlled lungs: cta bilaterally card: rrr, no m/r/g abd: soft, appropriately tender, dressing c/d/i, jp in place with serosanguinous fluid extr: no edema, warm/well perfused pertinent results: at admission: wbc-4.7 rbc-2.79* hgb-9.3* hct-31.1* mcv-111* mch-33.5* mchc-30.0* rdw-18.2* plt ct-281 glucose-114* urean-37* creat-5.4*# na-144 k-4.5 cl-107 hco3-23 angap-19 calcium-8.8 phos-6.8*# mg-2.0 at discharge wbc-3.6* rbc-2.26* hgb-8.0* hct-24.4* mcv-108* mch-35.5* mchc-32.9 rdw-18.2* plt ct-187 glucose-92 urean-18 creat-0.8 na-141 k-4.0 cl-109* hco3-26 angap-10 calcium-9.2 phos-0.9* mg-1.7 brief hospital course: 74 y/o male who is s/p failed kidney transplant from , back on hemodialysis who underwent living unrelated renal transplant. surgeon was dr. . notation was made in the op note that the arteries were heavily calcified and there was some extra time spent finding appropriate areas for the anastomosis. due to the patients age he received simulect on pod 0 and 4. he also received solumedrol 500 mg intra-op with routine steroid taper, mmf 1 gm (adjusted to 500mg qid)and prograf started on the evening of pod 1. dose was adjusted per trough levels. urine output was excellent with creatinine decreasing to 0.8 by postop day 4. diet was advanced and tolerated. abdomen was non-distended. pain was well controlled. incision was intact, dry and without redness. he was ambulatory. medication education occurred with wife and daughter present. he was discharged to home with vna (1-). medications on admission: pantoprazole 40, metoprolol tartrate 100'', azathioprine 75, tacrolimus 3'', bactrim ss, valgancyclovir 450mf, lamivudine 12.5, sevelamer 800''', epogen with dialysis discharge medications: 1. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 2. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po qid (4 times a day). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. brimonidine 0.15 % drops sig: one (1) drop ophthalmic (2 times a day): left. 7. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime): both eyes. 8. pilocarpine hcl 1 % drops sig: one (1) drop ophthalmic q6h (every 6 hours): both eyes. 9. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic q12h (every 12 hours): left eye. 10. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 11. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 12. prednisone 5 mg tablet sig: five (5) tablet po once (once) for 1 days: take on wednesday then prednisone dosing is complete. 13. tacrolimus 1 mg capsule sig: ten (10) capsule po q12h (every 12 hours): take evening dose 8/24, hold am dose 8/25, have labs drawn and then take pills. 14. metoprolol tartrate 100 mg tablet sig: one (1) tablet po twice a day. 15. lamivudine 100 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: home with service facility: vna nursing services discharge diagnosis: esrd s/p renal transplant discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: have labs drawn at lab on wednesday . take your prograf dose after having your labs drawn. await call from transplant clinic for continued dosing advice. please call the transplant office if you have any of the warning signs listed below you will need to have blood drawn for labs every monday and thursday at medical office building you may shower. pat incision dry and leave open to air. no tub baths or swimming no driving if taking narcotic pain medication no heavy lifting drink enough fluids to keep urine light yellow in color followup instructions: , transplant social work date/time: 10:00 , md phone: date/time: 10:45 , md phone: date/time: 9:40 Procedure: Other kidney transplantation Transplant from live non-related donor Diagnoses: End stage renal disease Renal dialysis status Tobacco use disorder Chronic airway obstruction, not elsewhere classified Unspecified glaucoma Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Atherosclerosis of renal artery Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Complications of transplanted kidney Other abnormal glucose Unspecified renovascular hypertension |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization history of present illness: the patient is a 87 yo female with h/o cad s/p stent to the rca, htn, and recently diagnosed melanoma, who presented from with nstemi. on , the patient developed chest pain which awoke her from sleep. she thought the chest pain was indigestion and was treated with maalox by her rehab facility, with improvement of symptoms. on monday , pt re-developed the pain and was again treated with maalox, this time with no relief. she stated that the pain was sharp, , substernal, non-radiating, and occured at rest. she had associated diaphoresis and shortness of breath. ems was called, and the patient was found to have sbp 60's. she was treated with iv fluids and transferred to . there, she was found to have a ck of 1441 and a troponin increase from 0.65 to 35. she was loaded with 300 mg plavix and started on heparin and ntg gtts, and she was then transferred to for cardiac catheterization. . this morning, the patient underwent cardiac cath, which showed severe 3vd without an obvious culprit lesion. she was also found to have severe lv diastolic heart failure (lvedp of 35). ct surgery was consulted, and they stated that the patient is not a candidate for surgical intervention. . on arrival to the floor, the patient states that she is currently chest pain free. she does complain of a headache, and she states that she feels subjectively short of breath (at her baseline). otherwise, the patient has no new complaints. . 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 paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: diabetes (-), dyslipidemia (+), hypertension (+) 2. cardiac history: -cabg: none -percutaneous coronary interventions: rca stent (15-20 years ago, hospital) 3. other pmh mild dementia mild chronic gastritis s/p melanoma resection x2, right groin and right thigh (dx'd 6 weeks ago) recent inguinal ln dissection 10 days ago anxiety/depression social history: the patient currently resides at a rehab facility, where she has been for the past 10 days s/p r inguinal ln resection. prior to this, she lived at home alone and was able to perform all of her adls. she never smoked and drinks etoh socially. family history: father died of mi in his 70s, mother had dm2, sister w/ colorectal cancer. no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: vs: t 98.9 bp 103/58 hr 69 rr 19 o2 sat 92% on 2l general: elderly woman, pleasant, hard of hearing, in nad heent: perrl, eomi, oropharynx clear and without exudate. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. dry oral mucosa neck: supple. jvd elevated to angle of jaw. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. multiple pvcs. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. bibasilar crackles to mid-lung field. no 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. dressing on left femoral artery c/d/i skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: 02:30pm cbc: 10.5 9.7 >---< 278 32.1 diff: neuts-79.3 lymphs-13.5 monos-4.8 eos-1.8 basos-0.6 . coag's: pt-13.6 ptt-26.4 inr(pt)-1.2 142 | 108 | 21/ 105 3.7 | 24 | 0.9 \ . ce: troponins: 0.65 -> 35 (osh) ck: 1441 (osh) creatinine: 1.3 (osh) 02:30pm ck-mb-176* mb indx-19.3* ctropnt-4.50* 09:16pm ck(cpk)-584* . lft's: alt(sgpt)-38 ast(sgot)-216* ck(cpk)-914* alk phos-69 amylase-91 tot bili-0.6 . %hba1c-5.9 vit b12-301 albumin-3.7 . ekg: nsr with rate of 64. biphasic t waves in iii and avl. diffuse low voltage and poor r wave progression. . cardiac cath: selective coronary angiography of this right dominant system revealed severe multivessel coronary artery disease. the lmca had proximal and distal 30% stenoses. the lad was moderately calcified with a near ostial 80% lesion. there was diffuse disease of the proximal-mid lad to 50% before s1, a mid 65% lesion after s1 and s2 and before d1 and a bifurcation lesion involving mid-lad at d1 which extended to a 90% diffuse lesion in the mid-distal lad after d1 with twin distal lad of only modest caliber and a d1 larger in caliber than the distal lad. the lcx was moderately calcified with anostial 30% and a proximal 50% lesion just before om1. mid, serial 90-05% stenoses bracketing. . tte the left atrium is mildly dilated. the right atrial pressure is indeterminate. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with mild hypokinesis of the distal half of the anterior septum and distal inferior and anterior walls. the remaining segments contract normally (lvef = 40-45 %). 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 leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction c/w cad. mild pulmonary artery systolic hypertension. mild mitral regurgitation. brief hospital course: 1. coronary disease: the patient has known cad s/p rca stent years ago. she presented to from osh with chest pain and cardiac biomarker elevation, without significant ecg changes; consistent with nstemi. cardiac cath showed diffuse 3 vessel disease, with no culprit lesion identified. patient was transferred to ccu on . ct surgery was consulted, but felt that there were no good distal targets for bypass. in addition, the patient was felt to be a poor surgical candidate due to recent melanoma diagnosis. the possibility of rca stent was considered, but since patient had no severe wall motion abnormalities in the rca territory, stent was not indicated. the patient was managed medically with asa, plavix, statin, heparin gtt, and metoprolol. metoprolol was decreased to 12.5 mg hypotension weekend of . pt will need to be restarted on ace inhibitor at some point after for her low ef. it was held during this hospital course hypotension and renal insufficiency. . 2. htn the patient was hypertensive immediately after cath, and received nitro gtt. blood pressures normalized and nitro gtt was d/ced overnight. pt later became mildly hypotensive (sbp 90-100s) with slight improvement by the end of her hospital stay. pt continued on her home metoprolol (decreased to 12.5 mg), ace-i held. . 3.acute on chronic diastolic and systolic chf: the patient had evidence of elevated lvedp in cath lab. she was given 20 mg iv lasix and diuresed 2l overnight the first night. she continued to have evidence of volume overload including jvd, crackles on exam, and cxr showing mild-moderate pulmonary edema. patient was given an additional 10 mg iv lasix and diuresed 300 cc. patient then developed atrial fibrillation and hypotension, worse with sitting. patient initially received fluid boluses, and hemodynamics improved. when a fib was better controlled, she was started on lasix gtt with good effect and stable hemodynamics. lasix decreased to 5 mg and then stopped completely in setting of increasing creatinine, shift from fluid overload to euvolemia. at present, pt appears to be euvolemic with weights of 60 kg and no peripheral edema. she will not be discharged on lasix because of low po intake. please consider lasix if her weight increases > 3 pounds and she develops signs of chf. weight was 61 kg. . 4. atrial fibrillation patient developed new onset a fib on . hr was 100, sbp dropped from 99 to 86. patient was asymptomatic at the time. notably temperature was 100.3, which may have contributed to increased heart rate. she received tylenol, fluid bolus, and additional metoprolol. patient was then started on amiodarone on since she did not appear to tolerate a fib, becoming intermittently hypotensive and diaphoretic. patient fluctuated between nsr and a fib, returning to nsr on her own, with scheduled medications (beta blocker, amio). pt remained asymptomatic throughout her episodes. patient did develop nausea, poor po appetite on the amiodarone 200 so dosage was decreased on . she is currently in nsr. pt will be continued on amio 200 daily for a full month, then decreased after seeing her cardiologist. given score of 3, pt was started on heparin gtt w/ bridge to coumadin 2.5 mg. patient was supra-therapeutic with an inr of 3.7 on day of . coumadin will be held and she will an need inr check on . . 5. uti patient had borderline fever and intense sweating on . ua was positive and culture grew >100,000 pan-sensitive e. coli. she was initially started on po cipro, then received one dose of both iv ctx and cipro. wbc was elevated to 16.5, trended down to normal with antibiotics. repeat ua on was within normal limits and she completed a total seven day course of antibiotics. 6. urinary retention: she has experienced urinary retention in the past and needed to have her foley replaced for retention of 600cc. currently, her foley was d/c'ed on and pt appears to be voiding normally. if urinary retention becomes a problem, would recommend urology consult as this problem has never been formally worked up. 6. patient's creatinine was 0.9 at admission and trended up to a maximum of 2.3 in the setting of hypotension and then lasix. lasix was d/c'd w/ some improvement to a creatinine of 1.7. . 7. melanoma patient was recently diagnosed with melanoma, s/p excision and right inguinal lymphnode dissection 10 days prior to admission. results pending () but per pt's children, mets were not highly suspected. . 8. dementia patient was continued on home dose of donepezil and zyprexa w/o issues. . 9. psych patient was continued on home dose of wellbutrin. her ritalin was d/c'ed per her pcp as it is contraindicated in severe cad. she sees an outside psychiatrist for her depression and should follow-up with this doctor . if her depression worsens, she should be started on an alternate medicine. medications on admission: medications on admission: methylphenidate 40 mg daily donepezil 10 mg daily imdur 30 mg daily asa 81 mg daily clonazapam 0.5 mg daily cymbalta 60 mg daily boniva 150 mg q month zyprexa 2.5 mg daily medications on transfer: atorvastatin 80 mg qhs bupropion hcl 150 mg daily clopidogrel 75 mg daily donepezil 10 mg daily qhs enoxaparin 40 mg/0.4 ml syringe sq q12 hrs methylphenidate 20 mg daily metoprolol tartrate 25 mg tablet aspirin 325 mg tablet daily ntg sl medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 4. nitroglycerin 0.3 mg tablet, sublingual sig: tablet, sublinguals sublingual prn (as needed) as needed for chest pain. 5. bupropion hcl 150 mg tablet sustained release sig: one (1) tablet sustained release po qam (once a day (in the morning)). 6. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 7. olanzapine 2.5 mg tablet sig: two (2) tablet po hs (at bedtime). 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 9. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic tid (3 times a day). 10. warfarin 2.5 mg tablet sig: one (1) tablet po once daily at 4 pm: hold on and . recheck inr on and titrate as needed. 11. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 12. outpatient lab work please check inr on saturday , goal inr 2.0-3.0. call results to provider. 13. boniva 150 mg tablet sig: one (1) tablet po once a month: first day of the month. 14. aspirin 81 mg tablet sig: one (1) tablet po once a day. 15. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 16. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 17. senna 8.6 mg tablet sig: 1-2 tablets po twice a day as needed for constipation. disposition: extended care facility: ne sianai at hospital diagnosis: non-st elevation myocardial infarction coronary artery disease recent diagnosis of melanoma dementia hypertension condition: improved. vital signs stable. patient ambulating without issues. instructions: you were admitted with chest pain and found to have had a heart attack. it was determined that open heart surgery (cabg) would not be helpful, given the anatomy of your heart vessels. you have been carefully managed with medications instead. your stay in the hospital was complicated by some inflammation around the heart that has since resolved, and some rhythm problems that your are still being treated for with medications. both are common things that happen after heart attacks. -it is important that you continue to take your medications as directed. we made the following changes to your medications during this admission: --> we started atorvastatin 80mg daily, plavix 75mg daily, amiodarone 200 mg daily. --> please continue the following medications you were on at home/rehab: eyedrops, olanzapine 5 mg before bed, duloxetine 60mg daily, buproprion 150mg daily, donepezil 10mg before bed, nitroglycerin 0.3mg under tongue as needed --> stop taking ritalin --> we have decreased your metoprolol dose to 12.5 mg twice a day -->you were started on a medication for your heart rhythm called amiodarone. please discuss with dr. when you can discontinue it (likely in a month). also discuss restarting your ace-inhibitor (blood pressure medication) with him. you were also started on a blood thinning medication, coumadin, for your heart rhythm. this decreases your likelihood of stroke but it is very important that your blood levels are followed while on this medication. please discuss setting up regular "inr checks" with your cardiologist/pcp. . -contact your doctor or come to the emergency room should your symptoms return. also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. you should weigh yourself every morning and call your pcp if your weight increases by more than 3 lbs. start a low sodium (2 mg) diet followup instructions: primary care provider: . , within 1-2 weeks after d/c from facility cardiology: dr. phone: ( date/time: wednesday at 10:45am. Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Left heart cardiac catheterization Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Other persistent mental disorders due to conditions classified elsewhere Dysthymic disorder Hypotension, unspecified Old myocardial infarction Other left bundle branch block Retention of urine, unspecified Acute on chronic combined systolic and diastolic heart failure Malignant melanoma of skin of trunk, except scrotum |
allergies: no known allergies / adverse drug reactions attending: chief complaint: seizures major surgical or invasive procedure: right frontal cavernoma resection with dr. on forehead lipoma resection with dr. on history of present illness: ms. is a 53 yo f from bermuda with no pmhx transferred from for new-onset seizure. patient arrived to us today; was grocery shopping with her husband this morning when she suddenly became limp from the waist up and developed right-sided facial twitch. per husband she had altered mental status during episode but never fell or struck head. no urinary incontinence or tongue biting. ems was called and she was transported to by ambulance. she had two more of the same seizures in the ambulance. at , she had two more of these seizures. she received ativan in ed and was loaded with 1200mg of dilantin. noncontrast head ct revealed 1x1cm right frontal mass without associated vasogenic edema. she was transferred to for further evaluation. for the past 2 days, patient has had severe bifrontal headache that is worse when bending down; not worse at any time of day or when lying flat. has taken asa which is unhelpful for headache. has never had headaches like this before. denies vision change, blurred vision, tinnitus, weakness/numbness, ataxia, falls. endorses social etoh but no abuse. denies illicit drugs, h/o cancer, h/o animal/insect bites. on arrival to ed, vitals were: 98.7 145/83 68 16 100% ra. patient sleepy but opens eyes to voice and answers questions appropriately. complains of frontal headache. past medical history: gerd hypercholesterolemia (total 231, trig 111 hdl 70 ldl 139) social history: works as a minister at her church, lives with her husband and has four children. social drinker, no tobacco or illicits. family history: noncontributory. physical exam: admission physical exam: vitals: 98.7 68 145/83 16 100% general: awake and alert, somewhat anxious. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp pulses bilaterally. skin: no rashes or lesions noted. neurologic: -mental status: alert and oriented x 3. able to relate history without difficulty. language is fluent with intact repetition and comprehension. normal prosody. there were no paraphasic errors. speech was not dysarthric. able to follow both midline and appendicular commands. the pt had good knowledge of current events. there was no evidence of apraxia or neglect. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. funduscopic exam revealed no papilledema, exudates, or hemorrhages. iii, iv, vi: eomi with end-gaze nystagmus b/l. normal saccades. v: facial sensation intact to light touch. vii: no facial droop, facial musculature symmetric. viii: hearing intact to finger-rub bilaterally. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: normal bulk, tone throughout. no pronator drift bilaterally. no adventitious movements, such as tremor, noted. no asterixis noted. delt bic tri wre ffl fe io ip quad ham ta l 5 5 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: no deficits to light touch throughout. -coordination: no intention tremor, no dysdiadochokinesia noted. no dysmetria on fnf bilaterally. -gait: deferred ***** discharge physical exam: afvss gen exam: patient with well healing surgical scar across her head, staples removed. otherwise unchanged. neurological exam: cranial nerves, strength and sensation intact. ambulating with cane, gait is cautious but steady. pertinent results: admission labs: 10:30pm blood wbc-9.4 rbc-4.25 hgb-11.8* hct-36.3 mcv-86 mch-27.7 mchc-32.4 rdw-13.0 plt ct-317 08:54am blood pt-12.0 ptt-28.5 inr(pt)-1.1 10:30pm blood glucose-92 urean-9 creat-0.7 na-140 k-4.1 cl-106 hco3-28 angap-10 08:54am blood albumin-4.3 calcium-9.4 phos-3.4 mg-2.1 10:30pm blood asa-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg relevant labs: 10:30pm blood phenyto-10.2 10:00pm blood phenyto-20.7* 05:45am blood phenyto-19.8 07:40am blood phenyto-18.9 10:25am blood phenyto-23.0* 03:45pm blood phenyto-19.8 01:00pm blood phenyto-22.4* 05:11am blood phenyto-17.2 imaging: eeg : this is an abnormal continuous video eeg given the presence of brief subclinical electrographic seizures over the right greater than left frontal leads. the seizures were predominantly appreciated with the onset of the recording at 18:00 hours until midnight. there is a significant reduction during the morning hours. there was one pushbutton activation without a clear electrographic correlate. on video, there is some trembling in the patient's left cheek. the patient however is able to respond to command. automated sampling captured some of the sharper alpha which correlated with the patient's electrographic events. eeg : this is an abnormal continuous video eeg given the presence of brief subclinical electrographic seizures over the right greater than left frontal leads. the seizures were predominantly appreciated in the early portion of the recording. there is a significant reduction to no seizures appreciated after the morning hours. there was one pushbutton activation without a clear electrographic correlate. on video, the patient is moaning with her family around. automated sampling captured a couple of the sharper alpha which correlated with the patient's electrographic events. the telemetry is significantly improved from the prior day's recording. eeg : this is an abnormal continuous video eeg given the presence of burst of bilateral frontal and temporal generalized slowing. this may represents her subcortical dysfunction. there were no electrographic seizures detected. mri brain : 1. 10 x 6 mm enhancing lesion in the right frontal lobe, with central intrinsic t1-hyperintensity, "blooming" susceptibility and adjacent filamentous vascular structures extending to the nearby dura. taken together, these findings suggest hemorrhage related to underlying cavernous angioma with possible associated developmental venous anomaly. a more remote possibility is dural av fistula, with cortical venous drainage. further evaluation via consultation with interventional neuroradiology service has been recommended. 2. expanded sella turcica, with an appearance suggestive of an "empty sella," a common variant, or possibly, arachnoid cyst of the suprasellar cistern. 3. large frontal subcutaneous lipoma. cxr : normal radiographic study of the chest. cerebral angiogram : underwent a diagnostic cerebral angiogram which was grossly normal, specifically with no evidence of a dural arteriovenous fistula. given the pre-procedural imaging, this favours an occult vascular malformation (ie. cavernoma) as the underlying cause for the findings on those studies. mri : 1. limited pre-operative study redemonstrating the 7 x 7 mm enhancing lesion in the right frontal region consistent with the previously-characterized cavernous angioma, unchanged in appearance since . 2. large left frontal subcutaneous lipoma. head ct : no evidence of postoperative hemorrhage. head ct : no evidence of interval hemorrhage from . head ct : expected evolution of postoperative bed in the right frontal lobe. no evidence of new hemorrhage. brief hospital course: 53 yo rh f who p/w new onset seizure, found to have r frontal cavernoma. her seizure was controlled with keppra and dilantin, and patient underwent cavernoma resection for better control of her seizures. she was monitored in the icu in immediate post op setting, but was called out to the floor. she was managed on the floor and stabilized prior to her discharge. # neuro: patient presented with seizure and found to have right frontal cavernoma, which was the likely cause of her seizures. patient's seizures were typified by leftward gaze, crying spells and confusion. on admission, patient was noted to be confused and lethargic, and eeg revealed that she was still having seizures while on dilantin. she was loaded with keppra and her confusion resolved. given that her seizures were difficult to control, discussion was had with neurosurgery and patient decided to undergo cavernoma resection. lipoma resection was done at the same time. post op course was complicated by continued headache, but repeat head cts only showed expected post op changes and no hemorrhages. her dilantin was adjusted to 450 mg daily, and her seizures were under control. she was seen by pt/ot and was discharged home with home pt and home safety evaluation. # cv: she was continued on telemetry without events, and her lipid panel showed slightly elevated ldl, but given no other risk, she was recommended lifestyle changes for now. # id: patient developed fevers during her post op period, and was started on iv vancomycin for a few days. however, her blood cultures were negative and her fevers resolved, so vancomycin was stopped without further issues. patient never developed leukocytosis. # gi: patient suffered from constipation, likely from decreased mobility and narcotics during her post op period. her bowel regimen was increased, and she was given magnesium citrate, which has helped her in the past. her constipation improved with increased bowel regimen. # heme: patient developed progressive anemia after her surgery for unclear reason. hemolysis labs were checked and were negative, and her guaiac was also negative. she was not transfused rbcs as her hct remained in high 20s. her hct improved to low 30s without any intervention. iron studies were done and did not show iron deficiency. medications on admission: preadmissions medications listed are incomplete and require futher investigation. information was obtained from patient. 1. multivitamins 1 tab po daily 2. magnesium citrate dose is unknown po frequency is unknown discharge medications: 1. levetiracetam 1500 mg po bid rx *keppra 750 mg 2 tablet(s) by mouth twice a day disp #*60 tablet refills:*2 2. multivitamins 1 tab po daily 3. docusate sodium 100 mg po bid rx *colace 100 mg 1 capsule(s) by mouth twice a day disp #*60 tablet refills:*0 4. senna 1 tab po bid constipation rx *senna 8.6 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 5. polyethylene glycol 17 g po daily rx *miralax 17 gram 1 packet(s) by mouth daily disp #*30 packet refills:*0 6. bisacodyl 10 mg po/pr daily:prn constipation rx *bisacodyl 5 mg tablet(s) by mouth daily disp #*30 tablet refills:*0 7. magnesium citrate 300 ml po prn constipation 8. acetaminophen 1000 mg po q 8h rx *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours disp #*50 tablet refills:*0 9. hydromorphone (dilaudid) 2 mg po q4h:prn pain hold if sedated or rr<12 rx *hydromorphone 2 mg 1 tablet(s) by mouth every 6 hours disp #*30 tablet refills:*0 10. ibuprofen 600 mg po q8h pain rx *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours disp #*42 tablet refills:*0 11. phenytoin infatab 150 mg po tid rx *dilantin infatabs 50 mg 3 tablet(s) by mouth every 8 hours disp #*90 tablet refills:*2 discharge disposition: home with service facility: steward home care and hospice discharge diagnosis: primary diagnosis: right frontal cavernoma s/p resection, lipoma s/p resection, seizures discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). neurologic status: alert and oriented to self, and date. strength intact throughout, sensation intact. discharge instructions: dear mrs. , it was a pleasure to take care of you at . you were admitted to the hospital because you had a seizure and then in the ed, you were found to have a cavernoma in your brain. your seizures were controlled with medications, and upon consultation with neurosurgery, you decided to undergo resection of the cavernoma as well as the lipoma on your forehead. please follow up with dr. as scheduled below. you will need a repeat ct of your head prior to your appointment. followup instructions: department: radiology when: thursday at 10:15 am with: cat scan building: cc campus: west best parking: garage department: neurosurgery when: thursday at 11:15 am with: , md building: lm campus: west best parking: garage department: neurology when: monday at 4:00 pm with: drs. and building: campus: east best parking: garage Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Reconstruction of eyelid with hair follicle graft Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue Arteriography of cerebral arteries Diagnoses: Anemia, unspecified Esophageal reflux Pure hypercholesterolemia Constipation, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Hemiplegia, unspecified, affecting nondominant side Epilepsia partialis continua, with intractable epilepsy Anomalies of cerebrovascular system Postprocedural fever Lipoma of skin and subcutaneous tissue of face |
allergies: aspirin / ampicillin / penicillins / latex attending: chief complaint: increase in drainage at thyroidectomy and parathyroidectomy site and shortness of breath. major surgical or invasive procedure: drainage of seroma direct laryngoscopy history of present illness: 74 yo female presented to the emergency department four days s/p thyroidectomy and parathyroidectomy complaining of increased drainage from the surgical site and shortness of breath. she reported shortness of breath since her procedure and presented with some new tightness in the throat. past medical history: pmh: hepatitis c, dm, htn, erythema nodosum, thyroid goiter, urinary incontience, diabetic neuropathy, obesity psh: open ccy with ioc social history: no alcohol or drug use. lives alone, has involved family and assistance from a home health aide. physical exam: on presentation: 99.7, hr 100, 123/104, 20, 97% constitutional: mild difficulty breathing heent: anicteric thyroid incision intact with mild surrounding induration and serosanguineous drainage from lateral aspect of wound. chest: prominent upper airway sounds and mild stridor. cardiovascular: regular rate and rhythm abdominal: soft, nontender pelvic: normal gu/flank: no costovertebral angle tenderness extr/back: no cyanosis, clubbing or edema skin: no rash neuro: speech fluent psych: normal mood pertinent results: 06:50am blood wbc-12.7*# rbc-4.45 hgb-13.1 hct-39.1 mcv-88 mch-29.4 mchc-33.4 rdw-12.8 plt ct-358 04:57am blood wbc-6.3# rbc-4.20 hgb-12.5 hct-38.0 mcv-91 mch-29.9 mchc-33.0 rdw-13.1 plt ct-284 12:20pm blood neuts-78.9* lymphs-13.8* monos-5.6 eos-1.2 baso-0.6 04:57am blood glucose-182* urean-25* creat-0.7 na-142 k-3.5 cl-106 hco3-23 angap-17 12:20pm blood glucose-109* urean-22* creat-0.9 na-142 k-3.9 cl-102 hco3-25 angap-19 06:50am blood calcium-7.6* phos-2.7 mg-2.0 04:57am blood calcium-7.8* phos-4.2# mg-1.9 12:29pm blood ph-7.44 comment-green top 12:29pm blood lactate-1.5 k-5.1 12:29pm blood freeca-0.92* brief hospital course: the patient was seen in the emergency department by ent. neck films showed fluid or hematoma projecting into the airway. ent visualized airway by laryngoscope which revealed significant soft tissue edema which was attributed to recent intubation. the appearance of the patience neck without erythema or purulent drainage indicated seroma as most likely diagnosis. the seroma was drained in the emergency room and the patient received iv decadron and iv antibiotics, she was stabilized in the emergency department and then transferred to the for further monitoring of the airway. gram stain of the fluid of the seroma showed leukocytes and no microorganisms. preliminary culture of the wound showed sparse growth of beta streptococcus group b. the patients stay in the was uneventful, wicks were placed in the anterior neck wound and she was transferred to the inpatient floor for further monitoring. the patients stay on the inpatient floor was uneventful. the wound was changed as ordered, and appeared stable. the patients laboratory values were stable and she was discharged home with appropriate discharge instruction. medications on admission: lasix 20 mg tablet sig: one (1) tablet po twice a day. lisinopril 40 mg tablet sig: one (1) tablet po once a day. glyburide 2.5 mg tablet sig: one (1) tablet po once a day. amlodipine 2.5 mg tablet sig: one (1) tablet po once a day. colchicine 0.6 mg tablet sig: one (1) tablet po twice a day. metformin 850 mg tablet sig: one (1) tablet po once a day. ursodiol 250 mg tablet sig: one (1) tablet po three times a day. discharge medications: 1. lasix 20 mg tablet sig: one (1) tablet po twice a day. 2. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 3. glyburide 2.5 mg tablet sig: one (1) tablet po once a day. 4. amlodipine 2.5 mg tablet sig: one (1) tablet po once a day. 5. colchicine 0.6 mg tablet sig: one (1) tablet po twice a day. 6. metformin 850 mg tablet sig: one (1) tablet po once a day. 7. ursodiol 250 mg tablet sig: one (1) tablet po three times a day. 8. calcium carbonate 1,000 mg tablet, chewable sig: three (3) tablet, chewable po twice a day. disp:*180 tablet, chewable(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: seroma supraglottic edema discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted for a fluid collection in the incision of your thyroidectomy. this fluid collection as well as irritation to your throat caused you to have some difficulty breathing. you were admitted to the icu for airway mointoring, and with some medications and draining of the fluid collection you were able to breath easily. you were found to have a fluid collection known as a seroma. a seroma is a collection of fluid under the skin that can develop after surgery. there is not an infection in this fluid and you do not need antibiotics. this fluid collection was drained, wicks were placed in the wound and you are now stable to be discharged home. it is important that you monitor the wound for signs of infeciton incliding: increasing redness, increased pain not relieved with medication, or white, green or light pink drainage. the wick will need to be chagned twice daily and please apply sterile dry gauze to the wicked area three times daily. you will be referred to visiting nurses who will monitor the wound and assist you with the dressing. followup instructions: please see dr. in one week. call ( to make an appointment. Procedure: Laryngoscopy and other tracheoscopy Other incision with drainage of skin and subcutaneous tissue Diagnoses: Chronic hepatitis C without mention of hepatic coma Unspecified acquired hypothyroidism Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Obesity, unspecified Seroma complicating a procedure Edema of larynx |
allergies: sulfa (sulfonamide antibiotics) / lipitor attending: chief complaint: abdominal pain, diarrhea major surgical or invasive procedure: extubation history of present illness: 58f with a history of c. diff colitis admitted to with abdominal pain, diarrhea, confusion, and generalized weakness. wbc# 10.5 with 25% bands, cr 1.7. ct abdomen showed diffuse concentric colonic thickening, as well as possible acalculous cholecystitis. hida scan did not show cholecystitis or obstruction. she was treated with ivf and neosynephrine for bp 79/43 on presentation and transferred to the icu. she was started on iv flagyl and po vancomycin for presumed recurrent severe c. diff colitis. po was changed to pr vanco on out of concern for ileus. she was intubated for respiratory failure attributed to acute pulmonary edema on the morning of . tropi peaked at 0.48 on , tte showed diffuse lv hypokinesis with ef ~25%. she was treated with bolus diuresis and extubation was attempted but she reportedly had recurrent flash pulmonary edema and needed to be reintubated. treated with ppn. course also complicated by acute on chronic anemia, for which she was transfused 2u prbc (hct 26.1->33.9). v/s prior to transfer 98.3 128-151/63-93 80-100 19-22 94% on 500x12/5/0.6. on arrival here, complains of discomfort at the ett site but denies fever, chills, chest pain, palpitations, shortness of breath, abdominal pain, nausea. past medical history: c. diff colitis seizure disorder bipolar disorder with prior suicide attempt anxiety disorder fibromyalgia rotator cuff repair social history: lives in with her husband. smoked 1.5-2 ppd x 50 years. drinks 2-4 alcoholic beverages 3-4 times per week. no history of withdrawal symptoms. no illicit drug use. her son committed suicide approx 3 yrs ago. family raises concerns about prescription drug abuse since that time. family history: mother died of complications of chf in her 70s physical exam: physical exam on arrival to the : vs: t 100.4 hr 99 bp 144/73 rr 20 o2sat 100% on 500x12/5/0.4 gen: intubated, awake, alert, interacting appropriately heent: ng tube in place, macerated erythematous perioral rash resp: diminished at bases coarse rhonchi bilaterally no wheeze cv: reg rate nl s1s2 no m/r/g abd: soft ntnd hypoactive bs ext: warm, dry no edema neuro: 5/5 strength in all 4 ext, prox/dist pertinent results: labs: - cbc with differentials: wbc-15.2* rbc-4.03* hgb-11.8* hct-37.4 mcv-93 mch-29.2 mchc-31.5 rdw-15.3 plt ct-292 neuts-81.1* lymphs-12.0* monos-5.7 eos-1.1 baso-0.2 - coagulations: pt-14.4* ptt-29.3 inr(pt)-1.2* - chem 10: glucose-86 urean-11 creat-0.4 na-138 k-3.8 cl-102 hco3-26 calcium-8.5 phos-2.9 mg-1.6 - lfts: alt-6 ast-9 ld(ldh)-167 alkphos-71 totbili-0.3 albumin-3.0* - ua: color-yellow appear-clear sp -1.011 blood-sm nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.5 leuks-neg rbc-19* wbc-<1 bacteri-few yeast-none epi-<1 renalep-<1 ============ microbiology ============ 2:00 pm stool consistency: not applicable source: stool. **final report ** fecal culture (final ): no enteric gram negative rods found. 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. . moderate polymorphonuclear leukocytes. 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). ============ imaging ============ - cxr: endotracheal tube terminates 3.7 cm above the carina. right subclavian line ends in the mid svc. a nasogastric tube courses into the stomach. bilateral pleural effusions are seen with associated atelectasis. left-sided atelectasis is greater involving a large portion of the left lower lobe. mild pulmonary vascular engorgement is also seen. there is no pneumothorax. cardiomediastinal silhouette is unremarkable. impression: 1. moderate bilateral pleural effusions with bibasilar atelectasis, significantly greater on the left. 2. endotracheal tube, nasogastric tube, and right subclavian line in satisfactory position without evidence of pneumothorax. - tte: there is moderate global left ventricular hypokinesis (lvef = 35%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). 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 leaflets are mildly thickened. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a very small pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. impression: suboptimal image quality. global left ventricular hypokinesis (left ventricular dysfunction appears to involve both anterior and inferor territories, but suboptimal image quality prevents detailed segmental analysis). 07:40am blood wbc-9.0 rbc-4.09* hgb-12.7 hct-37.4 mcv-92 mch-31.2 mchc-34.0 rdw-14.8 plt ct-391 12:09 am stool consistency: soft source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). brief hospital course: 58f with recurrent severe c. diff colitis admitted with hypoxemic respiratory failure. #hypoxemic respiratory failure- attributable to acute pulmonary edema from myocardial dysfunction and aggressive fluid resuscitation in the setting of sepsis. patient was aggressively diuresed prior to extubation. also her anxiety was managed by home medication ativan prior to extubation. she did well post extubation. echocardiogram was ordered to re-evaluate her cardiac function, which showed a slightly improved ef (35%) compared to her echo. she was continued on lisinopril, and she was started on a low dose of daily lasix. we recommend follow up with cardiology, as the etiology of her heart failure is not entirely clear, although we suspect a combination of chronic alcohol abuse and severe illness with volume resuscitation. #septic shock- pt was in septic shock at , and her osh ct showed severe colitis and she had a bandemia. she was treated empirically as recurrent c.diff with vanc/flagyl, however, all of the c-diff tox screens returned negative. her abdominal exam/diarrhea improved with treatment, so she was continued on an empiric course of 14 days po vanc/flagyl despite lack of positive tox screen. #acute systolic heart failure. thought due to sepsis. repeat tte here at showed improved ef compared to (25% improved to 35%). she was continued on bb, ace inhibitor, as well as lasix. her lasix dose was titrated to maintain euvolemia. she was instructed to get cardiology referral from her pcp #epilepsy/bipolar. non-active. patient continued with home depakote. #depression/anxiety. she was restarted on her ativan prior to extubation, as she exhibited significant anxiety during the hospitalization. a significant amount of anxiety/depression/guilt seem to surround her son's suicide 3 yrs ago, which seems to exacerbate her substance abuse issues. #etoh use. she was started on thiamine, folate, and multivitamin given history of alcohol use. she did not show signs of alcohol withdrawl during the admission. social work was consulted and provided support and resources for addictions. she was encouraged to stop drinking. #emergency contact: husband #code: full (confirmed with patient and husband) medications on admission: depakote (delayed release) 1000 mg po bid ativan 2 mg po tid percocet prn after shoulder surgery discharge medications: 1. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 10 days. disp:*40 capsule(s)* refills:*0* 2. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 10 days. disp:*30 tablet(s)* refills:*0* 3. divalproex 500 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day). 4. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. lorazepam 1 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. disp:*24 tablet(s)* refills:*0* 10. cortisone 1 % cream sig: one (1) appl topical tid (3 times a day). disp:*1 tube* refills:*0* discharge disposition: home discharge diagnosis: # severe colitis; presumed c-diff # hypoxemic respiratory failure # acute congestive heart failure with low ef # epilepsy # depression/anxiety # history of etoh use discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted in transfer from with severe colitis and respiratory failure which required intubation. you were treated with antibiotics for your colitis, and your heart failure was treated with diuretics and lisinopril. you will need to follow up with your primary care physician and cardiologist, as the etiology of your heart failure is not entirely clear. followup instructions: call your primary care physician office to be seen next week. ask your pcp for referral to cardiologist for establishing care within 2-3wk. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Anemia, unspecified Tobacco use disorder Unspecified pleural effusion Congestive heart failure, unspecified Severe sepsis Alcohol abuse, unspecified Pulmonary collapse Acute respiratory failure Septic shock Intestinal infection due to Clostridium difficile Epilepsy, unspecified, without mention of intractable epilepsy Acute systolic heart failure Septicemia due to anaerobes Myalgia and myositis, unspecified Other bipolar disorders Secondary cardiomyopathy, unspecified Family disruption due to death of family member |