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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: food stuck in throat major surgical or invasive procedure: intubation extubation egd history of present illness: ms. is a 50 yo f w/ h/o schatzki's ring with multiple food impactions and s/p multiple dilations who, this evening, swallowed some steak and immediately was uncomfortable w/ throat pain and unable to swallow her secretions. . in the ed, she was noted to have no resp distress but with pain in throat and unable to swallow her own saliva. she was given 2mg iv lorazepam and 1mg glucagon to help dilate her esophagus as well as 4mg zofran iv. in the ed, gi and ed attempted egd under concious sedation but she was given 90cc propofol without adequate sedation achieved and then began to drop her sats to 96% on 4l and have rr to 8. notable, in the past, she has had to have intubation with egd. anaesthesia was consulted and plan was made to intubate and sedate her in the or for egd and food retrieval. vitals on leaving ed to or were 97.8 76 114/73 20 98% ? on nc. . egd was noteable for food in stomach antrum and some esophagitis only. . on arrival to the icu, pt extubated and states her symptoms are entirely resolved. she does state she was in her usoh prior to this episode with the exception of an episode of lightheadedness and tingling around her mouth last weekend which she attributed to dehydration. she drank more icf and these symptoms quickly resolved. . review of systems: (+) per hpi (-) denies fever, chills, shortness of breath, chest pain, chest nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria. past medical history: h/o dilated schatzki's ring gerd pud ectopic pancreas s/p removal of "part of her stomach" per pt cholecystectomy for gall stones ? fibromylagia h/o chronic abdominal pain depression social history: lives with husband and dtr - : denies - alcohol: 2 cocktails 2 x/wk - illicits: denies family history: significant for multiple siblings and daughter with bipolar disorder. father had meningitis. physical exam: general appearance: well nourished, no acute distress eyes / conjunctiva: perrl, anicteric head, ears, nose, throat: normocephalic cardiovascular: rrr, no mrg respiratory: ctab, no wheezing/rhonchi/crackles abdominal: soft, non-tender, non-distended, bowel sounds present extremities: no edema, dp pulses skin: no rash, no jaundice neurologic: attentive, follows simple commands, responds to: verbal stimuli, oriented (to): ox3, movement: purposeful, no(t) sedated, no(t) paralyzed, tone: normal pertinent results: 02:00am blood wbc-9.8 rbc-3.83* hgb-11.9* hct-34.9* mcv-91 mch-31.2 mchc-34.3 rdw-13.5 plt ct-243 . . 02:00am blood glucose-95 urean-14 creat-0.8 na-142 k-4.1 cl-109* hco3-24 angap-13 brief hospital course: mrs. is a 50yo woman with a pmh significant for pud, gerd and esophageal strictures. presents with esophageal pain following eating steak. # odonyphagia ?????? in the ed, she was noted to have no resp distress but with pain in throat. she was unable to swallow her own saliva. she was given 2mg iv lorazepam and 1mg glucagon to help dilate her esophagus as well as 4mg zofran iv. in the ed, gi and ed attempted egd under concious sedation but she was given 90cc propofol without adequate sedation achieved and then began to drop her sats to 96% on 4l and have rr to 8. anaesthesia was consulted and plan was made to intubate and sedate her in the or for egd and food retrieval. egd was noteable for food in stomach antrum and some esophagitis only. on arrival to the icu, pt extubated and stated that her symptoms had entirely resolved. she likely passed obstructing food particle prior to repeat egd, perhaps in response to medications (including glucagon) or time. # gastroesophageal reflux disease (gerd) - the patient was continued on her home dose of protonix. dose was at 40 mg . she was given a prescription for the drug as she was discharged to continue on the ppi at home. medications on admission: (pt states she often doesn't remember her home meds) protonix 20mg daily prempro 0.3/1.5 mg daily discharge medications: 1. conjugated estrogens 0.3 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 q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: food impaction discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted for steak impaction in your throat secondary to the rings in your esophagus. you had an endoscopy (egd) and the steak had passed already. you remained stable and were discharged home with follow up with your gastroenterologist. you were started on the following medication: - pantoprazole 40mg twice daily. followup instructions: follow up with: dr. , . please call ( to arrange a follow up appointment within the next two weeks. please call the office of your pcp (see below) to arrange a follow up appointment within one month. name: , e. location: healthcare - group address: , , , phone: fax: md Procedure: Other endoscopy of small intestine Diagnoses: Esophageal reflux Esophagitis, unspecified Myalgia and myositis, unspecified Other specified diseases of pancreas Stricture and stenosis of esophagus Foreign body accidentally entering other orifice Foreign body in esophagus Personal history of peptic ulcer disease Dysphagia, unspecified Unspecified menopausal and postmenopausal disorder |
allergies: sulfa (sulfonamide antibiotics) / codeine / prochlorperazine attending: chief complaint: s/p bilateral thrombectomy attempt iliac veins major surgical or invasive procedure: bilateral thrombectomy attempt iliac veins history of present illness: 66 y/o f with pmhx of advanced endometrial stromal tumor, s/p hysterectomy complicated by extensive dvt and pe. pt was put on lovenox and had ivc filter placed , and underwent further ex- lap on . pt was found to have iliac vein thrombus that extends from the level ivc filter to common iliac vein on left and and external iliac on the right. pt was taken for elective ir thrombolysis and thrombectomy with local tpa infusion. pt tolerated the procedure well but developped lower back pain that she felt was related to lying flat on the procedure table for >4hrs. she reports that she has developed a similar pain in the past that she relates to her osteopenia. pt was admitted for overnight monitoring post tpa infusion. per ir report, thrombectomy was unsuccessful and there is no need for continued tpa or repeat venogram in the am. . on arrival to the ccu, pt was describing nausea and lower back pain that improved with dilaudid. she denies cp, palpitations, ha, abd pain, lower extremity pain/weakness. past medical history: past medical history: significant for thyroid cancer. past surgical history: thyroidectomy in , cesarean section, diagnostic laparoscopy for infertility, and tonsillectomy. ob history: c-section x1. gyn history: last pap smear was and normal. last mammogram was in and normal. social history: the patient does not smoke. she drinks occasionally. she is a medical transcriptionist. family history: mother died of lymphoma at 78 no family history of ovarian, uterine, colon, or prostate ca physical exam: vitals: bp: 148/89 p: 77 rr: 12 o2: 98% on 2l general: alert, oriented, no acute distress heent: sclera anicteric, dry mm neck: supple lungs: cta anterior/laterally, no wheezes, rales, ronchi cv: rrr normal s1/s2, no murmurs, rubs, gallops abdomen: soft, non-tender, nabs, no rebound or guarding ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema groin: femoral caths bilaterally pertinent results: 10:00pm hct-26.4* 04:08pm glucose-100 urea n-22* creat-1.3* sodium-139 potassium-4.4 chloride-107 total co2-21* anion gap-15 04:08pm calcium-7.7* phosphate-5.6*# magnesium-2.1 04:08pm wbc-8.7 rbc-2.83* hgb-8.9* hct-25.5* mcv-90 mch-31.4 mchc-34.8 rdw-14.6 04:08pm plt count-363 04:08pm pt-15.8* ptt-40.6* inr(pt)-1.4* 04:08pm fibrinoge-252# 01:46pm hct-25.5* 01:46pm plt count-395 01:46pm pt-14.1* ptt-38.5* inr(pt)-1.2* 01:46pm fibrinoge-410* 08:00am wbc-8.8 rbc-3.19* hgb-9.9* hct-28.9* mcv-91 mch-31.1 mchc-34.4 rdw-14.4 08:00am plt count-442* 08:00am pt-13.0 inr(pt)-1.1 brief hospital course: 66 y/o f with pmhx of advanced endometrial stromal tumor s/p hysterectomy complicated by extensive dvt/pe who underwent elective thrombectomy with tpa today. . in the ccu: # dvt/thrombectomy/tpa: pt with extensive dvt who was admitted to icu for monitoring s/p failed thrombectomy with attempted tpa infusion. pt developed lower back pain during procedure that she reports is similar to prior msk pain. abd exam benign though c/o nausesa currently. hct stable and hypertensive, low suspicion for rp bleed, serial hct remained stable. per ir pt to continue lovenox 60mg sc bid. pt remained hemodynamically stable. venous fem catheter sites without evidence of hematoma. fibrinogen level normal in the am. on the am of discharge the pt denied ha, visual change, abdominal pain, numbness, weakness. . # nausea: pt with mild nausea and non-bloody emesis, most likely due to pain meds. pt responded to ativan, benadryl, zofran prn. pt denied abd pain. tolerating pos on the am of discharge, without abd pain. . # arf: baseline creatinine 1.0, currently elevated at 1.3 after being npo for almost 24hrs. suspect pre-renal, challenged with 1l of ns ivf overnight and f/u am labs revealed creatinine 1.2. bun down to 18. . # endometrial stromal ca: followed closely by onc/ob/gyn, continued megace per outpt regimen & lovenox 60mg sc bid. will follow-up as outpatient. pt discharged from the ccu hemodynamically stable, tolerating po intake, voiding without problem, pain controlled. medications on admission: levoxyl 125 mcg daily colace 100 mg every day as needed lovenox 60 mg twice daily megace 80 mg a day ativan as needed multivitamin calcium magnesium discharge medications: 1. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. megestrol 40 mg tablet sig: two (2) tablet po daily (daily). 4. enoxaparin 60 mg/0.6 ml syringe sig: one (1) subcutaneous (2 times a day). 5. multivitamin tablet sig: one (1) tablet po daily (daily). discharge disposition: home discharge diagnosis: primary: endometrial stromal sarcoma s/p failed thrombectomy discharge condition: stable, normotensive, pain free discharge instructions: you were admitted to the icu for post procedure monitoring after your elective procedure with interventional radiation. please call your doctor if you have any fever, chills, nausea, vomiting, bleeding from site, lightheadedness, black tarry stools, or any other concerning symptoms. followup instructions: provider: , md phone: date/time: 11:00 provider: , md phone: date/time: 11:00 provider: scan phone: date/time: 1:00 please make an appointment to follow-up with your primary doctor. Procedure: Injection or infusion of thrombolytic agent Diagnoses: Unspecified essential hypertension Acute kidney failure, unspecified Personal history of venous thrombosis and embolism Nausea alone Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Lumbago Personal history of malignant neoplasm of thyroid Malignant neoplasm of other specified sites of uterine adnexa |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: thoracentesis history of present illness: 72 year old female s/p coronary artery bypass grafting times four(lima->lad, svg->, , pda) who presented to the ed from rehab with acute shortness of breath while walking to the bathroom. on room air her o2 sat was in the 70s. past medical history: systolic heart failure diabetes mellitus coronary artery disease s/p cabg dyslipidemia social history: lived with spouse - however he has past away on this admission 50 pack year smoking history - was currently smoking prior to surgery alcohol 1 drink a month family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death. physical exam: pulse: 67 resp: 22 o2 sat: 100% b/p right: 127/67 general: skin: dry intact heent: perrla eomi neck: supple full rom chest: r basilar rales, left base decreased heart: irregularly irregular abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: 2+ pitting edema neuro: grossly intact pertinent results: 05:22am blood wbc-7.4 rbc-2.72* hgb-9.1* hct-27.5* mcv-101* mch-33.3* mchc-33.0 rdw-15.8* plt ct-257 10:35am blood wbc-8.6 rbc-3.13* hgb-10.1* hct-30.3* mcv-97 mch-32.3* mchc-33.3 rdw-16.0* plt ct-249 10:35am blood neuts-79.2* lymphs-11.0* monos-5.0 eos-4.6* baso-0.2 05:22am blood plt ct-257 05:22am blood pt-17.2* ptt-28.8 inr(pt)-1.5* 10:44am blood pt-16.6* ptt-28.1 inr(pt)-1.5* 10:35am blood plt ct-249 04:25am blood urean-29* creat-1.1 k-3.7 05:22am blood glucose-112* urean-26* creat-0.9 na-136 k-3.6 cl-95* hco3-33* angap-12 10:35am blood glucose-241* urean-13 creat-0.7 na-135 k-5.7* cl-92* hco3-38* angap-11 07:55am blood ck(cpk)-27* 10:35am blood ck(cpk)-90 04:25am blood mg-2.1 2:02 am mrsa screen source: nasal swab. **final report ** mrsa screen (final ): positive for methicillin resistant staph aureus. 11:00 pm sputum source: endotracheal. **final report ** gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and chains. quality of specimen cannot be assessed. respiratory culture (final ): moderate growth commensal respiratory flora. 11:01 am urine site: catheter **final report ** urine culture (final ): no growth , f f 72 radiology report chest (pa & lat) study date of 9:25 am , fa6a 9:25 am chest (pa & lat) clip # reason: assess effusions medical condition: 72 year old woman s/p cabg and bilat thoracentesis reason for this examination: assess effusions final report reason for examination: followup of the patient after cabg with bilateral thoracocentesis. pa and lateral upright chest radiographs were reviewed with comparison to . the right picc line tip appears to be below the cavoatrial junction and should be pulled back for approximately 2.5-3 cm as previously recommended to secure its position of the cavoatrial junction. bilateral pleural effusions are small, decreased since the prior study related to recent thoracocentesis. there is no evidence of pneumothorax. there is no evidence of new consolidation to suggest interval development of infectious process. dr. approved: 10:33 am echocardiography report , portable tte (complete) done at 11:31:20 am final referring physician information , c. , status: inpatient dob: age (years): 72 f hgt (in): bp (mm hg): 82/42 wgt (lb): 136 hr (bpm): 67 bsa (m2): indication: coronary artery disease. s/p cabg. left ventricular function. shortness of breath. icd-9 codes: 786.05, 414.8, 424.0, 424.2 test information date/time: at 11:31 interpret md: , md test type: portable tte (complete) son: , rdcs doppler: full doppler and color doppler test location: west sicu/ctic/vicu contrast: none tech quality: adequate tape #: 2010w001-0:07 machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: 3.5 cm <= 4.0 cm left atrium - four chamber length: 4.9 cm <= 5.2 cm right atrium - four chamber length: 4.9 cm <= 5.0 cm left ventricle - septal wall thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.6 cm <= 5.6 cm left ventricle - ejection fraction: 35% to 40% >= 55% left ventricle - stroke volume: 43 ml/beat left ventricle - cardiac output: 2.85 l/min left ventricle - lateral peak e': *0.04 m/s > 0.08 m/s left ventricle - septal peak e': *0.04 m/s > 0.08 m/s left ventricle - ratio e/e': *25 < 15 aorta - sinus level: *3.8 cm <= 3.6 cm aorta - ascending: 2.9 cm <= 3.4 cm aortic valve - peak velocity: 1.7 m/sec <= 2.0 m/sec aortic valve - lvot vti: 15 aortic valve - lvot diam: 1.9 cm mitral valve - e wave: 1.0 m/sec mitral valve - a wave: 0.4 m/sec mitral valve - e/a ratio: 2.50 mitral valve - e wave deceleration time: 188 ms 140-250 ms tr gradient (+ ra = pasp): 21 mm hg <= 25 mm hg findings left atrium: normal la and ra cavity sizes. right atrium/interatrial septum: increased ivc diameter (>2.1cm) with <35% decrease during respiration (estimated ra pressure (10-20mmhg). left ventricle: normal lv wall thickness and cavity size. mild-moderate global left ventricular hypokinesis. estimated cardiac index is normal (>=2.5l/min/m2). no lv mass/thrombus. trabeculated lv apex. tdi e/e' >15, suggesting pcwp>18mmhg. no resting lvot gradient. right ventricle: normal rv chamber size. moderate global rv free wall hypokinesis. aortic valve: mildly thickened aortic valve leaflets (3). no as. mitral valve: mildly thickened mitral valve leaflets. no mvp. mild mitral annular calcification. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets. mild tr. mild pa systolic hypertension. pericardium: trivial/physiologic pericardial effusion. general comments: suboptimal image quality - poor parasternal views. left pleural effusion. conclusions the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thicknesses and cavity size are normal. there is mild to moderate global left ventricular hypokinesis. quantitative (biplane) lvef = 40 %. the left ventricle is heavity trabeculated. the estimated cardiac index is normal (>=2.5l/min/m2). no masses or thrombi are seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size is normal. with moderate global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: normal left ventricular cavity size with prominent trabeculations and mild-moderate global hypokinesis. mild mitral regurgitation. mild pulmonary artery systolic hypertension. increased pcwp. in the absence of a history of myocardial infarction, non-compaction would be included in the differential diagnosis. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. electronically signed by , md, interpreting physician 14:08 brief hospital course: presented to emergency room with acute shortness of breath and chest xray revealed pleural effusions and due to increased work of breathing she was intubated after admission to intensive care unit. on the next day after holding coumadind she had bilateral thoracentesis with a total of 1.7 l of serous fluid removed and then was extubated without complications. she continued to do well and was monitored in the intensive care unit. she then was transferred to the floor for the remainder of her care. her diuretics were adjusted with fluid balance negative and her chest xray revealed small bilateral effusion with no increase in size on discharge. plan for discharge to rehab with continued diuresis and plan for follow up chest xray and clinic visit with dr . medications on admission: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 5. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 7. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 8. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 9. warfarin 1 mg tablet sig: as directed for afib tablet po daily (daily): goal inr 2-2.5. 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. potassium chloride 10 meq capsule, sustained release sig: one (1) capsule, sustained release po once a day. 12. bumetanide 0.5 mg tablet sig: two (2) tablet po bid (2 times a day). 13. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day): keep sbp > 140 for renal perfusion . discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 5. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 6. carvedilol 6.25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 8. metolazone 2.5 mg tablet sig: two (2) tablet po daily (daily). 9. bumetanide 2 mg tablet sig: one (1) tablet po once a day. 10. outpatient lab work please check potassium, magnesium, bun, creatinine twice a week while on zarolyxn and bumex 11. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day. discharge disposition: extended care facility: continuing care center - discharge diagnosis: pleural effusion acute on chronic systolic heart failure coronary artery disease s/p cabg diabetes mellitus hyperlipidemia discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with tylenol prn discharge instructions: weigh yourself every morning, md if weight goes up more than 3 lbs. weigh yourself every morning, md if weight goes up more than 3 lbs. 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: 1:00 please go to radiology in clinical center building for cxr prior to clinic visit with dr please call to schedule appointments primary care dr. () in weeks cardiologist dr. () in weeks Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Thoracentesis Arterial catheterization Diagnoses: Unspecified pleural effusion Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Acute on chronic systolic heart failure Dysphagia, unspecified Functional disturbances following cardiac surgery |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: malaise x 3 weeks major surgical or invasive procedure: s/p coronary artery bypass grafting times four(lima->lad, svg->, , pda) history of present illness: 72f with history of cad, dm2, tobacco abuse, who presented to c/o malaise, sob and cough x 3 weeks. she reports baseline sob with exertion, which has not significantly worsened over the past several weeks. denies cp and dizziness but does report an epigastric "empty feeling," which she has experienced intermittently at rest over the past several weeks, which lasts minutes and is not associated with eating. in addition, she describes baseline sob with exertion that has been unchanged for the past 4 months, but denies significant orthopnea or pnd. she does have peripheral edema in ankles at baseline, which has not worsened recently. she has had a cough productive of yellow sputum over the past 3 weeks, but denies hemoptysis, fever, chills, night sweats and sick contacts. in the , she was found to have elevated cardiac biomarkers (troponin i of 4.8) and elevated bnp (1900), with ecg showing inferolateral twi. treated with heparin, clopidogrel, aspirin, statin and transferred to ed for further management. . in the ed, initial vitals were t 98.9 hr 86 bp 168/98 rr 17 sao2 98% on ra. she was treated with heparin and had a cxr showing right pleural effusion and diffuse interstitial markings. labs were significant for trop t 1.04 and flat cks. she was admitted to the cardiology service for further managment. past medical history: 1. cardiac risk factors: diabetes, dyslipidemia 2. cardiac history: -pt reports mi x 3 in , with pci at where bms to rca in setting of acute imi 3. other past medical history: -pad with b/l stents to le in social history: lives with husband and granddaughter. -tobacco history: current smoker with 40 pack-year smoking hx -etoh: occasional (1 drink/month) -illicit drugs: none family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death. reports one daughter with dm. denies any fh of cancer, htn, hl. physical exam: vs: t= 98.9 bp=134/58 hr=69 rr=24 o2 sat= 91% on 3l general: elderly appearing female, lying comfortably in bed 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 difficult to appreciate ? near angle of jaw cardiac: pmi located in 5th intercostal space, midclavicular line. rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. tachypneic but not using accessory muscles. crackles b/l at bases, r>>l. otherwise poor air movement in upper lung fields. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: 1+ le edema in ankles b/l. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: radial 2+ dp 1+ pt 1+ left: radial 2+ dp 1+ pt 1+ pertinent results: 04:07am blood wbc-10.2 rbc-3.37* hgb-11.0* hct-33.4* mcv-99* mch-32.6* mchc-32.8 rdw-16.2* plt ct-372 04:07am blood pt-18.5* inr(pt)-1.7* 04:07am blood glucose-103* urean-18 creat-0.6 na-144 k-3.7 cl-105 hco3-29 angap-14 02:12am blood alt-39 ast-126* ld(ldh)-467* alkphos-43 totbili-0.9 , f f 72 radiology report renal u.s. study date of 8:57 am , csru 8:57 am renal u.s.; duplex dopp abd/pel clip # reason: pt just had cabg, ? ras echocardiography report , (complete) done at 11:21:38 am final referring physician information , - department of cardiac s , 2a , status: inpatient dob: age (years): 72 f hgt (in): 62 bp (mm hg): 145/89 wgt (lb): 115 hr (bpm): 78 bsa (m2): 1.51 m2 indication: intraoperative tee for cabg. chest pain. left ventricular function. mitral valve disease. preoperative assessment. pulmonary hypertension. right ventricular function. shortness of breath. icd-9 codes: 786.05, 424.0, 424.2 test information date/time: at 11:21 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 #: 2010aw1-: machine: aw1 echocardiographic measurements results measurements normal range left ventricle - septal wall thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *5.8 cm <= 5.6 cm left ventricle - ejection fraction: 25% >= 55% aorta - ascending: 3.2 cm <= 3.4 cm aortic valve - peak velocity: 1.3 m/sec <= 2.0 m/sec aortic valve - peak gradient: 6 mm hg < 20 mm hg 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: mild symmetric lvh. right ventricle: moderate global rv free wall hypokinesis. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. simple atheroma in aortic arch. simple atheroma in descending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. tricuspid valve: mild tr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. no tee related complications. the patient appears to be in sinus rhythm. results were personally reviewed with the md caring for the patient. conclusions prebypass no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. with moderate global free wall hypokinesis. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results on at 900am post bypass patient is av paced and receiving an infusion of phenylephrine, milrinone and norepinephrine. rv systolic function is slightly improved. lvef is unchanged. aorta is intact post decannulation. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 12:47 medical condition: 72 year old woman with cabg reason for this examination: ? ras final report indication: 72-year-old female with coronary artery bypass graft. please assess for renal artery stenosis. comparison: cta of the chest from . findings: there is a moderate right pleural effusion as visualized on the prior ct from . right kidney: the right kidney measures 12.4 cm. there is no hydronephrosis, stones, or masses. the main renal artery on the right shows normal flow, brisk upstroke and normal waveform with antegrade diastolic flow. evaluation of the interlobar artery is limited secondary to respiratory artifact. within those limitations, the resistive indices are normal with an ri of 0.86 at the upper, 0.76 at the mid and 0.85 at the lower pole. the right main renal vein shows normal flow and is patent. left kidney: the left kidney measures 12.9 cm. there is a simple, 1.7-cm measuring cyst in the left lower pole. the main renal artery on the left shows normal flow, brisk upstroke and normal waveforms with antegrade diastolic flow. evaluation of the interlobar arteries is very limited secondary to respiratory artifact. the left main renal vein is patent with normal flow. the bladder is empty and a foley catheter is visualized within the bladder lumen. impression: 1. the study is limited secondary to respiratory artifact. however, within those limitations, there is no evidence of renal artery stenosis bilaterally. 2. moderate right pleural effusion as visualized on the ct from . the study and the report were reviewed by the staff radiologist. dr. dr. sun approved: 2:07 pm , f f 72 radiology report chest (portable ap) study date of 7:13 am , csru 7:13 am chest (portable ap) clip # reason: eval for ptx medical condition: 72 year old woman s/p cabg reason for this examination: eval for ptx final report history: cabg, to evaluate for pneumothorax. findings: in comparison with the study of , there is continued prominence of the cardiac silhouette with evidence of bilateral pleural effusions and compressive basilar atelectasis. the upper lung zones are clear and there is no evidence of pneumothorax. right central catheter extends to the cavoatrial junction or into the right atrium itself. dr. approved: wed 10:25 am brief hospital course: the patient was transferred from the ed on and was admitted to the cardiology service. she was continued on plavix and her cardiac enzymes were cycled. she was on heparin and underwent cardiac cath on which revealed severe left and right sided diastolic dysfunction with severe pulmonary hypertension. she also had three vessel disease which included an 80% distal left main lesion and a totally occluded rca. her lvef was 30%. she was swanned and transferred to the ccu. she was unable to have an iabp secondary to bilateral iliac disease. cardiac surgery was consulted. she remained in the ccu and was gently diuresed. on she underwent urgent coronary artery bypass grafting times four with lima->lad, svg-> , , and pda. she tolerated the procedure well and was transferred to the cvicu on milrinone and levophed. she was weaned from the ventilator and extubated on pod#3 but continued to require aggressive pulomnary tiolet due to underlying lung disease. she was treated with betablockers, and diuresis for acute on chronic diastyloic heart failure. mrs. developed acute renal failure with a doubling of her creatinine and low urine output. renal was consulted and a renal ultrasound was done revealing no renal artery stenosis. it was determined that her blood pressure needed to be >140 to perfuse her kidney's. her urine output improved and her creatinine recovered over time. she was also seen by electrophysiology for varying av conduction. she was felt to possibly need an aicd in the future. she has remained in rate controlled afib which then converted to sinus rhythm. coaumdin was started for atrial fibrillation. she was evaluated by physical therapy for strength and conditioning and rehab was recommended. she was transferred to the stepdown unit for ongoing post operative care. a small area of incisional erythema was noted at the distal aspect of her incision and per recommendation of dr. a 7 day course of keflex was started. mrs. was discharged to rehab on pod#8. medications on admission: -bumetanide 1 mg daily -asa occasionally (per patient, pcp took her off all other meds about 4 years ago) discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 5. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 7. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 8. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 9. warfarin 1 mg tablet sig: as directed for afib tablet po daily (daily): goal inr 2-2.5. 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. potassium chloride 10 meq capsule, sustained release sig: one (1) capsule, sustained release po once a day. 12. bumetanide 0.5 mg tablet sig: two (2) tablet po bid (2 times a day). 13. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day): keep sbp > 140 for renal perfusion . 14. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 7 days. 15. outpatient lab work inr check daily for coumadin dosing until inr stable discharge disposition: extended care facility: rehab in quency discharge diagnosis: niddm hyperlipidemia s/p mix3, pci, and bms current smoker discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with percocet prn discharge instructions: weigh yourself every morning, md if weight goes up more than 3 lbs. 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: you have requested information about seeing a cardiologist in your area (). you may call our cardiology office at to see one of our heart failure specialists (dr. ), or seek their recommendation about cardiologist in the , ma area. recommended follow-up:please call to schedule appointments surgeon dr. in 4 weeks primary care dr. () in weeks cardiologist dr. () in weeks wound check appointment - 6 () - your nurse will schedule Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Other and unspecified coronary arteriography Thoracentesis Arterial catheterization Combined right and left heart angiocardiography Diagnoses: Hyperpotassemia Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Tobacco use disorder Other postoperative infection Unspecified pleural effusion Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Atrial fibrillation Acute on chronic diastolic heart failure Other chronic pulmonary heart diseases Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Anxiety state, unspecified Other specified cardiac dysrhythmias 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 Enlargement of lymph nodes Atherosclerosis of native arteries of the extremities, unspecified Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use Other second degree atrioventricular block Unspecified psychosis Other specified analgesics and antipyretics causing adverse effects in therapeutic use Neoplasm of unspecified nature of respiratory system |
allergies: lisinopril / diltiazem attending: chief complaint: shortness of breath, dyspnea on exertion major surgical or invasive procedure: : 1. bentall procedure with a 29-mm freestyle valve graft, serial #, with coronary button reimplantation. 2. hemi-arch replacement and replacement of ascending aorta with a 28-mm vascutek gelweave single side-arm graft, catalog #, lot #, serial number . history of present illness: mr. is a 67 year male with known aortic aneurysm involving the root and ascending portion. his pmh is notable for copd and hypertension. his aneurysm has been followed with yearly echocardiograms and ct scans. given current size of 5.7 centimeters, he was referred by dr. for cardiac surgical intervention. patient denies chest and back pain. he has longstanding shortness of breath and dyspnea on exertion secondary to his copd. he does experience palpitations with exertion. past medical history: ascending aortic aneurysm, s/p bentall procedure pmh: chronic obstructive pulmonary disease hypertension hypercholesterolemia supra-ventricular tachycardia intention tremor, mostly right hand chronic back pain renal cyst peptic ulcer disease arthritis gastroesophageal reflux disease social history: retired machinist. recently seperated, lives alone. active smoker - about 3 cigs/day. admits to 45 pack year history of tobacco. rare etoh. family history: non-contributory physical exam: height: 6'3" weight: 196 lbs general: appears well, lying flat post cath, in nad skin: dry intact heent: perrla eomi neck: supple full rom chest: clear with some ronchi bilaterally heart: rrr irregular - distant heart sounds abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused trace edema lle varicosities: none neuro: alert and oriented, cn 2-12 grossly intact, no focal deficits pulses: femoral right: 2 left: 2 dp right: 1 left: 1 pt : 1 left: 1 radial right: 2 left: 2 carotid bruit right: none left: none pertinent results: pre-bypass: 1. the left atrium and right atrium are normal in cavity size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 2. no atrial septal defect is seen by 2d or color doppler. 3. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). 4. right ventricular chamber size and free wall motion are normal. 5. the aortic root is moderately dilated at the sinus level. the ascending aorta is moderately dilated. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. there is no aortic valve stenosis. moderate (2+) aortic regurgitation is seen. 6. the mitral valve appears structurally normal with trivial mitral regurgitation. 7. there is no pericardial effusion. post-bypass: av paciong. on infusion of phenylephrine. well-seated bioprosthetic valve in the aortic position. no ai; systolic gradient is trivial. ascending graft visible in the aortic positoion. no dissection seen. aortic contour is normal in the descending aorta. biventricular systolic function is preserved. 06:00am blood wbc-7.6 rbc-2.65* hgb-7.8* hct-24.5* mcv-93 mch-29.6 mchc-32.0 rdw-13.4 plt ct-146* 12:09pm blood wbc-12.0* rbc-2.85*# hgb-9.2*# hct-26.6*# mcv-93 mch-32.4* mchc-34.7 rdw-12.9 plt ct-139* , m 67 radiology report chest (pa & lat) study date of 1:36 pm , fa6a 1:36 pm chest (pa & lat) clip # reason: pl.eff medical condition: 67 year old man s/p bentall/hemiarch reason for this examination: pl.eff final report two-view chest of comparison: . indication: evaluate pleural effusion in postoperative patient. findings: cardiomediastinal contours are stable in appearance compared to previous postoperative radiographs. small pleural effusions, right greater than left, are unchanged from the two most recent radiographs. minor atelectatic changes persist at the bases. on the lateral view, retrosternal gas and fluid is likely related to the recent sternotomy. due to patient obliquity, it is difficult to exclude small loculated anterior hydropneumothorax, but no visible apical pleural line is evident on the corresponding frontal view. high-grade compression deformity in the mid thoracic spine is unchanged since the preoperative study. impression: small pleural effusions, right greater than left with adjacent basilar atelectasis. dr. approved: 2:18 pm imaging lab 01:30pm blood pt-15.0* ptt-45.7* inr(pt)-1.3* 12:09pm blood pt-16.0* ptt-43.2* inr(pt)-1.4* 06:00am blood glucose-97 urean-11 creat-0.7 na-133 k-4.1 cl-93* hco3-32 angap-12 03:31am blood glucose-111* urean-12 creat-0.7 na-135 k-4.8 cl-104 hco3-25 angap-11 brief hospital course: the patient was admitted to the hospital and brought to the operating room on where he underwent bentall procedure as well as ascending aorta and hemi-arch replacement. see operative note for further details. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. he awoke neurologically intact and was extubated without difficulty. weaned off nitroglycerin. beta-blocker/aspirin/statin/diuresis was initiated. preoperative meds were resumed. all lines and drains were discontinued in a timely fashion. pod#1 he was transferred to the step down unit for further monitoring. physical therapy was consulted to evaluate mobility and strength. he continued to progress although he was not able to be weaned off of supplemental oxygen completely. as discussed with his pulmonologist, mr. continued his inhalers and diuresis, and would require o2 arranged for discharge to home. postoperatively he had transient hyponatremia requiring free water restriction and diuresis to correct his electrolytes. on pod# 6 he was cleared by dr. for discharge to home. all follow up appointments were advised. medications on admission: hctz 25 qd, atenolol 100 qd, amiodarone 200 qd, nifedipine 30 qd, pravastatin 40 qd, advair prn, trazadone 150 qd, oxycontin 20-60 tid, alendronate 70 qweek, spiriva 18mcg daily, asa 81mg po daily, fluticasone 50mcg 2 sprays each nostril daily, albuterol prn discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. multivitamin tablet sig: one (1) tablet po daily (daily). 3. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 4. trazodone 50 mg tablet sig: three (3) tablet po hs (at bedtime) as needed for insomnia. 5. oxycodone 10 mg tablet sustained release 12 hr sig: three (3) tablet sustained release 12 hr po q8h (every 8 hours) as needed for pain. disp:*90 tablet sustained release 12 hr(s)* refills:*0* 6. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 7. pravastatin 20 mg tablet sig: two (2) tablet po daily (daily). 8. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 9. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 10. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). 11. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 12. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). disp:*60 disk with device(s)* refills:*2* 13. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed for dyspnea. disp:*qs * refills:*0* 14. ibuprofen 600 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 15. alendronate 70 mg tablet sig: one (1) tablet po once a week. 16. 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* 17. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 18. atenolol 50 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 19. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 20. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 21; home oxygen arranged for nasal cannula discharge disposition: home with service facility: vna discharge diagnosis: ascending aortic aneurysm, s/p bentall procedure pmh: chronic obstructive pulmonary disease hypertension hypercholesterolemia supra-ventricular tachycardia intention tremor, mostly right hand chronic back pain renal cyst peptic ulcer disease arthritis gastroesophageal reflux disease discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with ** prn 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 home oxygen arranged for nasal cannula followup instructions: surgeon dr. #, appointment arranged for at 1:30pm primary care dr. in weeks cardiologist dr. ( in weeks pulmonologist dr in weeks wound check appointment - 6 () - your nurse will schedule Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Resection of vessel with replacement, thoracic vessels Diagnoses: Esophageal reflux Tobacco use disorder Unspecified essential hypertension Hyposmolality and/or hyponatremia Thoracic aneurysm without mention of rupture Chronic airway obstruction, not elsewhere classified Aortic valve disorders Pulmonary collapse Other and unspecified hyperlipidemia Lumbago Congenital insufficiency of aortic valve Arthrodesis status Essential and other specified forms of tremor |
allergies: no known allergies / adverse drug reactions attending: chief complaint: trauma: pedestrian hit by car: bilateral foci of sah intraventricular hemorrhage frontal sinus fx l occipital condyle fx t1 transverse process tip of clivus fx ? small epidural hematoma at c1 sternal fx spleen lac r pubic ramus fx r anterior acetabulum open r radius/ulna fx bilateral open tib/fib fx sacral fx injury to r tp trunk major surgical or invasive procedure: washout by ortho b/l le washout b/l le with vac placement on left b/l le washout rt humerus orif, b/l tibial nails washout b/l tib/fib, rle vac, ivc filter placement ex-lap, splenectomy evd ex fix bilateral tib/fib fxs, bilateral fasciotomy right elbow washout history of present illness: history of presenting illness this patient is a 30 year old male who complains of ped struck. patient says pushed and struck at high rate of speed. patient had a seizure at the event. the patient has bilateral lower extremity fractures, right upper extremity fracture, suspected open skull fracture. past medical history: unknown social history: unknown family history: unknown physical exam: physical examination: upon admission constitutional: agonal heent: right forehead laceration with likely open fracture c. collar chest: clear to auscultation cardiovascular: tachycardic abdominal: soft, nontender gu/flank: no costovertebral angle tenderness extr/back: bilateral lower extremity fractures, right upper extremity fracture with a large laceration measuring approximately 9 cm skin: abdominal abrasion, right hip abrasion, right shoulder abrasion neuro: posturing pertinent results: 05:00am blood wbc-19.3* rbc-3.26* hgb-10.0* hct-29.9* mcv-92 mch-30.7 mchc-33.5 rdw-16.4* plt ct-371 05:00am blood wbc-18.3* rbc-3.16* hgb-9.5* hct-29.3* mcv-93 mch-30.1 mchc-32.5 rdw-16.4* plt ct-335 06:30am blood wbc-16.5* rbc-3.07* hgb-8.8* hct-28.8* mcv-94 mch-28.8 mchc-30.6* rdw-16.9* plt ct-330 05:00am blood neuts-42.3* lymphs-45.7* monos-5.3 eos-5.8* baso-0.8 03:35am blood neuts-79.0* lymphs-15.1* monos-3.2 eos-1.3 baso-1.4 01:36am blood neuts-60 bands-2 lymphs-17* monos-15* eos-4 baso-0 atyps-0 metas-2* myelos-0 nrbc-1* 01:36am blood hypochr-2+ anisocy-1+ poiklo-normal macrocy-2+ microcy-normal polychr-1+ 05:00am blood plt ct-371 05:00am blood plt ct-335 01:59am blood pt-13.5* ptt-22.1 inr(pt)-1.2* 09:30pm blood pt-14.1* ptt-36.4* inr(pt)-1.2* 12:58am blood fibrino-414*# 03:40am blood fibrino-139* 09:05am blood glucose-125* urean-10 creat-0.5 na-137 k-3.9 cl-100 hco3-28 angap-13 05:00am blood glucose-379* urean-10 creat-0.5 na-132* k-5.2* cl-99 hco3-29 angap-9 06:30am blood glucose-89 urean-10 creat-0.5 na-144 k-3.3 cl-107 hco3-27 angap-13 01:25am blood alt-39 ast-41* ld(ldh)-268* alkphos-283* totbili-0.5 02:11am blood alt-49* ast-55* ld(ldh)-360* alkphos-319* amylase-240* totbili-0.5 01:36am blood alt-69* ast-78* ld(ldh)-323* alkphos-284* totbili-0.6 01:25am blood ggt-142* 02:11am blood lipase-129* ggt-199* 09:05am blood calcium-8.8 phos-4.0 mg-2.0 05:00am blood calcium-8.0* phos-3.7 mg-1.8 06:30am blood vanco-12.1 11:43pm blood vanco-23.9* 09:41am blood vanco-27.4* 02:25am blood phenyto-14.3 12:18am blood phenyto-12.9 01:42am blood phenyto-13.4 09:30pm blood asa-neg ethanol-22* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 08:26am blood glucose-113* 09:29am blood hgb-7.1* calchct-21 12:31am blood freeca-1.07* : cat scan of abdomen and pelvis: impression: 1. hemoperitoneum and spleen laceration. active extravasation from the spleen. possible small pseudoaneurysm at the inferior tip of the spleen. 2. small liver hypodensity, could be focal sparing, less likely small laceration. 3. bulky right adrenal gland could be hematoma in the setting of trauma. 4. questionable abnormal loops of small bowel in the pelvis with bowel wall thickening could be related to trauma. 5. right superior and inferior pubic ramus fracture. comminuted fracture of the right anterior acetabulum. nondisplaced fracture through the sacrum. 6. small step-off at the sternum with similar step-off in the adjacent skin, likely artefact. if concern for fractrure lateral chest radiograph can be considered. : cat scan of the head: impression: 1. bilateral foci of subarachnoid hemorrhage. 2. intraventricular hemorrhage. 3. non-displaced fracture through the right frontal sinus involving both outer and inner table with blood in the right frontal sinus and several ethmoid air cells. 4. soft tissue contusion along the right frontal bone. 5. foci of air along the right stylohyoid process and dense material in the right external auditory canal; cannot exclude right temporal bone fracture. correlate clinically and if concern cosnider temporal bone ct. d/w dr. by dr. in person at 12:14 am on . : x-ray of the right forearm: findings: there is a linear displaced fracture through the mid shaft of the ulna. additionally, there is a second fracture line through the distal ulna which appears nondisplaced. the radial head appears displaced. findings are concerning for monteggia fracture. soft tissue abrasions in the forearm, likely post-traumatic. immobilization material gives suboptimal evaluation of subtle bony details. : x-ray of the pelvis: findings: there is a comminuted fracture of the right anterior acetabulum and right inferior pubic ramus which are better evaluated on the subsequent ct torso. additionally, there is a nondisplaced fracture line through the sacrum which is also evaluated better on the ct torso. contrast is in the urinary bladder from the recent ct scan : cat scan of the c-spine: impression: 1. non-displaced fracture through the left occipital condyle. 2. minimally displaced fracture through the right c7 and t1 transverse process. 3. nondisplaced fracture of the tip of clivus. 4. possible small epidural hematoma in the anterior epidural space at c1, near foramen magnum. : cta: impression: 1. bilateral comminuted fractures in tibia and fibula. 2. nondisplaced sacral fracture. 3. right comminuted acetabular and pubic rami fracture. 4. pseudoaneurysm at the right proximal tibial trunk and focus of active extravasation near proximal right fibular fracture. 5. distally from the pseudoaneurysm on the right, there is only faint flow in the right anterior tibial artery. 6. on the left only two-vessel runoff with the peroneal artery being best perfused. the posterior tibial artery could be compressed from a hematoma from the fracture : bil. tib/fib x-ray: left tibia and fibula: comminuted displaced fracture through left tibia. comminuted displaced fracture through proximal left fibula. fracture through patella : cat scan of the head: impression: 1. hypodensity of the cerebral parenchyma consistent with diffuse cerebral edema with effacement of the cisterna magna, and slightly low-lying cerebellar tonsils, concerning for central herniation. assessment for changes from ischemia is limited. correlate clinically and followup/consider further workup. 2. hypodense/isodense subdural collection in the bilateral frontal space without a component of hemorrhage, concerning for csf leak given the fracture through the right frontal sinus. 3. redistribution of subarachnoid hemorrhage with now blood in the intrapeduncular cistern as well as the fourth ventricle without evidence of new hemorrhage. 4. fluid in the maxillary sinuses bilaterally. : cat scan of the head: impression: no significant interval change. 1. hypodensity of the cerebral parenchyma consistent with diffuse cerebral edema. similar effacement of cisterna magna. 2. bilateral stable hypodense - isodense subdural collections in bilateral frontal spaces. 3. stable bilateral foci of subarachnoid hemorrhage and stable intraventricular hemorrhage. : right elbow x-ray: impression: no significant interval change. 1. hypodensity of the cerebral parenchyma consistent with diffuse cerebral edema. similar effacement of cisterna magna. 2. bilateral stable hypodense - isodense subdural collections in bilateral frontal spaces. 3. stable bilateral foci of subarachnoid hemorrhage and stable intraventricular hemorrhage. : eeg: impression: this is an abnormal continuous icu monitoring study because of severe diffuse background slowing and attenuation and periods of discontinuity. these findings are indicative of severe diffuse cerebral dysfunction which is etiologically non-specific. there were no epileptiform discharges or electrographic seizures. : cat scan of the head: impression: 1. evolving bilateral subdural collections, and bilateral subarachnoid hemorrhage with no new hemorrhage. decrease in bilateral intraventricular hemorrhage when compared to prior study. 2. interval removal of intracranial pressure device. 3. nondisplaced fracture of the right frontal sinus, with opacification of sinuses as mentioned above. this fracture line increases the risk of csf leak or infection. 4. pneumocephalus, likely from bolt placement and trauma, whihc has decreased from prior study. : mr of cervical spine: impression: limited study secondary to patient motion. within these limitations, no evidence of epidural hematoma. no spinal cord signal abnormality. the limited evaluation demonstrates multilevel degenerative changes : echo: conclusions the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. left ventricular systolic function is hyperdynamic (ef>75%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). 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 stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: suboptimal image quality. normal left ventricular cavity size and wall thickness with hyperdynamic left ventricular systolic function. no clinically significant valvular disease. moderate pulmonary artery systolic hypertension. : chest x-ray: confluent left lower lobe opacity with a developing lingular opacity and moderate effusion could represent atelectasis or pneumonia. : cat scan of abdomen and pelvis: impression: 1. development of small bilateral pleural effusions with associated compressive atelectasis in both bases. 2. the patient is status post splenectomy and placement of infrarenal ivc filter. no intra-abdominal fluid collection. no free intra-abdominal gas or significant free fluid. 3. position of endotracheal tube as described. stable sacral and pelvic fractures as described. : mr of the head: impression: 1. multiple areas of increased signal intensity, specifically in corpus callosum, right corona radiata, right frontal lobe, and left medulla that are consistent with diffuse axonal injury in the setting of trauma. 2. small subdural collections along the occipital lobes, cerebellum, as and the falx. bilateral frontal subdural collections, likely a combination of hygroma and hematoma. 3. small amount of intraventricular blood bilaterally and unchanged from prior study. 3. opacification of the mastoid air cells on the right. : sinus and mandible: impression: 1. persistent opacification of the right frontal sinus, frontal bulla, and right frontal recess, related to the known nondisplaced fracture of the anterior and posterior walls of the right frontal sinus. superimposed infection cannot be excluded by imaging, but definite signs of new infection are seen. 2. persistent fluid in the right mastoid and left middle ear, partially visualized : chest x-ray: the feeding tube has been removed. there is a tracheostomy tube. there is a small amount of free air underneath the hemidiaphragm which can be consistent with recent splenectomy. there is no focal consolidation or definite signs for overt pulmonary edema. there is mild coarsening of the bronchovascular markings. there are no pneumothoraces on either side. : c-spine: findings: there are no signs for acute fractures or dislocations. intervertebral disc spaces are relatively preserved. the prevertebral soft tissues are normal. there is no abnormal antero- or retrolisthesis. with flexion and extension, there is no abnormal motion. the visualized lung apices are grossly clear. : video swallow: impression: 1. trace aspiration of nectar thick. 2. moderate amount of residue in the pharynx. 3. delayed oropharyngeal swallowing phase. : chest x-ray: lungs are fully expanded and clear. tracheostomy tube is in standard placement. heart size is normal. there is no obvious pleural abnormality. : bil. tib/fib films: impression: 1. unchanged alignment of comminuted fractures of the tibia and fibula bilaterally with minimal callus formation. 2. transversely oriented fracture through the mid left patella, little changed. 3. left tibial spine fracture and bony fragments within left knee joint, stable : x-ray of right forearm: impression: 1. orif of an ulnar fracture with small fracture line seen at the mid-to-distal right ulna. no hardware complication. 2. heterotopic ossification adjacent to the radial head and neck. : right elbow x-ray: impression: 1. orif of an ulnar fracture with small fracture line seen at the mid-to-distal right ulna. no hardware complication. 2. heterotopic ossification adjacent to the radial head and neck. : video swallow: penetration of nectar-thick contrast. 2. gross aspiration of thin liquids : chest xray: findings: in comparison with the study of , there is little change in the appearance of the heart and lungs. no evidence of acute pneumonia or vascular congestion. of incidental note is removal of the tracheostomy tube. 9/81/11: head cat scan: impression: 1. unchanged bilateral prefrontal hygromas with no new hemorrhage. 2. resolved bilateral intraventricular hemorrhages. 7:40 pm blood culture blood culture, routine (pending): 5:44 pm urine source: catheter. **final report ** urine culture (final ): no growth. 4:25 pm urine source: catheter. **final report ** urine culture (final ): no growth. : 2:00 pm sputum source: endotracheal. **final report ** gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). quality of specimen cannot be assessed. respiratory culture (final ): rare growth commensal respiratory flora. pseudomonas aeruginosa. sparse growth. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 16 i ceftazidime----------- 16 i ciprofloxacin--------- =>4 r gentamicin------------ 8 i meropenem------------- =>16 r tobramycin------------ <=1 s : 3:21 am sputum source: induced. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. sparse growth of two colonial morphologies. sensitivities performed on culture # () : /13/11 3:35 am sputum source: induced. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram negative rod(s). smear reviewed; results confirmed. respiratory culture (final ): rare growth commensal respiratory flora. pseudomonas aeruginosa. moderate growth. of two colonial morphologies. piperacillin/tazobactam sensitivity testing performed by . klebsiella pneumoniae. sparse growth. piperacillin/tazobactam requested by dr.() on : pending. piperacillin/tazobactam sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | klebsiella pneumoniae | | ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- 32 r <=1 s ceftazidime----------- =>64 r <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r 2 i gentamicin------------ 8 i <=1 s meropenem------------- 1 s <=0.25 s piperacillin/tazo----- s i tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s : 12:16 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): multiple organisms consistent with oropharyngeal flora. respiratory culture (final ): sparse growth commensal respiratory flora. klebsiella pneumoniae. moderate growth. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s 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 : 26/11 12:02 am mini-bal **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram negative diplococci. respiratory culture (final ): sparse growth commensal respiratory flora. klebsiella pneumoniae. sparse growth. piperacillin/tazobactam sensitivity testing available on request. klebsiella pneumoniae. sparse growth. second morphology. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | klebsiella pneumoniae | | ampicillin/sulbactam-- 4 s <=2 s cefazolin------------- <=4 s <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s <=1 s brief hospital course: this is a 50-ish gentleman who presented to after being struck by a car at high speed on route 9. he had serious injuries at the time of presentation, and was taken emergently to the operating room with general surgery, neurosurgery, and orthopedics. at that time, a bolt was placed, an exploratory laparotomy and splenectomy were performed, and he had his bilateral lower extremities washed out, ex-fixes placed to fractures, and fasciotomies performed. he was brought to the ticu post-operatively. his post-injury course has been long and complicated. please see below for summary of pertinent events by system. neuro: he was brought to the ed with a gcs of , and was sedated for the or. a bolt was placed for icp monitoring, and he was loaded with dilantin. he had a brief episode of seizure-like activity on hd 3, which resolved with ativan. his bolt was removed on hd 6. his mental status remained poor throughout his icu stay, with concern for diffuse axonal injury causing a permanent vegetative state. on (hd 20), he spontaneously opened his eyes and began tracking. his mental status slowly improved until , when he was felt to be able to protect his airway, and was extubated. cv: he had sinus tachycardia throughout his icu admission. despite beta-blockade, this was never fully controlled in the icu, nor was a clear etiology identified. cardiology was consulted, and did not have any recommendations for change in management. pulm: he was kept intubated while his mental status was poor, though did not have any other pulmonary issues. when he began to wake-up, the vent was weaned and he was successfully extubated on . fen/gi: he was kept npo while intubated and obtunded. tube feeds were started early in his hospital course and were advanced to goal. gu: a foley catheter was placed on admission, and was kept due to his altered mental status. heme: his hematocrit was closely monitored, and he received prbc transfusions when needed. he had an ivc filter placed on . id: he had a refractory leukocytosis and fevers throughout his stay. he underwent many lower extremity washouts with orthopedics for infection and necrosis of his fasciotomies and fracture sites. he ultimately grew klebsiella from a bal, acinetobactor from a sputum, and enterobacter cloacae from his leg wound, all of which were treated with appropriate antibiotics. despite appropriate antibiotics and wound debridement, he continued to spike fevers and have a leukocytosis at the time of transfer out of the icu. he was transferred to the surgical floor on . he continued to have an elevated white blood cell count at 22.9. within 24 hours of discharge, he returned to the intensive care unit after he became febrile and tachypneic. blood and sputum cultures were sent and he was found to have pseudomonas and klebseilla in his sputum. because he had copious secretions, a tracheostomy was performed on . at this time, he underwent placement of a feeding tube to provide him with nutrition. he continued to have temperature spikes and an elevated white blood cell count and infectious disease was consulted. his antibiotic coverage was broadened to tobramycin, meropenum, and a five day course of vancomycin. his tobramycin and meropenum were discontinued on . once his white blood cell count stabilized, he was taken to operating room on where he underwent a wash-out of his right tib/fib fracture and application of a vac dressing. he returned to the operating room in 24 hours for left lower extremity washout and vac change. his operative course was stable with minimal blood loss. his vac and jp drain were removed on . his cervical spine was cleared by ortho spine and his cervical collar was removed. he was evaulated by speech and swallow to determine his ability to take oral nutrition. a video swallow was obtained which showed trace aspiration with nectar-thick liquid, but no aspiration or penetration with any other consistency of contrast. he was started on pureed regular diet. his trach was down-sized to a #6 fenestrated, cuffless tube on . he coughed out his trach tube later that day and has maintained his oxygen saturation without evidence of respiratory compromise. he was re-evaluated by speech and swallow and cleared for a regular diet. since he was nutritionally depleted, a calorie count was ordered and tube feedings continued to be cycled at night alternating with a regular diet during the day. he has had no evidence of aspiration on a regular diet. both physical and occupational therapy have been involved in his care. with his reported history of bipolar disease, he was evaluated by the psychiatrist after his trach tube was removed and it was determined that his bipolar disease was not active and recommended haldol if he became agitated. he has been very cooperative and has not required haldol. since his admission, he was maintained on keppra and it was felt that provided him with adequate mood stablization. his keppra is currently being weaned. during the course of his hospitalization, he had been followed by social services who were closely working with outside resources to determine his identity. a guardian was appointed during this process. through investigative sources, he was identified and his family was contact. social services have continued to provide support to both the patient and family. one month after his admission, a repeat head cat scan was done to evaluate his tbi and it showed no new hemorrhages. his keppra is being weaned off. his vital signs are stable and he has been afebrile. he is maintaining an oxygen saturation of 100% on room air with a normal respiratory rate. he has been cleared to resume a regular diet after evaluation of speech and swallow with cyclic tube feedings at bedtime. he still requires straight bladder catherization every 6 hours for a neurogenic bladder. he is preparing for discharge to a rehabilitation facility to help him regain his strength and mobility. he has been ordered to receive his post-splenectomy immunizations prior to discharge. he has follow-up appointments with the acute care service, plastics, orthopedics, and neurology. medications on admission: unknown discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day): hold for loose stool. 2. levetiracetam 500 mg tablet sig: two (2) tablet po once a day: thru then decrease to 500 mg daily for 4 days then discontinue. 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q4h (every 4 hours) as needed for wheezing/sob. 5. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation: hold for diarrhea. 6. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily). 7. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for rash. 8. metoprolol tartrate 50 mg tablet sig: one (1) tablet po qid (4 times a day): hold for hr <60, systolic blood pressure <90. 9. enoxaparin 40 mg/0.4 ml syringe sig: forty (40) mg subcutaneous qpm (once a day (in the evening)). 10. colace 100 mg capsule sig: one (1) capsule po twice a day: hold for loose stool. 11. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours: as needed for pain,fever. 12. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain: hold for increased sedation, resp. rate <12. disp:*35 tablet(s)* refills:*0* discharge disposition: extended care facility: discharge diagnosis: s/p pedestrian struck 1. bilateral subarachnoid hemorrhage 2. intraventricular hemorrhage 3. frontal sinus fracture 4. left occipital condyle fracture 5. t1 transverse process fracture 6. tip of clivus fracture 7. epidural hematoma at c1 8. sternal fracture 9. splenci laceration 10.right pubic rami fracture 11.right anterior acetabular fracture 12.open right radial and ulnar fracture 13.bilateral tibia/fibular fractures 14.sacral fracture 15.right transverse process trunk injury 16.acute blood loss anemia 17.pneumonia 18.tbi discharge condition: opens eyes to tactile and verbal stimulation disoriented to time, person, and place occasional words spoken after pmv placed discharge instructions: you were admitted to the hospital after you were struck by a car. you sustained a skull and sinus fractures along with injuries to your upper and lower extremities. you had exploratory surgery of your abdomen and had an injury to your spleen and it was removed. you were admitted to the intensive care unit where you required monitoring of the pressures in your head because of increased swelling. you underwent several surgical procedures for repair of your lower extremity injuries. you had a tracheostomy tube placed to help clear the secretions from your lungs because you were unable to clear them on your own. to maintain your nutritional status, you had a feeding tube placed through which you received additional supplements. you are now preparing for discharge to a rehabilitation facility where you can further regain your strength. followup instructions: please follow up with dr. in 1 month () for a non-contrast repeat head cat scan. the telephone number to make this appoinment is #. you should also remain on the keppra until then. please follow up with the acute care service in 2 weeks. you can schedule this appointment 24 hours after you are discharged. the telephone number is # . please follow up with plastic surgery, dr. , in 2 weeks. call for appointment. please follow up with orthopedics nurse practitioner, in 2 weeks. the telephone number is # md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Interruption of the vena cava Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Fasciotomy Other skin graft to other sites Graft of muscle or fascia Attachment of pedicle or flap graft to other sites 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 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 Total splenectomy Closure of skin and subcutaneous tissue of other sites Nonexcisional debridement of wound, infection or burn Open reduction of fracture with internal fixation, radius and ulna Closed reduction of fracture without internal fixation, radius and ulna Closed reduction of fracture without internal fixation, radius and ulna Debridement of open fracture site, radius and ulna Debridement of open fracture site, radius and ulna Debridement of open fracture site, radius and ulna Excision of lesion of other soft tissue Closed reduction of fracture without internal fixation, tibia and fibula Other suture of muscle or fascia Removal of implanted devices from bone, tibia and fibula Angiocardiography of venae cavae Insertion or replacement of (cement) spacer Application of external fixator device, monoplanar system Intracranial pressure monitoring Magnetic removal of embedded foreign body from cornea Diagnoses: Other postoperative infection Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute posthemorrhagic anemia Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Open wound of forehead, without mention of complication Closed fracture of sternum Alkalosis Closed fracture of patella Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Bipolar disorder, unspecified Closed fracture of seventh cervical vertebra 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, peritoneum Closed fracture of pubis Open fracture of shaft of fibula with tibia Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Closed fracture of acetabulum C1-C4 level with other specified spinal cord injury Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration Open Monteggia's fracture Disruption of traumatic injury wound repair |
allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: cardiac catheterization aortic valve replacement ( porcine aortic) mitral valve repair (28 mm annuloplasty ring) coronary artery bypass graft x3 (left internal mammary artery > left anterior descending, saphenous vein graft > diagonal, saphenous vein graft > posterior descending artery) history of present illness: this is a 66 year old male with history of aortic valve disease followed with serial echocardiograms. over the past several months he has noticed worsening of his exertional angina. his symptoms worsened when he was celebrating his sons engagement by eating more sodium then normal. he also has developed peripheral edema and pillow orthopnea. he denies syncope, presyncope, palpitations, pnd, fevers, chills and rigors. a recent echocardiogram from revealed progression of his aortic stenosis. given that finding and worsening symptoms, he has been referred for surgical evaluation. he is admitted today for catherization tomorrow/iv heparin bridge with plans for or on thurs for avr/?mvr/?cabg. past medical history: aortic stenosis and insufficiency mitral regurgitation chronic atrial fibrillation, history of unsuccessful cardioversion hypertension hypercholesterolemia obesity anxiety varicose veins s/p brain surgery age 13 after a fall s/p tonsillectomy s/p appendectomy s/p ventral hernia repair s/p cataract surgery social history: lives with: wife in occupation: musician cigarettes: smoked no yes last cigarette hx: 1ppd x 27 yrs etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use: denies family history: father died of an mi at 32 and father's brother died of mi at age 40 physical exam: pulse:66 af resp:12 o2 sat: 98% room air b/p right: left:132/75 height: 5'9" weight: 195# general: aao x 3 in no acute distress skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade 4/6 sem abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema: trace le edema varicosities: significant gsv varicosities noted bilaterally neuro: grossly intact pulses: femoral right: 2 left: 2 dp right: 1 left: 1 pt : 1 left: 1 radial right: 2 left: 2 carotid bruit: transmitted murmurs bilaterally pertinent results: intraop tee conclusions pre-bypass: -no spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. -the left ventricle is not well seen. there is mild regional left ventricular systolic dysfunction with inferior wall hypokinesis. -there are simple atheroma in the descending thoracic aorta. -there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (valve area 0.8-1.0cm2). moderate (2+) aortic regurgitation is seen. -the mitral valve leaflets are moderately thickened. moderate to severe (3+) mitral regurgitation is seen. -due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (coanda effect). dr. was immediately notified of the result. postbypass the patient is receiving epinephrine at 0.03 ucg/kg/min lv systolic function is moderately impaired. the inferior wall and inferior septum are dyskinetic. lvef 30-35% rv systolic functiom is normal. there is a well seated, well functioning bioprosthesis in the aortic position. no ai is visualized. there is a ring prosthesis in the mitral position. the mr is now trace. the remaining exam is unchanged from prebypass 05:25am blood wbc-7.9 rbc-2.80* hgb-9.0* hct-25.7* mcv-92 mch-32.2* mchc-35.1* rdw-14.8 plt ct-199 06:15am blood wbc-10.1 rbc-2.87* hgb-9.6* hct-26.2* mcv-91 mch-33.4* mchc-36.5* rdw-14.6 plt ct-174 06:20am blood wbc-12.1* rbc-2.49* hgb-8.3* hct-23.2* mcv-93 mch-33.1* mchc-35.7* rdw-13.7 plt ct-128* 05:25am blood pt-21.5* inr(pt)-2.0* 06:15am blood pt-17.6* inr(pt)-1.6* 06:20am blood pt-14.9* inr(pt)-1.3* 05:18am blood pt-13.5* ptt-21.2* inr(pt)-1.2* 03:26am blood pt-14.5* ptt-31.1 inr(pt)-1.2* 01:43pm blood pt-16.2* ptt-36.3* inr(pt)-1.4* 12:26pm blood pt-17.5* ptt-36.3* inr(pt)-1.6* 06:45am blood pt-13.8* ptt-53.0* inr(pt)-1.2* 05:25am blood urean-22* creat-0.8 na-134 k-3.8 cl-96 06:15am blood glucose-107* urean-22* creat-0.9 na-132* k-4.7 cl-96 hco3-30 angap-11 06:20am blood glucose-136* urean-21* creat-0.7 na-129* k-4.4 cl-94* hco3-28 angap-11 05:18am blood glucose-134* urean-16 creat-0.8 na-132* k-5.0 cl-101 hco3-24 angap-12 brief hospital course: admitted preoperative for heparin bridge from coumadin for atrial fibrillation. he underwent preoperative workup that included cardiac catheterization on which revealed coronary artery disease. on he was brought to the operating room for aortic valve replacement, mitral valve repair and coronary artery bypass graft surgery. see operative report for further details. he was transferred to the intensive care unit for post operative management.he was extubated later that day and transferred to the floor on pod #2 to begin increasing his activity level. chest tubes and pacing wires removed per protocol. he was gently diuresed toward his preop weight and beta blockade was titrated. coumadin restarted for chronic a fib. continued to make good progress and was cleared for discharge to home with vna on pod #5. target inr 2.0-2.5. first inr check tomorrow with vna. all f/u appts were advised. he does have 2+ edema of the lower extremities, and some serous drainage from evh sites. he is advised to cover these with dsd until it stops. medications on admission: warfarin 4 mg tablet daily q mon wed fri and 5mg tues thurs sat sun - last dose nifedipine 60mg daily atenolol 100mg daily lisinopril 20mg daily crestor 20mg daily aspirin 81mg daily discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*1* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*1* 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. disp:*28 tablet(s)* refills:*0* 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 6. rosuvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 7. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 8. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 9. warfarin 1 mg tablet sig: five (5) tablet po daily (daily): 5 mg dose today only;all further dosing by clinic;target inr 2.0-2.5 for chronic a fib. disp:*40 tablet(s)* refills:*1* 10. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 10 days. disp:*20 tablet(s)* refills:*0* 11. potassium chloride 20 meq packet sig: one (1) packet po q12h (every 12 hours) for 10 days. disp:*20 packet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: aortic stenosis and insufficiency s/p avr mitral regurgitation s/p mv repair chronic atrial fibrillation coronary artery disease s/p cabg hypertension hypercholesterolemia obesity anxiety varicose veins discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions: sternal - healing well, no erythema or drainage leg-healing well, no erythema, slight serosanguinous drainage from evh sites 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 **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 chronic afib goal inr 2.0-2.5 first draw results to: clinic fax phone / followup instructions: you are scheduled for the following appointments surgeon: dr. phone: date/time: 1:15 in the medical office building wound check date/time:thursday @ 10:15 am in the medical office building cardiologist:dr. (her office will call you with appt in 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** labs: pt/inr for coumadin ?????? indication chronic afib goal inr 2.0-2.5 first draw results to: clinic fax phone / Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Open and other replacement of aortic valve with tissue graft Annuloplasty Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Hyposmolality and/or hyponatremia Atrial fibrillation Personal history of tobacco use Anxiety state, unspecified Other and unspecified angina pectoris Mitral valve insufficiency and aortic valve stenosis Obesity, unspecified Examination of participant in clinical trial |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: - coronary artery bypass grafting x3 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the right coronary artery and the obtuse marginal artery. history of present illness: 62m with history of abnormal stress tests. there has also been question of bicuspid aortic valve on previous echo. he was admitted recently for recurrent lightheadedness and fall (without syncope). ett on revealed a large area of fixed reversible ischemia in the inferolateral segment. he underwent cardiac cath on which revealed three vessel coronary artery disease. he is transferred for surgical evaluation. past medical history: hypertension, hypercholesterolemia, multiple falls, renal calculi, bicuspid aortic valve social history: last dental exam: last week lives with: wife occupation: gas company tobacco: never etoh: 2 glasses wine/week family history: + cad, father died at 36 from mi, sister died at 50 from mi physical exam: general: skin: dry intact heent: perrla eomi neck: supple full rom limited rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: 2+ carotid bruit right:no left:no pertinent results: echo prebypass: the left atrium is normal in size. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef 60-65%). right ventricular chamber size and free wall motion are normal. the aortic valve is bicuspid or tricuspid with fusion of the left and right coronary leaflets. there is no aortic valve stenosis by continuity equation or by planimetry ( calculated to be >2.0 cm2 with both measurements repeated several times). mild (1+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there are simple and complex atheroma in the descending aorta there is no pericardial effusion. postbypass: the patient is a-paced on a phenylephrine infusion. biventricular function is preserved without wall motion abnormalities. aortic valve area was recalculated and found to be unchanged (approximately 2.0 cm2 by continuity equation). mild aortic regurgitation (1+) remains. normal aortic contours. brief hospital course: mr. was admitted to the on for surgical management of his coronary artery disease. he was worked-up in the usual preoperative manner. plavix was allowed to clear from his system. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. over the next several hours, he awoke neurologically intact and was extubated. beta blockade, aspirin and a statin were resumed. on postoperative day one he was transferred to the step down unit for further recovery. his chest tubes and temporary pacing wires were removed per protocol. he was evalutaed by physcial therapy for strength and conditioning and was cleared for discharge to home. he was noted to have scant sanguinous drainage from the midportion of his sternal incision. the incision was painted daily with cloroprep and covered with a dry dressing. his ace-i was resumed at 1/2 his home dose and his -benicar 40 daily was not resumed due to blood presssure parameters. on pod #4 was cleared for discharge to home with vna and all appointments were advised. medications on admission: norvasc 10mg daily lipitor 20mg daily aspirin 81mg daily toprol xl 50mg daily benicar 40mg daily percocet prn discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*65 tablet(s)* refills:*0* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever, pain. 8. norvasc 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. lasix 20 mg tablet sig: one (1) tablet po twice a day for 7 days. disp:*14 tablet(s)* refills:*0* 10. 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* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: coronary artery disease s/p cabg hypertension hyperlipidemia bicuspid aortic valve discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with incisions: sternal - healing well, no erythema. scant sanguinous drainage from mid portion of incision. leg right/left - healing well, no erythema or drainage. trace edema. discharge instructions: 1) please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage 2) please no lotions, cream, powder, or ointments to incisions 3) each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) no driving for approximately one month until follow up with surgeon 5) no lifting more than 10 pounds for 10 weeks 6) please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. wednesday 1:15pm. please call to schedule appointments with your primary care dr. in weeks cardiologist dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Family history of ischemic heart disease Congenital insufficiency of aortic valve |
allergies: codeine attending: chief complaint: chest pressure major surgical or invasive procedure: cardiac cathetherization history of present illness: is a 81 yo female with a past medical history of cad with a 1 vessel cabg (svg to lad) in who presents with chest pressure. she woke up at 8 am with substernal chest pressure. it was severe initially. she took sl ntg x3 with relief of cp for a short period of time. the cp radiated to her right side and eventually down both arms. she reports diaphoresis, but denied associated nausea, vomiting, lightheadedness or dizziness. she reports that she has felt mildly sob since her recent pneumonia (first diagnosed appox weeks ago). she denied worsening dyspnea. her cough has improved substantially and is very minimal at this time. she went to her pcp's office and was found to have a new lbbb and anterior st elevations. she was transferred to the ed. she received plavix 300mg, aspirin, boluses of heparin and integrillin. code stemi was called and went to the cath lab. cath showed occluded svg, native 3vd, occluded proximal lad. wiring the lad was difficult and there was concern about a possible dissection. one bms was placed in the proximal lad. distal lad is diminutive past 1st septal and diag branches. she has been hemodynamically stable with hr 60-70s and sbp 120-130s. on the floor, she is currently chest pain free and feels well. . . on review of systems, she denies any prior history of 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. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: - diabetes, + dyslipidemia, + hypertension 2. cardiac history: -cabg: pt with mi in and subsequent 1 vessel cabg svg ->lad -percutaneous coronary interventions: none -pacing/icd: none 3. other past medical history: # cva - small left posterior frontal infarct in for which she is on tab of plavix daily # hypercholesterolemia. # small pfo. # macular degereration social history: # clopidogrel 75 mg tablet po daily # ezetimibe-simvastatin ] 10 mg-20 mg po daily # nifedipine 30 mg sr po qday # nitroglycerin 0.4 mg/hour patch 24 hr 1 patch once a day # nitroglycern sublingual tabs prn - has not used recently prior to today # propranolol 80 mg tablet po once a day # multivitamin . family history: her father died due to cad at age 52. her mother had stomach cancer and bone cancer. physical exam: general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 8 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. cta anteriorly, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. femoral sheath in place in right groin. 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: ekg: new lbbb with ste in v1 -v3 & v5 that in some leads are >5mm. telemetry: nsr 75, few nsvts. 2d-echocardiogram: pending ett: n/a . cardiac cath: lmca: 40% distal lad: occluded difficult to cross; was crossed and stented in proximal lad. distal lad diffuse diseased. lcx: occluded om2, 50% lcx rca: occluded brief hospital course: is a 81 yo female with a history of cad who presented with an stemi s/p catheterization and was incidentally found to have multiple pulmonary nodules consistent with adenocarcinoma. #. stemi: pt presented with an anterior stemi. her timi risk score was 7 indicating a 41% risk at 14 days of mortality, new or recurrent mi, or severe recurrent ischemia requiring urgent revascularization. her svg found to be completely occluded and a bms was placed in the proximal lad. due to the timing of the svg placement over 20 years ago, it was thought that her lad had managed to self revascularize and was partially supplied by the rca. she was started on routine acs medications: eptifibatide for 18 hrs, plavix 75 and aspirin 325mg, metoprolol, captopril, and atorvastatin. cardiac enzymes trended down appropriately with peak ck and ckmb at 107 and 18.2. there was concern for acute heart failure from ischemic insult oxygen requirement. however, she was noted to also have a rll pneumonia and no significant pulmonary edema (see below). echo showed moderate to severe regional left ventricular systolic dysfunction with anterior and anterospetal akinesis and inferior/inferolateral hypokinesis. initially, patient was started on coumadin for ventricular thrombus prophylaxis, but this was subsequantly discontinued as risk of bleeding outweighed benefit. # hypoxia: upon hospitalization, patient was maintaing saturations in low 90s on 6l from baseline 92% on ra. cxr showed rll pneumonia, and patient was subsequantly started on ceftriaxone, azithromycin, metronidazole. as the patient had history recurrent rll pneumonia, a ct scan was obtained which showed severe right lower lobe consolidation and extensive, new diffuse lung nodules with sputum cytology positive for adenocarcinoma. hypoxia was initially felt to be a combination of postobstructive pneumonia and tumor burden from adenocarcinoma. antibiotics were changed to vancomycin, levofloxacin and flagyl of which she completed a 10 day course. repeat ct scan showed little interval improvement in right lower lobe infiltrate. respiratory status remained tenuous, patient requiring high flow o2 with 6lnc with desaturations to high 70s with activity. prior to discharge o2 requirement was 5l by nasal cannula. she was breathing comfortably with oxygen saturation in the low 90s. likely this will continue to be necessary for some time. a shovel mask may be used to assist with oxygenation as needed. # lung nodules/ broncheoalveolar carcinoma: ct scan with diffuse pulmonary nodules and sputum cytology positive for adenocarcinoma. etiology was felt to be primary bronchioalveolar vs metastatic thyroid dx (prior dx of possible microfollicular carcinoma) although routine cancer screening was not up-to-date. a tissue diagnosis was not attained given the patient's high oxygen requirement and anticoagulation with plavix/asa in the setting of recent bms placement. although patient did not have imaging of her head, staging based on ct torso was iiia with pulmonary nodules in both lung fields without obvious distal lad or metastasis. empiric therapy with single chemotherapy was initiated on with pemetrexed. she tolerated this well. she received dexamethasone on to prevent rash. # chronic renal insufficiency - patient with gfr 48. medications were renally dosed and renal function was carefully followed. she was treated prophylactically with mucomyst prior to and post iv contrast dose. creatinine remained stable at 1-1.1. # hyperkalemia: the patient was mildly hyperkalemic the day prior to discharge to 5.6 without ekg changes. this responded promptly to kayexalate. electrolytes should be checked daily until stable. if necessary acei could be stopped. # htn: she was normotensive on acei and b-blocker. medications on admission: # clopidogrel 75 mg tablet po daily # ezetimibe-simvastatin ] 10 mg-20 mg po daily # nifedipine 30 mg sr po qday # nitroglycerin 0.4 mg/hour patch 24 hr 1 patch once a day # nitroglycern sublingual tabs prn - has not used recently prior to today # propranolol 80 mg tablet po once a day # multivitamin discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: st elevation myocardial infarction presumed broncheoalveolar carcinoma discharge condition: stable, with 5l oxygen requirement and o2 sat in the low 90s discharge instructions: you were admitted to the hospital for chest pressure and found to have a heart attack. you had a cardiac catheterization and had a bare metal stent placed. after this, you had some trouble breathing and had a scan that showed some nodules in your lungs. a sputum sample was sent and malignant cells were seen. this was thought to be broncheoalveolar lung cancer, and you were treated with one dose of chemotherapy for this. please follow-up with dr. and to determine if further treatment will be needed. weigh yourself every morning, md if weight goes up more than 3 lbs. the following changes were made to your medications: 1. you were started on plavix, a medication to thin your blood. you must take this medication for 1 month to ensure that your heart stent does not become blocked. followup instructions: please follow up with drs. and . their office will be calling to schedule your appointment. if you do not hear from them this week please call ( to arrange. we made an appointment with the cardiologist: , md phone: date/time: 10:40 please also call your primary care doctor, dr. to schedule follow up. he may be reached at . Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Injection or infusion of cancer chemotherapeutic substance Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Acute myocardial infarction of other anterior wall, initial episode of care Coronary atherosclerosis of autologous vein bypass graft Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Anxiety state, unspecified Ostium secundum type atrial septal defect Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other complications due to other cardiac device, implant, and graft Malignant neoplasm of other parts of bronchus or lung Hypoxemia Diarrhea Acute systolic heart failure Accidents occurring in residential institution |
allergies: codeine attending: chief complaint: dyspnea and melena major surgical or invasive procedure: none history of present illness: ms. is a 83yo f with history of stage iv non-small cell lung cancer, cad and ckd who presents with dyspnea, productive cough and melena. patient has had 7-8 days of melena without abdominal pain and dyspnea with worsening cough for the past day. she denies fevers or chest pain. . in the er, initial vitals were 97.2, 89, 156/53, 22, 86% 4l. her hct was 22 from recent baseline of 25 (she has transfusion dependent anemia), and she initially was hypoxic. abg was 7.29/64/42/32 and lactate was 2.4. patient responded to nebs, stress dose steroids, levaquin and ceftriaxone with improvement in her sats to mid 90s on 5l nc. she was started on iv ppi for her guaiac positive dark brown stool. cxr showed large r pleural effusion and questionable l lower lobe collapse. ekg showed sinus tach with st depressions in v2-6. vitals on transfer to the micu were 97.2, 105, 127/50, 29, 96% 5l nc. . in the micu, she reports feeling better after her breathing treatments today. she cannot recall when her difficulty breathing started and per her family, she has difficulty hearing but no memory loss. patient had intermittent dyspnea for weeks for which she previously took codeine syrup but then a period of improvement. she developed worsening dypsnea and cough yesterday without fevers, chills or chest pain. she denies prior history of melena but has had stable nausea and poor appetite for months. no heartburn or dysphagia. past medical history: stage iv nonsmall cell lung cancer, adenocarcinoma, egfr wild-type, kras mutated cad s/p cabg in , mi s/p pci to lad. chronic renal insufficiency - patient with gfr < 50. cva - small left posterior frontal infarct in . hypercholesterolemia. macular degeneration social history: prior smoker, quit in . 30 pack-year history of smoking. married, 3 children, 7 grandchildren. drinks 1 glass wine per day. previously employed as a court stenographer. family history: her father died due to cad at age 52. her mother had stomach cancer and osteosarcoma. physical exam: general: elderly, chronically ill appearing female in nad heent: nc/at, eomi, sclera anicteric, mmm neck: supple, jvp not elevated, 1+ firm bilateral submandibular lad lungs: decreased percussion way up right lung with decreased breath sounds, l basalar crackles, upper lobes with some mild wheezing cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops appreciated abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge: expired pertinent results: 07:42pm blood wbc-9.8# rbc-2.60* hgb-7.5* hct-22.4* mcv-86 mch-28.7 mchc-33.3 rdw-18.8* plt ct-407 07:42pm blood neuts-83.0* lymphs-8.5* monos-5.7 eos-2.4 baso-0.4 07:42pm blood pt-11.6 ptt-24.5 inr(pt)-1.0 07:42pm blood glucose-133* urean-45* creat-1.4* na-120* k-5.7* cl-85* hco3-26 angap-15 07:42pm blood alt-20 ast-24 ld(ldh)-297* ck(cpk)-73 alkphos-81 totbili-0.3 07:42pm blood ck-mb-4 ctropnt-<0.01 02:04am blood ck-mb-10 mb indx-10.1* ctropnt-0.05* 11:02pm blood calcium-8.4 phos-2.6* mg-1.8 07:42pm blood osmolal-268* 07:42pm blood type- po2-42* pco2-64* ph-7.29* caltco2-32* base xs-1 comment-green top 12:15am blood type-art po2-55* pco2-43 ph-7.32* caltco2-23 base xs--3 04:39am blood lactate-4.2* 01:46am blood lactate-5.9* 12:15am blood lactate-7.7* 07:42pm blood lactate-2.4* 12:58am urine color-straw appear-clear sp -1.013 12:58am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 12:58am urine rbc-1 wbc-<1 bacteri-none yeast-none epi-<1 12:58am urine castgr-1* casthy-1* 12:58am urine hours-random creat-65 na-21 k-37 cl-19 12:58am urine osmolal-469 pcxr: interval enlargement of the now massive right pleural effusion. denser and larger consolidation of the left lung, possibly extension of tumor or focal, acute infiltrate, or combination thereof. brief hospital course: the patient was admitted to the micu and placed on bipap for comfort. her outpt. oncologist was contact overnight. she underwent thoracentesis for palliation with significant volume taken off. palliative care was consulted and the decision was made to focus on comfort. her oncologist visited with her and her family. she was transitioned out of the icu and expired on the floor soon after. medications on admission: robitussin with codeine tsp qhs atorvastatin - 80 mg tablet - one tablet(s) by mouth one daily - no substitution benzonatate - 100 mg capsule - 1 capsule(s) by mouth three times a day calcitriol - 0.25 mcg capsule - 1 capsule(s) by mouth every other day citalopram - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth once a day clopidogrel - (prescribed by other provider) - 75 mg tablet - 1 tablet(s) by mouth once a day folic acid - 1 mg tablet - one tablet(s) by mouth one daily - no substitution lorazepam - 0.5 mg tablet - tablet(s) by mouth q6 hours as needed for nausea metoprolol tartrate - (prescribed by other provider) - 50 mg tablet - one tablet(s) by mouth - no substitution tramadol - (prescribed by other provider) - 50 mg tablet - 0.5 (one half) tablet(s) by mouth three times a day as needed for pain trazodone - 50 mg tablet - one tablet(s) by mouth one daily as needed - no substitution aspirin - (prescribed by other provider: , .) - 81 mg tablet, chewable - 1 tablet(s) by mouth one daily - no substitution ranitidine hcl - 150 mg tablet - one tablet(s) by mouth one daily - no substitution discharge medications: n/a discharge disposition: expired discharge diagnosis: 1. non small cell lung cancer 2. melena discharge condition: expired discharge instructions: n/a followup instructions: n/a md, Procedure: Thoracentesis Diagnoses: Pneumonia, organism unspecified Acute posthemorrhagic anemia Hyposmolality and/or hyponatremia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Obstructive chronic bronchitis with (acute) exacerbation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Acute and chronic respiratory failure Blood in stool Old myocardial infarction Macular degeneration (senile), unspecified Malignant neoplasm of other parts of bronchus or lung Hypoxemia Tachycardia, unspecified Anemia in neoplastic disease |
allergies: azulfidine / penicillins / aspirin / allopurinol / dilantin / tegretol / keppra / trileptal attending: chief complaint: fungal uti, infected renal calculus, acute renal failure, septicemia major surgical or invasive procedure: percutaneous nephrostomy tube history of present illness: 88 year old female transferred from with chief complaint of persistent acidosis in spite of more aggressive treatment of uti. on urine culture grew klebsiella pneumonea and e.coli. she received 10 days ciprofloxacin po. on they started ceftriaxone iv. on ordered for vancomycin but did not receive (remote u/c mrsa). also noted to have co2: 12 (had been 16-20 lately). abg at hrc 7.31/27/94, hco2 13.6/total co2 14.4. she has not had any fever in past week but continued to have dysuria, malaise and failure to thrive. she was recently (/09) admitted to for epistaxis & vaginal bloody discharge on asa; now off asa and no more epistaxis/?vaginal blood. also has had arf at hr responding to ivf. vaginal u/s that admit (patient declined vaginal u/s) showed bilateral renal calculi- largest right 1.2 cm with prominent renal pelvis and no hydronephrosis. ed course: labs consistent with metabolic acidosis, arf. she got ivf and iv vancomycin. her urine cultures at that time grew out yeast. past medical history: 1) ulcerative colitis, status post colostomy in 2) hypertension 3) chronic renal insufficiency (baseline 1.4-2.0) 4) osteoarthritis 5) history of seizures, on topiramate 6) atrial fibrillation, on amiodarone 7) urge incontinence, on tolterodine 8) bilateral cataracts 9) history of microscopic hematuria 10) nephrolithiasis 11) depression 12) renal cysts social history: lives at rehab. smoked 2 packs per week many years ago. no smoking currently, no etoh, no ivdu. daughters: , family history: non contributory physical exam: vss: 98, 78, 22, 127/72, 96/ra gen: appears lethargic, drowsy, although answers appropriately pain: 0/0 heent: eomi, mmm, - op lesions pul: cta b/l cor: rrr, s1/s2, - mrg abd: diffuse tenderness, colostomy bag present draining copius clear fluid ext: - cce nephrostomy cdi midline cdi neuro: lethargic, open eyes to commands, able to communicate, oriented atleast x2; able to lift all extremities pertinent results: 06:25am blood wbc-10.1 rbc-3.03* hgb-9.0* hct-29.4* mcv-97 mch-29.7 mchc-30.6* rdw-15.9* plt ct-288 09:15am blood wbc-16.5* rbc-3.11* hgb-9.5* hct-29.7* mcv-95 mch-30.7 mchc-32.1 rdw-15.6* plt ct-276 07:53am blood wbc-26.3* rbc-2.97* hgb-9.1* hct-28.1* mcv-95 mch-30.5 mchc-32.3 rdw-15.8* plt ct-269 03:50am blood wbc-29.9* rbc-2.89* hgb-8.6* hct-27.1* mcv-94 mch-29.9 mchc-31.8 rdw-16.0* plt ct-273 05:35pm blood wbc-39.7* rbc-3.08* hgb-9.5* hct-29.2* mcv-95 mch-31.0 mchc-32.7 rdw-15.4 plt ct-297 03:15pm blood wbc-37.5* rbc-3.19* hgb-9.9* hct-31.0* mcv-97 mch-30.9 mchc-31.8 rdw-15.8* plt ct-287 01:20pm blood wbc-41.0*# rbc-3.31* hgb-10.2* hct-31.5* mcv-95 mch-30.7 mchc-32.3 rdw-15.5 plt ct-279 06:20am blood wbc-9.2 rbc-3.54* hgb-10.7* hct-33.3* mcv-94 mch-30.4 mchc-32.3 rdw-15.8* plt ct-325 09:52am blood wbc-9.4 rbc-3.99* hgb-12.1 hct-36.8 mcv-92 mch-30.3 mchc-32.9 rdw-16.1* plt ct-387 06:25am blood wbc-9.8 rbc-3.33* hgb-10.4* hct-31.4* mcv-95 mch-31.3 mchc-33.1 rdw-16.2* plt ct-353 07:52pm blood wbc-9.9 rbc-3.71* hgb-11.1* hct-35.3* mcv-95 mch-30.0 mchc-31.5 rdw-15.7* plt ct-443* 06:50pm blood wbc-10.9 rbc-3.90*# hgb-11.8*# hct-37.4# mcv-96 mch-30.3 mchc-31.6 rdw-15.6* plt ct-421 07:53am blood neuts-90.7* lymphs-5.7* monos-2.9 eos-0.6 baso-0.1 03:50am blood neuts-94.1* lymphs-2.8* monos-2.9 eos-0.1 baso-0 06:25am blood pt-17.2* ptt-41.6* inr(pt)-1.5* 09:15am blood pt-16.8* ptt-44.0* inr(pt)-1.5* 07:53am blood pt-17.9* ptt-44.5* inr(pt)-1.6* 05:35pm blood pt-17.5* inr(pt)-1.6* 06:25am blood glucose-105 urean-41* creat-1.7* na-137 k-3.6 cl-102 hco3-20* angap-19 09:15am blood glucose-88 urean-36* creat-1.7* na-136 k-3.6 cl-105 hco3-19* angap-16 07:53am blood glucose-105 urean-33* creat-1.7* na-140 k-3.7 cl-109* hco3-20* angap-15 03:50am blood glucose-125* urean-32* creat-2.0* na-139 k-3.1* cl-107 hco3-20* angap-15 06:20am blood glucose-107* urean-36* creat-2.5* na-134 k-4.3 cl-98 hco3-23 angap-17 07:52pm blood glucose-106* urean-37* creat-3.0* na-128* k-4.0 cl-100 hco3-11* angap-21* 06:50pm blood glucose-112* urean-37* creat-3.2*# na-130* k-4.2 cl-99 hco3-14* angap-21* 09:15am blood alt-33 ast-34 alkphos-116 totbili-0.4 03:15pm blood alt-34 ast-128* ld(ldh)-454* alkphos-89 totbili-0.5 06:20am blood alt-17 ast-28 alkphos-75 amylase-91 totbili-0.2 06:20am blood lipase-33 06:25am blood calcium-9.7 phos-2.5* mg-2.3 09:15am blood albumin-2.7* calcium-9.3 phos-2.3* mg-2.4 08:45am blood vanco-15.5 03:54pm blood type- ph-7.52* comment-green top 03:54pm blood lactate-2.9* 08:10pm blood glucose-105 lactate-2.2* na-137 k-4.1 cl-104 calhco3-11* 03:13pm urine color-yellow appear-cloudy sp -1.025 09:51am urine color-yellow appear-cloudy sp -1.016 08:00pm urine color-yellow appear-cloudy sp -1.012 03:13pm urine blood-lg nitrite-neg protein-300 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-lg 09:51am urine blood-mod nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-lg 08:00pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-mod 03:13pm urine rbc-0 wbc->1000* bacteri-mod yeast-none epi-0 09:51am urine rbc-42* wbc->1000* bacteri-none yeast-none epi-0 08:00pm urine rbc-0 wbc->50 bacteri-mod yeast-none epi-0 10:08 am stool consistency: watery source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). urine nephrostomy tube (cup). **final report ** gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): budding yeast. urine culture (final ): yeast. 10,000-100,000 organisms/ml.. 5:00 pm blood culture ( myco/f lytic bottle) blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. 3:15 pm blood culture 1 of 2. blood culture, routine (pending): 3:48 am 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). 5:06 pm stool consistency: watery **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). fecal culture (final ): no enteric gram negative rods found. no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. 3:13 pm urine source: catheter. **final report ** urine culture (final ): yeast. 10,000-100,000 organisms/ml.. 7:52 pm blood culture **final report ** blood culture, routine (final ): no growth. renal u.s. study date of 2:04 pm impression: 1. bilateral extensive nephrolithiasis, appearing greatest on the left as above with evidence of left renal obstruction. no right hydronephrosis. 2. suboptimal assessment of the urinary bladder. chest (portable ap) study date of 5:46 pm impression: no pneumonia or evidence of chf. ct pelvis w/o contrast study date of 3:05 pm impression: 1. extensive bilateral nephrolithiasis, most severe on the left with a staghorn calculus and consequent obstruction, overall similar to an ultrasound done one day earlier. 2. marked atherosclerotic calcification. 3. prominent loops of small bowel and collapsed ileum entering the ileostomy. recommend close monitoring of ostomy output for signs of possible partial small bowel obstruction. 4. small hepatic hypodensities likely cysts and hyperdensities, possibly calcified granulomas. 5. hyperdense gallbladder material, possibly sludge. portable abdomen study date of 8:04 am impression: air in loops of small and large bowel without evidence for ileus or obstruction. there is no free air given limitation of supine technique. renal scan study date of impression: differential renal function demonstrated with the left kidney performing 18% of total renal function and the right performing 82%. there is a large renal pelvis on the right, but there is prompt washout from the pelvis after administration of lasix. intro cath to pelvis for drainage and inj study date of 6:23 pm impression: 1. large stone in the left renal collecting system. 2. dilatation of the upper pole calices, containing pus. 3. uncomplicated ultrasound and fluoroscopically guided left nephrostomy tube placement. portable abdomen study date of 5:11 am abdomen, supine and upright: comparison is made to the two days earlier. a left-sided percutaneous nephrostomy tube has been placed since the prior study. a nasogastric tube terminates in the stomach, but a leading sidehole is likely within the distal esophagus. advancement of the tube by several centimeters would lead to more optimal placement. there is moderate persistent distention of small bowel loops, little changed since both films from the prior day, and non-specific as to etiology. brief hospital course: - pt was admitted to the s/p left percutaneous nephrostomy due to high risk of hemodynamic instability with active infection and markedly elevated wbc. pt was recieved to the unit with stable vitals and no complaints. she was placed on iv fluids and monitered. there were no overnight events, electrolytes were replaced and she was transferred back to the floor with stable vital signs and improvement in wbc. # septicemia, fungal uti, obstructing renal calculus, leukocytosis - cultures of the urine, including from the percutaneous nephrostomy tube have repeatedly grown yeast, and although never speciated clinical there was impressive effect from diflucan, with resolution of her leukocytosis. she had a brief stay in the icu, but rapidly improved. initially in the she was started on cefepime, vancomycin, mtronidazole and floconazole, but nothing other than yeast was ever isolated, so other than diflucan these were stopped. - urology was consulted and a percutaneous nephrostomy tube was inserted. after insertion, the urology team was deciding between a nephrectomy versus lithotripsy. both of these would be high risk in this patient. it was noted that the stone appears radiolucent on xray, so there is a thought this is a uric acid stone; the patient was started on bicitra to dissolve the stone. the plan is 6 weeks of bictra then followup ct, with plan that if stone is dissolving then continue current therapy, but if not, then patient will require intervention, likely lithotripsy. # acute renal failure on ckd stage iii: - this is likely multifactorial given her obstructing renal calculus. it improved with the nephrostomy and hydration. at time of discharge she was at her baseline. - given decision of what to do with the stone, a renal scan was performed as above. # metabolic acidosis: in setting of arf - iv hydration with bicarb drip with resolution in icu # hypoxemia: developed mild o2 requirement while on floor (was also getting ivf). reports of hypoxia at rehab, this had resolved by time of discharge and was likely due to septicemia. # seizure disorder: - cont topiramate 50 - cont neurontin for now (neurontin may also be contributing to her lethargy in the setting of arf), however this can be addressed by dr. at . # atrial fibrillation: continued amiodarone 200, (deemed not a candidate for coumadin in past, not on asa given vaginal bleed/epistaxis). well controlled. # access: midline . #. code - dnr/dni (ok to intubate in case of status epilepticus) . #. communication - (daughter) is cell . medications on admission: ceftriaxone iv 1 gm daily topiramate 50mg tylenol amiodarone 200mg daily remeron 15mg qhs artificial tears gabapentin 1600mg tid psyllium 1 scoop tid cholecalciferol 1000unit daily discharge medications: 1. topiramate 25 mg tablet sig: two (2) tablet po bid (2 times a day). 2. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 3. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 4. gabapentin 400 mg capsule sig: four (4) capsule po tid (3 times a day). 5. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 days. 6. sodium citrate-citric acid 500-300 mg/5 ml solution sig: thirty (30) ml po tid (3 times a day). 7. heparin, porcine (pf) 10 unit/ml syringe sig: ten (10) ml intravenous once a day as needed for line flush. 8. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). discharge disposition: extended care facility: for the aged - ltc discharge diagnosis: fungal uti pyelonephritis renal calculi septicemia - fungal leukocytosis stage iii chronic kidney disease epilepsy atrial fibrillation discharge condition: good discharge instructions: you are being discharged with a very large kidney stone in place, along with a nephrostomy tube in place to drain the urine around the stone. we are trying to dissolve the stone with a medication. this medication can affect your electrolytes, so will need to be closely monitored. you will need a cat scan in 6 weeks to assess. you need to eat carefully, as you have a high-risk of aspirating food into your lung which can cause pneumonia. you are going on a medication called fluconazole which is an antibiotic to treat the infection you had in the kidney. you must complete the course of this medication. followup instructions: provider: , m.d. phone: date/time: 10:30 ct scan pelvis with/without contrast in 6 weeks with results to urology Procedure: Percutaneous nephrostomy without fragmentation Diagnoses: Acidosis Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Depressive disorder, not elsewhere classified Chronic kidney disease, Stage III (moderate) Other specified septicemias Epilepsy, unspecified, without mention of intractable epilepsy Ulcerative colitis, unspecified Calculus of kidney Colostomy status Other and unspecified mycoses Acute pyelonephritis without lesion of renal medullary necrosis |
allergies: no known allergies / adverse drug reactions attending: chief complaint: right-sided scapular pain major surgical or invasive procedure: ercp with stone extraction and biliary stent placement history of present illness: 88 year-old woman s/p cholecystectomy with a history of pneumobilia presented to the ed with sudden onset right scapular and chest pain on the day of admission. the pain developed at rest and progressively increased over the day, associated with nausea and one episode of non-bloody emesis. she had two bowel movements, but did not note their color; denied diarrhea. the pain increased in severity to the point where she decided she needed to come to the ed. she denied fevers, chills, shortness of breath, palpitations, and abdominal pain. in the ed inital vitals were: 98.3 88 167/75 18 99% ra. cta chest ruled out aortic aneurysm and pe, but it did reveal a new 9-mm rll pulmonary nodule and pneumobilia. elevated liver tests led to ruq ultrasound to be done which showed cbd dilation to 1.1. in the ed, she spiked a fever to 101 and had ruq tenderness. her hr increased to 130's. lactate was 3.8. she was given unasyn and admitted to the for concern of developing sepsis. review of systems: (+) per hpi (-) denies night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - atrial fibrillation on warfarin - coronary artery disease with des to rca and lad in - systolic heart failure, lv ef 40-45% - moderate mitral regurgitation - severe pulmonary artery systolic hypertension. - hypertension - hyperlipidemia - osteoporosis - s/p cholecystectomy (about 30 years prior) - s/p sigmoid resection (dysplastic polyp, ?) social history: pt born in , lives in . lives alone in an facility. does her own shopping and cooking. she used tobacco in the past, drinks alcohol about once weekly, and denies illicit drug use. family history: mother with cad and brother was mi in his 50s. physical exam: admission exam: vitals: t: 99.2 bp: 109/52 p: 101 r: 21 o2: 95% on 2l. general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: +bibasilar crackes, no wheezes, ronchi cv: irregularly irregular, no m/r/g appreciated abdomen: soft, non-distended, +tenderness in ruq, borderline positive sign, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema exam upon transfer out of icu: vitals: t 99.4 bp 156/78 hr 94 rr 20 o2 96% on 2l pain: 0 out of 10 gen: nad heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated chest: bibasilar crackles, no wheezing or rhonchi cv: irregularly irregular abd: soft, mild tenderness in ruq, non-distended, bowel sounds present ext: warm, no edema neuro: alert, oriented x3, cn 2-12 intact (except hard of hearing), bue/ble strength 5/5, sensory intact, normal coordination, fluent speech. psych: calm, appropriate pertinent results: labs on admission: 05:55pm blood wbc-3.6* rbc-4.40 hgb-13.4 hct-40.8 mcv-93 mch-30.4 mchc-32.8 rdw-14.0 plt ct-238 05:55pm blood neuts-74* bands-8* lymphs-18 monos-0 eos-0 baso-0 atyps-0 metas-0 myelos-0 05:55pm blood pt-27.3* ptt-24.9 inr(pt)-2.6* 05:55pm blood glucose-151* urean-21* creat-0.9 na-143 k-3.3 cl-105 hco3-28 angap-13 05:55pm blood alt-301* ast-667* ld(ldh)-634* alkphos-215* totbili-1.4 05:55pm blood ctropnt-<0.01 03:50am blood ctropnt-<0.01 03:50am blood calcium-7.8* phos-2.8 mg-1.5* 10:28pm blood lactate-3.8* microbiology: urine culture (final ): escherichia coli. >100,000 organisms/ml.. ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 64 i tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s blood culture : klebsiella pneumoniae. enterococcus sp.. klebsiella pneumoniae ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s 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 aerobic bottle gram stain (final ): gram negative rod(s). gram positive cocci in pairs in short chains. mrsa screen : no mrsa isolated blood culture : gram negative rod(s). blood culture : gram negative rod(s). urine culture : no growth blood culture : pending blood culture : pending imaging: cxr pa/lat : markedly low lung volumes but grossly no definite superimposed acute process identified. cta chest : 1. no evidence of aortic dissection or pulmonary embolism. 2. cardiomegaly, moderate atherosclerotic disease. 3. extensive pneumobilia and dilated common bile duct to 1.1 cm, increased since prior ct dated , suggest distal obstruction unless proven otherwise. pancreas is poorly assessed on current exan, with a pancreatic head lesion not excluded. recommend dedicated abdominal imaging. 4. new 9-mm suspicious right lower lobe pulmonary nodule. recommend three-month interval followup and potential fdg/pet evaluation. 5. new subcentimeter splenic hypodensity, too small to fully assess, but suspicious in the setting of new pulmonary nodule. metastatic lesion from occult primary malignancy is a consideration. ruq ultrasound : increasing extensive pneumobilia and common bile duct dilatation suggest distal obstruction. limited evaluation of pancreas; pancreatic head lesion not excluded. recommend mrcp or ct for further assessment, with preference for mrcp. ercp : - there appeared to be a wide open connection to the biliary tree adjacent to the major papilla - this was most likely a biliary-enteric fistula vs. less likely a previous wide open sphincterotomy. - the biliary tree was dilated with cbd measuring 15 mm. - the patient is s/p ccy with dilated cystic duct stump. - cholangiogram demonstrated possible filling defects in the distal cbd. - the biliary tree was swept with a balloon x 3 with extraction of multiple large stones/concretions and debris. - the biliary tree appeared clear at the end of the balloon sweeps. - given cholangitis, decision was made to place a stent facilitate continued drainage. - a 5cm by 10fr double pigtail biliary stent was placed successfully. portable abdomen : no evidence of free air or pneumatosis. pneumobilia seen on prior ct is not well seen on this study. no evidence of obstruction. cxr portable : comparison is made to prior study . there are lower lung volumes, new opacity in the left lower lobe is consistent with atelectasis. cardiomegaly and mediastinal silhouette are stable, there is no evident pneumothorax. if any, there are small bilateral pleural effusions. the main pulmonary arteries are inimally enlarged. mild vascular congestion has improved. ct abdomen/pelvis : 1. improved moderate pneumobilia in comparison to the ct examination. s/p placement of a double pigtail biliary catheter, in appropriate position. 2. no intrahepatic lesion/abscess detected. small amount of abdominal/pelvic simple ascites. no free air. no bowel obstruction. 3. bilateral moderate-sized pleural effusions with adjacent compressive atelectasis. 4. contrast refluxing via the ivc and hepatic veins compatible with right sided heart failure. 5. chronic collapse of the t12 vertebral body, new since . brief hospital course: 88 year-old woman with history of cholecystectomy admitted with sepsis from cholangitis, bacteremia, and uti. she underwent an ercp on hospital day #2. she was found to have a possible biliary-enteric fistula and cbd dilation to 15-mm. multiple large stones were removed from her cbd. a biliary stent was placed to facilitate biliary drainage. while in the , the patient had ercp as described above, she was managed for sepsis (fever, hypotension) likely from cholangitis. she was treated with vanco and unasyn. she also had hypoxemia likely secondary to volume overload and was diuresed carefully. she also developed new thrombocytopenia with plt 239 (on admit) down to about 100 on hd#2. resolved to 153 () she transferred to the medicine floor on hd#4. problem list: active issues: # sepsis with hypotension from cholangitis, klebsiela and enterococcus bacteremia, and e.coli uti: initially treated with vancomycin and ceftriaxone. id consult recommended zosyn to cover the polymicrobial sepsis for 2 weeks from first sterile blood culture. please continue zosyn to complete a 2 week course (end date ). repeat blood cultures on . # choledocholithiasis s/p ercp with stone extraction and biliary stent placement. patient will need to have a repeat ercp in 1 month to have stent removed. # acute systolic heart failure fluids used for management of sepsis (iv fluids, antibiotics). -patient was restarted on her home lasix dose 20mg. she will also continue losartan and metoprolol . . # atrial fibrillation: initially admitted with afib with rvr with hr in 140s in the setting of severe sepsis. with fluid resuscitation and treatment of underlying sepsis, tachycardia resolved and patient was well rate controlled on home dose of nodal agents. additionally, she initially received 2 units ffp for supratherapeutic inr in the anticipation of possible sphincterotomy with ercp. following initial procedure, patient was restarted on coumadin given chads score of 3. her inr was slightly supratherapeutic 3.5 and it was held for picc placement. her inr was 3.1 on day of discharge. please recheck inr on , if between can restart coumadin 2.5 mg daily. please continue to check twice weekly until inr stable between and adjust dosing appropriately. . # new pulmonary nodule with remote smoking history. get further evaluation as outpatient in 3-months with fdg/pet. letter sent to patient and pcp. medications on admission: furosemide - 20 mg tablet - 1 tablet(s) by mouth once a day losartan - 25 mg tablet - 1 tablet(s) by mouth once a day metoprolol tartrate - 25 mg tablet - 0.5 (one half) tablet(s) by mouth twice a day nitroglycerin - 0.4 mg tablet, sublingual - one tablet(s) sublingually as directed omeprazole - 20 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth once a day potassium chloride - (on hold from to unknown for starting losartan) - 10 meq capsule, extended release - 1 capsule(s) by mouth daily simvastatin - 20 mg tablet - one tablet(s) by mouth daily warfarin - 2.5 mg tablet - 1 tablet(s) by mouth day medications - otc acetaminophen - (prescribed by other provider; otc) - 325 mg tablet - 2 tablet(s) by mouth hs for sleep aspirin - 81 mg tablet, delayed release (e.c.) - one tablet(s) by mouth daily bisacodyl - (otc) - 5 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth prn cholecalciferol (vitamin d3) - (otc; 1000 units daily plus adequate calcium via dietary sources) - dosage uncertain docusate sodium - (prescribed by other provider; otc) - 100 mg capsule - 1 capsule(s) by mouth once a day discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 2. losartan 25 mg tablet sig: one (1) tablet po daily (daily): hold for sbp<100. 3. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for sbp<100 or hr<50. 4. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet sublingual every 5 minutes as needed for chest pain: if you still have chest pain after 3 doses, seek immediate medical atention. 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever, pain. 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po once a day. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 10. piperacillin-tazobactam-dextrs 4.5 gram/100 ml piggyback sig: 4.5 grams intravenous q8h (every 8 hours) for 10 days: two week course to . 11. potassium chloride 10 meq tablet extended release sig: one (1) tablet extended release po once a day. 12. outpatient lab work check k, bun, cr, mg, and inr on . adjust coumadin for goal . please continue to check inr twice weekly until stable on coumadin. 13. outpatient lab work please check blood cultures on discharge disposition: extended care facility: newbridge on the - discharge diagnosis: primary diagnoses: - sepsis - cholangitis - polymicrobial bacteremia with klebsiella, enterococcus, and other gnr - urinary tract infection, e. coli - choledocholithiasis - thrombocytopenia secondary diagnoses: - atrial fibrillation - systolic heart failure - pulmonary nodule 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 sepsis caused by infection in your bile duct, blood stream, and urinary tract. the infection started in the bile duct and was caused by stones obstructing the bile duct. a procedure was performed called ercp which removed these obstructing stones and a bile duct stent was placed to help drain the obstruction. you will need to complete a 2-week total course of antibiotics for these infections. you have an appointment on to have the bile duct stent removed. your platelet counts did become low during the hospitalization; likely from severe infection. they returned to the normal range by the end of your hospitalization. in addition, on the ct chest, a 9-mm pulmonary nodule was seen in the right lower lung. you should speak to your primary doctor to see if there is any indication for you to have a follow-up scan. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: department: medical specialties when: wednesday at 7:40 am with: bone density testing building: campus: east best parking: garage department: digestive disease center when: thursday at 11:00 am with: , md building: building (/ complex) campus: east best parking: main garage Procedure: Parenteral infusion of concentrated nutritional substances Endoscopic removal of stone(s) from biliary tract Endoscopic insertion of stent (tube) into bile duct Central venous catheter placement with guidance Diagnoses: Acidosis Thrombocytopenia, unspecified Esophageal reflux Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Unspecified septicemia Atrial fibrillation Sepsis Hypopotassemia 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 Accidents occurring in other specified places Hypoxemia Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Acute on chronic systolic heart failure Cholangitis Other and unspecified Escherichia coli [E. coli] Solitary pulmonary nodule Fistula of bile duct Other digestive system complications |
allergies: no known allergies / adverse drug reactions attending: chief complaint: altered mental status major surgical or invasive procedure: intubation and extubation hemodialysis catheter line placed cardiac catheterization with two bare metal stents to the left circumflex artery and the left artery. history of present illness: please see nightfloat admission note for full details of admission history. in brief, this is a 62yom with cad s/p cabg , dchf, esrd (on hd - ), history of dvt & pe on coumadin who presented with ams and acute on chronic kidney injury. . of note, the patient was recently admitted for melena from duodenal ulcer from migration of a metal biliary tract stent that was exchanged for a new stent. his course was complicated by septic pancreatic stent, micro bowel perforation, citrobacter bacteremia, as well as hypoxia from volume overload. he was ultimately discharged to rehab. two weeks ago, the patient developed abdominal pain for two weeks and began having nausea/vomiting on monday. he was to have the biliary stent changed but missed his appointment due to excessive vomiting. . on , the patient went to the bathroom and had an unwitnessed fall for unclear reasons. the patient reports he slipped and fell. since the fall, the patient had altered mental status and presented to an osh with a negative ct head and neck. he was given vancomycin and zosyn at transferred to the ed, where he was 99% nc. repeat ct head and neck was negative, and abdominal ct showed no migration of the biliary stent. cxr showed pulmonary edema but not significantly different from prior, and trop 0.19, previously 0.26. k was 5.9 without ekg changes. cr was 3.9 from 2.5. he remained afebrile. on transfer to the medicine floor, the patient had hr 101 with 92%3l. he was delirious and oriented x1 with myoclonic jerks but was redirectable. . the morning of transfer to the micu, the patient became tachycardic and became hypoxic. he was transferred to the micu for further management. . on arrival to the micu, the patient was breathing comfortably on 4l nc and denied shortness of breath, chest pain, nausea, or other symptoms. however, he was delirious and oriented x1. past medical history: dmii complicated by neuropathy, nephropathy ckd on hd briefly cad s/p cab on at - 1 vessel -- diffuse multi-vessel disease. lima-lad but other vessels were not amenable to intervention ?copd on 2l nc hypothyroidism dvt in has been on coumadin pe ? seizure renal mass right adrenal mass cholecystectomy left femur fracture left humeral fracture fall depression chronic pancreatitis s/p biliary tract metal stenting pancrectomy in for necrosis pvd with angioplasty pvd s/p femoral popliteal artery pta pericarditis c. diff colitis on po vanco s/p rotator cuff repair in s/p carotid endarterectomy laminectomy c-spine cholecystectomy tonsillectomy social history: currently living in rehab. he has two daughters who are involved in his care - and . - tobacco: quit 11 months prior - alcohol: denies - illicits: denies family history: unable to answer due to altered mental status physical exam: physical exam: t 97.8 hr 111 bp 145/94 rr 18 sao2 100% on 100% nrb general - alert and interactive but oriented x1 heent - dry mucous membranes, sclera anicteric neck - supple lungs - coarse inspiratory crackes at bases b/l, no wheezes or rhonchi heart - tachycardic but normal rhythm, nl s1/s2, no m/g/r abdomen - soft, non-tender, non-distended, +bs extremities - no pedal edema neuro - oriented to self, able to follow commands, moving all extremities. pertinent results: admission labs: 10:50pm blood wbc-11.0 rbc-3.29* hgb-9.8* hct-30.0* mcv-91 mch-29.7 mchc-32.7 rdw-14.9 plt ct-173 10:50pm blood neuts-79.2* lymphs-10.8* monos-3.0 eos-6.7* baso-0.4 10:50pm blood plt ct-173 11:12pm blood pt-32.3* ptt-48.2* inr(pt)-3.1* 09:30pm blood fdp-10-40* 10:50pm blood glucose-119* urean-75* creat-3.9*# na-137 k-5.9* cl-102 hco3-22 angap-19 10:50pm blood alt-12 ast-22 ck(cpk)-63 alkphos-126 totbili-0.5 10:50pm blood ctropnt-0.19* 07:31am blood ck-mb-6 ctropnt-0.17* probnp-> 07:31am blood calcium-8.7 phos-5.5* mg-1.3* 09:30pm blood hapto-260* 10:50pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:50pm blood holdblu-hold 07:22am blood type-art po2-98 pco2-37 ph-7.31* caltco2-20* base xs--6 11:05pm blood lactate-1.0 micro: stool clostridium difficile toxin a & b test-negative stool clostridium difficile toxin a & b test-final positive blood culture blood culture, routine-negative blood culture blood culture, routine-negative sputum gram stain-final; respiratory culture-neg blood culture blood culture, routine-negative blood culture blood culture, routine-negative urine urine culture-negative serology/blood rapid plasma reagin test-negative urine urine culture-negative mrsa screen mrsa screen-final {positive for methicillin resistant staph aureus} inpatient blood culture blood culture, routine-negative imaging: echo: the left atrium is moderately dilated. left ventricular wall thicknesses and cavity size are normal. there is mild to moderate regional left ventricular systolic dysfunction with inferior/inferolateral akinesis and lateral hypokinesis. the remaining segments contract normally (lvef = 35-40%). 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 but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. moderate to severe (3+) mitral regurgitation is seen, stemming from a posterior mitral leaflet being tethered to the akinetic inferolateral lv wall. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: moderate regional left ventricular systolic dysfunction, c/w cad. moderate to severe ischemic mitral regurgitation. at least moderate pulmonary hypertension. compared with the prior study (images reviewed) of , left ventircular cavity has further dilated, lv function has deteriorated and amount of mitral regurgitation has increased. the regional distribution of wall motion abnormalities is quite similar. findings discussed with dr. at 1600 hours on the day of the study. radiology ct abd & pelvis w/o con , approved 1. unchanged location of biliary stent. 2. right lower lung consolidation may represent aspiration, pneumonia, or worsening atelectasis. 3. within the limits of a non-contrast study, no acute intra-abdominal process. bilateral adrenal and left renal nodules as described above. consider non-emergent followup. cardiovascular c.cath , m. preliminary 1. limited selective coronary angiography of this right dominant system revealed three vessel coronary artery disease. the lmca had a 50% ostial lesion and calcified distal 50% lesion. the lad was heavily calcified and diffusely diseased with 80% ostial lesion; there was competative flow in the distal lad indicating patent lima. the single diagonal arises from the proximal vessel and has 80% ostial lesion. the lcx was severely and diffusely diseased; it had a retroflexed takeoff with 80% long segment from the ostium onward followed by ectatic segment, then another 60% lesion; the lcx supplies three om's, the first is very proximal originating from the diseased segment and is substantive bifurcating with two branches supplying lateral wall. collaterals to rca seen on prior cath are no longer as apparent. the rca was not engaged and known to be chronically occluded from osh films. 2. limited resting hemodynamics showed severe systemic hypertension with central pressure of 184/91/131 mmhg on nitroglycerin iv gtt. 3. successful ptca and stenting of proximal lm into lcx with 2.5x26mm integrity bare metal stent, postdilated with 3.5mm nc balloon. stent placement complicated by spiral dissection in distal lcx. final angiography showed dissection and timi 2 flow. 4. successful ptca and stenting of lmca with 4.0x15mm integrity bare metal stent. 5. unsuccessful attempt to stent distal spiral dissection as unable to deliver stents into lcx. final diagnosis: 1. three vessel coronary artery disease. 2. severe systemic hypertension. 3. successful pci of proximal lcx with bms, complicated by edge spiral dissection. 4. successful pci of lmca with bms. 5. unsuccessful attempt to stent dissection. 6. continue heparin and reopro. 7. continue aspirin and plavix. cardiovascular echo , finalized the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed (lvef= 20 %) with global hypokinesis and akinesis of the infero-lateral segments. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. with depressed free wall contractility. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. tricuspid regurgitation is present but cannot be quantified. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (images reviewed) of , lvef has decreased. radiology shoulder 1 view left po , m. \ history: old left fracture with persistent pain. findings: in comparison with study of , there is progressive healing of the left proximal humeral fracture. evidence of prior rotator cuff repair with mild widening of the ac joint. radiology ct head w/o contrast , approved impression: no intracranial hemorrhage or fracture. radiology ct c-spine w/o contrast , approved impression: no fracture or malalignment with normal prevertebral soft tissue thickness. brief hospital course: 62yom with cad s/p cabg , dchf, esrd (on hd - ), history of dvt & pe on coumadin admitted s/p fall with worsening respiratory distress in the setting of arf and new ischemic mr, who is now s/p stenting to lad and lcx c/b spiral dissection of ldx and recurrent mi, and who now has worsening renal failure requiring initiation of hd. . # ischemic mr/cad: patient became acutely tachycardic and hypoxic on the floor, with flash pulmonary edema. he was monitored in the micu after this event. the patient's wife reports she was in the room at the time of the event and the patient was resting in bed without any triggers for his tachycardia or dyspnea. he was given diuretics and improved. another episode occured several hours later. he had an echocardiogram that showed ischemic mr affecting the posterior mitral leaflet and worsening lv function. cardiology was consulted and requested transfer to the ccu for further intervention. patient was electively intubated in preparation for possible cardiac cath. prior cabg records from revealed that pt has completely occluded rca and significant disease of collaterals perfusing the posterior wall. it was decided to perform cardiac cath to determine whether pt having intermittent occlusion of coronary artery (e.g. rca) causing posterior leaflet dysfunction and posterior wall dysfunction. prior to cath, mr managed with afterload reduction and goal cvp~8. on pt had viability study and then underwent cardiac cath, with stents placed to lmca and lcx. procedure c/b spiral dissection inside the lcx stent. several balloon angioplasties were performed at dissection site without success, but as interim angiography showed reasonable flow in dissected lcx attempts were aborted and it was decided not to repeat cath as risks outweigh benefits. mb peaked to 49 and troponin to 0.77 after the dissection. after this, pt went into acute pulmonary edema several more times (see below), in the setting of becoming progressively more oliguric and volume overloaded. repeat tte showed ef to 20% and basilar hypokinesis. pulmonary edema improved greatly once pt started cvvh with significant fluid ultrafiltration. mitral valve replacement was considered, but per patient and family preference this was ultimately not pursued. given ef 20% and basilar hypokinesis, patient was anticoagulated with heparin gtt (goal ptt 60-80) to decrease risk of apical thrombus. he also received plavix 75mg po daily, asa 81mg po daily, atorvastatin 80mg po daily and metoprolol 12.5mg po bid. hydralazine and isosorbide mononitrate were also started for afterload reduction (pt was also intermittently on nitro gtt and esmolol gtt for refractory htn before starting cvvh). lisinopril was initiated on after cvvh was initiated. . #.acute on chronic renal failure: patient has h/o stage iv ckd and required hd during prior hospitalization, at the end of which cr was 2.9. on admission cr had risen to 3.9, and pt was acutely hyperkalemic with anion gap acidosis. etiology of worsening renal failure most likely poor forward flow new severe ischemic mr cardiac output. patient also had peripheral eosinophilia on admission, making ain or cholesterol embolus as possible etiology. renal u/s showed good flow to both kidneys with no e/o thrombolembolic events. patient was making urine up to the point of cardiac catheterization. despite pre- and post-hydration with hco3, and lasix during cath, his creatinine rose significantly in the 48 hours following cath and he became severely oliguric. he had several episodes of flash pulmonary edema at this time with suboptimal response to lasix, morphine, nitrates and afterload reduction. due to these changes he required initiation of cvvh on , with large ultrafiltrate removal daily and temporary line was placed by interventional radiology. his volume status subsequently improved greatly, with improved bps and resolution of pulmonary edema on cxr. as patient had now progressed to stage v ckd, decision was made to initiate hemodialysis. tunnelled line was placed on . . # leukocytosis likely secondary to c diff colitis: - initial ddx included infectious versus reactive versus allergic given eosinophilia. no new medications, but initially considered allergic interstitial nephritis in context arf, eosinophilia and urinary eosinophils. initially, mr. was treated for vap starting with vanc/zosyn/levaquin. c diff stool assay was positive, and po vancomycin was started. after mr. cardiogenic pulmonary edema resolved, there were no further pulmonary infiltrates and vap therapy was stopped. furthermore, mr. and decrease in wbc coincided with po vanc therapy for c diff. oral vancomycin was started on and will be continued until for a planned 14 day course. # ams: the patient had been delirious with leukocytosis and was worked up for potential infectious cause of ams. ct head following his fall showed no ich. there were reportedly no new medication changes. bun 70s near baseline and not high enough to cause uremia typically. renal also felt the patient was not likely to have uremic encephalitis. neurology was curbsided overnight and recommended r/o infection, seizure (given history), toxic metabolic syndrome. given the patient's recent abdominal pain, n/v, initial consideration was given to a gastrointestinal cause but gi felt this to be unlikely. after discontinuation of benzodiazepines and initiation of hd, mr. mental status began to clear tremendously. he was alert and oriented x 3 upon discharge. # pain control: during this admission, mr. complained of worsening of his baseline back/abdominal and flank pain. due to exquisite pain, a left shoulder x ray was obtained on which demonstrated a healing proximal humerus fracture. pain control improved with starting long acting oxycodone. according to his outpatient pain specialist he took a total of 240 of oxycodone at home (including long and short acting medications) in addition to 30mg morphine (long acting mscontin) at night. given his new onset renal failure, we decided to go slow on the morphine, but at patient's insistence we started prn iv morphine for breakthrough pain. . # biliary stent: mr. is status post stenting of the biliary duct. ct abdomen this admission demonstrated stability of the placement. he should follow up with ercp for follow up for this stent as an outpatient. . # depression: continued home duloxetine at 40mg initially. due to concerns for worsening mood, a psych consult was obtained. they recommended 60mg daily, avoidance of benzodiazepines given profound altered mental status in the peri-extubation setting, use of trazodone for sleep (with caution for orthostatic hypotension), and recommended referral for an outpatient therapist. . # history of dvt/pe: mr. suffered a provoked perioperative dvt/pe 6 months prior to admission, and was on warfarin for this indication. he was continued on anticoagulation for low-ef and concern for apical hypokinesis and lv thrombus. . transitional issues: - needs tsh/lfts rechecked 6 weeks after discharge as adjustments have been made to levoxyl while inpatient and his statin was increased. - mr. will need to follow up in psych as an outpatient following discharge from rehab for evaluation and management of his chronic depression and anxiety. - mr. will need to follow up with ercp at for follow up of stent placement and possible removal upon discharge from rehab - see other f/u appts medications on admission: furosemide 120 mg - furosemide 160 mg daily prn shortness of breath or wheezing - diltiazem 30 mg tid - duloxetine 40 mg daily - labetalol 200 mg - levothyroxine 25 mcg daily - simvastatin 40 mg qhs - aspirin 81 mg daily - insulin lispro sliding scale tid fbs: 100-150=2u 151-200=4u 201-250=6u 251-300=8u 301-350=10u - nph 12 units sc bid - warfarin 3 mg daily - lidocaine 5% patch daily - ativan 1 mg po q6h prn anxiety - morphine 30 mg er q12h - hydromorphine 8 mg q4h prn pain - niacin 500 mg - zofran 8 mg q8h prn nausea - pantoprazole 40 mg - sevelamer 800 mg tid - b complex-vitamin c-folic acid 1 mg daily - camphor-menthol 0.5-0.5 % lotion qid prn itching - trazodone 50 mg qhs prn - acetaminophen 325-650 mg po q6h prn - polyvinyl alcohol-povidone 1.4-0.6 % eye drops prn dry eyes - prochlorperazine 10 mg q6h 30 minutes prior to meals - miconazole 2 % prn - epoetin alfa 10,000 unit/ml injection qweek - cholecalciferol (vitamin d3) 800 units daily - calcium carbonate 500 mg tid - sodium polystyrene sulfonate 15 g/60 ml suspension: 30 g po bid prn k > 5.5 discharge medications: 1. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 2. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 3. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 5. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 6. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 7. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day): with meals. 8. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): continue for at least one month. 9. heparin (porcine) 1,000 unit/ml solution sig: 4,000-11,000 units injection prn (as needed) as needed for line flush. 10. sodium citrate 4 % (3 ml) syringe sig: 1.2-1.4 ml miscellaneous asdir (as directed): dialysis catheter. 11. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). 12. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 10 days: last day . 13. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 14. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 15. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 16. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. 17. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: check inr on and titrate warfarin to inr 2.0-3.0. 18. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 19. insulin glargine 100 unit/ml solution sig: twenty (20) units subcutaneous once a day: before breakfast. 20. cyclobenzaprine 10 mg tablet sig: one (1) tablet po at bedtime as needed for back pain. 21. oxycodone 20 mg tablet extended release 12 hr sig: three (3) tablet extended release 12 hr po q12h (every 12 hours): pts dose at home was 240 mg daily (oxycodone po). 22. 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. 23. heparin (porcine) in ns 2,500 unit/500 ml (5 unit/ml) parenteral solution sig: 0- units intravenous continuous: see weight based protocol attached. 24. morphine sulfate 2 mg iv q4h:prn pain hold for somnulance or rr< 12 25. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: extended care facility: center nh/rmu discharge diagnosis: acute kidney failure requiring dialysis non st elevation myocardial infarction diabetes hypertension dyslipidemia c-difficile chronic pancreatitis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure caring for you during your hospitalization at . you had a heart attack and received 2 bare metal stents to blocked arteries in your heart. you will need to take plavix every day for at least one month and possibly longer. do not stop taking plavix or miss unless dr. (at ) tells you it is ok. your heart is weaker after the heart attack and you have been started on medicines to help the heart pump better and to prevent blood clots from forming in your heart. for your heart failure diagnosis: weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 3 day or 5 lbs in 2 days, follow a low salt diet and restrict your fluidsto 1500 ml/ day or about 6 cups. after the cardiac catheterization, your kidneys stopped working and you were started on dialysis. you will likely need dialysis for a long time and will need to have permanant access placed in your arm to get the dialysis. you will have a kidney doctor at your new dialysis center. you have an infection in your bowel called c difficile again and are on vancomycin to treat this. . we made the following changes to your medicines: 1. stop taking lasix, diltiazem, labetolol, compazine, zofran, miconazole, kayexelate 2.increase duloxetine to 60mg daily 3. increase levothyroxine to 50 mcg as your tsh was low. you will need to check another tsh in 6 weeks. 4. change simvastatin to atorvastastin to lower your cholesterol after your heart attack 5. change nph to glargine insulin to be taken before breakfast, continue the humalog sliding scale according to blood sugars before meals and at bedtime. 6. increase warfarin to 5mg daily 7. stop taking ativan 8. cont epoetin per your nephrologists 9. stop pantoprazole, take famotidine instead 10. stop morphine pills, take oxycontin instead to treat your pain. you are on your normal dose and will increase slowly. 11. take morphine intravenously as needed for severe pain 12. increase trazadone to 100 mg at hs, decrease this medicine once pain control is better. . *please continue to not smoke. quitting smoking is the best thing you can do for your health. followup instructions: dr. cardiovascular consultants a department of hospital 1 , , , phone: ( fax: ( date/time: at 11:00am . primary care: please make an appt with family medicine when pt is leaving rehab. please stress to pt and family the importance of keeping all physician to prevent rehospitalization. . pain clinic: name: , address: 1 mound court, , phone: fax: monday at 11:15 am . gastroenterology: , b. , phone:( fax:( 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 Hemodialysis Venous catheterization for renal dialysis Venous catheterization for renal dialysis Pharyngoscopy Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on two vessels Diagnoses: Acidosis Hyperpotassemia Thrombocytopenia, unspecified End stage renal disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Toxic encephalopathy Other pulmonary insufficiency, not elsewhere classified Hyposmolality and/or hyponatremia Cardiac complications, not elsewhere classified Aortocoronary bypass status Other chronic pulmonary heart diseases Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease 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 Intestinal infection due to Clostridium difficile Cardiac catheterization 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 anticoagulants Personal history of venous thrombosis and embolism Acute systolic heart failure Ventilator associated pneumonia Chronic pancreatitis Other and unspecified coagulation defects Fall from other slipping, tripping, or stumbling Acute pain due to trauma Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Pain in joint, shoulder region Personal history of pulmonary embolism Dissection of coronary artery |
allergies: no known allergies / adverse drug reactions attending: chief complaint: gib, hypoxia major surgical or invasive procedure: endoscopic biliary stent replacement history of present illness: mr. is a 62yo m with pmh cad s/p cabg in , diastolic congestive heart failure, esrd on hd since tu,th,sat, history of dvt & pe (previously on coumadin), recent c. diff colitis, who is transferred from the osh for melena with duodenal ulcer seen on egd likely to mechanical injury from the metal stent in the biliary tract that may require intervention. . at the osh inital vitals prior to transfer were bp 134/63 hr 87 rr 20 temp 98.6. he was noted by nursing notes to be a&ox2, on 60% mask, rr 17 with o2 sat 98%. he presented to after melena at rehab that began on . he was noted to have melena with drop in his hct, and had inr 4, and was given vitamin k, in addition to 2 units prbc's. he continued to have melena, and was given 2 more units prbc's prior to transfer to . on admission to on his wbc was 15.9 with 87% pmn's, hct 26.3, plts 174, inr 1.7, ptt 38, na 139, k 5.2, cl 98, hco3 29, bun 26, cr 2.5, gluc 202. ck 23 trop 0.09, bnp 4982. cxr there reported as mild pulmonary vascular congestion and possible interstitial edema. he was placed on protonix gtt for gib there, transfused 1 unit prbc's. he had an egd that found a stent in the second portion of the duodenum and an ulcer in the second portion of the duodenum. the ulcer was injected with epi and cauterized, with cessation of bleednig. surgery was consulted there, and recommended removal of the stent and consideration of ivc filter placement given recent bleed and history of dvt's. however, given the egd findings with stent migration, he was transferred to . also at , he was thought to be in diastolic heart failure, with poor response to lasix, and had 3.5l fluid removal with hd on . . today at in the morning prior to transfer he had a fever to 100.3, and was found to have wbc to 30 up from 14, with 27 bands. he was given vancomycin 1gm at 10am, zosyn 2.25gm iv x1 at 10am, metronidazole 500mg iv at 10am. . pt has had complicated course over the past year. he had stent placed to common bile duct in for stricture thought to be due to ccy in . since then, he has had multiple admissions, mostly at . he had cad s/p cabg in , which was complicated by hcap, treated with zosyn. that hospitalization was then further complicated by acute on chronic renal failure, resulting in initiation of hd in 12/. that hospitalization further was complicated by a seizure, pericarditis, and a fall resulting in left humerus fracture. lastly, he developed c. diff colitis at the end of , and started on po vancomycin. . on arrival to the icu, initial vs t 98.2, hr 88, bp 118/68, rr 15, 95% on 5lnc. on exam, he appears mildly fatigued and has crackles 2/3 up to lungs. he feels thirsty and has some mild abdominal pain, but no other complaints. he says that he has been having ~ 2 black bowel movements per day. he has also had cough, mildly productive of tan sputum. he denies chest pain. past medical history: t2dm complicated by neuropathy, neprhopathy ckd on hd since renal mass right adrenal mass cad s/p cabd on at - 1 vessel copd cholecystectomy left femur fracture left humeral fracture fall hypothyroidism depression seizure chronic pancreatitis s/p biliary tract metal stenting pancrectomy in for necrosis pvd with angioplasty dvt in has been on coumadin pe ? pericarditis c. diff colitis on po vanco s/p rotator cuff repair in s/p carotid endarterectomy laminectomy c-spine cholecystectomy pvd s/p femoral popliteal artery pta tonsillectomy social history: social history: he has two daughters who are involved in his care - and . - tobacco: quit 11 months prior - alcohol: denies - illicits: denies family history: nc physical exam: admission physical exam: vitals: t 98.2, hr 88, bp 118/68, rr 15, 95% on 5lnc general: alert, oriented, no acute distress, mildly lethargic, but easily arousable, responding to questions heent: sclera anicteric, eomi, dry mm, oropharynx clear neck: supple, jvp elevated to just below the mandible lungs: no use of accessory muscles, decreased bs at bases with crackles up to of lung, no rales or rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops; right-sided hd cath with no erythema, tenderness or purulent drainage abdomen: nabs, soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, no lower extremity edema, feet warm though unable to palpate dp's or pt's, pain to movement of left arm neuro: oriented to person, states " hospital", knows it is no clubbing, cyanosis or edema . discharge physical exam: afebrile, bp 130-150/70, hr 70-90, o2 saturations 93-97% 1lnc exam unchanged except: very trace crackles in bases bilateral on lung exam, no wheezes, good air entry bilaterally left shoulder with decreased range of motion secondary to pain cardiac exam regular rate and rhythm, no murmurs no edema pertinent results: admission labs: 04:24pm blood wbc-23.6* rbc-2.62* hgb-8.1* hct-23.1* mcv-88 mch-30.8 mchc-34.8 rdw-15.6* plt ct-125* 04:24pm blood neuts-92.5* lymphs-3.1* monos-4.1 eos-0.3 baso-0.1 04:24pm blood pt-17.0* ptt-29.9 inr(pt)-1.6* 04:24pm blood glucose-200* urean-42* creat-2.6* na-140 k-3.8 cl-99 hco3-30 angap-15 04:24pm blood alt-94* ast-159* ld(ldh)-222 ck(cpk)-21* alkphos-642* totbili-4.8* dirbili-4.2* indbili-0.6 04:24pm blood ck-mb-2 ctropnt-0.28* 05:20am blood ck-mb-2 ctropnt-0.26* 04:24pm blood albumin-2.8* calcium-8.4 phos-3.8 mg-2.4 uricacd-5.2 08:46pm blood %hba1c-5.5 eag-111 11:07pm blood type-art po2-63* pco2-37 ph-7.52* caltco2-31* base xs-6 11:07pm blood lactate-0.8 . micro: osh bcx cultures ?????? 2/4 bottles grown citrobacter freundii, 1 bottle now growing coag negative staph, and 4th bottle with no growth . blood culture no growth final picc tip no growth final . c. diff neg urine culture negative . imaging: ercp report: a metal stent placed in the biliary duct was found in the major papilla. this had migrated distally slightly and was partially embedded in the duodenal wall. the duodenal wall was friable and ulcerated at the site of stent migration. this was likely due to stent erosion, although underlying mass lesion cannot be excluded. there was a yellowish bulging that appeared attached to the duodenal wall of unclear significance. the metal stent was removed - this was sent for cytology. cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. contrast medium was injected resulting in complete opacification. a single irregular stricture that was 3 cm long was seen at the distal common bile duct. there was moderate post-obstructive dilation with the cbd measuring 18 mm. a 9cm by 10fr biliary stent was placed successfully . lower extremity non-invasive ultrasound: comparison: none. findings: the bilateral common femoral veins demonstrate a normal respiratory flow pattern. bilateral vascular grafts are noted in the superficial tissue at the level of the common femoral veins. the bilateral common femoral, superficial femoral, and popliteal veins demonstrate normal compressibility, flow, and augmentation. there is normal compressibility of the bilateral posterior tibial and peroneal veins. impression: no evidence of deep vein thrombosis. . plain films left arm: indication: history of humeral fracture. pain in left arm. findings: the visualized left lung and ribs demonstrate low lung volumes. no definite rib fractures. osteopenia which limits evaluation for subtle fractures. proximal humerus surgical neck fracture is seen, with varus angulation and mild impaction. there is mild callus formation indicating healing. prior probable rotator cuff repair, as there is a suture anchor within the humeral head near the greater tuberosity. mild ac joint widening, which may have indicated prior ac joint separation. no definite humeral head dislocation. the visualized elbow joint is unremarkable. no acute fracture or dislocation of the forearm. surgical clips are seen within the volar soft tissues of the wrist. impression: 1. healing left proximal humerus surgical neck fracture, as described above. 2. probable prior rotator cuff repair. 3. probable prior ac joint separation. 4. no acute abnormality of the forearm. . ct abd/pelvis: comparisons: no relevant comparisons are available. technique: multidetector ct examination of the abdomen and pelvis with no iv contrast administration. oral contrast was given. sagittal and coronal reformations were made. total exam dlp: 627.79 mgy-cm. findings: the patient is status post cabg. the base of the heart is enlarged. no pericardial effusion is seen in the visualized pericardium. bilateral atelectases are seen, right greater than left. air bronchogram is seen at the right side and consolidation component cannot be ruled out no pleural effusion is seen. abdomen: a plastic biliary stent is well positioned with its tip within the duodenum. no signs of perforation or bleeding are observed. of note, duodenal wall edema is seen in proximity to the tip of the stent (301b,28). the liver is within normal limits. no intra- or extra-hepatic biliary duct dilatation is detected. the spleen is within normal limits. the pancreas is unremarkable. right heterogeneous adrenal mass is identified measuring 30 x 35 mm. the mass has some fatty components within it along with soft tissue density in its medial portion (301b, 41). nodularity of the left adrenal body is observed (2, 24), measuring 14 x 30 mm. the right kidney is with no gross pathology. an exophytic ovoid renal lesion is seen in the interpolar region of the left kidney. the density of this lesion is 32 hounsfield units. otherwise, the left kidney is unremarkable. no peritoneal or retroperitoneal lymphadenopathy is observed. no free fluid or free air is detected. the large and small bowel are unremarkable. atherosclerotic changes are seen along the aorta. pelvis: a foley catheter is seen within the urinary bladder. the prostate gland is within normal limits. no free fluid or lymphadenopathy is seen within the pelvis. osseous structures: diffuse degenerative changes are seen along the spine with no concerning osteolytic or osteoblastic lesion. impression: 1. well-positioned plastic biliary stent with no signs of bleeding or perforation. 2. duodenal wall edema is seen in proximity to the tip of the stent, compatible with the ercp findings of friable and ulcerated duodenal wall. 3. right heterogeneous adrenal mass is identified, that contains soft tissue components within it. this mass most probably represents an adenoma; still, other lesions can not be excluded. given the patient's abnormal renal function follow-up examination is recommended. 4. right lower lobe pulmonary opacity with air bronchogram is detected. might represent atelectasis or consolidation, clinical correlation is recommended. 4. exophytic lesion in the interpolar region of the left kidney is identified, could not be definitely assessed without iv contrast administration. follow-up examination with us is recommended. brief hospital course: mr. is a 62 year old male with history of coronary artery disease (cad) status post bypass in , diastolic congestive heart failure (dchf), end-stage renal disease (esrd on hd) since tu,th,sat, history of dvt & pe (previously on coumadin), recent c. diff colitis, who is transferred from the outside hospital (osh)for melena with duodenal ulcer seen on egd likely due to mechanical injury from a metal stent in the biliary tract that was exchanged for a new stent. post-stent exchange course was complicated by bacteremia and hypoxia from volume overload. . active issues by problem: # melena: was found to have duodenal ulcer secondary to migration of biliary stent seen on egd on at osh. this duodenal ulcer was cauterized at osh. patient was transfused to hct goal > 25 given his cardiac comorbidities, which required 6 units of prbcs in total. also, due to ongoing bleeding, his inr was also reversed w/ ffp, and he was started on a ppi drip. pating had a repeat ercp on , which showed a migrated bare metal common bile duct (cbd) stent, which was removed. pt also had some stricturing of his cbd proximally, which was dilated, and another stent was placed. pt had friability of his duodenum, but no active bleeding, and a brown "bulge" of unclear origin. ercp service recommended holding his anticoagulation for 3 days post-procedure. he also had a ct abdomen which confirmed proper placement of the new stent, and which ruled out partial perforation of the duodenum. his transaminases were trending down before discharge and had normalized. he still had nausea with eating but his abdominal pain had resolved. . # hypoxia: most likely secondary to volume overload from several units prbc transfusions with little urine output in response to lasix. likely also contribution from pulmonary artery hypertension creating baseline oxygen needs 1-3 l nasal cannula. pneumonia was also possible given fevers, recent hospitalization, infiltrates vs. atelectasis on cxr. however, after having 5l of fluid removed in 2 dialysis sessions, his hypoxia resolved and he was saturating 100% on 3l nasal cannula (his baseline oxygen requirement). he responded to diuresis with furosemide and was able to wean down to 1l nasal cannula. whenever he requires blood products, he also needs to have iv furosemide 100 mg to reverse volume overload. he was discharged on furosemide 120 mg po bid for ongoing diuresis to prevent further volume overload. additionally, he had an echo to assess for wall motion abnormalities and worsening heart failure as a possible cause for hypoxia. his ef was 50-55% but he did have severe pulmonary hypertension. thus, he was started on diltiazem 30 mg tid for pulmonary hypertension which also helped his oxygen requirement resolve. . # chronic kidney disease: currently, his gfr categorizes him as chronic kidney disease stage 4. was recently on hd as of 12/. patient requires at least furosemide 120 mg iv to diurese. he was dialysed through right tunneled catheter. the renal team felt that he would be able to sustain his electrolytes and volume with po diuretic and without further dialysis. his tunneled catheter was discontinued before discharge and he underwent upper extremity venous/arterial mapping for future dialysis graft placement. his creatinine stabilized between 2.5-3 and his electrolytes remained stable without dialysis. continued sevalamer 800mg tid, nephrocaps daily. he was started on epoetin 10,000 units weekly. also, his parathyroid hormone levels came back elevated to 125, suggesting secondary hyperparathyroid from ckd. thus, he was started on calcium and vitamin d daily. . # citrobacter bacteremia: initially, patient presented with leukocytosis, fevers, and productive cough. he was treated empirically with pip/tazo for anaerobic and gram negative coverage; vanc for possible gram positive coverage. on , osh called with report of bottles of gram negative rods in blood, and ciprofloxacin was added to provide more coverage, again due to suspicion of gi source given his symptoms. on , gnrs were speciated as citrobacter freundii- sensitive to gent, tobra, amikacin, bactrim, cipro, levofloxacin, imipenem, cefepime, pip/tazo. at this point, his pip/tazo was changed to cefepime to complete a 2-week course. id team felt that his source was most likely biliary/gi given his clinical situation above. patient also grew coagulase-negative staph at the osh but only in bottles and so id recommended discontinuing the vancomycin as these are likely contaminants. surveillance cultures were drawn on several days and showed no growth. pt had a picc which was pulled, and his hd catheter was also discontinued. he completed a 14-day course of cefepime on . . # hyperkalemia: maximum potassium was 6.4. ekg with slightly peaked t waves although not much change from prior. patient was monitored on telemetry and did not have any events. his k improved with kayexelate. possible cause of elevation was the discontinuation of daily iv lasix. . # c. diff colitis: developed after recent hospitalization at hospital, in setting of hcap treated with zosyn. abdomen soft with no peritoneal signs. only mild loose stool, likely due to catharsis from prior gi bleeding. pt's c diff stool toxin is negative here. completed 14 days po vanc course . . # cad s/p 1-vessel cabg: denied chest pain. ecg appears unchanged from prior, flat ck and mb, and trop 0.28, in setting of renal failure. his aspirin was initially held for gi bleeding but was restarted 3 days after the ercp procedure. his labetalol was continued at 200 mg . . # history of deep vein thrombosis and possible pulmonary embolus( dvt's, ?pe): pt had supratherapeutic inr at osh, reversed with ffp and vitamin k given gi bleed. warfarin was held during the gi bleed and for 3 days after ercp changed his stent. pt's bilateral lower extremity dopplers were negative for dvt so no ivc filter needed to be placed. warfarin was later restarted and had therapeutic inr without evidence of bleeding prior to discharge. . # hypertension (htn): pt's hydralazine, labetalol, amlodipine were held in the setting of gi bleed as above. he was restarted on labetalol 200mg po bid as his bp recovered to 150s/70s-80s. however,the hydralazine and amlodipine were still held. he was also started on diltiazem 30 mg tid for pulmonary artery hypertension which assisted with his systemic bp control. . # diabetes mellitus, type 2 (t2dm): unsure of most recent a1c, though likely poorly controlled given that it has been complicated by nephropathy and neuropathy. he was continued on his nph 12 units and insulin sliding scale. . # recent left humerus fracture: in setting of fall at osh. patient has tenderness to palpation of l upper arm but sensation is intact over the deltoid. had plain films here showing humeral head avulsion fracture. ortho evaluated the patient and recommended a sling. continued pain control with morphine sr 30mg ; hydromorphone 8 mg q6hrs prn pain. . # hypothyroidism: continued levothyroxine 25mcg daily . # depression/anxiety: continued duloxetine 40mg daily, lorazepam 1mg q6hrs prn . # code: full confirmed (discussed with patient) . transitional issues: - he should follow-up with the ercp team in 1 month to have the biliary stent replaced. - check inr, potassium, creatinine, hematocrit weekly. - patient will need outpatient renal follow-up to discuss if/when dialysis will be indicated in the future. - right heterogeneous adrenal mass is identified, that contains soft tissue components within it. this mass most probably represents an adenoma; still, other lesions cannot be excluded. given the patient's abnormal renal function, follow-up examination is recommended. - exophytic lesion in the interpolar region of the left kidney is identified, could not be definitely assessed without iv contrast administration. follow-up examination with us is recommended. medications on admission: medications: home: amlodipine 10mg daily cyclobenzaprine 10mg q4hrs prn duloxetine 40mg daily hydralazine 100mg q8hrs insulin lispro ss labetalol 400mg q12hrs levothyroxine 25mcg daily lidoderm patch 5% daily lorazepam 1mg q6hrs prn morphine sr 30mg q12hrs niacin 500mg q12hrs zofran 4mg iv q6hrs prn nph 12 units qam, and 12 units qpm oxycodone 10mg ir q4hrs prn _______ 2 caps tid pantoprazole 40mg q12hrs iv sevelamer 800mg tid simvastatin 40mg qhs nephrocaps daily vancomycin 125mg po q8hrs started , end date warfarin held . medications on transfer: duloxetine 30mg daily insulin lispro ss labetalol 200mg levothyroxine 25mcg daily lorazepam 1mg po q6hrs prn anxiety morphine sr 30mg oxycodone 10mg q6hrs prn pain pantoprazole 8mg gtt/hr vanc po 125mg q8hrs discharge medications: 1. duloxetine 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 2. insulin lispro 100 unit/ml solution sig: as directed units subcutaneous three times a day: fbs: 100-150=2u 151-200=4u 201-250=6u 251-300=8u 301-350=10u >351= md, 12u. 3. labetalol 200 mg tablet sig: one (1) tablet po bid (2 times a day). 4. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 5. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) patch topical once a day. 6. lorazepam 1 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for anxiety. 7. morphine 30 mg tablet extended release sig: one (1) tablet extended release po q12h (every 12 hours). 8. niacin 500 mg tablet sig: one (1) tablet po twice a day. 9. ondansetron hcl (pf) 4 mg/2 ml solution sig: eight (8) mg injection q8h (every 8 hours) as needed for nausea. 10. nph insulin human recomb 100 unit/ml suspension sig: twelve (12) units subcutaneous twice a day. 11. hydromorphone 2 mg tablet sig: four (4) tablet po q4h (every 4 hours) as needed for pain. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 13. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 14. simvastatin 40 mg tablet sig: one (1) tablet po at bedtime. 15. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 16. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 17. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itching. 18. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. 19. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever, pain. 20. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. 21. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours): take 30 minutes before meals. 22. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for itchy, moist skin. 23. epoetin alfa 10,000 unit/ml solution sig: qweek units injection once a week. 24. furosemide 40 mg tablet sig: three (3) tablet po bid (2 times a day). 25. diltiazem hcl 30 mg tablet sig: one (1) tablet po tid (3 times a day). 26. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 27. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 28. sodium polystyrene sulfonate 15 g/60 ml suspension sig: thirty (30) g po twice a day: for hyperkalemia with k > 5.5. can use until bowel movement. 29. furosemide 80 mg tablet sig: two (2) tablet po once a day as needed for shortness of breath or wheezing: use in addition to 120 mg if short of breath or increasing oxygen requirements. 30. warfarin 1 mg tablet sig: three (3) tablet po once a day. tablet(s) discharge disposition: extended care facility: hills discharge diagnosis: primary diagnoses: duodenal ulcer secondary to biliary stent migration end stage renal disease citrobacter bacteremia/septic shock clostridium difficile colitis . secondary diagnoses: deep vein thrombosis 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 you were having dark and bloody stools. this is because the stent in your biliary tree (ducts draining the liver and gallbladder) had migrated and caused an ulcer in your intestine. the gi doctors did a procedure to replace the stent and also cauterize the ulcer and it stopped bleeding. during this process, some bacteria migrated for your gi tract into the blood stream and caused you to have a blood-stream infection. you got antibiotics for this infection. . you also needed to have dialysis because your kidneys stopped working. you were not making enough urine so the extra fluid backed up into your lungs and caused you to have difficulty breathing. you had a breathing tube placed for a short time and then the dialysis helped remove fluid. now, you should take furosemide every day to make sure that the fluid does not back up into your lungs again. if you feel short of breath or you need higher levels of oxygen, you should take higher doses of furosemide to help pull fluid out of your lungs. . the following changes were made to your medications: - stop taking hydralazine and amlodipine for blood pressure - change your labetalol to 200 mg twice daily for blood pressure - start taking diltiazem 30 mg three times a day for high blood pressure in your lungs - start taking furosemide 120 mg twice daily for fluid - start taking an extra dose of furosemide 160 mg by mouth as needed for shortness of breath or increasing oxygen requirements - start taking epoetin injections 10,000 units once a week for your anemia - start hydromorphone 8 mg every 4 hours as needed for pain - restart your warfarin at 3 mg daily for blood clots - start calcium and vitamin d daily because your kidneys will cause bone breakdown - start taking prochlorperazine 10 mg before meals to help with nausea. you can also take ondansetron at any time to help with nausea - start taking kayexelate as needed for high potassium until you have a bowel movement . it was a pleasure taking care of you in the hospital! followup instructions: department: gastroenterology when: wednesday at 12:30 pm with: , md building: lm campus: west best parking: garage department: orthopedics when: tuesday at 10:00 am with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: tuesday at 10:20 am with: , np building: campus: east best parking: garage md Procedure: Hemodialysis Endoscopic retrograde cholangiopancreatography [ERCP] Replacement of stent (tube) in biliary or pancreatic duct Diagnoses: Hyperpotassemia Renal dialysis status Congestive heart failure, unspecified Acute posthemorrhagic anemia Acute kidney failure, unspecified Unspecified acquired hypothyroidism Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Acute on chronic diastolic heart failure Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Unspecified fall Dysthymic disorder Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Bacteremia Intestinal infection due to Clostridium difficile Mechanical complication due to other implant and internal device, not elsewhere classified Personal history of venous thrombosis and embolism Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Accidents occurring in residential institution Obstruction of bile duct Atherosclerosis of native arteries of the extremities, unspecified Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Closed fracture of unspecified part of upper end of humerus Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Personal history of pulmonary embolism |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass graft x 3 mediastinal re-exploration for bleeding history of present illness: this 62 year old man presented to the emergency room at complaining of sunsternal pressure for 24 hours prior to presentation. he states that the pain similar to his previous myocardial infarction and was worse with exertion. he was also complaining of dyspnea with exertion. he stated he had stents about 10 years ago and took medications for about two years after the stents but stopped them himself and has not had follow up for several years. past medical history: coronary artery disease s/p mi/ptca of lad and rca-10yrs ago cardiomyopathy alcohol abuse social history: race: caucasian last dental exam: none recently lives: alone contact: none/ has ex wife, 2 sons(age 24/25) and sister occupation: automatic door repair cigarettes: smoked yes last cigarette hx:1ppd x 25yrs other tobacco use: etoh: 6 beers/day -last drink illicit drug use: none family history: no premature coronary artery disease physical exam: pulse: 65 resp: 18 o2 sat: 97%-ra b/p right: 124/79 left: height: weight: 55.4kg general: cachetic skin: dry intact psoriasis left ear/neck heent: perrla eomi 1 loose tooth-only tooth neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur none abdomen: soft non-distended non-tender +bs extremities: warm , well-perfused edema none varicosities: none neuro: grossly intact a&ox3, mae pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 1+ left: 1+ radial right: 2+ left: 2+ (cath site) carotid bruit none pertinent results: echo : pre-bypass: the left atrium is dilated. moderate to severe spontaneous echo contrast is seen in the body of the left atrium. the left atrial appendage emptying velocity is depressed (<0.2m/s). no thrombus is seen in the left atrial appendage. the right atrium is dilated. mild spontaneous echo contrast is seen in the body of the right atrium. a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed (lvef= 15-20 %) on low dose epinephrine infusion). the apical, inferior, inferoseptal, inferolateral, and lateral segments appear severlely hypokinetic and the anterior segments appear mildly to moderately hypokinetic. the right ventricular cavity is dilated with severe global free wall hypokinesis. there are simple atheroma and focal calcifications in the ascending aorta. there are simple atheroma & calcifications in the aortic arch. there are complex (>4mm) atheroma & focal calcifications in the descending thoracic aorta. epiaortic scanning was performed prior to aortic pursestring placement & cannulation. 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. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. dr. was notified in person of the results in the operating room. postbypass: the patient was initially av paced and then was in sinus rhythm. the patient is receiving epinephrine & milrinone infusions. the inferior, inferoseptal, lateral and apical segments remain severely hypokinetic but the function of the anterior, anterolateral, and anteroseptal segments is improved. overall left ventricular systolic function is improved with an ef of about 25-30%. right ventricular systolic function is improved and is now mild to moderately globally depressed. valvular function remains unchanged. the aorta is intact after decannulation. 02:42pm blood wbc-11.6* rbc-4.58* hgb-14.1 hct-41.5 mcv-91 mch-30.8 mchc-34.0 rdw-13.4 plt ct-307 06:18pm blood wbc-15.4* rbc-3.74* hgb-11.6* hct-32.6* mcv-87 mch-31.1 mchc-35.7* rdw-14.2 plt ct-116* 06:11am blood wbc-13.2* rbc-3.56* hgb-10.9* hct-33.6* mcv-94 mch-30.6 mchc-32.4 rdw-13.8 plt ct-350 05:20am blood wbc-12.4* rbc-3.20* hgb-9.5* hct-29.4* mcv-92 mch-29.7 mchc-32.3 rdw-14.1 plt ct-458* 02:42pm blood pt-10.6 ptt-29.8 inr(pt)-1.0 02:25am blood pt-13.6* ptt-34.4 inr(pt)-1.3* 04:40am blood pt-19.1* inr(pt)-1.8* 11:15am blood pt-19.9* inr(pt)-1.9* 04:50am blood pt-22.0* inr(pt)-2.1* 02:42pm blood glucose-89 urean-12 creat-0.8 na-133 k-5.2* cl-96 hco3-27 angap-15 04:50am blood glucose-81 urean-34* creat-2.0* na-137 k-4.2 cl-97 hco3-29 angap-15 02:42am blood alt-40 ast-64* alkphos-182* totbili-1.6* 05:20am blood calcium-8.5 phos-4.8* mg-2.4 brief hospital course: mr. was transferred from the outside hospital to for surgical management of his coronary artery disease. upon transfer he was worked up for surgery. he required a plavix washout and on he was brought to the operating room for coronary artery bypass graft x 3. please see operative report for surgical details. he weaned from bypass on milrinone, epinephrine and neo synephrine. following surgery he was transferred to the cvicu for invasive monitoring in stable condition. very early on post-op day one he began having increased chest tube output and the chest x-ray was suspicious for hemothorax. he was brought back to the operating room for re-exploration and was found to have a branch of the lima bleeding. following this procedure he was brought back to the cvicu for invasive monitoring. he remained stable on a moderate amount of pharmacologic support. he weaned from the ventilator, and pressors over two days. the milrinone was left for several days and slowly weaned off. after eight or so hours his urine output fell and he was begun again on the inotrope with a good response. the milrinone was again weaned slowly, and ace-i was started and he remained stable. coumadin was given for his paroxysmal atrial and low ejection fraction. the heart failure service was consulted and he will follow up in their clinic. he progressed slowly, was diuresed towards his preoperative weight and his appetite gradually improved. her had a large fungating mass on the left parietal scalp in the area of a scalp laceration from two years ago. the plastic surgery and dermatology services were consulted and a biopsy was positive for basal cell cancer. this will be followed at the clinic and excision will be performed. in the meanwhile, bacitracin ointment and a dry sterile dressing will be used topically. the patient was ready for rehab on and discharged with appropriate appointments, medications and instructions. medications on admission: aspirin 325 daily discharge medications: 1. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 3. dronabinol 2.5 mg capsule sig: one (1) capsule po bid (2 times a day). 4. metoprolol succinate 25 mg tablet extended release 24 hr sig: 0.5 tablet extended release 24 hr po daily (daily). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 6. bacitracin 500 unit/g ointment sig: one (1) appl ophthalmic daily (daily): to scalp lesion. 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po daily (daily) as needed for constipation. 8. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever or pain. 9. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. coumadin 2.5 mg tablet sig: as directed tablet po once a day: inr 2-2.5 for atrial fibrillation. 12. outpatient lab work inr/pt day after transfer, 48 hours later then prn. discharge disposition: extended care facility: - discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 3 basal cell carcinoma of scalp past medical history: s/p percutaneous coronary intervention of lad and rca-10yrs ago severe ischemic cardiomyopathy alcohol abuse discharge condition: alert and oriented x3, nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions: sternal - healing well, no erythema or drainage leg 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 **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 cardiologist: dr. on at 2:45pm **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr for coumadin ?????? indication atrial fibrillation goal inr 2-2.5 first draw day after admission results to:will need coumadin follow up arranged at discharge Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Arterial catheterization Incision of mediastinum Other incision of pleura Other surgical occlusion of vessels, thoracic vessels Closed biopsy of skin and subcutaneous tissue Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified pleural effusion Acute posthemorrhagic anemia Acute kidney failure, unspecified Cardiac complications, not elsewhere classified Atrial fibrillation Hematoma complicating a procedure Percutaneous transluminal coronary angioplasty status Other specified forms of chronic ischemic heart disease Hemorrhage complicating a procedure Other specified cardiac dysrhythmias Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Old myocardial infarction Other respiratory complications Family history of ischemic heart disease Alcohol abuse, continuous Other specified forms of effusion, except tuberculous Basal cell carcinoma of scalp and skin of neck |
allergies: erythromycin base / tetracycline / percocet / cipro / gluten / adhesive tape attending: chief complaint: respiratory failure major surgical or invasive procedure: ercp biliary drain size change history of present illness: 76f with pmhx of afib, cad, chf, htn, pancreatic adenocarcinoma (stage iib at diagnosis in ) s/p whipple and adjuvant chemoradiation therapy now with metastatic disease, presenting to micu with respiratory failure s/p ercp. patient with history of recurrent painless jaundice / biliary obstruction attributed to pancreatic cancer progression, with accompanying recent radiographic findings concerning for malignant progression. an ercp was initially scheduled for but was aborted because of inr of 5.9. patient was admitted for normalization fo inr adn repeat ercp. on , repeat ercp was conducted, but the choledocho-jejunostomy could not be accessed and no stent was placed. therefore, an ir-guided percutaneous drainage procedure was performed on . was initially noted to have good drainage. however, subsequently was noted to have poor drainage, perhaps due to proximal jejunal limb obstruction. plan was to go for repeat enteroscopy. patient was discharged home in the meantime, per famiy preference. today went for repeat single balloon ercp for stenting of hepatical-jejunal anastamosis. this was again unsuccessful. the procedure was complicated by large amounts of muddy stomach contents which was visualized by endoscopy and attempted suction, but eventually requiring suction by og tube x3. patient was extubated (difficult extubation), but did not tolerate, desatting, tachypneic, tachycardic, increased wob. was assessed in ercp suite by micu resident. in context of respiratory failure, was re-intubated and admitted to micu for further management. on arrival to the micu, patient's vs were 98.8 58 141/52 100%/100%fio2, intubated on cmv 450x14, peep 5. past medical history: pmh: -pe () -coronary artery disease s/p pci/des -chf lvef 45%, septal/anteroseptal hk, mod mr, mod pulm htn, mod tr -atrial fibrillation -hl -htn -cryptosporidiosis () -mi () -pancreatic adenoca s/p chemo () and xrt ()(adjuvant gemcitabine/xeloda/radiation) overseen by dr. psh: -whipple ( pancreatic ductal adenocarcinoma pt3 pn1 (7 of 12 lymph nodes involved), +lvi, +perineural invasion, margins uninvolved by adenocarcinoma and closest margin <1.0mm (pancreatic neck) -rotator cuff repair x2 () -hysterectomy for endometriosis () -cataracts/eyelid lift surgery social history: lives with her husband with four children who live in . ex-smoker, quit in after 20 pack-years. daughter is her health care proxy. status of dnr confrimed with patient on admission. family history: brother with pancreatic cancer in his 40s, resected. sister with lung cancer in her 50s which proved terminal. another sister with breast cancer at age 57. father with prostate cancer and cad, died of mi at 77. mother with cancer, died of liver failure due to hepatitis c. physical exam: physical exam on admission: general: sedated, intubated, jaundiced heent: scleral icterus, mmm, perrl neck: supple, jvp not elevated, no lad cv: rrr, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi abdomen: well-healed ruq surgical incision. tense, distended. nontender. tympanitic diffusely, including over ruq. bowel sounds present, no organomegaly gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: deferred due to sedation. physical exam on discharge: gen: nad. jaundiced. aa0x3 heent: sclera icteric. perrl. cv: rrr. pulm: ctab, no rales, wheezes, rhonchi abd: +bs. nontender, distended, tympanitic. no r/g. bile drain in place, with scant leakage. extr: trace pedal edema. no cyanosis pertinent results: admission labs: 12:10pm wbc-8.8# rbc-3.06* hgb-10.2* hct-32.1* mcv-105* mch-33.4* mchc-31.9 rdw-15.6* 12:10pm neuts-88.0* lymphs-6.2* monos-5.1 eos-0.5 basos-0.2 12:10pm plt count-311# 12:10pm pt-13.6* ptt-24.3* inr(pt)-1.3* 12:10pm alt(sgpt)-26 ast(sgot)-63* alk phos-113* amylase-4 tot bili-7.6* dir bili-5.5* indir bil-2.1 12:10pm urea n-8 creat-0.3* sodium-130* potassium-4.6 chloride-101 total co2-16* anion gap-18 05:15pm type-art po2-100 pco2-33* ph-7.35 total co2-19* base xs--6 11:53pm pt-13.6* ptt-37.3* inr(pt)-1.3* 11:53pm plt count-312 11:53pm wbc-13.9*# rbc-2.91* hgb-9.7* hct-30.3* mcv-104* mch-33.5* mchc-32.2 rdw-15.3 11:53pm calcium-7.4* phosphate-3.4# magnesium-1.6 11:53pm glucose-86 urea n-10 creat-0.6 sodium-130* potassium-4.0 chloride-102 total co2-19* anion gap-13 : 06:31am blood wbc-15.8* rbc-2.89* hgb-9.7* hct-29.8* mcv-103* mch-33.4* mchc-32.5 rdw-15.6* plt ct-375 06:31am blood neuts-96* bands-0 lymphs-2* monos-2 eos-0 baso-0 atyps-0 metas-0 myelos-0 06:31am blood ck-mb-1 ctropnt-<0.01 06:11am blood vanco-19.2 10:04am blood type-art temp-36.7 peep-5 fio2-40 po2-90 pco2-26* ph-7.47* caltco2-19* base xs--2 06:52am blood lactate-1.7 10:04am blood lactate-1.4 04:53am blood vanco-29.8* discharge labs: 05:53am blood wbc-11.8* rbc-3.18* hgb-10.5* hct-32.5* mcv-102* mch-33.0* mchc-32.4 rdw-14.5 plt ct-370 05:53am blood pt-16.2* ptt-29.7 inr(pt)-1.5* 05:53am blood plt ct-370 05:53am blood glucose-65* urean-10 creat-0.6 na-129* k-3.9 cl-100 hco3-20* angap-13 05:53am blood alt-51* ast-128* ld(ldh)-166 alkphos-142* totbili-10.1* 05:53am blood calcium-7.7* phos-3.1 mg-2.0 05:53am blood vanco-16.1 micro: 1:03 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): budding yeast. respiratory culture (final ): sparse growth commensal respiratory flora. yeast. sparse growth. of two colonial morphologies. 9:50 am blood culture source: line-aline. blood culture, routine (pending): imaging: chest (portable ap) study date of findings: in comparison with the study of , there has been placement of an endotracheal tube with its tip at the clavicular level, approximately 6.5 cm above the carina. extensive opacification is seen in the right mid-to-lower zone, worrisome for pneumonia. prominence of the hilar regions could be a sign of elevated pulmonary venous pressure. mild atelectatic changes are seen at the bases. there is a generalized lucency of the upper abdomen. this suggests the possibility of free intraperitoneal gas. massively distended bile could also be considered. right biliary drain is in place. abdomen (supine & erect) port study date of findings: portable supine and left lateral decubitus images of the abdomen demonstrate a large amount of intra-abdominal free air. ther are multiple air-fluid levels, presumably secondary to the patient's ascites as demonstrated on previous ct. there is a percutaneous biliary drain in place. the visualized osseous structures are unremarkable. impression: large amount of intra-abdominal free air and free fluid. chest (portable ap) study date of findings: there has been placement of a nasogastric tube that extends well into the stomach. again there is generalized lucency in the abdomen, most likely reflecting free intraperitoneal gas. chest port. line placement study date of findings: in comparison with the earlier study of this date, the lucency in the upper abdomen is not well appreciated, though this may merely be due to differences in technique. otherwise, little change. brief hospital course: 76f with pmhx of afib, cad, chf, htn, pancreatic adenocarcinoma (stage iib at diagnosis in ) s/p whipple and adjuvant chemoradiation therapy now with metastatic disease, presenting to micu with respiratory failure s/p ercp. # shock: patient admitted to icu s/p ercp with hypotension and respiratory failure. etiology likely bowel perforation during ercp. patient arrived intubated and was volume resuscitated with iv fluids and started on vasopressors in the icu. an arterial line was placed to monitor blood pressure, which was subseuently removed due to cyanosis of her right hand. she was started on broad coverage antibiotics with vancomycin, zosyn and micafungin. she was able to be exctubated on . following discussion with family about goals of care, it was decided that she would not be reintubated or resuscitated. her blood pressure improved and she was subsequently weaned off of levophed. micafungin was discontinued on . patient discharged on vancomycin and zosyn as described in discharge paperwork. # pancreatic adenocarcinoma: patient is status post whipple for pancreatic ductal adenocarcinoma pt3 pn1 (7 of 12 lymph nodes involved), s/p chemotherapy and radiation therapy 3/. she was recently readmitted for obstructive jaundice just proximal to the level of the anastomosis. she had an ercp on that was unsuccessful and subsquently underwent ptc drainage. she was admitted this time for ercp, complicated by bowel perforation and free air in the abdomen. transaminitis stable to improved, with t bili down from 14 on discharge to 7.6 and alk phos to 113 from 205the surgical team was consulted who felt there was no further surgical interventions indicated. the goals of care were discussed with the patient and family who wish for the patient to return home. ir changed the drain size on monday to a 10 french to decreased the amount of leakage around the drain. they noted that the fluid leaking is ascitic fluid and not bile. they were also able to advance the tube past a stricture during this procedure. the patient will follow up with ir the week following discharge to have internal drainage system placed. patient to remain on antibiotics (vancomycin and zosyn last day ) on discharge (picc line in place) with care oriented towards comfort. # diastolic heart failure and history of mi: patient has history of diastolic heart failure on lasix at home. these medication were held given hypotension. patient did not appear to be in heart failure during admission. home aspirin 81 mg given. home medications restarted on discharge, except for propanolol given low heart rate. # atrial fibrillation: chads2 score of 3 (age, htn, chf). taken off coumadin for procedures and started on lovenox 60 sc bid. lovenox subsequently held in setting of shock. home amiodarone and propanolol held given hypotension. amiodarone and digoxin restarted on discharge, propanolol held. transitional issues: -ir appointments -vna on discharge, followed by hospice as requested by family -iv antibiotics as described in discharge planning medications on admission: medications: 1. amiodarone 200 mg po daily 2. loperamide 4 mg po bid 3. digoxin 0.25 mg po daily 4. fluoxetine 20 mg po daily 5. pantoprazole 40 mg po q24h 6. propranolol la 60 mg po daily 7. megestrol acetate 40 mg po prn poor appetite 8. furosemide 40 mg po daily 9. creon 12 2 cap po tid w/meals takes two in morning, one at lunch, and two at night 10. aspirin 81 mg po daily 11. acidophilus *nf* (l.acidoph & sali-b.bif s.therm;<br>lactobacillus acidophilus) 3 billion oral 12. enoxaparin sodium 60 mg sc bid 13. hydromorphone (dilaudid) 2 mg po q6h:prn severe pain 14. acetaminophen 650 mg po q6h:prn mild pain discharge medications: 1. morphine sulfate (concentrated oral soln) 2-5 mg po q1h:prn pain/ air hunger hold for sedation 2. trazodone 25 mg po hs:prn restlessness 3. creon 12 2 cap po tid w/meals takes two in morning, one at lunch, and two at night 4. amiodarone 200 mg po daily 5. aspirin 81 mg po daily 6. fluoxetine 20 mg po daily 7. pantoprazole 40 mg po q24h 8. vancomycin 1000 mg iv q 24h last day rx *vancomycin 1 gram 1000 mg iv q 24 hours disp #*3 unit refills:*0 9. loperamide 4 mg po bid:prn diarrhea 10. digoxin 0.25 mg po daily 11. hydromorphone (dilaudid) 2 mg po q6h:prn severe pain hold for oversedation or rr <12 12. acetaminophen 325-650 mg po q6h:prn pain please do not exceed 4 g/day 13. furosemide 40 mg po daily hold for sbp < 100 14. 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. 15. megestrol acetate 40 mg po prn poor appetite 16. docusate sodium (liquid) 100 mg po bid:prn constipation 17. enoxaparin sodium 60 mg sc q12h 18. piperacillin-tazobactam 4.5 g iv q8h last day rx *piperacillin-tazobactam 4.5 gram 4.5 grams every 8 hours disp #*9 unit refills:*0 discharge disposition: home with service facility: angels at home discharge diagnosis: primary: bowel perforation s/p ercp, pancreatic cancer secondary: hypotension, respiratory failure 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: mrs. , you were admitted to the icu after you had an ercp and developed low blood pressure and difficulty breathing due to a hole in your bowel. you were treated with blood pressure support, a breathing tube and antibiotics. you also had your biliary drain changed by interventional radiology on the day prior to discharge. you will follow up with interventional radiology doctors as described below. due to the serious nature of your various medical problems you have elected for more comfort focused care at home once your antibiotic course has completed. you should call hospice at once your antibiotics complete. medication changes: -please stop taking propanolol due to low blood pressure -please start vancomycin 1000 mg iv infusion every 24 hours (last day ) -please start piperacilli-tazobactam 4.5g iv q 8 hours (last day ) -please take colace 100 mg :prn constipation -please take all other medications as previously prescribed followup instructions: angiography: for internal biliary drainage system you will be called by the end of this week with an appointment. if you don't get a call, you may call to schedule. please call hospice when antibiotics complete to set up hospice care Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other percutaneous procedures on biliary tract Percutaneous hepatic cholangiogram Endoscopic retrograde cholangiopancreatography [ERCP] Central venous catheter placement with guidance Diagnoses: Acidosis Coronary atherosclerosis of native coronary artery Other postoperative infection Congestive heart failure, unspecified Unspecified essential hypertension Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Atrial fibrillation Perforation of intestine Other specified intestinal obstruction Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Accidental puncture or laceration during a procedure, not elsewhere classified Acute respiratory failure Other ascites Do not resuscitate status Obstruction of bile duct Chronic diastolic heart failure Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Malignant neoplasm of other specified sites of pancreas Accidental cut, puncture, perforation or hemorrhage during endoscopic examination Postoperative shock, septic |
allergies: no known allergies / adverse drug reactions attending: chief complaint: iph major surgical or invasive procedure: cerebral angiogram () history of present illness: mr is a 47 year old man with htn and daily etoh abuse who woke up at 7am who presents as a transfer from an osh following a seizure and an iph. today the patient was awoken around 7:20 am per his wife with worse ha of his life. he had been drinking all weekend, and the wife assumed it was a "hang over" and he called in to work. around noon he was sleeping on the couch and she took the kids to the pool. however, she forgot something and returned around 1 pm. she hurt a loud grunt and walked over to find her husband with his head deviated to the left and rigid. this lasted less than a minute and he was somnolent afterwards. ems was notified and he was brought over to and was reportedly lethargic but answering questions appropriately and a noncontrast head ct showed a 3 cm left temporal bleed. his vitals at that time were t 98.7 / pulse 127, resp 20, bp 144/81. patient was given keppra 1 g at osh, 2 mg of ativan and 5 mg of diazepam and 4 mg of zofran and transferred for further management. past medical history: broken leg sleep apnea? htn no surgeries social history: lives at home wiht his wife / works as a mechanic for a dodge dealership. he has three children 12, 11 and 6 who are all at home with him. he has a 15-20 pack year of tobacco. daily etoh 12-18 beers per day / does not recall history of dt's., smokes mj ocassionally, no coccaine and no heroin use. family history: does not believe there is a history of strokes or seizures physical exam: at admission: o: t: af bp:150 / 82 hr: 109 r 11 o2sats100 on 2 l heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no nuchal rigidity pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, no masses or organomegaly noted. extremities:warm and well perfused skin: no rashes or lesions noted. -mental status: alert, oriented x 2, stated it was "". attentive, able to name dow backward without difficulty. language is fluent with intact repetition and comprehension. normal prosody. there were no paraphasic errors. pt. was able to name both high and low frequency objects. able to read without difficulty. speech was not dysarthric. able to follow both midline and appendicular commands. pt. was able to register 3 objects and recall 0/3 at 5 minutes. the pt. had good knowledge of current events. there was no evidence of apraxia or neglect. calculation was intact (answers seven quarters in $1.75) . -cranial nerves: i: olfaction not tested. ii: left eye 5 mm to 3 mm, r eye 4 mm to 3mm and brisk. iii, iv, vi: eomi without nystagmus. 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. + asterixis bl, postural tremur (high freq, low amp) 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 plantar response was flexor bilaterally. . -coordination: no dysmetria on fnf or hks bilaterally. at transfer out of neuroicu: neuro: 1 mm of anisicoria (l > r), r hand may be slightly slower on rams than l hand. otherwise normal. pertinent results: labs on admission: 04:35pm wbc-11.2* rbc-4.88 hgb-14.9 hct-45.6 mcv-93 mch-30.5 mchc-32.6 rdw-13.4 04:35pm plt count-197 04:35pm pt-9.9 ptt-25.3 inr(pt)-0.9 04:35pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 04:35pm urea n-13 creat-0.7 04:43pm glucose-120* na+-139 k+-4.1 cl--99 tco2-26 . stroke risk factors: 04:22am blood triglyc-96 hdl-66 chol/hd-3.3 ldlcalc-136* 04:22am blood %hba1c-5.4 eag-108 . lft's 04:22am blood alt-24 ast-37 ld(ldh)-174 alkphos-45 totbili-0.7 . cta head and neck: impression: 1. left temporal parenchymal hemorrhage with associated small subdural hematoma. mass effect is mild with effacement of the left ambient cistern and compression of the ventricle of the left temporal . no intraventricular extension. 2. no evidence of vascular malformation or aneurysm. 3. cystic lucency in right anterior alveolar process of maxilla for which differential considerations include chronic abcess and clinical correlation should be performed. . portable cxr: findings: the lung volumes are normal. there is no evidence of pleural effusion or pneumothorax. normal size of the cardiac silhouette. in the lung parenchyma, there is no evidence of a mass or pulmonary nodules. the hilar and mediastinal contours are unremarkable. . repeat head ct: stable left temporal parenchymal hematoma with associated small subdural hematomas along the left tentorium and left temporal lobe, unchanged from . there is mild associated mass effect with no evidence of herniation. . mri/mrv: 1. left temporoparietal intraparenchymal hematoma, with left hemispheric and left tentorial subdural hematoma, not significantly changed. 2. no evidence of venous sinus thrombosis. 3. mild peripheral enhancement along the hematoma, likely represents reactive changes. no evidence of underlying mass lesion in this study. 4. opacification of the left mastoid sinus. please correlate clinically for signs of infection. cortical venous sinus thrombosis cannot be excluded in this study. . cerebral angiogram: preliminary report prior to discharge: mr. underwent diagnostic cerebral angiography which was unremarkable. there is no evidence of vascular malformation or aneurysm in the intracranial circulation. . labs at discharge: 05:30am blood wbc-6.3 rbc-4.30* hgb-13.3* hct-39.8* mcv-93 mch-30.9 mchc-33.4 rdw-12.4 plt ct-196 05:30am blood glucose-108* urean-9 creat-0.7 na-138 k-4.3 cl-102 hco3-29 angap-11 05:30am blood calcium-9.0 phos-3.7 mg-2.0 brief hospital course: mr. is a 47 year old man with htn and daily etoh abuse who woke up at 7am with worse ha of life at noon found by wife in a likely complex partial seizure with secondary generalization (loud vocalization left head deviation and then tonic rigidity) that self resolved in about 1 minute. brief icu course: patient was initially admitted to the neuroicu for close monitoring. neurological exam shows unequal, reactive pupils (l>r) but otherwise, nonfocal exam. noncontrast head ct showed a 3 cm left temporal bleed with mild surrounding vasogenic edema and localized mass effect, but no midline shift and basal cisterns intact. etiology for bleed unlikely to be hypertensive given location and only mildly elevated bp at osh. underlying structural lesion is possible, especially since there appears to be prominent vasculature on cta. venous thrombosis was also considered. . #left temporoparietal intraparenchymal hemorrhage: the patient underwent and mri/mrv to further delineate an underlying mass/lession (see full report above). there was no evidence of venous sinus thrombosis or mass, and the previously identified bleed was deemed stable. our colleagues in neurosurgery were consulted and a cerebral angiogram was performed but did not identify any pertinent vascular abnormalities. the patient due to initial presentation of seizure (likely secondary to temporoparietal bleed) was placed on keppra 1000mg without any notable seizure events. he will continue this as an outpatient. the patient had his stroke risk factors evaluated, hba1c wnl, and ldl of 136. he did not require starting of a statin as this has been shown to increase the risk of bleeding. the patient did have noticeable memory deficits on cognitive evaluation with occupational therapy. it has been recommended to the patient to schedule an appointment with dr. (behavioral neurology) in order to receive a full cognitive evaluation prior to returning to work. as to the etiology of the stroke, it is possible that is htn related although the location is not necessarily specific for this. patient will have a follow up mri in about one month, and follow-up with neurosurgery and neurology to help delineate if there is another underlying lesion that was not identified on current studies. #etoh: per report from wife patient had been drinking up to 18 beers/day. patient was placed on ciwa while in the unit and received only minimal doses. he clinically did not go into withdrawl. the ciwa was kept upon transfer to the floor but he did not require any bzd's. lft's were wnl, with no transminitis, and liver synthetic function was normal. patient was given thiamine, folic acid, and multivitamin while in the hospital. #htn: patient initially had goal sbp<160 with prn hydralazine. he was on lotrel (5 amlodipine, 40 benezepril) at home. he had this restarted upon arrival to the floor and acheived good control with this. he will continue his home lotrel as he received #tobacco use: patient has been a lifelong smoker. we discussed that this was a risk factor for stroke. he was given a nicotine patch while in hospital. he will discuss cessation options (including welbutrin or chantix) with his pcp. was given a prescription for nicotine patches. # social issues: the patient's wife was uncomfortable coping before baseling and more worried after her husband's stroke. social work was consulted and helped provide resources to mr. regarding alcohol cessation, in addition the patient's wife was given support resources as well. transitional issues: 1) continue keppra until follow up with neurology (dr. 2) repeat mri in about 1 month, f/u with nsurg 3) continued monitoring of blood pressure control per pcp 4) discussion of continued tobacco cessation with pcp medications on admission: lotrel (almodipine 5, benzepril 40) discharge medications: 1. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*0* 2. amlodipine-benazepril 5-40 mg capsule sig: one (1) capsule po once a day. 3. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily) as needed for nicotine withdrawal: apply when you feel the craving for cigarette. do not smoke with patch. disp:*60 patch 24 hr(s)* refills:*0* 4. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours) as needed for pain: do not take more than 4000mg in 24 hours. . disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: left temporal intraparenchymal hemorrhage secondary diagnosis: hypertension, tobacco use discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you at . you were sent to the hospital after having had a seizure and a terrible headache. you were admitted to the neurology service, and a scan was performed of your head that showed a bleed in the left side of your brain. while it is still unclear exactly what caused the bleed, the most likely cause is your high blood pressure. you had a study of your blood vessels of the brain which was reassuring, but did not help to reveal a potential cause for the bleed in your brain. your seizure that you had was most likely due to the bleed in the brain. for this reason we are starting you on an anti-seizure medication known as keppra. you will need to continue this until your follow up with the neurology team (dr. . please see below for your scheduled appointment. because you had a seizure, it will be important that you do not drive for the next 6 months. in addition to this please avoid dangerous activities such as climbing. also, do not take baths or swim as you are at an increased risk for drowning if you were to have a seizure. in addition, we discussed with you the risk factors for your bleed in the brain. there are several things you can do to reduce your risk of stroke. you should continue to take your blood pressure medication, and reduce your sodium intake to help control your blood pressure. in addition, smoking is a large risk factor for having a stroke, and if you were to quit it would greatly reduce your risk. for this reason we are presribing you a patch known as the nicotine patch to help you fight off the craving. do not smoke while you have the nicotine patch in place. there are other medications as well that can be used to help you quit smoking (bupropion and welbutrin), you should discuss this with your primary care provider. , sometimes heavy drinking of alcohol can cause problems with your blood clotting. the social work team has provided you options about certain programs that can help you with your alcohol intake. social work has also provided you with information on programs to help with your alcohol use, in addition, for your wife to have support as well. also, due to the location of your bleed you were noted to have issues associated with your memory. you were seen by occupational therapy who has recommended a full neurocognitive evaluation before you return to work. please call to setup an appointment with dr. , the contact information will be provided below. also, the neurosurgery team would like for you to follow-up and get a repeat scan of your head in a month. please see below. we made the following changes to your medications: start keppra 1000mg take one tablet by mouth twice daily (continue to take this until your follow-up with dr. start tylenol (acetaminophen) take one to two 500mg tablets every 8 hours as needed for headache start nicotine patch (transdermal) 14mg apply once every 24 hours as needed for cigarette craving followup instructions: you will need to follow-up with your primary care provider weeks. please call dr. on monday to setup an appointment. you should discuss your smoking cessation and your blood pressure medication. the phone number is . you need to follow up with dr. from neurosurgery in 1 month. you will need an mri/mra prior to this appt. appt can be made by calling . you will need a formal neuro-cogntive evaluation to evaluate for your safety to return to work. please call to setup an appointment with dr. at (. department: neurology when: wednesday at 2:00 pm with: , md, phd building: sc clinical ctr campus: east best parking: garage md Procedure: Arteriography of cerebral arteries Diagnoses: Tobacco use disorder Unspecified essential hypertension Other convulsions Intracerebral hemorrhage Unspecified sleep apnea Cerebral edema Alcohol abuse, continuous |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p motor vehicle crash major surgical or invasive procedure: exploratory laparotomy () . right lower extremity procedures including: () 1. irrigation and debridement down to and inclusive of bone open tibia shaft fracture. 2. fasciotomies right leg. 3. placement of external fixator across tibia. 4. placement of the external fixator across femur. 5. closed reduction with traction of left tibia fracture. 6. closed reduction with traction of right femur. . () 1. removal of external fixation, right tibia. 2. irrigation and debridement open fracture, right tibia down to and including some of the bone. 3. intermedullary nailing of right tibia with synthes pin #10 x 345 mm nail. 4. removal of external fixator, right femur. 5. intramedullary nail fixation with gamma nail #11 x 125 x 400 mm, 90 mm lag screw. . () 1. closure right lower extremity fasciotomies both medially and laterally. history of present illness: 17yo m unrestrained passenger in high speed auto crash with prolonged extrication. transfered to from referring hopsital tachycardic to the 150's and hypotensive despite having received 9 liters of ivf, 4u prbc's, and ffp. as the fast examination was positive and free-fluid was noted in the abdomen on ct the patient was taken to the operating room emergently for an exploratory laporatomy. past medical history: none social history: lives with parents. 2 ppd smoker, etoh, no drugs family history: noncontributory physical exam: upon admission: 134 15 100% cmv 50%/500/15/5 gen: intubated sedated heent: partial thickness laceration to upper lip ~2cm long on left face lateral to philtral columns. crosses the white roll. full thickness laceration to lower lip near the midline through mucosa and skin. violates the border. forehead lac closed with staples wound is non-draining, well approximated. small hematoma present. no periorbital echymosis/edema. midface with moderate instability. neck: cervical collar cor: tachy chest: clear abd: soft extr: deformity rle pertinent results: 03:37pm glucose-110 urea n-8 creat-0.7 sodium-138 potassium-4.1 chloride-111* total co2-24 anion gap-7* 03:37pm calcium-7.0* phosphate-4.0 magnesium-1.5 03:37pm wbc-6.1 rbc-3.42*# hgb-10.9*# hct-29.7* mcv-87 mch-31.8 mchc-36.7* rdw-15.6* 03:37pm plt count-113* 03:37pm pt-16.9* ptt-38.8* inr(pt)-1.5* findings: no previous studies available for a direct comparison. there is a fracture involving the proximal femur with multiple fracture lines extending from the lesser trochanter as well as to the proximal to mid diaphysis of the right femur. external fixation pins are seen within the proximal femur and within the distal femur. a single frontal view of the lower leg shows a compound fracture along the fibula as well as a complex fracture involving the mid shaft of the tibia. external fixation hardware limits evaluation of the entire tibia. echocardiography report done at 9:00:00 am left atrium - long axis dimension: 2.4 cm <= 4.0 cm left atrium - four chamber length: 4.3 cm <= 5.2 cm left atrium - peak pulm vein s: 0.4 m/s left atrium - peak pulm vein d: 0.5 m/s left atrium - peak pulm vein a: 0.3 m/s < 0.4 m/s right atrium - four chamber length: 4.6 cm <= 5.0 cm left ventricle - septal wall thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.3 cm <= 5.6 cm left ventricle - systolic dimension: 2.9 cm left ventricle - fractional shortening: 0.33 >= 0.29 left ventricle - ejection fraction: >= 60% >= 55% aorta - sinus level: 3.2 cm <= 3.6 cm aorta - ascending: 2.4 cm <= 3.4 cm aortic valve - peak velocity: 1.0 m/sec <= 2.0 m/sec mitral valve - e wave: 0.5 m/sec mitral valve - a wave: 0.4 m/sec mitral valve - e/a ratio: 1.25 mitral valve - e wave deceleration time: 242 ms 140-250 ms tr gradient (+ ra = pasp): *33 mm hg <= 25 mm hg findings left atrium: normal la and ra cavity sizes. left ventricle: normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). no resting lvot gradient. no vsd. right ventricle: mildly dilated rv cavity. rv function depressed. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: normal mitral valve leaflets with trivial mr. no mvp. normal mitral valve supporting structures. normal lv inflow pattern for age. tricuspid valve: normal tricuspid valve leaflets. mild tr. pulmonic valve/pulmonary artery: pulmonic valve not visualized. no ps. physiologic pr. pericardium: no pericardial effusion. conclusions the left atrium 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. the right ventricular cavity is mildly dilated with depressed free wall contractility. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is no pericardial effusion. impression: mildly dilated and hypokinetic right ventricle. this may be due to right ventricular contusion. normal left ventricular systolic function. no lvot obstruction or significant valvular lesion seen. impression: no dvt in both lower extremities. tib/fib xray 1. right grade 3 open tibia shaft fracture, status post four-compartment fasciotomy. 2. right closed femoral shaft fracture. 3. left lateral leg wound 4. complex fascial laceration. information from the patient's chart indicates that he has a full thickness laceration to the lower lip near the midline through the mucosa and skin, and there is concern for facial fractures given mechanism of injury. comparison: none. technique: contiguous axial images were obtained through the paranasal sinuses, facial bones, and mandible. coronal reformatted images were prepared. findings: no definite facial fractures identified. there is mucosal thickening and aerated debris within ethmoid sinuses bilaterally, and mucosal thickening of the maxillary sinuses, left greater than right, with small air-fluid levels in the maxillary sinuses. however, no underlying facial fracture is identified. there are also air-fluid levels within the sphenoid sinus. there is absence of the left ninth left upper frontal teeth (9, 10, and 11) (central and lateral incisors). the nasal septum is deviated slightly toward the left. there is also slight mucosal thickening of the frontal sinuses bilaterally. impression: 1. no fracture identified. 2. absence of the left central and lateral incisors. please correlate clinically to determine whether this is acute. 3. mucosal thickening of all sinuses, with small air-fluid levels in the maxillary and sphenoid sinuses. however, no underlying fracture is identified. this was discussed with dr. on at 11:45 a.m. brief hospital course: he was admitted to the trauma service. because he was in shock upon arrival he was taken immediately to the operating room for an exploratory laparotomy which was negative. orthopedics was consulted because of his extremity fractures; he was taken to the operating room on for irrigation and debridement down to and inclusive of bone open tibia shaft fracture on right; fasciotomies right leg; placement of external fixator across tibia placement of the external fixator across femur, right; closed reduction with traction of tibia fracture; closed reduction with traction of right femur. there were no intraoperative complications. he was taken back to the operating room by orthopedics on for removal of external fixation, right tibia; irrigation and debridement open fracture, right tibia down to and including the bone; intermedullary nailing of right tibia with synthes pin #10 x 345 mm nail; removal of external fixator, right femur; intramedullary nail fixation with gamma nail #11 x 125 x400 mm, 90 mm lag screw. on he was again taken back to the operating room for closure right lower extremity fasciotomies both medially and laterally. because of his multiple facial injuries there was concern for fractures. plastic surgery was consulted who initially requested ct scan of the face but because of hemodynamic instability the facial ct was deferred until . no fractures were identified. his extensive lip laceration was irrigated and sutured. postoperatively he was taken to the trauma icu where he remained sedated and vented. his tachycardia persisted. he underwent an echo which revealed ef >55% with mildly dilated and hypokinetic right ventricle which was likely due to right ventricular contusion. normal left ventricular systolic function. no lvot obstruction or significant valvular lesion was seen. cardiology was consulted and recommended continued beta blockade. he was eventually weaned and extubated and would later be transferred to the regular nursing unit. his tachycardia persisted requiring several trigger events. cardiology involved the eps service who recommended to continue with the lopressor and recommended adding flecainide. the tachycardia did improve with this regimen. he will require outpatient follow up with clinic for further studies. his heparin was changed to lovenox for which he will continue post discharge until discontinued by orthopedics in follow up. social work was closely involved with patient and his family throughout his entire hospital stay. physical and occupational therapy were consulted and worked with him regularly to prepare him for home as there was no insurance in place and so rehab placement was not a feasible option. he made significant gains and was eventually cleared for safe discharge to home with his parents. discharge medications: 1. oxycodone 5 mg tablet sig: 2-3 tablets po q3h (every 3 hours) as needed for pain. disp:*100 tablet(s)* refills:*0* 2. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 3. enoxaparin 40 mg/0.4 ml syringe sig: 0.4 ml's subcutaneous daily (daily) for 4 weeks. disp:*30 ml's* refills:*0* 4. flecainide 50 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*2* 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 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. milk of magnesia 800 mg/5 ml suspension sig: thirty (30) ml's po twice a day as needed for constipation. 9. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 10 days. disp:*40 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: s/p motor vehicle crash injuries: - right tibial fracture (open) - right femoral fracture (closed) - left lateral leg wound - complex lip laceration - cardiac contusion with avnrt - right middle lung contusion - non-operative facial fractures - dental fractures & tooth loss discharge condition: stable vital signs. pain controlled with medication. tolerating a regular diet. discharge instructions: you sustained fractures to your right leg for which you underwent multiple operations. per these injuries, please return to the emergency department or see your own doctor right away if any problems develop, including the following: * swelling, pain or redness getting worse. * pain not much better within 3 days. * fingers or toes become pale (whiter) or become dark or blue. * numbness, tingling or coldness of your fingers or toes. * loss of movement. * rubbing sensation, burning or soreness of your skin, especially under a cast. * chest pain, shortness of breath or trouble breathing. * fever or shaking chills. * headache, confusion or any change in alertness. * for any other concerning symptoms that are concerning to you in the course of your stay, you were diagnosed with an abnormal heart rhythm and were treated for it. please call your doctor or return to the emergency room if any of the following problems develop: * are having new symptoms that your doctor doesn??????t know about or your palpitations get worse * you have trouble breathing while resting * you have new or worsening swelling in your feet or ankles * you have any questions or concerns about your illness or medicine * chest pain, tightness, or pressure that lasts more than a few minutes * feeling very short of breath * feeling faint, or too dizzy to stand up * sudden onset of weakness or numbness (loss of feeling) in your arms or legs * watch carefully for signs of infection at your surgical sites and wounds: redness, warmth, increasing pain, swelling, drainage of pus (thick white, yellow or green liquid) or fevers. * if you have numbness, pins-and-needles or pain in the area of your injury. followup instructions: please follow-up with the following departments: - orthopedic surgery within 1 week following discharge at ( with , np for removal of your sutures and staples. - plastic surgery within 1 week following discharge at (. - trauma surgery in around 2 weeks following discharge at (. - follow up with your primary dentist for your teeth issues; you will need to call for an appointment. - you have indicated that you would like to follow up with an electrophysiologist closer to your home. if you'd like you may follow up with cardiac electrophysiology here at in weeks at ( with dr. . Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Exploratory laparotomy Arterial catheterization 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 Open reduction of fracture with internal fixation, femur Suture of laceration of lip Closure of skin and subcutaneous tissue of other sites Closed reduction of fracture without internal fixation, tibia and fibula Other suture of muscle or fascia Closed reduction of fracture without internal fixation, femur Removal of implanted devices from bone, tibia and fibula Application of external fixator device, femur Other division of soft tissue Removal of implanted devices from bone, femur Diagnoses: Acidosis Alcohol abuse, unspecified Open wound of forehead, without mention of complication Other specified cardiac dysrhythmias Closed fracture of subtrochanteric section of neck of femur Traumatic compartment syndrome of lower extremity Traumatic shock Closed fracture of shaft of femur Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle Open fracture of shaft of tibia alone Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication Contusion of heart without mention of open wound into thorax Open wound of lip, complicated Loss of teeth due to trauma |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: intracranial hemorrhage major surgical or invasive procedure: none history of present illness: the pt is a 58 year-old l-handed male who presents with new onset iph. history taken over the phone from wife and daughter. around 7 pm yesterday evening the patient some weakness in his left arm, however, he did not think much of it and went to sleep. he then awoke around 11 pm having to use the restroom. at that time he was unable to walk with profound weakness in his left lower and upper extremities. at that time his wife called an ambulance. patient was then taken to an osh. per report patient had a seizure in transit, however no discription of the event is available. patient was then intubated for unresponsiveness and was found to have an initial sbp of 290. initial nchct demonstrated a large intraparenchymal hemorrhage and patient was transferred to for further management. patient was reportedly given the following medications at the osh: vec 10 ivp atomidate 10 ativan 2 mg protonix 40 mg hydralazine 10 lopressor clindamycin 600 mg ivpb fosphenytoin 1 gram propofol gtt patient has a pmh of renal disease (no dialysis), dm, htn, anemia, hep c. patient was recently released from prison 4 weeks ago after 5 years of incarceration. patient has not taken any of his medications since being released from prison. past medical history: renal failure dm2- non insulin dependent, had been on glucophage/metformin htn anemia hep c social history: has past etoh, tobacco, and drug history including cocaine prior to prison. formerly worked in construction, no longer working. family history: unknown physical exam: vitals: t:97.8 p:74 r:19 bp:130/89 sao2:98% general: awake, cooperative, nad. heent: nc/at, neck: supple, no nuchal rigidity pulmonary: lungs cta bilaterally cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, no masses or organomegaly noted. extremities: warm well perfused skin: no rashes or lesions noted. neurologic: -mental status: patient unable to open eyes to noxious stimuli -cranial nerves: brain stem reflexes ii: perrl 3 to 2mm and brisk. bl dolls was not performed at this time until neck injury ruled out v/vii: + corneal reflex bilateral. ix, x: + gag / motor: r upper and lower extremity spontaneous movement and withdrawl from noxious. left upper and lower extremity with minimal withdrawal to noxious. -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 crossed adductor reflex on left patellar plantar response was flexor bilaterally. -coordination:unable to assess -gait: unable to assess pertinent results: laboratory studies: 08:15am blood wbc-12.6* rbc-4.17* hgb-12.4* hct-36.7* mcv-88 mch-29.8 mchc-33.9 rdw-15.8* plt ct-234 08:15am blood neuts-89.9* lymphs-6.6* monos-2.1 eos-0.7 baso-0.6 08:15am blood pt-13.6* ptt-25.4 inr(pt)-1.2* 03:50pm blood glucose-154* urean-57* creat-4.2* na-140 k-5.0 cl-106 hco3-22 angap-17 08:15am blood alt-15 ast-25 ck(cpk)-649* alkphos-124 totbili-0.3 cardiac enzymes: 03:50pm blood ck(cpk)-485* 11:57pm blood ck(cpk)-429* 05:10am blood ck(cpk)-458* 03:50pm blood ck-mb-5 ctropnt-0.12* 11:57pm blood ck-mb-4 ctropnt-0.12* 09:37am blood ctropnt-0.10* 09:37am blood albumin-3.4* 09:37am blood triglyc-208* hdl-35 chol/hd-4.1 ldlcalc-66 cholest-143 03:53am blood %hba1c-6.5* eag-140* 09:37am blood pth-340* 09:00am urine color-yellow appear-slhazy sp -1.021 09:00am urine blood-lg nitrite-neg protein-500 glucose-tr ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg 09:00am urine rbc-* wbc-* bacteri-mod yeast-none epi-0 09:00am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-pos amphetm-neg mthdone-neg micro: urine cx negative discharge laboratories: 03:53am blood wbc-9.8 rbc-3.27* hgb-9.7* hct-29.1* mcv-89 mch-29.7 mchc-33.3 rdw-15.7* plt ct-187 imaging: head ct : unchanged right parietal lobar hemorrhage. mri/a head and neck 1. stable appearance of the right frontal and parietal intraparenchymal hemorrhage with surrounding vasogenic edema. stable ventricular size. no evidence of underlying vascular malformation on this non-contrast study. however, when the patient is able, additional post-contrast imaging as well as cta can be considered to further evaluate for underlying lesion/vascular malformation. 2. foci of susceptibility artifact in the right cerebellum, left subcortical white matter, right temporal cortex/subcortical white matter, could represent areas of microhemorrhage, cavernomas, or amyloid angiopathy. no calcifications were noted on prior ct in these areas. 3. unremarkable non-contrast mra of the head and neck. of note, the mra of the head did not entirely cover the area of hemorrhage. tte mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mild mitral regurgitation with normal valve morphology. mild pulmonary artery systolic hypertension. dilated thoracic aorta. brief hospital course: neuro: mr was transferred from an outside hospital for a right parietal intracranial hemorrhage. he was intubated before being transferred. he also had a witnessed gtc seizure at osh, and was started on phenytoin. he was admitted into the icu and was placed on a nicardipine gtt for blood pressure control. in the icu was extubated the next day without problems. had a ct scan of the head which demonstrated a stable hemorrhage. he was placed on po medications for blood pressure management amlodipine and labetalol. he was also seen by nephrology for his acute on chronic renal failure. the etiology of his hemorrhage as well as his acute kidney injury was due to hypertensive emergency as a result of primary htn with medication non-compliance and cocaine abuse. troponin were also measured and were stable. he had an uncomplicated course in the icu and was transferred to the floor for further care. for seizure secondary ppx, patient was initially continued on phenytoin, and then switched to keppra for easier compliance and fewer side effects. no further seizure activity. on the floor, blood pressure medications were titrated for goal sbp<160 and dbp<110. he may restart asa 81 mg on . he will follow up in stroke clinic, he will need a pcp . patient was treated with insulin sliding scale rather than oral hypoglycemics given renal failure. he will follow up with renal outpatient. medications on admission: none discharge medications: 1. insulin regular human 100 unit/ml solution sig: per sliding scale injection asdir (as directed). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for loose stool. 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain or temp > 100.0. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 8. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 9. calcium carbonate 200 mg (500 mg) tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day). 10. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 11. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 12. levetiracetam 750 mg tablet sig: one (1) tablet po bid (2 times a day). 13. labetalol 300 mg tablet sig: one (1) tablet po three times a day. discharge disposition: extended care facility: hospital - discharge diagnosis: right parietal intraparenchymal hemorrhage hypertension diabetes mellitus acute on chronic renal insufficiency discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. neuro status: left hemiparesis and hemisensory deficit, tactile extinction, no visual field cut. discharge instructions: you were admitted with a brain hemorrhage caused by cocaine and high blood pressure. you were monitored carefully in the intensive care unit, and remained stable. you were treated for high blood pressure, and you need to take your medications every day to prevent more strokes. do not use cocaine or other drugs, these can cause more strokes and hemorrhages which are often life threatening. you should start taking a baby aspirin in 10 days. you also had kidney injury, and you will need to follow up with a kidney specialist. followup instructions: ** you will need to establish a primary care physician and obtain referrals for these appointments. provider: , m.d. phone: date/time: 2:00 provider: , md phone: date/time: 2:30 clinical center Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Arterial catheterization Diagnoses: Hypocalcemia Intermediate coronary syndrome Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of other infectious and parasitic diseases Cocaine abuse, unspecified Intracerebral hemorrhage Chronic kidney disease, unspecified Cerebral edema Personal history of noncompliance with medical treatment, presenting hazards to health Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified Other specified hemiplegia and hemiparesis affecting dominant side |
allergies: lisinopril attending: chief complaint: he presented with exertional shoulder pain and was found to have significant st segment depression on stress test with inferior ischemia. he underwent cardiac catheterization which demonstrated triple-vessel coronary artery disease. major surgical or invasive procedure: coronary artery bypass grafts x3(lima-lad,sv-ri,sv,om2) history of present illness: mr. is a 62-year-old man with a history of coronary artery disease that has been medically managed. he presented with exertional shoulder pain and was found to have significant st segment depression on stress test with inferior ischemia. he underwent cardiac catheterization which demonstrated triple-vessel coronary artery disease. he was then referred for surgical revascularization. past medical history: htn, cad, syndrome, fx l clavicle, ruptured l achilles tendon, r dental implant social history: very active 62 yo male who runs 21 miles/week. non-smoker occas etoh physical exam: discharge vs t 98.5 hr 54sr bp 107/56 rr 18 o2sat 93%ra gen nad neuro a&ox3, nonfocal exam cv rrr, sternum stable. incision cdi pulm cta-bilat abdm soft, nt/+bs ext warm well perfused. trace edema bilat. left svg site w/steri strips pertinent results: 02:36pm pt-14.4* ptt-27.0 inr(pt)-1.2* 02:36pm plt count-185 02:36pm wbc-8.3 rbc-2.84*# hgb-9.3*# hct-25.4*# mcv-89 mch-32.8* mchc-36.7* rdw-13.6 02:36pm glucose-133* lactate-1.6 na+-135 k+-4.7 cl--107 04:15pm wbc-8.8 rbc-3.35* hgb-10.9* hct-29.4* mcv-88 mch-32.4* mchc-37.0* rdw-13.8 04:15pm urea n-15 creat-0.9 chloride-113* total co2-24 04:21pm glucose-74 na+-138 k+-4.2 12:35pm blood wbc-8.7 rbc-3.17* hgb-10.4* hct-28.1* mcv-89 mch-32.9* mchc-37.0* rdw-14.4 plt ct-170 12:35pm blood plt ct-170 08:04am blood pt-13.8* ptt-28.5 inr(pt)-1.2* 12:35pm blood glucose-94 urean-20 creat-1.1 na-140 k-4.3 cl-100 hco3-31 angap-13 , (complete) done at 12:33:55 pm final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 62 m hgt (in): bp (mm hg): / wgt (lb): hr (bpm): bsa (m2): indication: abnormal ecg. chest pain. coronary artery disease. icd-9 codes: 402.90, 440.0 test information date/time: at 12:33 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 #: 2009aw2-: machine: echocardiographic measurements results measurements normal range left ventricle - ejection fraction: 45% to 55% >= 55% findings left atrium: normal la size. good (>20 cm/s) laa ejection velocity. no thrombus in the laa. right atrium/interatrial septum: normal ra size. 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 and cavity size. mildly depressed lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. simple atheroma in aortic root. normal ascending aorta diameter. simple atheroma in ascending aorta. normal aortic arch diameter. simple atheroma in aortic arch. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: three aortic valve leaflets. mildly thickened aortic valve leaflets. no as. no ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: trivial/physiologic pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. the patient received antibiotic prophylaxis. the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope. no tee related complications. patient. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions pre-cpb:1. the left atrium is normal in size. no thrombus is seen in the left atrial appendage. no atrial septal defect is seen by 2d or color doppler. 2. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is mildly depressed (lvef= 45 %). 3. right ventricular chamber size and free wall motion are normal. 4. there are simple atheroma in the aortic root. there are simple atheroma in the ascending aorta. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 5. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. 6. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. 7. there is a trivial/physiologic pericardial effusion. dr. was notified in person of the results. post-cpb: on infusion of phenylephrine. in sinus rhythm. preserved biventricular systolic function post cpb. trivial mr. aortic contour is preserved post decannulation. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician , m 62 medical condition: 62 year old man with s/p cabg reason for this examination: s/p ct removal ? ptx final report history: status post cabg with chest tube removal. findings: in comparison with the earlier study of this date, the left chest tube has been removed. no convincing evidence of pneumothorax. persistent opacification at the left base. dr. approved: 5:08 pm brief hospital course: on mr was a direct admit to the operating room for coronary bypass surgery. at that time he had cabg x3 with left internal mammary to left anterior descending artery, saphenous vein to ramuus and saphenous vein to obtuse marginal. he tolerated the operation well and was transferred to the cardiac icu in stable condition. he was hemodynamically stable i and was extubated shortly after arriving in the icu. on pod1 he was transferred to the step down floor for continued post-operative care. he progressed well over the next several days, all tubes, drains and wires were removed according to cardiac surgery protocol. his activity was advanced and on pod5 he was discharged home with vna medications on admission: lipitor 40', ramipril 10', cardizem 120', asa 81' discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. 5. hydromorphone 2 mg tablet sig: 1-2 tablets po every 4-6 hours as needed. disp:*50 tablet(s)* refills:*0* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily): 400mg qd x7 days then 200mg qd. disp:*35 tablet(s)* refills:*0* discharge disposition: home with service facility: hospice and vna discharge diagnosis: coronary artery disease s/p coronary artery bypass grafts hyperlipidemia syndrome hypertension discharge condition: good discharge instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed followup instructions: dr. in 3 weeks @ dr. in weeks () dr. in 3 weeks please call for appointments Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Atrial fibrillation Other and unspecified hyperlipidemia Other and unspecified angina pectoris 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 Disorders of bilirubin excretion |
allergies: sulfa (sulfonamide antibiotics) / bactrim / lipitor attending: chief complaint: shortness of breath major surgical or invasive procedure: right mid-line placement history of present illness: 77 y o f with bronchiectasis, severe copd with baseline 2l 02 requirement, tracheobronchomalacia s/p y-stent admitted to micu with influenza a on . as per patient, her symptoms began on with sore throat, headache, cough and sob. denied any fevers, chills, myalgias or other systemic symptoms at the time. in ed, initial vs: 98.5, 71, 127/70, r=38, 96% 2lnc. pt received methyprednisolone 125 mg x 1, albuterol and ipratropium nebs x1, ativan, and iv ciprofloxacin. she was placed on bipap 10/5 with fio2 30% and sent to micu. patient was unable to tolerate bipap secondary to inability to clear upper airway secretions; but was able to maintain saturations on nasal cannula alone although she remained tachypnic. in micu, the patient was started on oseltamivir for influenza and azithromycin. micu course was complicated by low urine output with a fena < 1% which resolved with 500 cc bolus. also found to have dysuria with positive urinalysis: started empirically on ciprofloxacin prior to transfer to floor. on transfer to the floor, vs 98.2 146/77 67 18 96% on ra. still complains of dyspnea greated than baseline, although notes an improvement in initial symptoms of headache and sore throat. her cough is at baseline and she denies any increase in purulence or quantity of sputum. review of systems is otherwise negative besides that noted in hpi. past medical history: copd/tbm s/p y stent placement . 3 other admissions and 9 therapeutic bronchoscopies since y stent placement. bronchiectasis htn gerd hypothyroid hyperlipidemia anxiety recurrent uti anemia hysterectomy at 33yo from anemia b/l cataract sx total knee replacement 2yrs ago bladder sling social history: lives alone at home, attends pulmonary rehab 3x/week. has 4 children, all live locally. worked as a store clerk, retired 3 years ago, volunteered at until 3 mo ago. drinks wine infrequently. no h/o tobacco or illicit drug use. husband smoked until ~22 yrs ago. daughter is a nurse. reports decreased appetite and enthusiasm for eating in past year, markedly decreased activity and exercise tolerance, weight loss. family history: mother had mi, brother died from heart disease and had minor stroke. no family history of lung disease/copd/asthma. 4 children and 7 grandchildren are generally healthy; grandaughter has spherocytosis and was just hospitalized for 5 days with flu physical exam: general: thin, elderly female in mild respiratory distress heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. purses lips during expirations neck supple, no lad, no thyromegaly. cardiac: distant heart sounds. regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: dyspneic with speech; using accessory muscles of respiration with substernal retractions and scalene muscle use; scattered rhonchi, limited air movement bilaterally. abdomen: nabs. soft, nt, nd. no hsm extremities: no clubbing/ cyanosis/ edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 grossly intact. psych: listens and responds to questions appropriately, pleasant pertinent results: 11:42pm urine blood-tr nitrite-neg protein-75 glucose-neg ketone-50 bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 11:42pm urine rbc-0-2 wbc-* bacteria-none yeast-none epi- 06:50pm type- po2-54* pco2-60* ph-7.32* total co2-32* base xs-2 comments-green top 05:05pm glucose-136* urea n-17 creat-0.8 sodium-132* potassium-4.2 chloride-94* total co2-28 anion gap-14 05:05pm wbc-12.5* rbc-4.98 hgb-13.3 hct-41.3 mcv-83 mch-26.7* mchc-32.2 rdw-13.6 05:05pm neuts-73.0* lymphs-23.4 monos-2.7 eos-0.5 basos-0.3 05:05pm plt count-238 05:05pm pt-12.3 ptt-27.1 inr(pt)-1.0 06:11am urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-lg 06:11am urine rbc-8* wbc-245* bacteri-mod yeast-none epi-2 transe-1 06:11am urine wbc clm-rare mucous-rare microbiology data: positive for influenza a viral antigen. positive for swine-like influenza a (h1n1) virus by rt-pcr at state lab. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). 4+ (>10 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and chains. respiratory culture (final ): heavy growth commensal respiratory flora. pseudomonas aeruginosa. moderate growth. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 16 i ceftazidime----------- 32 r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem------------- 1 s piperacillin/tazo----- =>128 r tobramycin------------ <=1 s 6:11 am urine source: cvs. **final report ** urine culture (final ): culture workup discontinued. further incubation showed contamination with mixed skin/genital flora. clinical significance of isolate(s) uncertain. interpret with caution. escherichia coli. >100,000 organisms/ml.. presumptive identification. warning! this isolate is an extended-spectrum beta-lactamase (esbl) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by esbl-producing species. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- r ceftriaxone----------- r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r ekg: baseline artifact is present. sinus rhythm. the axis is indeterminate. non-specific st-t wave changes. compared to the previous tracing voltage has improved in the limb leads. cxr: the lungs are massively hyperexpanded but stable from prior exam. this likely indicates underlying obstructive lung disease. no consolidation or edema is evident. there is a markedly tortuous aorta with calcified plaque at the arch. the cardiac silhouette is within normal limits for size. no effusion or pneumothorax is seen. there is blunting of the right costophrenic angle, presumably due to scarring. the osseous structures are grossly unremarkable. impression: underlying copd. no acute pulmonary process cxr: cardiac size is normal. the aorta is tortuous. the lungs are hyperinflated but clear. there is no evidence of pneumothorax. if any, there is a small left pleural effusion. cardiomediastinal contours are unchanged, with cardiac size top normal. the patient has known bibasilar and right middle lobe bronchiectasis. brief hospital course: mrs. is a 77 yo woman with severe copd, severe bronchiectasis, tracheobronchomalacia s/p y-stent placed who was admitted with h1n1 influenza on , stabilized in the micu on bipap for a few hours and transferred to the floor on . 1. influenza a: confirmed h1n1 by state lab. pt received a course of 5 day course of oseltamivir 75 mg beginning . pt was placed on droplet precautions and given symptomatic relief prn. 2. sob/respiratory distress: throughout her stay, pt sat in the tripod position and breathed with pursed lips, with varying amounts of superimposed respiratory distress. her cough was typically productive of green sputum. pt received home nebs (ipratropium, levalbuterol, acetylcysteine) as well as guaifenesin. her copd exacerbation was treated with 5 days of prednisone 40 mg followed by a prolonged prednisone taper as well as 5 days of azithromycin. she received chest pt regularly beginning on . her respiratory status fluctuated throughout her stay, with respiratory rate ranging from 24-40. hco3 was in the high 20s on admission and the low to mid 30s through most of the hospitalization, climbing as high as 37 on before decreasing to 33 by discharge. abg on showed a mild metabolic alkalosis (ph 7.46, pco2 49) likely consistent with acutely improved ventilation overlying chronic metabolic compensation for respiratory acidosis. respiratory status on discharge had not yet improved to her baseline: saturating 94-96% on 3lnc. 3. uti: history of frequent utis. complained of dysuria, found to have sterile pyuria on admission. she was started on cipro 500 mg which was discontinued after 3 doses given resolving symptoms and negative cultures. she developed new dysuria and mild leukocytosis on and was begun on cipro again on when her ua showed positive nitrite, 245 wbc, and moderate bacteria. urine culture grew esbl e.coli so patient was started on meropenem. finally antibiotics were switched to ertapenem on day of discharge for ease of administration: instructed to complete 10 day course (9 additional days) with repeat urinalysis and urine culture upon completion. 4. anxiety: pt received lorazepam 0.25 mg while in house, which she takes at home. 5. htn: pt was maintained on home dose atenolol 50 mg daily. sbp 130s to 180s throughout, likely due to stress state and increased steroid dose. 6. hypothyroidism: pt maintained on home dose levothyroixine 112 mcg daily medications on admission: simvastatin 20 mg qhs asa 81 mg daily atenolol 50 mg daily mucomyst nebs 3 ml q8hr albuterol inhaler q 2h prn levalbuterol neb q 6-8 hr prn tiotropium 18 mcg daily fluticasone 50-100 mcg daily prednisone 5 mg every other day flovent 110mcg, 4 puffs mucinex 1200 mg citalopram 50 mg daily mirtazapine 7.5 mg qhs lorazepam 0.5 mg prn levothyroxine 112 mcg daily methenamine hippurate 1 g omeprazole 40 mg sucralfate achs discharge medications: 1. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 2. guaifenesin 600 mg tablet sustained release sig: two (2) tablet sustained release po bid (). 3. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). 4. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 5. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 6. lorazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for anxiety. 7. acetylcysteine 20 % (200 mg/ml) solution sig: one (1) ml miscellaneous q 8h (every 8 hours). 8. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). 9. simvastatin 10 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 10. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 11. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation prn (as needed) as needed for see below: please use when giving mucinex. 12. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for wheezing, dyspnea. 13. prednisone 20 mg tablet sig: one (1) tablet po qd () for 3 days. 14. prednisone 10 mg tablet sig: one (1) tablet po qd () for 3 days. 15. prednisone 5 mg tablet sig: one (1) tablet po qd () for 3 days. 16. ertapenem 1 gram recon soln sig: one (1) intravenous daily () as needed for complicated uti for 9 days. 17. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). 18. citalopram 10 mg tablet sig: five (5) tablet po once a day: total dose of 50mg. 19. methenamine hippurate 1 gram tablet sig: one (1) tablet po twice a day. 20. sucralfate 1 gram tablet sig: one (1) tablet po qchs. 21. outpatient lab work please repeat urinalysis and urine culture on ; after completing antibiotic course discharge disposition: extended care facility: - discharge diagnosis: h1n1 influenza copd exacerbation urinary tract infection discharge condition: hemodynamically stable; respiratory status near baseline: tripods, uses accessory muscles of respirations, intermittent tachypnea to 30s, saturating 94-96% on 3 lnc discharge instructions: you were admitted to the hospital with increased shortness of breath and cough and were diagnosed with h1n1 influenza. your breathing was briefly supported with a mask ventilator in the intensive care unit. you were treated with oseltamivir (tamiflu) for your influenza and prednisone and azithromycin (antibiotics) for your copd flare, along with your usual oxygen and nebulizers. you were treated with cipro for a possible urinary tract infection which seemed to go away; you developed a urinary tract infection after the cipro was stopped; it was re-started on . please limit your exertion while you are getting over your influenza and continue your usual routine of nebulizer treatments and pulmonary rehab appointments. please call your doctor or go to the emergency room if you develop new fevers, chills, increased difficulty breathing, cough up blood, chest pain, bloody urine, or any other symptom that you find concerning. followup instructions: please make an appointment with your primary car physician 1-2 weeks of your discharge from rehab. -dr. phone: md, Procedure: Non-invasive mechanical ventilation Diagnoses: Anemia, unspecified Esophageal reflux Urinary tract infection, site not specified Unspecified essential hypertension Unspecified acquired hypothyroidism Anxiety state, unspecified Chronic obstructive asthma with (acute) exacerbation Bronchiectasis without acute exacerbation Knee joint replacement Other diseases of trachea and bronchus Mixed acid-base balance disorder |
allergies: sulfa (sulfonamide antibiotics) / bactrim / lipitor attending: chief complaint: hypoxia major surgical or invasive procedure: intubation, extubation. mechanical ventilation. arterial line placement (in ed) central venous line placement (in ed) bronchoscopy picc line placement tracheostomy and g-tube placement () history of present illness: 78 y/o f bronchiectasis, severe copd with baseline 2l 02 requirement, tracheobronchomalacia s/p y-stent who presents with acute respiratory distress. patient initially presented to hospital speaking in 1 word sentances, tripoding, found to have an abg 7.22/110/176/43 and was consequently intubated. patient was given solmedrol 125 mg iv, levofloxacin and zosyn. per records patient had a cxr which demonstrated right pleural effusion and rll infiltrate. . in ed, initial vs were: t 98 p 120 bp 137/70. patient was felt to be desynchronous on vent, started on propofol became hypotensive and was switched over to versed. central line was placed and 3 l ns given. patient was also given vancomycin. labs pertinent for a lactate of 4, left shift n 91.5%, platelets 122. . according to family patient demonstrated increasing respiratory distress the past week and yesterday "lungs sounded junky". she was also increasingly somnelent and confused the past week. they denie fever, chills, abdominal pain, nausea, vomiting, headaches, vision changes, neck stiffness or chest pain. the do report decreased fluid intake. . of note, patient was recently admitted for h1n1 influenza, copd exacerbation with pseudomonas growing from sputum, urinary tract infection (+ esbl). patient discharged on ertapenem for 10 days total. . review of systems: patient intubated. past medical history: copd/tracheobronchomalacia s/p y stent placement . 3 other admissions and 9 therapeutic bronchoscopies since y stent placement. patient had bronchoscopy which ensured patent stent, minimal secretions, small amount of granulation tissue at the distal limb of the stent. pfts fev/fvc 44% . bronchiectasis htn gerd hypothyroid hyperlipidemia anxiety recurrent uti anemia hysterectomy at 33yo from anemia b/l cataract sx total knee replacement 2yrs ago bladder sling social history: has 4 children, all live locally; daughter is nurse. worked as a store clerk, retired 3 years ago. volunteered at until 4-5 months ago. drinks wine infrequently. no h/o tobacco or illicit drug use. husband smoked until ~22 yrs ago. daughter is a nurse. reports decreased appetite and enthusiasm for eating in past year, markedly decreased activity and exercise tolerance, weight loss. family history: mother had mi, brother died from heart disease and had minor stroke. no family history of lung disease/copd/asthma. 4 children and 7 grandchildren are generally healthy; grandaughter has spherocytosis and was recently hospitalized for 5 days with flu physical exam: general: thin, elderly female, intubation heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. drymm. op clear. cardiac: distant heart sounds. regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: limited air movement bilaterally, no wheezes or crackles abdomen: nabs. soft, nt, mildly firm. no hsm. extremities: no clubbing/ cyanosis/ edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. cool extremity. skin: no rashes/lesions, ecchymoses. neuro: will squeeze hands to name. pertinent results: chem 10 139 99 21 195 agap=13 3.8 31 0.6 ca: 8.1 mg: 1.1 p: 2.7 . ck: 24 mb: notdone trop-t: <0.01 . alt: 22 ap: 45 tbili: 0.2 alb: ast: 34 ldh: 187 . cbc 91 7.9 > 10.0 < 122 ∆ 31.2 n:91.5 l:6.8 m:1.5 e:0 bas:0.2 . pt: 13.2 ptt: 27.7 inr: 1.1 . micro: blood culture ngtd urine culture ngtd . prior micro: sputum: pseudomonas aeruginosa cefepime-------------- 16 i ceftazidime----------- 32 r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem------------- 1 s piperacillin/tazo----- =>128 r tobramycin------------ <=1 s . urine culture : escherichia coli ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- r ceftriaxone----------- r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r . images: cxr: my read - hyperinflated. increased hilar vasculature. no infiltrate. . ekg: : ekg hr 99, st depressions ii, iii, avf. on admission: hr 103, st depressions resolved. difficult baseline. . cta (prelim): 1. no pulmonary embolus or aortic dissection is seen. 2. emphysematous changes with diffuse bronchiectasis. there are new scattered opacities in the bibasilar regions which most likely represent atelectasis, less likely pneumonia. clinical correlation recommended. 3. stable et tube and tracheal y stent. 4. scattered 5 mm pulmonary nodules, some new. in a high-risk patient continued followup is recommended to assess stability. . lenis: right lower extremity ultrasound: -scale and doppler son of the right common femoral, femoral, popliteal, and calf veins was performed. there is normal flow, compressibility and augmentation of the veins. impression: no evidence of dvt in the right lower extremity. . cxr: findings: frontal chest radiograph is compared to the prior study from . endotracheal tube terminates in the thoracic inlet. lungs are clear. mediastinum is within normal limits. brief hospital course: 78 y/o f bronchiectasis, severe copd, tracheobronchomalacia s/p y-stent who presents with respiratory distress and hypotension. s/p trach and peg tube this admission, now being discharged to pulm rehab. see below for specific discussion of each problem. # respiratory distress: thought to be likely due to copd exaerbation with underlying component of tracheobronchomalacia and bronchiectasis. initial work-up revealed troponins negative for myocardial ischemia, pe cta negative for pulmonary embolus, and bronchoscopy/bronchoalveolar lavage with y-stent for tracheobronchomalacia in appropriate place. she was started on iv methylprednisolone 125mg iv q6h for presumed copd exacerbation, and this was gradually tapered. remained on q4h ipratropium and albuterol inhalers. respiratory cultures from grew gram negative rods. given previous respiratory cultures positive for pseudamonas, she completed a 12-day course of vancomycin and levofloxacin and an 11-day course of levofloxacin. for respiratory support, she was intubated on on ac ventilation. failed multipled trials of psv until finally on was successfully transitioned from ac to psv. was extubated on for 10 hours, then re-intubated due to respiratory distress and hypertension to 200s requiring a nitro drip. subsequently failed several spontaneous breathing trials (became hypertensive and tachycardic during these periods) with significant distress. discussed treatment options with healthcare proxy (daughter) and rest of family, who ultimately decided on tracheostomy and g-tube placement. proceeded with trache/g-tube placement on and worked with respiratory therapist to wean off mechanical ventilation. on the trach mask, she has been weaned slowly but still continues to be pretty symptomatic when ps is <10. has been stable on for approximately a day. mostly seen is tachycardia when she becomes uncomfortable. # hypotension: patient arrived to micu with elevated lactate concerning for shock, however there was no evidence of end organ damage (adequate urine output, normal creatinine). concern for sepsis based on left shift and prior esbl urinary tract infection and pseudomonas pneumonia. however, ua was negative, cxr showed no infiltrate, negative blood cultures to date and patient remained afebrile. cvp 8 following 3 l ns suggesting hypovolemia from poor po intake and unlikely cardiac shock. treated with broad spectrum antibiotics for possible infection as above. has been stable with sbps in 120s when awake. intermittently drops to the 80s when sleeping, usually in conjunction with getting ativan. # respiratory acidosis: initial abg showed respitory acidosis without adequate compensation most likely secondary to overlying metabolic acidosis from elevated lactate. patient's abg resolved quickly during micu stay, on mechanical ventilation. lactate normalized with fluid hydration. # acute on chronic anemia: slightly down on arrival at 27.7, from baseline 34-37. guaiac negative on exam. transfused 1u prbcs on and to a hct 31.7. hematocrit remained stable for duration of hospital stay. # tachycardia: patient was initially tachycardic with temporary improvement with blood transfusion. patient remained intermittently tachycardic, usually during times of respiratory distress or anxiety. hr improved with sedation, optimization of ventilator settings and initiating of beta-blocker. she is on metoprolol 25 mg ; we tried to go to tid and she did not tolerated with moderately low bps in the 90s. # anxiety: patient has baseline anxiety. she was continued on home mitrazapine 15 mg hs. additional anxiolytic effects achieved with iv sedation (propofol) while on ventilator as well as ativan (0.25-0.5mg q6h, which is close to patient's home dose). she is on standing ativan and prn ativan per her home regimen. she still has intermittent anxiety. she seems to repsond well to sublingual zyprexa, too. # tracheobronchomalacia s/p y stent placement: continued outpatient stent care. patient underwent bronchoscopy by interventional pulmonary which confirmed good y-stent placement and patent airways. patient was continued on home regimen of guaifenesin 600 mg tablet and acetylcysteine 20 % (200 mg/ml) every 8 hours. # new thrombocytopenia: platels on admission 122 from baseline 300. platelets were trended daily and climbed to a normal baseline range during hospital stay. # impaired glucose control: blood sugar noted to be high in 200s in the hospital, felt to be secondary to steroids. placed on insuline sliding scale which was adjusted with the prednisone taper. will continue at rehab. # htn: was continued on lopressor 25mg , held when bp was low. held home dose of amlodipine. she has variable blood pressures based on her activity and anxiety levels. no flash edema noticed when she was high. # pain control: patient's pain was controlled with fentanyl 12.5-25 mcg iv q4h prn. she is still on fentanyl prn with good control. # gerd: remained on famotidine while intubated. # hypothyroid: continued outpatient levothyroxine. had tsh of 0.91 around admission. continued her home dose but should be rechecked when more stabalized. # hyperlipidemia: continued outpatient simvastatin. # fen: tube feeds via peg at 40ml/hr. at goal, tolerating well. zofran prn. # constipation: intermittent constipattion controlled on bowel regimen of colace 100 and senna prn. . # discharged to rehab. foley removed this afternoon. family aware and at bedside at the time of discharge. medications on admission: - ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). - guaifenesin 600 mg tablet sustained release sig: two (2) tablet sustained release po bid. - fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). - levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). - atenolol 50 mg tablet sig: one (1) tablet po daily (daily). - acetylcysteine 20 % (200 mg/ml) solution sig: one (1) ml miscellaneous q 8h (every 8 hours). - mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). - simvastatin 10 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). - albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation prn (as needed) as needed for see below: please use when giving mucinex. - levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for wheezing, dyspnea. - prednisone 5 mg tablet sig: one (1) tablet po qd () for 3 days. - omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). - methenamine hippurate 1 gram tablet sig: one (1) tablet po twice a day. - sucralfate 1 gram tablet sig: one (1) tablet po qchs. - asa 81 mg - norvasc 10 mg qd - ativan 0.25 mg po q6 hours anxiety - bipap at night with setting discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 2. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: six (6) puff inhalation q4h (every 4 hours). 3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 6-8 puffs inhalation q2h (every 2 hours) as needed for respiratory distress. 4. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 5. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 6. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: six (6) puff inhalation q4h (every 4 hours). 9. docusate sodium 50 mg/5 ml liquid sig: 50-100 mg po bid (2 times a day) as needed for constipation. 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 11. guaifenesin 100 mg/5 ml syrup sig: fifteen (15) ml po q6h (every 6 hours): in place of mucinex. 12. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours). 13. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. 14. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po tid (3 times a day) as needed for aggitation: given sometimes before trach mask trials. 15. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 16. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 17. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 18. heparin, porcine (pf) 10 unit/ml syringe sig: ten (10) ml intravenous prn (as needed) as needed for line flush. 19. prednisone 10 mg tablet sig: three (3) tablet po daily (daily): 30mg for 3 days () then 20mg for 3 days () and then 10mg for 4 days () and then stop. 20. insulin lispro 100 unit/ml solution sig: one (1) unit subcutaneous asdir (as directed): please give as directed in the attached insulin sliding scale. discharge disposition: extended care facility: hospital transitional care unit - discharge diagnosis: primary: copd, tracheobronchomalacia s/p y-stent placement, bronchiectasis secondary: htn, hl, hypothyroidism, gerd, anxiety, depression discharge condition: discharged on trach mask with psv of . tolerating well with intermittent symptomatic anxiety. hr in 100s-110s. is awake and alert and can mouth words, likley intermittently hallucinating, too, but difficult to tell based on understanding when she mouths words discharge instructions: dear ms. , you were admitted to the medical center due to difficulty breathing. to help support your breathing you were placed on mechanical ventilation with a breathing tube. you were also given steroids to support your lung function and antibiotics (meropenem, vancomycin, and levofloxacin) for treatment of a presumed lung infection. to evaluate what was causing you to have such difficulty breathing, we conducted a number of tests, including a ct scan of your chest to look for blood clots, blood tests to determine if you had an injury to your heart, and a bronchoscopy to look at the stent in your airways. all of these tests came back negative for any injury. we believe that your respiratory distress is due to poor lung function from your underlying lung disease. we tried to wean you off of mechanical ventilation several times, including at one point taking the breathing tube out completely, but you became significantly distressed with all of these attempts. after ongoing discussion with your family, it was decided to insert a tracheostomy tube to help support your breathing. we also placed a g-tube to allow you to receive nutrition. you tolerated this procedure well. you will continue to work with a respiratory therapist in managing your breathing with the tracheostomy tube. followup instructions: - please follow up with your primary care physician as needed per doctors at the pulmonary rehab facility Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Fiber-optic bronchoscopy Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Diagnoses: Thrombocytopenia, unspecified Anemia of other chronic disease Anemia, unspecified Unspecified pleural effusion Obstructive chronic bronchitis with (acute) exacerbation Dysthymic disorder Acute and chronic respiratory failure Malignant essential hypertension Hypovolemia Knee joint replacement Tachycardia, unspecified Other diseases of trachea and bronchus Mixed acid-base balance disorder Dependence on respirator, status Bronchiectasis with acute exacerbation |
allergies: penicillins / epinephrine / caffeine attending: chief complaint: chest pain major surgical or invasive procedure: left heart catheterization, coronary angiogram coronary artery bypass grafting x3(lima-lad,svg-marg,svg-pda) left heart catheterization, coronary angiogram coronary artery bypass grafting x3(lima-lad,svg-marg,svg-pda) left heart catheterization, coronary angiogram coronary artery bypass grafting x3(lima-lad,svg-marg,svg-pda) history of present illness: this 63 y/o female with pain radiating to both arms for 30 days, improved with leaning forward. . in ed, initial vs - hr: 76 bp: 137/80 o2 sat: 98. cxr showed findings c/w copd/emphysema. mid-to-lower thoracic spine compression fracture. no acute findings. ekg showed no stemi, no ischemic changes. cardiac enzymes negative x 1. . of note, patient failed prior stress test at medical management failed to control chest pain. per discussion with atrius cardiology, admission to caridology for consideration of cath. patient was heparinized in the ed. unfortunately, further records not available at this time. . past medical history: copd hypertension hyperlipidemia s/p tonsillectomy social history: positive for tobacco, reports social etoh, no drugs. reports 1 ppd tobacco x 40 years. family history: mom - cva - triple bypass, dm physical exam: on admission: vs - 99.5, 141/83, 76, 20, 98 ra general - well-appearing female in nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, no mrg appreciated, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, dtrs 2+ and symmetric, cerebellar exam intact, gait not assessed pertinent results: intra-op tee conclusions pre-bypass: the left atrium is mildly dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is mildly depressed (lvef= 40-50 %). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post cpb 1. marginally improved biventricular systolci funjction with background inotropic support (epinephrine) 2. no change in valve structure and function 3. intact aorta 04:44am blood wbc-11.0 rbc-3.17* hgb-10.1* hct-29.7* mcv-94 mch-31.8 mchc-34.0 rdw-13.5 plt ct-247 06:35am blood wbc-12.8* rbc-3.37* hgb-10.7* hct-31.4* mcv-93 mch-31.8 mchc-34.2 rdw-14.9 plt ct-187 03:09am blood pt-12.7 ptt-47.5* inr(pt)-1.1 04:44am blood urean-13 creat-0.4 na-137 k-3.9 cl-97 06:00am blood urean-11 creat-0.5 na-137 k-4.3 cl-99 06:35am blood glucose-102* urean-11 creat-0.5 na-134 k-4.8 cl-100 hco3-27 angap-12 brief hospital course: catheterization revealed triple vessel disease and she was referred for surrgery. a ct scan of a pulmonary nodule was obtained and the recommendation was for a 6month follow up. following a period of plavix washout, the patient underwent coronary artery bypass grafting x3 (left internal mammary artery graft to the left anterior descending, reverse saphenous vein graft to the marginal branch and the posterior descending artery) on with dr. .see operative note fro details. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable and had weaned from inotropic and vasopressor support. she was transfused two units of blood for post-operative anemia. plavix was given due to poor targets. beta blocker was initiated and the patient was gently diuresed toward her preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. she did have a brief burst of rapid atrial fibrillation which responded to iv lopressor. she had recurrent atrial fibrillatin and was started on amiodarone and maintained sinus rhythm susequently the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 7 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged home with vna in good condition with appropriate follow up instructions. medications on admission: - fish oil 1000 mcg daily - mvi - asa 81 mg daily - atenolol 25 mg daily - isosorbide dinitrite 10 mg tid - simvastatin 10 mg daily - ativan 1 mg daily discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*11* 2. lorazepam 1 mg tablet sig: one (1) tablet po daily (daily). 3. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 4. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. :*50 tablet(s)* refills:*0* 5. omega-3 fatty acids capsule sig: one (1) capsule po daily (daily). 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. :*28 tablet(s)* refills:*0* 7. amiodarone 200 mg tablet sig: as directed tablet po bid (2 times a day): two tablets (400mg) for two weeks, then one tablet(200mg) for two weeks then one tablet (200mg) daily until discontinued by your physician. :*120 tablet(s)* refills:*2* 8. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain for 4 weeks. :*50 tablet(s)* refills:*0* 9. aspir-81 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 10. acetaminophen 325 mg tablet sig: 1-2 tablets po every four (4) hours as needed for fever or pain. 11. metoprolol tartrate 100 mg tablet sig: one (1) tablet po three times a day. :*90 tablet(s)* refills:*2* 12. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation qid (4 times a day). :*2 2* refills:*6* 13. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain and fever . discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease s/p coronary artery bypass chronic obstructive pulmonary disease hypertension hyperlipidemia s/p tonsillectomy 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: none leg:left leg incision- 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 and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge followup instructions: you are scheduled for the following appointments: surgeon dr., r. md 1:00pm and wound care nurse phone: date/time: 10:45 in the medical office building cardiologist: dr. , @ 10:20am please call to schedule the following: primary care dr. in weeks: location: address: , , phone: fax: **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 (Aorto)coronary bypass of two coronary arteries Left heart cardiac catheterization Diagnoses: Acidosis Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrial fibrillation Peripheral vascular disease, unspecified Other and unspecified hyperlipidemia Anxiety state, unspecified Other specified cardiac dysrhythmias Other specified diseases of blood and blood-forming organs Body Mass Index less than 19, adult |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass grafting x3 with left internal mammary artery left anterior descending coronary; reverse saphenous vein single-graft from aorta to first obtuse marginal coronary; reverse saphenous vein single-graft from the aorta to second obtuse margin and coronary artery history of present illness: 61 yo f with chest pain with rest and exertion with ekg changes on stress test referred for cardiac catheterization. past medical history: hypertension hyperlipidemia depression/anxiety back pain s/p bladder suspension s/p back x3 social history: lives with:husband occupation: :denies etoh:occasional glass of wine family history: non-contributory physical exam: pulse:66 resp:16 o2 sat: 98%ra b/p right:97/66 left: 101/55 height:5'8" weight:152 lbs general:nad, alert, cooperative skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right:+2 left:+2 dp right: +1 left:+1 pt :+1 left:+1 radial right:+2 left:+2 carotid bruit right:none left:none pertinent results: cardiac cath: 1. selective coronary angiography in this left dominant system demonstrated three vessel and left main disease. the lmca had a 60% distal stenosis. the lad had a 60% proximal stenosis. the lcx had an 80% proximal stenosis and an 80% stenosis at the origin of a large om1. the rca had a 60% mid-vessel stenosis in a small, non-dominant vessel. 2. limited resting hemodynamics revealed elevated left sided filling pressures with lvedp of 23 mm hg. there was no gradient on pullback from the lv to the aorta. echo: the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with basal to mid inferoseptum and basal inferior wall hypokinesis. overall left ventricular systolic function is normal (lvef>55%). the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. impression: mild regional left ventricular systolic dysfunction with preseved global systolic function. carotid u/s: there is less than 40% stenosis within the right internal carotid artery. there is 40-59% stenosis within the left internal carotid artery. 04:23am blood wbc-10.8 rbc-3.01* hgb-9.2* hct-27.5* mcv-91 mch-30.7 mchc-33.6 rdw-15.2 plt ct-176 04:23am blood glucose-93 urean-21* creat-0.8 na-141 k-4.3 cl-106 hco3-27 angap-12 brief hospital course: admitted after cardiac cath which showed severe 2vd. she had a plavix loading dose prior to cath and had washout for several days. underwent surgery with dr. on . transferred to the cvicu in stable condition on titrated phenylephrine and propofol drips. awoke neurologically intact and was extubated. transferred to the floor on pod #2 to begin increasing her activity level. gently diuresed toward her preop weight. beta blockade titrated very slowly, as she developed hypotension with first dose of 25mg. 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. prior to discharge, chest x-ray revealed small-moderate right sided effusion. the patient remained stable from a pulmonary standpoint, saturating well on room air. she was diuresed aggressively for this, and will follow up with a cxr next week. by the time of discharge on pod 4, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to home with vna in good condition with appropriate follow up instructions. medications on admission: citalopram - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth every morning fluticasone - (prescribed by other provider) - 50 mcg spray, suspension - 1 spray to each nostril every morning isosorbide mononitrate - (prescribed by other provider) - 30 mg tablet sustained release 24 hr - 1 tablet(s) by mouth every morning lisinopril - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth every morning montelukast - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth every evening nitroglycerin - (prescribed by other provider) - 0.4 mg tablet, sublingual - 1 tablet(s) sublingually every five minutes for chest discomfort. call 911 if pain persists longer than 15 minutes simvastatin - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth every evening tramadol - (prescribed by other provider) - 50 mg tablet - 1 tablet(s) by mouth as needed for back pain aspirin - (prescribed by other provider) - 81 mg tablet, chewable - 1 tablet(s) by mouth every morning discharge medications: 1. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 2. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*1* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. disp:*28 tablet(s)* refills:*0* 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 7. simvastatin 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*1* 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 9. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 2 weeks. disp:*28 tablet(s)* refills:*0* 10. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours) for 2 weeks. disp:*28 tab sust.rel. particle/crystal(s)* refills:*0* 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain, fever. 12. fluticasone 50 mcg/actuation spray, suspension sig: one (1) nasal once a day. disp:*30 * refills:*2* 13. radiology pa, lateral chest x-ray dx: pleural effusions s/p cabg results to dr. discharge disposition: home with service facility: homecare discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 3 past medical history: hypertension hyperlipidemia depression/anxiety back pain s/p bladder suspension s/p back x3 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: 1+ bilateral les discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. on at 1pm. please call to schedule appointments with your primary care dr. in weeks cardiologist dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** wound check on tuesday, 11am **please go to radiology (clinical center- ) to have chest x-ray prior to this appointment** Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Diagnoses: Acidosis Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Unspecified essential hypertension Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Anxiety state, unspecified Other specified cardiac dysrhythmias 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 Chronic total occlusion of coronary artery |
allergies: shellfish derived attending: chief complaint: syncope major surgical or invasive procedure: cardiac catherization aortic valve replacement, 23-mm mosaic tissue heart valve, mitral valve repair with a triangular resection of the posterior leaflet and a 28-mm annuloplasty with a future cg ring, coronary artery bypass grafting x3: left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch onto the diagonal branch bronchoscopy history of present illness: 84 year old male with known aortic stenosis, progressively worsening over last six months. has had increased fatigue and syncopal episode while driving, and presents for cardiac catherization. past medical history: hypertension type 2 mitral regurgitation aortic stenosis hyperlipidemia social history: retired truck driver lives with spouse quit smoking > 30 years ago (cigars) etoh denies family history: father deceased 70's myocardial infarction mother deceased 70' myocardial infarction physical exam: general hr 52, rr 18, b/p 148/49 weight 153 pounds, no acute distress skin unremarkable heent unremarkable neck supple full range of motion, right carotid bruit chest clear to ausculatation bilateral heart regular, systolic ejection murmur abdomen soft nondistended non tender + bowel sounds extremeties warm well perfused, pulses palpable varicosites none neuro grossly intact discharge exam vs: 98.9, 134/76, 70sr, 20, 94%ra gen: nad, elderly male heent: unremarkable chest: lungs ctab cv: rrr, no murmur or rub abd: nabs, soft, non-tender, non-distended ext: 1+edema b/l incisions: sternum- c/d/i no erythema or drainage, levh- c/d/i, distal stab incision with serosanguinous drainage pertinent results: 03:35am blood wbc-5.5 rbc-2.96* hgb-9.2* hct-26.0* mcv-88 mch-31.1 mchc-35.5* rdw-15.2 plt ct-85* 03:35am blood glucose-100 urean-31* creat-1.4* na-142 k-4.3 cl-101 hco3-36* angap-9 03:35am blood mg-2.1 brief hospital course: presented for cardiac catherization, was admitted post procedure for preoperative workup. on he was brought to the operating room and underwent coronary artery bypass graft, mitral valve repair, and aortic valve replacement. please see operative report for further details. received vancomycin for periop antibiotics due to being in hospital preoperatively. he was transferred to the intensive care unit for hemodynamic monitoring. post operative chest radiograph revealed rll collapse and he was bronched for small amount of clots, but no secretions. in the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. he was started on betablockers and lasix for gentle diuresis. on postoperative day 2 he had atrial fibrillation treated with beta blockers and amiodarone, which he converted back to normal sinus rhythm. physical therapy worked with him on strength and mobility. he was transferred to the floor post operative day three. the patient remained in sinus rhythm and was maintained on amiodarone. he made good progress with physical therapy. the patient was found stable for discharge on pod 5. medications on admission: aspirin 81 mg daily atenolol 25 mg daily fosinopril 40 mg daily glipizide 5 mg daily metformin 1000 mg in am and 500 mg in pm multivitamin daily proscar 5 mg daily vitamin e 400 iu daily zetia 10 mg daily zocor 80 mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 2. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed. disp:*qs * refills:*0* 3. glipizide 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. metformin 500 mg tablet sustained release 24 hr sig: two (2) tablet sustained release 24 hr po daily (daily). disp:*60 tablet sustained release 24 hr(s)* refills:*0* 5. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg 2x/day x 2 weeks, then 200mg 2x/day for 2 weeks, then 200mg daily. disp:*120 tablet(s)* refills:*0* 6. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 9. 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* 10. furosemide 40 mg tablet sig: one (1) tablet po once a day for 2 weeks. disp:*14 tablet(s)* refills:*0* 11. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po bid (2 times a day) for 2 weeks. disp:*28 tab sust.rel. particle/crystal(s)* refills:*0* 12. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*0* 13. acetaminophen 325 mg tablet sig: 1-2 tablets po every hours. disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: interim discharge diagnosis: coronary artery disease s/p cabg aortic stenosis s/p avr mitral regurgitation s/p mr type 2 hypertension hyperlipidemia discharge condition: good discharge instructions: please shower daily including washing incisions, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: please call to schedule all appointments: dr in 4 weeks () please call for appointment dr in 1 week () please call for appointment dr in weeks - please call for appointment wound check appointment 6 as instructed by nurse () Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Fiber-optic bronchoscopy Open and other replacement of aortic valve with tissue graft Open heart valvuloplasty of mitral valve without replacement Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Mitral valve disorders Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Aortic valve disorders Pulmonary collapse Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Long-term (current) use of insulin |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p mcc major surgical or invasive procedure: exploratory laparotomy, left chest tube placement, splenectomy history of present illness: this patient is a 46 year old male who was in a motorcycle crash. he was in a high-speed motorcycle accident on 128 point loss of consciousness and he complains of diffuse pain on side of his body past medical history: pmh: none psh: ventral hernia repair social history: tobacco none etoh occasional family history: non contributory physical exam: hr:120 bp:110 o(2)sat:98 normal constitutional: comfortable heent: abrasions, pupils equal, round and reactive to light, extraocular muscles intact oropharynx within normal limits chest: clear to auscultation cardiovascular: regular rate and rhythm abdominal: soft diffuse tenderness on the left side at gu/flank: no costovertebral angle tenderness extr/back: no cyanosis, clubbing or edema left wrist pain pelvis stable skin: no rash neuro: speech fluent psych: normal mood heme//: no petechiae pertinent results: ct c spine : 1. no fracture or traumatic malalignment involving the cervical spine. no prevertebral soft tissue swelling. 2. mild spondylosis without critical canal stenosis. 3. posterior pulmonary opacities and nondisplaced fracture of the posterior aspect of the left third rib, better characterized on concurrent ct torso. head ct : 1. no acute intracranial process. 2. essentially nondisplaced fractures involving the lateral wall of the left maxillary sinus, with hyperdense hemorrhage seen layering within the sinus. no further facial fractures are identified. ct torso : 1. extensive splenic laceration involving the upper pole, grade iv, with large perisplenic hematoma. there are foci of high attenuation concerning for active extravasation, confirmed by delayed accumulation of contrast within the perisplenic hematoma. 2. no further solid organ injury in the abdomen or pelvis. high-attenuation perihepatic and pelvic fluid likely reflects sequelae of splenic injury. 3. small left upper lobe pulmonary contusion. 4. tiny left pneumothorax. no large effusion or hemothorax is noted. 5. non-displaced left third through fifth posterior rib fractures and minimally displaced left third through fifth anterolateral rib fractures. no pelvic or spinal structures are identified. left wrist : comminuted intra-articular fracture of the distal radius with no angulation; however, there is a level of impaction resulting in ulnar positive variance. left wrist : there is a highly comminuted intra-articular fracture of the distal radius as seen on the ct from . there is no significant change in fracture fragment position. there is some medial displacement of medial fragments towards the ulna as seen previously. the carpal bones are normally aligned. ct abd/pelvis : 1. small bowel loops are mildly dilated without obvious transition point particularly within the right upper quadrant. findings are most compatible with ileus however early obstruction cannot be completely excluded. recommend clinical correlation. 2. small left-sided pleural effusion, trace right-sided pleural effusion with probable adjacent compressive atelectasis, however aspiration cannot be completely excluded in the correct clinical setting. 3. fluid within the surgical splenectomy bed does not appear loculated or high density. free fluid with hounsfield unit up to 16 units is noted throughout the abdomen and pelvis. no focal fluid collection is identified. 4. dystrophic calcification adjacent to right hip joint. 03:20pm wbc-10.1 rbc-4.77 hgb-13.6* hct-38.1* mcv-80* mch-28.4 mchc-35.6* rdw-14.5 03:20pm pt-12.1 ptt-22.6 inr(pt)-1.0 03:20pm plt count-250 03:20pm asa-neg ethanol-49* acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 03:22pm glucose-107* lactate-2.6* na+-144 k+-3.7 cl--105 tco2-22 brief hospital course: mr. was evaluated in the emergency room and plans were made for embolization of his grade iv splenic laceration in interventional radiology after reviewing his abdominal ct. however, he became unstable with hypotension and tachycardia and was taken to the operating room emergently for an exploratory laparotomy. he underwent a left chest tube thoracostomy and splenectomy and was resuscitated with multiple units of packed red blood cells. he tolerated the procedure well and returned to the icu in stable condition. he maintained stable hemodynamics and his hematocrit remained stable in the range of 32. his pain was controlled with a dilaudid pca but he needed much encouragement to use his incentive spirometer. he was also evaluated by the ortho spine service to assess his left distal radial fracture and his arm was splinted and he was non weight bearing on that side. his chest tube was removed on post op day # 2 as there was minimal drainage and no pneumothorax. following transfer to the surgical floor he was slow to progress. he was reluctant to take pain medication early on which made it difficult for him to use his incentive spirometer and increase his activity. despite minimal pain medication he developed an ileus on post op day #4 requiring gastric decompression with a nasogastric tube for 4 days. due to the fact that he was slow to recover tpn was instituted while he had bowel rest. his abdomen was distended but he was having bowel movements. he was up and walking frequently and in time his ileus resolved. after his nasogastric tube was removed his diet was gradually advanced slowly to regular and he tolerated it well. his tpn was discontinued and his picc line was removed. his pain was controlled with tylenol and an occasional percocet. his abdominal wound was healing well and his left arm was re-splinted on . he will have more xrays next week and will be evaluated by the hand surgeons as an out patient for further treatment of his distal radial fracture. after marked improvement he was discharged to home on . his staples were removed prior to discharge and he will follow up in the clinic in 2 weeks. medications on admission: none discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain: for pain unrelieved by tylenol alone. disp:*60 tablet(s)* refills:*0* 3. tylenol 325 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. discharge disposition: home with service discharge diagnosis: s/p motor cycle crash 1. left rib fractures 2. left upper lobe pulmonary contusion 3. left pneumothorax ( small ) 4. left distal radial fracture 5. large splenic laceration 6. acute blood loss anemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: * you were admitted to the hospital with multiple injuries from your motor cycle crash including left rib fractures, a left pulmonary contusion, left radial fracture and a large splenic laceration requiring surgery. * your abdominal incision is healing well. * your injury caused left rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * you should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. if the pain medication is too sedating take half the dose and notify your physician. * pneumonia is a complication of rib fractures. in order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. this will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * you will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * symptomatic relief with ice packs or heating pads for short periods may ease the pain. * narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * do not smoke * your left wrist will be xrayed next week and further treatment will be determined by the hand service. in the meantime non weight bearing left hand/arm. keep splint clean and dry. * return to the emergency room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). or if you have any nausea or vomiting. followup instructions: call the clinic at for a follow up appointment in weeks call the plastics hand clinic at for an appointment in weeks with xrays of your left wrist Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Other incision of pleura Total splenectomy Diagnoses: Paralytic ileus Traumatic pneumothorax without mention of open wound into thorax Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Contusion of lung without mention of open wound into thorax Closed Colles' fracture Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum Closed fracture of three ribs Motor vehicle traffic accident of unspecified nature injuring motorcyclist Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: aortic valve replacement (#29 porcine) history of present illness: this 61 year old psychiatrist has a history of hypertension,hyperlipidemia and cad, s/p lad cypher stenting in . in addition, he has moderate to severe aortic insufficiency that has been followed by echocardiogram through the years. the patient reports that over the past year he has noticed a decline in his activity tolerance because of fatigue and dyspnea on exertion. he recently saw dr. in consultation where his echocardiogram revealed a minimal change in his aortic insufficiency. he is now being referred for cardiac catheterization to further evaluate his symptoms. past medical history: cad s/p cypher stenting lad -, ai, htn, dyslipidemia, hf, etoh none in 2 yrs, ri, compressed lumbar vertebrae, s/p appendectomy, s/p tonsillectomy, s/p post repair of deviated septum, gastroesophageal reflux disease, anxiety. social history: psychiatrist divorced, lives with 2 children, ages 14 and 18 denies tobacco etoh past abuse, stopped x2 years family history: no premature cad physical exam: pulse:58 resp:12 o2 sat:97%ra b/p right: 123/63 ht: 6 feet 2 inches wt: 292 lbs general: nad skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmurii/vi diastolic murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: 1+ left:1+ dp right: 2+ left:2+ pt : 2+ left:2+ radial right: 2+ left:2+ carotid bruit right:- left:- pertinent results: 07:45am hgb-12.3* calchct-37 07:45am glucose-110* lactate-1.5 na+-140 k+-4.2 cl--107 11:17am glucose-156* lactate-2.0 na+-138 k+-4.9 cl--110 12:26pm pt-13.9* ptt-40.0* inr(pt)-1.2* 12:26pm plt count-136* 12:26pm wbc-10.5# rbc-3.59* hgb-11.0* hct-31.8* mcv-89 mch-30.7 mchc-34.5 rdw-13.5 12:26pm urea n-14 creat-1.1 chloride-111* total co2-24 05:32am blood wbc-8.5 rbc-2.68* hgb-8.4* hct-23.7* mcv-88 mch-31.3 mchc-35.4* rdw-13.7 plt ct-105* 05:32am blood plt ct-105* 05:32am blood pt-12.6 ptt-34.9 inr(pt)-1.1 05:32am blood glucose-119* urean-23* creat-1.4* na-134 k-3.9 cl-97 hco3-27 angap-14 ================================== echocardiography report , (complete) done at 10:55:36 am preliminary referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 61 m hgt (in): 72 bp (mm hg): 130/60 wgt (lb): 295 hr (bpm): 63 bsa (m2): 2.52 m2 indication: aortic reguritation, s/p lad stent icd-9 codes: 746.9, 424.1, 746.4 test information date/time: at 10:55 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 #: 2009aw04-: machine: echocardiographic measurements results measurements normal range left ventricle - septal wall thickness: *1.9 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.9 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.3 cm <= 5.6 cm left ventricle - systolic dimension: 2.4 cm left ventricle - fractional shortening: 0.44 >= 0.29 left ventricle - ejection fraction: 50% to 55% >= 55% left ventricle - stroke volume: 172 ml/beat left ventricle - cardiac output: 10.86 l/min left ventricle - cardiac index: 4.31 >= 2.0 l/min/m2 aorta - sinus level: *4.2 cm <= 3.6 cm aorta - ascending: *3.6 cm <= 3.4 cm aorta - arch: *3.5 cm <= 3.0 cm aorta - descending thoracic: *2.8 cm <= 2.5 cm aortic valve - peak velocity: 1.9 m/sec <= 2.0 m/sec aortic valve - peak gradient: 15 mm hg < 20 mm hg aortic valve - mean gradient: 7 mm hg aortic valve - lvot pk vel: 1.12 m/sec aortic valve - lvot vti: 28 aortic valve - lvot diam: 2.8 cm aortic valve - valve area: 3.9 cm2 >= 3.0 cm2 aortic valve - pressure half time: 36 ms mitral valve - pressure half time: 92 ms mitral valve - mva (p t): 2.4 cm2 mitral valve - e wave: 0.7 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 0.88 mitral valve - e wave deceleration time: *317 ms 140-250 ms findings 61 yr old male w/ pmhx cad and ai w/ progressive regurg and exercise intolerance. pre-cpb: ef was noted to be normal to low normal at 50-55%, no significant rwma, moderate to severe ai was also seen. no evidence of asd was recognized. left atrium: normal la and ra cavity sizes. right atrium/interatrial septum: normal ra size. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness and cavity size. normal lv wall thickness. normal lv cavity size. right ventricle: normal rv chamber size and free wall motion. aorta: mildly dilated aortic sinus. aortic valve: bicuspid aortic valve. no masses or vegetations on aortic valve. no as. moderate to severe (3+) ar. mitral valve: normal mitral valve leaflets with trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: no pericardial effusion. post. cpb: patient weaned off with 0.6 mcg/kg/min phenylephrine, ef and rwm unchanged. 29 mm bioprosthetic well seated valve noted. no significant residual ai or as was seen. finding communicated to attending cardiac surgeon. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions the left atrium and right atrium are normal in cavity size. left ventricular wall thicknesses and cavity size are normal. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve is bicuspid. no masses or vegetations are seen on the aortic valve. there is no aortic valve stenosis. moderate to severe (3+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. i certify that i was present for this procedure in compliance with hcfa regulations. interpretation assigned to , md, interpreting physician brief hospital course: mr is a 61 yo man with known as/cad. he was a direct admission to the operating room for a scheduled aortic valve replacement. please see or report for details, in summary he had an aortic valve replacement with a #29 mosaic porcine valve, his bypass time was 86 minutes with a crossclamp of 64 minutes. he tolerated the operation well and was transferred from the operating room to the cardiac surgery icu in stable condition. in the immediate post operative period he remained hemodynamically stable, within several hours he woke neurologically intact and was extubated. he remained hemodynamically stable but stayed in the icu on pod1 to monitor his pulmonary status. on the morning of pod2 he was transferred from the icu to the step down floor for continued care and recovery. all tubes, lines and drains were removed per cardiac surgery protocol. the remainder of his hospitalization was uneventful. his medications were titrated to effect, his activity was advanced with the assistance of physical therapy and nursing and on pod five he was discharged home with visiting nurses. he is to have followup with dr and dr . medications on admission: atenolol 50mg two tablets daily every morning diovan 320mg daily every morning hctz 25mg daily norvasc 7.5mg qd aspirin 325mg daily zetia 10mg daily crestor 20mg daily prilosec 20mg daily seroquel 100mg daily every evening discharge medications: 1. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. rosuvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. prilosec otc 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. quetiapine 100 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 5. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 6. atenolol 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 8. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*0* 10. lasix 40 mg tablet sig: one (1) tablet po once a day for 10 days. disp:*10 tablet(s)* refills:*0* 11. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 10 days. disp:*10 tab sust.rel. particle/crystal(s)* refills:*0* discharge disposition: home with service facility: nursing services discharge diagnosis: s/p aortic valve replacement (#29 porcine) pmh: hypertension hyperlipidemia cad, s/p cypher stenting of the lad in aortic insufficiency ventricular ectopy prior etoh, abstinent for 2 years mild chf compressed lumbar vertebrae s/p appendectomy s/p submucus resection/rhinoplasty for deviated septum s/p tonsillectomy gerd anxiety discharge condition: good discharge instructions: keep wounds clean and dry. ok to shower, no bathing or swimming. take all medications as prescribed. call for any fever, redness or drainage from wounds. no powder, creams or ointment on wounds. no lifting greater than 10 pounds for 10 weeks followup instructions: clinic in 2 weeks dr (cardiac surgery) in 4 weeks () dr (cardiologist) in weeks. please see your pcp weeks. Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Esophageal reflux Congestive heart failure, unspecified Unspecified essential hypertension Aortic valve disorders Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Anxiety state, unspecified Acute diastolic heart failure Long-term (current) use of aspirin |
allergies: no known allergies / adverse drug reactions attending: chief complaint: asymptomatic except for earlier rectal bleeding major surgical or invasive procedure: minimally-invasive esophagectomy and jejunostomy tube placement history of present illness: a 78m w/ lower gi bleeding episode in . subsequent work up consisted of upper and lower endoscopies. egd showed an ulcer in the distal esophagus and the biopsy returned as cancer. (adenoca). he reports no symptoms otherwise: no dysphagia, no weight loss, no changes in the energy level, no abd/chest or bony pains. he presents now for surgery. past medical history: pm: cad with stents x 7 on plavix, daily etoh use ps: none social history: cigarettes: never ex-smoker; 30 pack years; stopped 40 years ago etoh: no yes drinks/day: _2-3 several times a week. he estimates that he has cut down about 75% of his alcohol intake since the diagnosis. drugs: exposure: no yes radiation asbestos other: occupation: retired advertising marital status: married single lives: alone w/ family other: family history: mother heart dz physical exam: vital signs sheet entries for : bp: 122/100. heart rate: 55. weight: 188.6. height: 68.75. bmi: 28.1. temperature: 97.5. resp. rate: 16. pain score: 0. o2 saturation%: 98. 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: 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: 10:40am hgb-14.2 calchct-43 01:57pm glucose-134* lactate-1.7 na+-137 k+-3.9 cl--105 04:11pm glucose-149* urea n-18 creat-0.9 sodium-139 potassium-4.0 chloride-104 total co2-26 anion gap-13 barium swallow : no evidence of anastomotic leak or obstruction. brief hospital course: mr. was admitted to the hospital and taken to the operating room where he underwent a minimally invasive esophagectomy. he tolerated the procedure well and returned to the pacu in stable condition. he maintained stable hemodynamics and his pain was controlled with a dilaudid pca. following transfer to the surgical floor on post op day #2 he continued to make good progress. his j tube feedings were well tolerated and gradually increased to goal and cycled. he was utilizing his incentive spirometer effectively and remained free of any pulmonary complications post op. he did develop some urinary retention following foley catheter removal and required replacement but a second voiding trial was successful. his nasogastric tube was removed on post op day # 4 and his swallow study was done on which reveal no leak. he was able to tolerate liquids in moderation and his pain was controlled with tylenol alone. due to his cardiovascular history and multiple coronary stents, aspirin was resumed on post op day 2 and plavix was resumed following his successful swallow study. he was tolerating a liquid diet as well as his cycled tube feedings and was ambulating independently. both he and his wife underwent tube feeding instructions and after an uneventful recovery he was discharged to home on and will follow up in the thoracic clinic in 2 weeks. medications on admission: atorvastatin 20', plavix 75', folic acid 1', lisinopril 40', metoprolol succinate 75' (25mg pills, 3 tabs of er form), omeprazole 20', aspirin 325', vitamin b daily discharge medications: 1. tube feeds replete full strength at 85cc/hour cycle over 18 hours flush w/10cc of sterile water prior to and after each feed. estimated need greater than three months, final duration to be determined in outpatient follow up pending oral intake and nutritional status 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. metoprolol succinate 25 mg tablet extended release 24 hr sig: three (3) tablet extended release 24 hr po daily (daily). 5. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. lisinopril 40 mg tablet sig: one (1) tablet po daily (daily). 7. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 8. acetaminophen 650 mg/20.3 ml solution sig: twenty (20) mls po every 4-6 hours as needed for pain. disp:*500 mls* refills:*2* discharge disposition: home with service facility: vna and hospice of vt & nh discharge diagnosis: esophageal cancer. urinary retention 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 greater than 101 or chills -increased shortness of breath, cough or chest pain -nausea, vomiting (take anti-nausea medication) -increased abdominal pain -incision develops drainage -cover drain site with dry gauze and remove in 48 hours if dry. replace with a bandaid. if site starts to drain, cover it with a dry dressing and change it daily until it dries up. pain -take stool softners with narcotics activity -shower daily. wash incision with mild soap & water, rinse, pat dry -no tub bathing, swimming or hot tub until incision healed -no driving while taking narcotics -no lifting greater than 10 pounds until seen -walk 4-5 times a day for 10-15 minutes increase to a goal of 30 minutes daily diet: tube feeds: replete at 85 mls/hr cycled from 3pm to 9am flush j-tube with water every 8 hours with 10 mls of water, before and after starting tube feeds and giving medications through tube full liquid diet, may increase to soft solids over the next few days as tolerated. eat small frequent meals. sit up in chair for all meals and remain sitting for 30-45 minutes after meals daily weights: keep a log bring with you to your appointment no carbonated drinks danger signs fevers > 101 or chills increased shortness of breath, cough or chest pain incision develops drainage nausea, vomiting (take anti-nausea medication) increased abdominal pain call if j-tube falls out (save the tube and bring with you to the hospital to be re-placed) or suture breaks followup instructions: department: hematology/oncology when: tuesday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage please report 30 minutes prior to your appointment to the radiology department on the of the clinicla center for a chest xray. Procedure: Other enterostomy Enteral infusion of concentrated nutritional substances Partial esophagectomy Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atrial fibrillation Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Alcohol abuse, unspecified Other and unspecified hyperlipidemia Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Old myocardial infarction Retention of urine, unspecified Malignant neoplasm of cardia Other benign neoplasm of connective and other soft tissue of abdomen |
allergies: patient recorded as having no known allergies to drugs attending: addendum: the patient has hyponatremia secondary to siadh from pulmonary disease (recent pcp infection and now rsv/cmv infection). he is very sensitive to fluid intake. he should have fluid restriction of 750cc-1000cc daily until his siadh improves. sodium level should be monitored closely until sodium level becomes normal and stable. if patient's blood pressure becomes low because of hypovolemia from strict fluid restriction, then relax fluid restriction and consider adding salt tablets to keep sodium levels stable. discharge disposition: extended care facility: - md Procedure: Closed [endoscopic] biopsy of bronchus Diagnoses: Human immunodeficiency virus [HIV] disease Pneumocystosis Other disorders of neurohypophysis Cytomegaloviral disease Pneumonia in cytomegalic inclusion disease Viremia, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever and shortness of breath major surgical or invasive procedure: bronchoscopy with bal history of present illness: mr. is a 41yo gentleman with recently diagnosed hiv/aids (cd 4 count 26, vl 528,000 in ) and multiple admissions for pcp pneumonia who presents with fevers and dyspnea on exertion. he was recently admitted to from with severe pcp pneumonia requiring mechanical ventilation. although he was markedly hypoxic on admission, he quickly improved and was extubated. he was discharged home on 2 more weeks of treatment-dose bactrim as well as a prednisone taper, both of which he completed the day prior to presentation, . he reports that he was compliant with his medications and did not have trouble with obtaining the meds. he also reports compliance with his haart regimen, though it appears he missed his appointment on with id. he does not recall knowing that he had this appointment scheduled. for the first week after discharge, he was feeling reasonably well. he was able to go to work, although he would have trouble climbing stairs. by the second week, he noticed he was having fevers to 102 at home. he then developed some worsening shortness of breath with exertion. a couple of days ago, he started having a cough productive of white sputum. he endorses feeling chilled. he also recently had a fever blister on his bottom lip. otherwise, he denies myalgias, headache, congestion, sore throat, neck stiffness, pleuritic chest pain, abdominal pain, n/v/d, dysuria, genital sores, rash, or joint pain. in the emergency department 103.8 102/46 138 30s 89% ra->97% on 4l. exam was notable for crackles at his bases. labs revealed a lactate of 2.1. cxr showed b/l patchy infiltrates, improved from prior. he received solumedrol 125mg, vancomycin, cefepime, levaquin, and bactrim. he was admitted to the icu for care because of his poor respiratory status. upon arrival to the icu, he had no complaints. past medical history: hiv/aids - cd4 count 26 on pneumocystis jirovecii pneumonia (identified on bal sample) recently admitted : intubated for respiratory failure in setting of severe pcp; course c/b some transaminitis, thought to be hiv medications social history: lives with his brother's family. currently working as an assistant manager at the restaurant cosi. he is a never smoker. denies drugs or alcohol. no pets, no contact with birds. states he is sexually active but does not answer when asked about men/women/both. family history: no dm. physical exam: vs: 98.9 97/56 105 31 96% 6l->98% 3l general: pleasant, thin man who is somewhat tachypneic, mildly diaphoretic. not having trouble speaking in sentences. heent: no conjunctival pallor. no scleral icterus. perrl/eomi. mmm. small scab on bottom lip, healing well. op clear. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: ctab, good air movement biaterally. no crackles, wheezes, or rhonchi. abdomen: nabs. soft, nt, nd. no hsm gu: non-circumcised. no ulcers or lesions, no rash. extremities: no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout. 1gait assessment deferred psych: listens and responds to questions appropriately, pleasant pertinent results: admission labs: imaging: cxr portable: bilateral interstitial and airspace opacities consistent with pcp pneumonia in the setting of hiv. overall improved since the prior study. microbiology: cx : negative influenza dfa neg legionella urine ag neg cryptococcal ag neg cmv viral load pend urine cx neg induced sputum neg respiratory culture : positive rsv brochoalveolar lavage : negative gs, legionella, fungus, pcp. cytopathic effect na : 132 brief hospital course: 41 year old man with hiv (cd4 26) and recent severe pcp pneumonia who was readmitted with recurrent fever, doe, and cough after initial significant improvement. he was completely compliant with, and had already finished, his full bactrim treatment on . the initial suspicion for this presentation was either relapsed pcp or cap. however, recurrent or relapsed pcp has only been described in few case reports. he initially received empiric treatment with broad spectrum antibiotics (vancomycin, cefepime, levofloxacin), and repeat full does bactrim and prednisone for presumed relapsed pcp. considerations included cmv pneumonitis, fungal infection, other opportunistic infections, or lip. his first bal from his last admission was positive for cmv-like particles but his serum cmv viral load was negative at that time. he was not treated for cmv pneumonitis during his first hospitalization (controversial in hiv/aids patients). during this admission, an induced sputum and repeat bronchoscopy/bal for pcp were both negative. influenza dfa, cryptococcal antigen, and legionella urine antigen were also negative. a hrct of the chest showed diffuse ground glass opacities in both lungs (nonspecific but consistent with pcp) and less consolidation than previous ct chest (done during the initial presentation). the bal, however, was positive for rsv and he was placed on respiratory precautions (no specific treatment available). his repeat cmv viral load became positive at >10.000 copies per ml. therefore, he was placed on ganciclovir to treat presumed cmv pneumonitis ( again its controversial whether he has cmv pneumonitis or its a clinically insignificant finding as clinical cmv in aids patients is less defined than transplant patients). his full dose bactrim and steroids were discontinued and was placed on prophylactic dose of bactrim. because of 2 negative pcp (sputum and bal), the likelihood of recurrent/relapsed pcp became even less. his recurrent symptoms were believed to be secondary to intercurrent hsv infection or cvm pneumonitis and not recurrent/relapsed pcp. the other hand, if her does not improve, he may need bronchoscopy with lung biopsy to rule out lip or other aids-associated lung diseases. the patient developed hyponatremia related to siadh from lung disease. he was placed on fluid restriction and his sodium normalized. he was advised to have biweekly chem 7 and cbc while on anti cmv treatment and fax the results to the clinic. the duration of anti-cmv treatment is controversial and the id doctors decide based on his symptoms during follow up. he has intermittent fever that is treated with tylenol. the patient has hyponatremia secondary to siadh from pulmonary disease (recent pcp infection and now rsv/cmv infection). he is very sensitive to fluid intake. he should have fluid restriction of 750cc-1000cc daily until his siadh improves. sodium level should be monitored closely until sodium level becomes normal and stable. the patient was transferred to for pulmonary rehabilitation. medications on admission: emtricitabine-tenofovir 200-300 mg daily darunavir 800 mg daily ritonavir 100 mg daily albuterol sulfate 2-4 puffs q6h prn -- not taking azithromycin 1200 mg weekly prednisone 20 mg until prednisone 20 mg daily until trimethoprim-sulfamethoxazole 160-800 mg two tablets until trimethoprim-sulfamethoxazole 160-800 mg daily starting discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 4. azithromycin 600 mg tablet sig: two (2) tablet po 1x/week (). 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for dyspnea. 6. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po daily (daily). 7. darunavir 400 mg tablet sig: two (2) tablet po daily (daily). 8. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). 9. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po daily (daily). 10. valganciclovir 450 mg tablet sig: two (2) tablet po bid (2 times a day). 11. codeine-guaifenesin 10-100 mg/5 ml syrup sig: ten (10) ml po q6h (every 6 hours) as needed for cough. 12. outpatient lab work cbc and chemistry-7 ( tests) checked twice a week while you are receiving anti-cmv treamtnet with valganciclovir and the results faxed to : dr. , ( - infectious disease) discharge disposition: extended care facility: - discharge diagnosis: aids pcp pneumonia cmv viremia possible cmv pneumonitits possible rsv pneumonitits siadh from lung disease discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you have completed a full course of pcp . however we found rsv (a virus) in your sputum and cmv (another virus) in your and sputum. you are receiving a treatment for the cmv virus. you need to follow up with you infectious disease doctors to decide on the duration of the cmv treatment. you developed low sodium (salt) in your and we placed you on water restriction. the low salt is related to your active lung disease or infection. please have your salt level checked twice weekly (see below). if your lung symptoms do not improve, you will need a lung biopsy to rule out other diseases such as (lip). followup instructions: you will follow up with dr. , ( - infectious disease). she will arrange the appointment. she has the number for the and will be in contact to arrange this appointment. if you have not heard from her by mid week, call to arrange the follow up appointment. you need to have your cbc and creatinine/bun ( tests) checked twice a week while you are receiving anti-cmv treatment with valganciclovir and the results faxed to . Procedure: Closed [endoscopic] biopsy of bronchus Diagnoses: Human immunodeficiency virus [HIV] disease Pneumocystosis Other disorders of neurohypophysis Cytomegaloviral disease Pneumonia in cytomegalic inclusion disease Viremia, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: intubation and extubation history of present illness: *limited due to intubated and sedated patient* 41 yo m with newly diagnosed hiv/aids () and s/p prolonged hospitalization (ending ) for pcp pneumonia, presents to hospital today with dyspnea. according to the ed resident, the patient was complaining of shortness of breath since discharge from the hospital that has been progressing. fevers in last few days. . vitals upon presentation to the ed were: t 103.6, hr 121, bp 122/72, rr 19, o2sat 98% nrb. cxr showed multifocal pneumonia. patient became more tachypneic and was intubated and started on fentanyl and midazolam drip. abg was performed and was 7.17/55/96 after intubation. rij central line was placed. he received total of 9 literes of ns and recorded as having ~1000 ml urine output. for antibiotics he was given vancomycin, ceftriaxone, levofloxacin. received methylprednisolone 125 mg iv and pr tylenol. immediately prior to transfer to the icu, norepinephrine drip was started. at time of signout of patient to the icu, vitals were: hr 102, bp 117/64, o2sat 99% (pc with p 30, fio2 100%, peep 10). . review of systems: *limited due to intubated and sedated patient* past medical history: 1) hiv/aids - cd4 count 26 on 2) pneumocystis jirovecii pneumonia (identified on bal sample) social history: *per d/c summary * works as an assistant manager at a restaurant. he lives with a roommate. tobacco: denies etoh: denies illicit: denies family history: prior records indicate family history is non-contributory. physical exam: vs: t 96.3, hr 89, bp 130/80, rr 28, o2sat 100% (ac (volume) vt: 340, rr: 26, fio2 100%, peep 10) gen: intubated heent: perrl, scleral edema, intubated with ogt in place, dried at nare on left neck: no pulm: rhonchi throughout card: rr, nl s1, nl s2, no m/r/g abd: bs+, soft, nt, nd ext: no c/c/e skin: no appreciable rashes neuro: limited exam due to sedation pertinent results: cxr : findings: multifocal ill-defined opacities in both lungs have progressed in the interval when compared to prior study. the cardiomediastinal silhouette is stable. lung volumes are preserved, unchanged. there is no pneumothorax or pleural effusion noted. impression: worsening multifocal pneumonia. cxr : findings: in comparison with the study of , there is little change in the appearance of the monitoring and support devices. the diffuse bilateral pulmonary opacifications have slightly decreased, but they are still very prominent and consistent with the diagnosis pcp. brief hospital course: 41 yo m with newly diagnosed hiv/aids () and s/p prolonged hospitalization (ending ) for pcp pneumonia who presented with dyspnea. he was found to be hypoxic in ed and was susequently intubated. #. hypoxemic respiratory failure: his respiratory failure was felt to be causing by worsening of his pcp . he was intubated in the ed and admitted to the medical icu. he underwent bronchoscopy which showed negative secretions but culture was again positive for pcp. was treated with iv bactrim and steroids. he was extubated without complication and was transferred to the floor on , where he continued to improve. at the time of discharge, his room air saturations were >94% both resting and with ambulation. he will be treated for a total of 21 days with treatment doses of bactrim and prednisone taper, after which he will continue to take prophylactic bactrim. #. hypotension: he was hypotensive after intubation in the setting of sedation. he was felt to have a component of septic shock and was aggressively fluid resuscitated. he was started on norepinephrine and was eventually weaned with the use of multiple fluid boluses. his pressure remained stable throughout the remainder of his admission. #. hiv/aids: his last measured cd4 was 26 on at time of diagnosis. his haart was initially held as he could not take it through an og tube during the perior of intubation but was started again after extubation. he was also started on azithromycin for mac prophylaxis. haart was continued. he has follow up with the infectious disease department here at . #. transaminitis: lft's were mildly elevated during this hospitalization, likely related to multiple new drugs. they should be monitored as an outpatient. #. code status: full code #. communication: the patient informed his brother of his diagnosis while hospitalized. medications on admission: *per d/c summary * 1) trimethoprim-sulfamethoxazole 160-800 mg 2 tabs po q8h for 14 days (ending ) 2) emtricitabine-tenofovir 200-300 mg 1 tab daily 3) darunavir 400 mg tablet two tabs po daily 4) ritonavir 100 mg capsule po daily 5) albuterol sulfate 90 mcg hfa 1-2 puffs q6h prn dyspnea or wheeze 6) colace 100 mg 7) senna 8.6 mg po bid:prn constipation discharge medications: 1. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po daily (daily). 2. darunavir 400 mg tablet sig: two (2) tablet po daily (daily). 3. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). 4. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 2-4 puffs inhalation q4h (every 4 hours) as needed for wheezing. 5. azithromycin 600 mg tablet sig: two (2) tablet po 1x/week (). disp:*8 tablet(s)* refills:*2* 6. prednisone 20 mg tablet sig: one (1) tablet po bid (2 times a day): (for four days) . disp:*8 tablet(s)* refills:*0* 7. prednisone 20 mg tablet sig: one (1) tablet po daily (daily) for 11 days: (11 days) . disp:*11 tablet(s)* refills:*0* 8. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: two (2) tablet po tid (3 times a day) for 15 days: (15 days) . disp:*90 tablet(s)* refills:*0* 9. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po once a day: start taking on . disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: pneumocistis jiroveci pneumonia hiv discharge condition: well, with oxygensaturation of 99% on room air discharge instructions: you were admitted with lung infection. you recovered well, but need to continue all your medication as prescribed, and follow up with infectious disease clinic on . followup instructions: appointment #1: provider: care id phone: date/time: 3:30 medical building () appointment #2: md: dr. specialty: pcp date and time: wednesday, at 11:20am location: health care - adult medicine, 1000 , , phone number: 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: Acidosis Anemia, unspecified Unspecified septicemia Severe sepsis Human immunodeficiency virus [HIV] disease Acute respiratory failure Pneumocystosis Septic shock Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] |
allergies: penicillins / sulfa (sulfonamides) / iodine; iodine containing / bactrim / biaxin attending: chief complaint: esrd major surgical or invasive procedure: renal transplant history of present illness: ms. is a 53-year-old lady with esrd secondary to type i dm. her status on the kidney transplant list was recently made tu in but then she was relisted in after cardiology clearance was obtained. she saw her cardiologist dr. on . at that time she reported intermitten episodes of chest pain, three episodes since , some at rest and some on exertion and all relieved by sublingual nitroglycerin. she is having no chest pain here but reports that she gets chest pain when she gets dialysis and occasionally at other times when she eats. according to her she was scheduled for a nuclear stress test tomorrow she also reports nausea and vomiting throughout the day yesterday and inability to keep down anything orally. she visited her pcp at that time who did a cxr which was read as normal, and lab work, which was negative for elevated wbc and bun. their impression was a viral bronchitis with associated nausea, vomiting and no diarrhea. she reports her nausea and vomiting subsided at 2am this morning, about 7 hours ago, and that has not had fevers. she had a small meal of oatmeal and ginger ale this morning that has stayed down thus far. she was last dialyzed on tuesday, , and was due to go again today. she currently denies any nausea, vomiting, fevers, or chest pain. past medical history: pmh: type i dm, esrd on dialysis, cva, carpal tunnel syndrome, diabetic retinopathy, peripheral vascular disease, myocardial infarction, coronary artery disease (mi in , nstemi ), hypercholesterolemia, history of tb in remote past and hypertension. psh: -status-post left femoral-popliteal artery bypass grafting. -status-post removal of cataract on the left. -status-post right carpal tunnel release for carpal tunnel syndrome. -s/p right cataract removal with vitreous hemorrhage - renal transplant social history: married physical exam: physical exam: 97.8 74 122/54 18 99ra bs: 145 dry weight: 80.5 weight here: 81.7 nad/aao rrr cta bilterally - no w/r/r, no consolidation or decreased bs sndnt abdomen - no pain on palapation lue fistula - + thrill, + bruit no edema in bilateral le - no clubbing or cyanosis pertinent results: 05:55am blood wbc-4.0 rbc-3.32* hgb-10.0* hct-30.8* mcv-93 mch-30.0 mchc-32.4 rdw-15.3 plt ct-147* 05:55am blood plt ct-147* 02:57am blood pt-14.1* ptt-31.9 inr(pt)-1.2* 05:55am blood glucose-166* urean-66* creat-1.8* na-140 k-4.5 cl-109* hco3-22 angap-14 05:40am blood alt-39 ast-25 alkphos-95 totbili-0.4 05:55am blood calcium-8.5 phos-3.2 mg-1.8 05:55am blood tacrofk-6.2 brief hospital course: on , she was admitted for renal transplant. given history of intermittent chest pain during previous dialysis sessions, cardiology was called and a nuclear stress test was done for operative clearance. this was notable for poor functional capacity. there were no anginal symptoms or ischemic st segment changes(changes were nonspecific) at the workload achieved. the nuclear part showed normal perfusion and wall motion; lvef was 62%. she was then taken to the or by dr. who performed a deceased donor kidney transplant into the right iliac fossa with a 6-french double-j ureteral stent place. drain was also placed. the kidney made urine immediately. induction immunosuppression was given (atg, cellcept and solumedrol). she was unable to extubate in the or due to desatting. urine output decreased with hyperkalemia. she also spiked a temperature to 102.3 and had hypotension requiring some pressure support (neo drip). hyperkalemia was treated with bicarb, calcium and insulin. she was pancultured and started on antibiotics with blood and urine cultures later returning negative. cxr was negative for pneumonia. she remained intubated and sedated until . cardiac enzymes were negative. neo was weaned off and bp was stable. fever spike and tachycardia were likely related to atg. atg was infused slowly after premeds with better tolerance. a total of three days of levaquin and flagyl were given. she did not spike again. urine output was low initially, but gradually increased. creatinine trended down daily to 1.8 by day 7. output was fairly high averaging 200-800. this fluid had been sent for creatinine (2.6)to rule out urine leak on day 5 when serum creatinine was 2.7. she experienced a fair amout of thin, clear yellow fluid drainage from the drain insertion site and incision. dry gauze dressings were changed frequently. diet was slowly advanced and tolerated. immediately , insulin drip was required. was consulted and home insulin doses were resumed and adjusted with improved control. activity level also improved. pt cleared her for home as she was ambulatory. immunosuppression consisted of cellcept that was well tolerated, steroid taper, atg (5 doses)and prograf. prograf was adjusted per trough levels. she was discharged to home on 3mg . vna services were arranged as she was sent home with the drain and the incision still required several dressing changes per day. medications on admission: medications - prescription albuterol - (prescribed by other provider) - 90 mcg aerosol - 1 puff as needed amlodipine - (dose adjustment - no new rx) - 10 mg tablet - 1 tablet(s) by mouth once a day atorvastatin - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth qpm b complex-vitamin c-folic acid - (prescribed by other provider) - 1 mg capsule - capsule(s) by mouth brimonidine - (prescribed by other provider) - 0.1 % drops - 1 gtt od twice a day clopidogrel - (prescribed by other provider) - 75 mg tablet - 1 tablet(s) by mouth qam fluticasone - (prescribed by other provider) - dosage uncertain fluticasone-salmeterol - (prescribed by other provider) - 250 mcg-50 mcg/dose disk with device - 1 puff as needed furosemide - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth qam gatifloxacin - (prescribed by other provider) - 0.3 % drops - 1 gtt od four times a day insulin glargine - (prescribed by other provider) - 100 unit/ml solution - 16am 10 in pm ss humalog insulin lispro - (prescribed by other provider) - 100 unit/ml solution - before meals isosorbide mononitrate - 60 mg tablet sustained release 24 hr - 1 tablet(s) by mouth once a day metoclopramide - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth as needed before supper metoprolol tartrate - 50 mg tablet - 1.5 tablet(s) by mouth twice a day pantoprazole - (prescribed by other provider) - 40 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth twice a day sevelamer hcl - (prescribed by other provider) - 800 mg tablet - 3 tablet(s) by mouth with each meal valsartan - 160 mg tablet - 1 tablet(s) by mouth once a day medications - otc aspirin - (prescribed by other provider) - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth qam docusate sodium - (prescribed by other provider) - 100 mg capsule - 1 capsule(s) by mouth qpm discharge medications: 1. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 4. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation twice a day as needed for shortness of breath or wheezing. 5. aspirin and plavix hold aspirin and plavix until next weeks' appointment to determine when to restart 6. lasix 20 mg tablet sig: one (1) tablet po once a day for 3 days. 7. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 9. brimonidine 0.15 % drops sig: one (1) drop ophthalmic q8h (every 8 hours). 10. isosorbide mononitrate 60 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 11. insulin glargine 100 unit/ml solution sig: sixteen (16) units subcutaneous once a day: am dose. 12. insulin glargine 100 unit/ml solution sig: twelve (12) units subcutaneous at bedtime. 13. insulin lispro 100 unit/ml solution sig: per sliding scale subcutaneous four times a day. 14. tacrolimus 1 mg capsule sig: three (3) capsule po q12h (every 12 hours). 15. hydromorphone 2 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for incision pain. disp:*40 tablet(s)* refills:*0* 16. valganciclovir 450 mg tablet sig: one (1) tablet po once a day. 17. metoprolol succinate 200 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*0* discharge disposition: home with service facility: , discharge diagnosis: esrd now s/p cadaveric kidney transplant htn cad dm discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: please call the transplant office if any of the warning signs listed below are experienced you will need to have lab work drawn every monday and thursday at , empty jp drain and record amount of drainage. bring record of no driving while taking pain medication no heavy lifting/straining shower. no tub bath or swimming. place new drain sponge around jp drain site after shower or daily stop taking metoprolol that you had at home and start taking metoprolol succinate once daily that you are being given a scrip for followup instructions: , md phone: date/time: 2:30 , transplant social work date/time: 3:00 , md phone: date/time: 4:10 Procedure: Other kidney transplantation Other operations on lacrimal gland Transplant from cadaver Diagnoses: Hyperpotassemia End stage renal disease Coronary atherosclerosis of native coronary artery Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Long-term (current) use of insulin Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Long-term (current) use of aspirin |
allergies: penicillins / sulfa (sulfonamides) attending: addendum: patient's discharge defered secondayr to elevated glucoses in 300's. sliding scale adjusted with better control of hyperglycemia. patient d/c to home with stable. discharge disposition: home with service facility: , discharge diagnosis: bilaateral calf claudication l>r,left heel rest pain history of pvd s/p left femoral pta w stenting history of dm2 with triopathy,controlled history of hyperlipdemia history of esrd in hemodialysis, tues,thurs,sat history of ischemic heart disease s/p ptca ,history of myocardia infract-stable angina history of gastroparesis history of gastric reflux disease history of left carotid bruit, asymptomatic, <40% stenosis bilateral postoperative hyperglycemia, corrected md Procedure: Hemodialysis Other (peripheral) vascular shunt or bypass Diagnoses: End stage renal disease Coronary atherosclerosis of native coronary artery Asthma, unspecified type, unspecified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Percutaneous transluminal coronary angioplasty status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Other and unspecified angina pectoris Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with rest pain Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Gastroparesis |
history of present illness: this 50 year-old female with known peripheral vascular disease who underwent a left femoral artery angioplasty and stenting 4 years ago at , presents with progressive claudication of the calves bilaterally, left greater than right. left heel rest pain over the last 4 years. the patient's rest pain is relieved with dangling her foot. symptoms were never totally relieved from the initial endovascular procedure because it was an incomplete procedure secondary to dye contrast atn. the patient underwent evaluation with arterial duplex of the lower extremities which showed occluded left sfa. an abdominal ct was done in of this year which showed multiple areas of atherosclerotic disease involving the aorta and bilateral iliac and external iliac arteries as well as common femoral arteries. there was apparent focal dissection in the left distal common femoral artery with extreme diminutive appearance of the superior portion of the left superficial femoral artery. there were numerous bilateral renal lesions too small to characterize, notably the possibility of mild hyperdense lesions. the patient underwent a diagnostic arteriogram on . the angiographic findings demonstrated patent infrarenal abdominal aorta with patent bilateral single renal arteries. there were patent bilateral common internal and external iliac arteries. there was a widely patent previously placed left common iliac stent. left lower extremity runoff revealed a patent common femoral and profunda femoris arteries. the sfa occludes early and reconstitutes distally in canal via profunda collaterals of the above and below knee popliteal and trifurcation are widely patent. there is 3-vessel runoff down to the foot with a patent anterior tibial, posterior tibialis and peroneal artery. the peroneal is of small caliber. on the right, the right lower extremity runoff revealed patent common profunda femoris superficial femoral arteries. there is mild to moderate disease within the right sfa. the below- knee popliteal and trifurcation are patent with 3-vessel runoff to the foot. the patient returns now for revascularization of the left lower extremity. allergies: topical betadine has caused a rash in the past but recent exposures have not produced any reactions. medications on admission: renocap one daily, renagel 800 mg tabs three before meals, protonix 40 mg b.i.d., lopressor 50 mg b.i.d. norvasc 10 mg b.i.d. imdur 30 mg b.i.d., lasix 20 mg daily, plavix 75 mg daily, lipitor 20 mg daily, aspirin 81 mg daily, colace 100 mg daily p.r.n., reglan 10 mg before meals p.r.n., lantus insulin 25 units at bedtime with a humalog sliding scale before meals, advair 50/250 inhaler p.r.n., albuterol inhaler p.r.n. past illnesses: peripheral vascular disease. history of hypertension, history of hyperlipidemia, history of type 2 diabetes with triopathy, end-stage renal disease on dialysis since tuesdays, thursdays and saturdays. status post left av fistula. history of coronary artery disease. myocardial infarction in . status post coronary angioplasty at that time. history of gastroparesis. history of gerd. history of asthma with recurrent uris. history of hemorrhoids with intermittent bright rectal bleeding post evacuation. colonoscopy in the past has confirmed hemorrhoids. past surgical history: includes cervical conization for abnormal pap and a left av fistula with revision. social history: the patient is married and lives with her husband. the patient is a current smoker, half a pack per day times 30 years. review of systems: negative for shortness of breath, cerebrovascular symptoms. history of angina denied on query but the pre angio query, she admits to intermittent angina, relieved with nitroglycerin. not necessary effort related. the last cardiac catheterization did not show either surgical or interventional amenable disease. physical examination: vital signs: she is afebrile. blood pressure 156/80, pulse 80, respirations 20, oxygen saturation 98% on room air. general appearance: alert, co-operative white female in no acute distress. lungs were clear to auscultation bilaterally. heart is regular rate and rhythm with no murmur, gallop or rub. there is a left carotid bruit. carotid pulses were palpable bilaterally. abdominal exam soft, nontender. there is a left iliac bruit. extremity exam is without edema. the feet are warm and pink bilaterally without ulcerations. there are bilateral femoral bruits. pulse exam shows palpable femorals bilaterally, right greater than left. the right popliteal was palpable. the right dp was palpable and the right pt was a dopplerable biphasic signal. on the left popliteal, there was an absent pulse. dp and pt were dopplerable signals, monophasic. neurological exam was nonfocal. the patient was oriented x3. hospital course: the patient was admitted to the preoperative holding area on . she underwent on a left fem ak with ptfe. she tolerated the procedure well and was transferred to the pacu with a palpable graft pulse. she remained hemodynamically stable and was transferred to the sicu for continued monitoring and care. postoperative day #1: overnight events. the iv fluids were hep-locked for concern of fluid overload. she was afebrile. physical exam was unremarkable. wounds were clean, dry and intact and she had dopplerable pedal pulses. the patient was seen by the renal dialysis service and they followed her during her hospitalization to manage her hemodialysis needs. her diet was advanced as tolerated. the postoperative hematocrit was 32.1. on postoperative day number 2, t-max was 101.7 to 100.7. pulmonary care was aggressive. the patient was de-lined. she was allowed to ambulate. physical therapy was requested to see the patient. they felt that she had good potential for progress to independence with mobility and anticipate discharge to home. the patient was assessed with negotiating stairs which she did well. the remainder of her hospital course was unremarkable. her last hemodialysis was on saturday the 16th. the patient is discharged to home in stable condition. wounds were clean, dry and intact. there is minimal drainage. the patient should follow up with dr. in 2 weeks time. a script for wheelchair for ambulation was written. discharge medications: aspirin 81 mg daily, metoprolol 50 mg b.i.d., reglan 10 mg at bedtime, isosorbide mononitrate 20 mg b.i.d., amlodipine 5 mg daily, valsartan 150 mg daily, lasix 20 mg daily, plavix 75 mg daily, atorvastatin 20 mg daily, silvamere 800 mg tablets 3 before meals. vitamin b complex, vitamin c, folic acid capsule one daily, fluconazole/fenoterol 100/50 mcd disk b.i.d., colace 100 mg b.i.d., aspirin 325 mg tablets 1 to 2 q. 4 to 6 hours p.r.n. for pain, insulin dose is glargine u100, 25 units at bedtime with a humalog sliding scale as preadmission dosing. discharge instructions: the patient may shower but no tub baths. ambulate essential distances. she should elevate the left leg when sitting in a chair. she should continue all medications as prescribed. she should call dr. office if she develops a fever greater than 101.5. she should call the office if her leg or groin wound incisions become red, swollen or drain. she should follow up with dr. in 2 weeks and call for an appointment at . discharge diagnosis: 1. bilateral calf claudication left greater than right with left heel rest pain. 2. history of peripheral vascular disease status post left femoral angioplasty with stenting. 3. history of type 2 diabetes with triopathy, controlled. 4. history of hyperlipidemia. 5. history of end-stage renal disease secondary to diabetes on hemodialysis tuesday, thursday and saturdays. 6. history of ischemic heart disease status post angioplasty prior to myocardial infarction in , now with stable angina. 7. history of gastroparesis. 8. history of gastric reflux. 9. history of left carotid bruit, asymptomatic with less than 40% stenosis bilaterally. major surgical procedures: left fem ak with ptfe on . discharge condition: stable. , Procedure: Hemodialysis Other (peripheral) vascular shunt or bypass Diagnoses: End stage renal disease Coronary atherosclerosis of native coronary artery Asthma, unspecified type, unspecified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Percutaneous transluminal coronary angioplasty status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Other and unspecified angina pectoris Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with rest pain Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Gastroparesis |
allergies: penicillins / sulfa (sulfonamide antibiotics) / iodine-iodine containing / bactrim / biaxin / percocet / vicodin / zyrtec / lovenox / cefepime / nitrate / nitrate attending: chief complaint: shortness of breath major surgical or invasive procedure: intubation cardiac catheterization with stent placement bronchoscopy history of present illness: ms. is a 55f with cad s/p nstemi, poorly controlled chf with recurrent exacerbation, and dm1 on insulin pump c/b esrd s/p renal transplant who was transferred from where she arrived in acute respiratory distress after nebulizers in chf exacerbation asking to be intubated. per notes, she had symptoms worsening for the past day of shortness of breath and was satting 89% on 6l nrb, with sbp of 180. she was intubated, started on a nitro gtt, and was not diuresed prior to transfer. her husband states that her shortness of breath starts suddenly and she told him he needed to call 911. this has happened a number of times over the past week and each time, the onset is sudden. she underwent an dcd kidney transplant in . she has had a couple of recent admissions into with shortness of breath and volume overload. she was just discharged yesterday from after 2 other recent admission for respiratory distress; she had been intubated, diuresed and then extubated. she stated that she still felt short of breath and does not feel back to normal. she is concerned about this worsening in her overall condition. she began her switch back from prograf to rapamycin while she was in the hospital (currently on both) she recently saw dr. in the clinic . in the setting of repeated episodes of volume overload, worsening hypertension and increase in creatinine, the concern for the possibility of transplant renal artery stenosis vs. prograf-induced hypertension (hence the transition to rapamycin) has been raised. transplant renal ultrasound was planned to be completed in the clinic, but no report is available. in the ed, she was intubated on transfer from . nitro gtt was continued for persistent hypertension and she was given asa pr. initial fsbg was 208 at 6am. fentanyl and midazolam were used for sedation and she was transferred to the micu with vitals of p 88 bp 152/44, and o2 sat of 97% on ac 400/20/8/80%. on arrival to the micu, she is sedated but arousable to voice and follows commands. she reports that her breathing is now easier with the et tube in place. past medical history: -type i dm on insulin pump -esrd now s/p dcd renal transplant -cva (: right centrum semi-ovale small vessel stroke in the setting of stopping her antiplatelet agents for cataract surgery) -diabetic retinopathy -peripheral vascular disease, status post left iliac stent , subsequent left ak femoral to popliteal bypass on -asthma (diagnosed ) -obstructive sleep apnea (on cpap --> recent change to bipap 12/8cm, 3l on ) -coronary artery disease (mi in , nstemi , mi ) -hypercholesterolemia -history of tuberculosis, treated in with 5 year multidrug regimen -hypertension -s/p removal of cataract on the left -s/p right cataract removal with vitreous hemorrhage -carpal tunnel syndrome -s/p right carpal tunnel release for carpal tunnel syndrome -s/p open left carpal tunnel release, open flexor tenosynovectomy of first & second digits () social history: the patient lives with her husband. she smoked 1 ppd x 30 yrs, quit . she denies etoh. she is originally from but has lived in the us for >30 years. she is retired but previously worked in electronics. family history: her father had a stroke in his forties, she is uncertain of the etiology but knows that he was hypertensive. physical exam: admission: vitals: t: 98.8 bp: 161/62 p: 95 r: 20, o2: 98% on ac 400/20/8/80% general: intubated, sedated but alert and arousable to voice no acute distress; dried blood noted around nares heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp elevated to 9-10cm, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: inspiratory wheezes without significant crackles (anterior/lateral), abdomen: soft, mildly tender, non-distended, bowel sounds present, no organomegaly gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 4/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . discharge: vs - 97.3 139/50 82 93% 1l i/o: 1100 i; 2200 o over 24 hours general - nad, appropriate heent - dry mm lungs - clear b/l heart - early systolic murmur abdomen - soft, non-tender extremities - wwp, no c/c/e neuro - awake, a&ox3 pertinent results: admission: 11:20am blood wbc-6.6 rbc-2.68* hgb-8.4* hct-26.2* mcv-98 mch-31.3 mchc-32.0 rdw-16.6* plt ct-226 11:20am blood urean-59* creat-1.8* na-142 k-4.2 cl-101 hco3-30 angap-15 11:20am blood alt-31 ast-21 totbili-0.5 09:44am blood ck(cpk)-33 02:55am blood ld(ldh)-292* totbili-0.6 05:41am blood ctropnt-0.09* probnp-3646* 09:44am blood ck-mb-1 ctropnt-0.10* 02:55am blood ck-mb-1 ctropnt-0.14* 11:20am blood albumin-4.5 calcium-9.4 phos-4.2 05:41am blood calcium-9.4 phos-3.5 mg-2.5 11:20am blood tacrofk-2.0* 10:50am blood tacrofk-less than rapmycn-5.6 11:05pm blood type-art temp-37.0 fio2-70 po2-77* pco2-43 ph-7.43 caltco2-29 base xs-3 intubat-not intuba 09:57am blood lactate-1.0 k-5.1 09:41pm blood hgb-6.8* calchct-20 11:20am urine color-yellow appear-clear sp -1.011 11:20am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 11:20am urine hours-random creat-121 totprot-12 prot/cr-0.1 . : 06:00pm blood fibrino-693* 06:00pm blood fdp-0-10 06:00pm blood ret aut-3.7* 04:30am blood ret man-4.6* 07:00am blood ret aut-2.5 06:00pm blood ld(ldh)-268* totbili-0.5 dirbili-0.2 indbili-0.3 05:20am blood alt-15 ast-27 alkphos-125* totbili-0.5 05:20am blood lipase-9 05:41am blood ctropnt-0.09* probnp-3646* 09:44am blood ck-mb-1 ctropnt-0.10* 02:55am blood ck-mb-1 ctropnt-0.14* 09:40pm blood ck-mb-2 ctropnt-0.20* probnp-8025* 12:32am blood ck-mb-2 ctropnt-0.19* 04:30am blood ck-mb-2 ctropnt-0.19* 06:31am blood ctropnt-0.11* 06:02am blood ctropnt-0.09* 04:14am blood ck-mb-1 ctropnt-0.05* 12:03pm blood ck-mb-1 05:03am blood ck-mb-1 ctropnt-0.07* 11:13pm blood ck-mb-2 07:00am blood caltibc-250* vitb12-1561* folate-greater th ferritn-334* trf-192* 06:00pm blood hapto-80 06:00pm blood d-dimer-883* 06:02am blood tsh-4.6* 06:21am blood pth-191* 05:55am blood cortsol-30.1* 05:20am blood anca-negative b 09:16pm blood vanco-27.8* 09:16pm blood vanco-20.9* 07:22pm blood vanco-33.6* 11:20am blood tacrofk-2.0* 10:50am blood tacrofk-less than rapmycn-5.6 07:00am blood rapmycn-8.2 04:30am blood rapmycn-8.9 06:02am blood tacrofk-less than rapmycn-9.2 05:24am blood rapmycn-17.6* 05:34am blood rapmycn-12.2 05:12am blood rapmycn-9.3 05:15am blood rapmycn-3.6* 06:00am blood rapmycn-3.6* 04:00pm blood metanephrines (plasma)-test metanephrines, fract., free normetanephrine, free h 1.0 < 0.90 nmol/l metanephrine, free <0.20 < 0.50 nmol/l 04:00pm blood renin-test plasma renin activity, 27.12 h 0.25-5.82 ng/ml/h 04:00pm blood aldosterone-test aldosterone, lc/ms/ms 21 ng/dl adult reference ranges for aldosterone, lc/ms/ms: upright 8:00-10:00 am < or = 28 ng/dl upright 4:00-6:00 pm < or = 21 ng/dl supine 8:00-10:00 am ng/dl 05:55am blood b-glucan-test fungitell (tm) assay for (1,3)-b-d-glucans results reference ranges ------- ---------------- <31 pg/ml negative less than 60 pg/ml 01:37pm blood aspergillus galactomannan antigen-test aspergillus antigen 0.1 <0.5 06:00am urine color-straw appear-clear sp -1.006 06:00am urine blood-sm nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-tr 06:00am urine rbc-6* wbc-3 bacteri-none yeast-none epi-0 . discharge labs: 05:48am blood wbc-5.3 rbc-3.01* hgb-8.7* hct-26.6* mcv-88 mch-28.9 mchc-32.6 rdw-17.0* plt ct-257 05:48am blood pt-10.4 inr(pt)-1.0 05:48am blood glucose-53* urean-47* creat-1.4* na-145 k-3.4 cl-103 hco3-33* angap-12 05:48am blood calcium-9.0 phos-4.1 mg-1.7 . mirobiology: urine culture: pseudomonas aeruginosa | cefepime-------------- <=1 s ceftazidime----------- 2 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem------------- 0.5 s piperacillin/tazo----- s tobramycin------------ <=1 s blood culture - no growth blood culture - no growth 4:52 pm sputum edotracheal, patient intubated run pcp. stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): no growth. fungal culture (preliminary): no fungus isolated. blood culture - no growth urine culture - no growth blood culture - no growth 10:12 pm sputum source: endotracheal. stain (final ): pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): sparse growth commensal respiratory flora. legionella culture (final ): no legionella isolated. 4:07 pm sputum source: induced. legionella culture (final ): no legionella isolated. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. blood culture - no growth blood culture - no growth mrsa screen - no mrsa isolated urine culture - no growth blood culture - no growth urine culture - no growth mrsa screen - no mrsa isolated urine culture - no growth mrsa screen - no mrsa isolated . imaging: : color doppler ultrasound images of the kidneys were obtained. comparison: renal ultrasound from (renal transplant). findings: the patient is status post right pelvis renal transplant, which measures 12.6 cm. there is no evidence of hydronephrosis or perinephric fluid collections. the resistive indices of the main renal artery, upper, mid and lower pole intrarenal arteries range between 0.68 and 0.83, so borderline to slightly increased, which may reflect a parenchymal abnormality. the main renal artery waveforms in the renal pelvis itself show slowed upstrokes although they generally appear fairly brisk among interlobar arteries. the renal vein is patent. the urinary bladder is normal. impression: delayed upstrokes measured among some renal artery branches suggesting there may be renal artery stenosis upstream . echo (): the left atrium is mildly dilated. color-flow imaging of the interatrial septum raises the suspicion of a small atrial septal defect, but this could not be confirmed on the basis of this study. the estimated right atrial pressure is 5-10 mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). there is regional hypokinesis of the basal and mid inferior left ventricular walls. there is no left ventricular outflow obstruction at rest or with valsalva. right ventricular chamber size and free wall motion are normal. the aortic arch is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. impression: suspicion of possible small atrial septal defect. mild symmetric left ventricular hypertrophy with hypokinesis of basal and mid inferior segments. mildly dilated aortic arch. mild mitral regurgitation. indeterminate pulmonary artery systolic pressure. compared with the prior study (images reviewed) of , the basal and mid inferior segments of the left ventricle are now hypokinetic; the previous images were suboptimal and regional wall motion was not assessed. mild dilitation of the aortic arch is now seen; not previously assessed. there is the suggestion of a possible small atrial septal defect on the current study; the interatrial septum was previously intact by 2d color doppler and saline contrast with maneuvers. the pulmonary artery systolic pressure was not able to be determined on the current study, but was previously moderate in severity. . cxr (): findings: pa and lateral chest views were obtained with patient in upright position. analysis is performed in direct comparison with the next preceding portable chest examination of . heart size is unchanged. previously described moderate pulmonary congestive pattern with some upper zone re-distribution has normalized. presently no evidence of pulmonary interstitial alveolar edema and the lateral as well as posterior pleural sinuses are free from any fluid accumulation. no pneumothorax in the apical area. no acute infiltrates. lateral and posterior pleural sinuses are free. a previously described old calcified granuloma in the left upper lobe area is unchanged. impression: no evidence of new acute pulmonary infiltrates. . ct chest (): impression: 1. no evidence of interstitial pulmonary disease. 2. right middle lobe bronchial obstruction with atelectasis. bronchoscopy is recommended for further evaluation. prominent right hilar lymph node measuring 7 mm in short axis diameter. 3. multiple pulmonary nodules bilaterally as described above. follow up chest ct is recommended in 6 months. 4. mildly prominent main pulmonary artery could suggest mild pulmonary artery hypertension. . cardiac cath (): comments: 1. selective coronary angiography in this right dominant system demonstrates three vessel disease. the circumflex contains a 90% lesion in the mid-vessel. the right coronary artery contains a 90% lesion in a small postero lateral branch. the left anterior descending contains a 60% long lesion in the mid vessel. 2. hemodynamics demonstrate normal biventricular filling pressures with a high cardiac output calculated using an assumed oxygen consumption. 3. successful pci to the lcx lesion with 2.5x15mm promus des. 4. manual sheath removal from right cfa. 5. no complications. final diagnosis: 1. three vessel coronary artery disease. 2. successful pci to the lcx lesion with promus des. 3. patient is to remain on aspirin indefinitely and clopidogrel for at least 1 year, uninterrupted. 4. no complications. . le ultrasound (): clinical indication: patient hypoxic with pulmonary edema to assess for dvt. all of the deep veins in the right and left lower extremity show normal and full compressibility from the groin to below the popliteal bifurcation. color flow and pulse doppler waveform analysis is normal throughout. conclusion: no evidence of dvt in right or left lower extremity. . cxr (): findings: cardiac silhouette remains enlarged, accompanied by pulmonary vascular congestion. interstitial edema has improved in the interval. bibasilar atelectasis is again demonstrated, with improvement on the left. bilateral small pleural effusions are also evident as well as multiple calcified granulomas in the left lung. . cxr (): findings: as compared to the previous radiograph, the lung volumes have increased. the right internal jugular vein introduction sheath has been removed. the pre-existing right pleural effusion has completely resolved. on the left, however, the pre-existing pleural effusion persists and has minimally increased in extent. there are subsequent areas of retrocardiac and basal atelectasis. borderline size of the cardiac silhouette. two calcified lung nodules in the left apex. . echo (): the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 5-10 mmhg. mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal 2/3rds of the inferior wall. the remaining segments contract normally (lvef = 55-60 %). the estimated cardiac index is high (>4.0l/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 stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. there is mild-moderate pulmonary artery systolic hypertension. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is a trivial/physiologic pericardial effusion. impression: mild symmetric left ventricular hyperrrophy with normal cavitry size and regional systolic dysfunction c/w cad (pda distribution). moderate mitral regurgitation most likely due to papillary muscle dysfunction. pulmonary artery hypertension. compared with the prior study (images reviewed) of , pulmonary artery hypertension is now quantified. left ventricular wall motion and severity of mitral regurgitation are similar. . cxr et tube has been removed. mild pulmonary edema has decreased. severe left lower lobe consolidation is probably atelectasis, but following removal of left pleural tube, there could be a component of small-to-moderate left pleural effusion that has developed. there is no pneumothorax. severe cardiomegaly is longstanding. right internal jugular line ends in the right atrium and would need to be withdrawn 5 cm to move it into the low svc. cxr: ap single view of the chest has been obtained with patient in sitting semi-upright position. analysis is performed in direct comparison with the next preceding similar study dated . a right-sided picc line is again identified. it is now seen to terminate overlying the right-sided mediastinal structures at the level of the carina. thus, it has been withdrawn by approximately 4 cm in comparison with the preceding examination and is now in good position in the mid portion of the svc provided good venous flow has been established. no pneumothorax or any other placement-related complications identified. cardiomegaly and pulmonary vascular congestive pattern with some pleural densities in left base as before. . cxr: in comparison with the study of , there is continued enlargement of the cardiac silhouette. pulmonary vascularity is mildly engorged but less prominent than on the previous study. opacification at the bases with obscuration of the hemidiaphragms is consistent with bilateral layering effusions, more prominent on the left, with underlying compressive atelectasis. central catheter tip again extends to the upper to mid portion of the svc. . labs at discharge: 06:32am blood wbc-4.3 rbc-3.18* hgb-9.4* hct-28.5* mcv-90 mch-29.6 mchc-33.1 rdw-15.8* plt ct-233 05:38am blood pt-11.2 ptt-31.0 inr(pt)-1.0 06:32am blood glucose-121* urean-58* creat-2.1* na-142 k-5.0 cl-100 hco3-33* angap-14 06:12am blood alt-33 ast-29 alkphos-88 totbili-0.6 06:32am blood calcium-9.5 phos-5.3* mg-1.9 06:32am blood tacrofk-7.3 brief hospital course: summary: ms. is a 55 y/o woman with hx esrd from t1dm s/p renal transplant in , cad s/p multiple mis and des to circumflex artery (), ischemic cardiomyopathy (lvef = 55-60 %) who had a very long hospital course notable for recurrent respiratory distress, which was multifactorial . # respiratory distress: she had multiple episodes of flash pulmonary edema in the setting of acute on chronic diastolic and systolic heart failure. this required multiple intubations and transfers to the icu. the precipitants for these events included volume overload, transfusions of blood products, hypertensive emergency, and coronary disease. it was also felt that rapamycin toxicity may have been playing a role, so she was changed to tacrolimus. it was also felt that nitrates may have been causing vq mismatch and worsening her hypoxia, so nitrates should be avoided in the future. a bronchoscopy on did not reveal any pathology. her hypertension was aggressively treated. she was aggressively diuresed. she was treated with albuterol, inhaled steroids, bronchodilators, anti-cholinergics, and a glucocorticoid taper. she was ultimately discharged to rehab with need for aggressive pulmonary rehabilitation. her persistent hypoxia that had been present for much of her admission, despite appearing euvolemic, improved prior to discharge, after rapamycin was changed to tacrolimus. rapamycin can cause an asthmatic type lung disease, and the patient did have evidence of wheezing and bronchiectasis on ct scan. . # subglottic stenosis: the patient was a difficult intubation, secondary to subglottic stenosis. . # pleural effusion: it was felt this effusion was most likely related to heart failure. due to the risks of the procedure, thoracentesis was deferred. she has follow-up with pulmonary, and the need for thoracentesis can be re-addressed at that time. anti-coagulation for atrial fibrillation was deferred given the potential need for a procedure. . # cad: she has had multiple myocardial infarctions. ms had a cardiac cath on showing diffuse disease. she had a des placed in the left circumflex. it was hypothesized that intermittent occlusion of this vessel (which supplies the mitral valve) contributed to flash pulmonary edema by causing mitral regurgitation. her hypertension was treated aggressively, she was maintained on atorvastatin, and she was instructed to take aspirin 81mg and plavix daily. . # renal disease: the patient has a h/o renal transplant in for esrd secondary to htn and t1dm. she was maintained on azathioprine with dapsone for pcp (sulfa allergy). she was transitioned to tacrolimus from rapamycin after it was suspected that rapamycin toxicity was worsening her lung function. her creatinine fluctuated widely this admission in the setting of ongoing diuresis, medications (ace-i / ), and contrast. angiography did not show renal artery stenosis. she had an acute rise in creatinine with lisinopril treatment. . # anemia: an extensive work-up was largely unrevealing. she did have persistent epistaxis while intubated in the icu, as well as persistent hemoptysis after a traumatic intubation. she was conservatively transfused, given that she was very sensitive to fluid. additional lasix was absolutely necessary to prevent flash pulmonary edema with blood products. darbopoetin should be considered as outpatient. . # fevers: ms developed fevers while in the hospital. she had urine cultures positive for pseudomonas, which was a likely source. however, she also had a pleural effusion, and she was treated empirically for pneumonia with meropenem and vancomycin. she was afebrile for many days off antibiotics prior to discharge. . # atrial fibrillation: 2 episodes (once in micu, once on floor) with rvr which responded to 10mg iv metoprolol and 30mg iv diltiazem. it was felt this was secondary to cardiomyopathy and pulmonary disease. she was initiated on warfarin (chads of 5). she became supratherapeutic, and after administration of ffp (for planned thoracentesis) she had an episode of flash pulmonary edema. re-initiation of warfarin was deferred to her primary outpatient providers given her anemia and sensitivity to blood transfusions (volume overload) and potential need for thoracentesis at a pulmonary follow-up appointment. . # type 1 dm: on insulin pump. had multiple changes to her regimen in setting of intubation, treatment with glucocorticoids. managed by in-house. . # iatrogenic complications: the patient had multiple complications from this hospitalization, including a fingerstick of 9 while on insulin gtt in the icu; multiple intubations in-house, with mis-communication about her subglottic stenosis; inadvertant placement of a venous catheter into the sub-clavian artery requiring removal in the or; multiple hand-offs of her care between services, with associated poor communication between primary teams and multiple consultanting services; and she was discharged from the hospital with a picc line that was being used only for lab draws without communication of this to the rehab center until after discharge. the patient was informed of these complications, and while frustrated, she was overall grateful regarding her care, and was excited about discharge and was planning to follow-up at her multiple appointments. . ====== transitional issues by system: -cardiology: severe 3 vessel cad, s/p des to l circumflex. on asa 81, plavix, atorvastatin. paroxysmal atrial fibrillation with chads score of 5. not on warfarin at the time of discharge due to potential need for thoracentesis at a follow-up pulmonary appointment. to follow-up with cardiology. . -pulmonary: multiple episodes of flash pulmonary edema. possible rapamycin toxicity. persistent hypoxia. pleural effusions. on multiple inhaled therapies. to follow-up with pulmonary. . -intubation: has subglottic stenosis. . -lines: was discharged with picc line - several hours after discharge the rehab facility was called, and informed of her line. . -renal: s/p transplant. on torsemide diuresis. on losartan. on tacrolimus and azathioprine (dapsone for pcp ). avoid rapamycin - may have contributed to lung disease. to follow-up with renal transplant, with labs to be drawn at rehab on the day after discharge. . -endocrine: t1dm on insulin pump. . -hematology: consider darbopoetin as outpatient for anemia. . -vascular: has pvd and an abdominal bruit was noted during the course of her admission, which will need close follow-up as outpatient. . -id: completed course of meropenem/vancomycin for pseudomonas uti and empiric pnemonia . -important notes: avoid nitrates; avoid rapamycin; for transfusions, consider iv lasix if the volume is not needed; consider starting coumadin after pulmonary appointment, as this was not started in house given the potential need for thoracentesis at outpatient follow-up appointment. medications on admission: amlodipine 10 mg atorvastatin 40mg qhs azathioprine 75 mg daily carvedilol 50mg clopidogrel 75 mg daily dapsone 100 mg daily (prophylaxis) darbepoetin alfa 60mcg/0.3 ml syringe - inject 1 s/c once a month fluticasone-salmeterol 250 mcg-50 mcg/dose, 1 puff furosemide 80 mg hydralazine 25 mg qid insulin lispro - dosage uncertain ipratropium-albuterol 18 mcg-103 mcg, 2 puffs(s) qid and prn as needed for sob isosorbide mononitrate er 60 mg daily metoclopramide 10 mg pantoprazole 40mg sirolimus 2.5 mg daily tacrolimus 1 mg capsule - recently stopped aspirin 81 mg qam calcium carbonate-vit d3-min 600 mg-400 unit tablet - 2 tablet(s) by mouth daily multivitamin-minerals-lutein 1 tab daily omega-3 fatty acids-vitamin e 1,000 mg daily pramoxine 1 % lotion - use topically discharge medications: 1. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. azathioprine 50 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po once a day. 4. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) breathing treatment inhalation every 6-8 hours as needed for shortness of breath or wheezing. 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 8. carvedilol 25 mg tablet sig: two (2) tablet po twice a day. 9. clonidine 0.1 mg tablet sig: one (1) tablet po bid (2 times a day). 10. dapsone 100 mg tablet sig: one (1) tablet po daily (daily). 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 13. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 14. hydralazine 25 mg tablet sig: three (3) tablet po q6h (every 6 hours). 15. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours). 16. losartan 50 mg tablet sig: two (2) tablet po daily (daily). 17. metoclopramide 10 mg tablet sig: one (1) tablet po bid (2 times a day). 18. polyethylene glycol 3350 17 /dose powder sig: one (1) po daily (daily) as needed for constipation. 19. sodium chloride 0.65 % aerosol, spray sig: sprays nasal (2 times a day). 20. tacrolimus 0.5 mg capsule sig: five (5) capsule po q12h (every 12 hours). 21. torsemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). 22. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 23. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 24. insulin pump according to attached settings 25. outpatient lab work next full set of labs including chemistry panel and tacromycin level to be checked on . results should be reported to dr. (phone ( ; fax:() 26. oxygen by nasal cannula, titrate to o2 >89% discharge disposition: extended care facility: - discharge diagnosis: primary: pulmonary edema hypertension coronary artery disease acute on chronic kidney injury . secondary: chronic anemia s/p renal transplant 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 for shortness of breath. you had an extended stay in the hospital that included several episodes of shortness of breath, high blood pressure, and kidney damage. your shortness of breath was determined to be from heart failure, volume overload, and pulmonary hypertension (high pressure in the blood vessels that supply your heart). you were treated with diuresis (water pills). cardiac catheterization (a procedure to visualize the arteries that supply your heart with blood) was performed and a stent placed in one of your coronary arteries to help keep it open. bronchoscopy was performed to look at your airways; this test was normal. you were also treated with antibiotics for pneumonia. you were seen by our pulmonary (lung) doctors, who recommended a course of steroids and nebulizers (breathing treatments). it is also possible that one of your medications (rapamycin) was causing damage to your lungs, so we changed this medication to a different medicine called tacrolimus. . you also have a condition called paroxysmal atrial fibrillation (an occasional abnormal heart rhythm). this puts you at a risk of having a stroke. to prevent strokes, patients are often started on coumadin (a blood thinner). you should speak with your outpatient doctors about starting this medication. we are not starting it in the hospital until you see the lung doctors in follow-up, in case they decide to do a procedure called a thoracentesis (to drain some fluid in part of your lung). . you have follow-up with the lung doctors, heart doctors, and kidney doctors. ****please note that we have made many changes to your medications during this hospitalization. listed below are the medications you should take at discharge. we have also listed the reason for taking them. it is very important that you stop taking all other medications unless directly instructed by your doctors. . please start: atorvastatin 40 mg po/ng daily to lower cholesterol and protect your heart azathioprine 50 mg po/ng daily to prevent rejection of your kidney aspirin 81 mg po/ng daily to prevent the stent in your heart from being blocked by a clot. amlodipine 10 mg po/ng daily to lower your blood pressure albuterol 0.083% neb soln 1 neb ih for shortness of breath, wheezing bisacodyl 10 mg po daily for constipation clopidogrel 75 mg po/ng daily to prevent the stent in your heart from being blocked by a clot carvedilol 50 mg po/ng to lower blood pressure and protect your heart clonidine 0.1 mg po bid to lower your blood pressure dapsone 100 mg po/ng daily to prevent an infection in your lung from developing docusate sodium 100 mg po bid for constipation fluticasone-salmeterol diskus (250/50) 1 inh ih to help your lungs protonix 40 mg po q12h to treat acid reflux guaifenesin ml po for cough hydralazine 75 mg po/ng q6h to lower blood pressure ipratropium bromide neb 1 neb ih q6h to help your lungs insulin pump sc to lower your blood sugar losartan potassium 100 mg po daily to lower blood pressure and help your kidneys metoclopramide 10 mg po bid to help your stomach empty into your intestine polyethylene glycol 17 g for constipation sodium chloride nasal spry nu for congestion (nasal) tacrolimus 2.5 mg po q12h to prevent rejection of your kidney torsemide 60 mg po bid to help get rid of extra fluid in your body zolpidem tartrate 5 mg po to help you sleep. . please follow-up with your outpatient providers as listed below. these are very important to help make sure you continue to improve after discharge. . please have a chest xray prior to your pulmonary appointment on . the order is in, just walk in on the (). followup instructions: tuesday 03:40pm , lm , transplant medicine (nhb) department: cardiac services when: 02:30pm with: , md building: campus: east best parking: garage department: orthopedics when: friday at 11:00 am with: , np building: sc clinical ctr campus: east best parking: garage department: medical specialties when: tuesday at 10:00 am with: rrt/dr. building: sc clinical ctr campus: east best parking: garage department: pulmonary function lab when: wednesday at 4:10 pm with: pulmonary function lab building: campus: east best parking: garage department: medical specialties when: wednesday at 4:30 pm with: , m.d. building: campus: east best parking: garage please have a chest xray prior to this appointment. the order is in, just walk in on the (). md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Coronary arteriography using two catheters Other bronchoscopy Arteriography of other intra-abdominal arteries Incision with removal of foreign body or device from skin and subcutaneous tissue Arteriography of renal arteries Insertion of drug-eluting coronary artery stent(s) Other diagnostic procedures on nasal sinuses Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Pneumonia, organism unspecified Anemia of other chronic disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Atrial fibrillation 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 Long-term (current) use of insulin Old myocardial infarction Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Epistaxis Mechanical complication of other vascular device, implant, and graft Diabetes with renal manifestations, type I [juvenile type], uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled Background diabetic retinopathy Pseudomonas infection in conditions classified elsewhere and of unspecified site Kidney replaced by transplant Acute on chronic combined systolic and diastolic heart failure Stenosis of larynx Insulin pump status Extrinsic asthma, unspecified Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified Transfusion associated circulatory overload |
allergies: no known allergies / adverse drug reactions attending: chief complaint: palpatations major surgical or invasive procedure: coronary artery bypass grafting x 5 (left internal mammary artery grafted to the left anterior descending artery/saphenous vein grafted to diag1/diag 2/obtuse marginal 1/obtuse marginal2)- history of present illness: 63 year old male whon underwent stress echo for symptoms of palpitations occurring at night, in temporal relation to alcohol intake, 3 times in the last 6 weeks or so. these episodes lasted from 30-90 minutes and resolve spontaneously. stress echo images were consistent with ischemia in the rca territory. he was referred by dr for left heart catheterization. he was found to have coronary artery disease upon cardiac catheterization. cardiac surgery was consulted for evaluation of coronary revascularization. past medical history: coronary artery disease secondary: mitral valve prolapse hypercholesterolemia prostatic hypertrophy, benign colonic polyp social history: race:caucasian last dental exam:1 month ago lives with:wife contact: (wife) phone # occupation:retired science educator cigarettes: smoked no yes hx:quit in other tobacco use:denies etoh: 2 drinks/day illicit drug use:denies family history: premature coronary artery disease- father died of heart attack at age 42-44 while undergoing ect; grandfather died at 56 thought secondary to mi physical exam: physical exam pulse:44 resp:16 o2 sat:100/ra b/p right:118/74 left:128/75 height:6'1" weight:190 lbs general: nad, wgwn skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen:soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema __none___ varicosities: none minor varicosities neuro: grossly intact pulses: femoral right: 2+ left:2+ dp right: 2+ left:2+ pt : 2+ left:2+ radial right: 2+ left:2+ carotid bruit right: left: pertinent results: intra-op tee conclusions prebypass 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 descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. physiologic mitral regurgitation is seen (within normal limits). postbypass preserved biventricular systolic function. study otherwise unchanged from prebypass i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 11:19 ?????? caregroup is. all rights reserved. . 04:56am blood wbc-8.7 rbc-3.30* hgb-10.2* hct-30.5* mcv-93 mch-31.0 mchc-33.5 rdw-12.8 plt ct-165 06:45am blood wbc-11.4* rbc-3.45* hgb-11.1* hct-31.9* mcv-93 mch-32.1* mchc-34.7 rdw-13.3 plt ct-137* 04:56am blood urean-20 creat-0.8 na-133 k-4.4 cl-97 06:45am blood glucose-119* urean-18 creat-0.8 na-133 k-4.4 cl-97 hco3-27 angap-13 04:56am blood mg-2.0 brief hospital course: on mr. was taken to the operating room and underwent coronary artery bypass grafting x 5 (left internal mammary artery grafted to the left anterior descending artery/saphenous vein grafted to diag1/diag 2/obtuse marginal 1/obtuse marginal2)with dr.. please refer to operative report for further surgical details. he tolerated the procedure well and was transferred to the cvicu for invasive monitoring. he awoke neurologically intact and was extubated without incident. he weaned off pressor support. beta-blocker, statin and aspirin were initiated. he was diuresed towards his preoperative weight. all lines and drains were discontinued per protocol. pod#1 he transferred to the step down unit for further monitoring. physical therapy was consulted for evaluation of strength and mobility. pod#2 he went into postoperative rapid atrial fibrillation requiring amiodarone and a diltiazem drip to break. he remained in raf <24 hours and converted to normal sinus rhythm. his iv medications were transitioned to oral. he progressed and the remainder of his hospital course was essentially uneventful. he was ambulating freely and his wound was healing well by pod 4. lisinopril should be resumed when blood pressure will tolerate. he was discharged to home with vna services. all follow up appointments were advised. medications on admission: fluticasone dosage uncertain lisinopril 5 mg daily metoprolol tartrate 25 mg simvastatin 20 mg daily vitamin d dosage uncertain aspirin 81 mg daily calcium carbonate dosage uncertain multivitamin dosage uncertain discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg x 1 week, then 400mg daily x 1 week, then 200mg daily. disp:*120 tablet(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: coronary artery disease secondary: mitral valve prolapse hypercholesterolemia prostatic hypertrophy, benign colonic polyp discharge condition: alert and oriented x3 non-focal ambulating with steady gait incisional pain managed with incisions: sternal - healing well, no erythema or drainage leg left - healing well, no erythema or drainage. edema- none discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. date/time: 1:00 wound care nurse phone: date/time: 10:30 cardiologist: - office will call you with appt. please call to schedule appointments with your primary care dr. , f. 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 (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Mitral valve disorders Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified angina pectoris Acute respiratory failure following trauma and surgery |
allergies: tegretol / vicodin attending: chief complaint: shortness of breath major surgical or invasive procedure: aortic valve replacement (21mm st. mechanical), mitral valve replacement( . mechanical), tricuspid valve repair (32mm contour 3d ring), and patent foreman ovale closure) history of present illness: 31 year old female with history of mssa endocarditis in , seizures, depression, hepatitis c p/w fever. fevr started 2 days ago, highest temp has been 103 at home, and also low back pain. in addition she has felt palpitations at night along with shortness of breath. yesterday symptoms got works with nausea and vomiting, vomited x 5 which was nonbloody and yellow. mostly she has been eating soup and water, as she has had difficulty eating solid foods. she feels that her back pain is worsening as well from her chronic low back pain. . initially pt presented to on . blood cultures were drawn, which are pending. she was started on vancomycin and gentamicin given concern for endocarditis. daptomycin was started in place of vancomycin for concern for vre on as blood cx pwere positive for likely enterococcus also per chart pt had an adverse reaction to vancomycin. cxr was concerning for infiltrate as well thought to be septic emboli. tee was done and concern for vegetations on mitral and aortic valves on , also noted ot have 2+ ai and 2+ mr. mri of spine showed no e/o osteomyelitis. abx changed to gentamicin and ampicillin following blood cx returned with enterococcus faecalis. id team was consulted regarding these recommendations. tte done on showed vegetations on av and on mv, c/w tee results on . cxr was done on which showed rll infiltrate, cefepime was started but discontinued after ct chest showed no pna and bilateral pleural effusions concerning for chf thought to be endocarditis. bnp was 508. pt transferred to for evaluation by cardiac surgery for surgical eval of valvular disease. . currently, pt complaining of mild back pain and abdominal pain, c/w pain that she had at osh resolving with percocet. no shortness of breath, nausea, or other 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 chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. referred for surgical evaluation. past medical history: mssa endocarditis in seizures x 3 years depression hepatitis c anemia ivdu social history: tobacco history: denies etoh: denies illicit drugs: endorses heroin use, last use 3 months ago herbal medications: denies lives alone, no sick contacts family history: adopted, family hx unknown physical exam: admission physical exam: 53 kg 61" vs: 98.5 96/44 111 18 95% ra general: wdwn f 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 15 cm. cardiac: rrr, ii/vi systoilic and diastolic murmurs heard throughout, no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. no femoral bruits. picc line in place in l arm skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: labs: 03:52am blood wbc-8.2 rbc-3.33* hgb-9.1* hct-28.4* mcv-85 mch-27.3 mchc-32.1 rdw-16.8* plt ct-276# 04:49am blood wbc-9.9# rbc-3.10* hgb-8.6* hct-26.0* mcv-84 mch-27.8 mchc-33.1 rdw-17.0* plt ct-178 03:56am blood wbc-21.4* rbc-3.60* hgb-9.8* hct-29.5* mcv-82 mch-27.3 mchc-33.3 rdw-16.9* plt ct-238 03:52am blood pt-22.4* ptt-37.0* inr(pt)-2.1* 04:49am blood pt-15.0* inr(pt)-1.4* 03:56am blood pt-14.1* ptt-26.8 inr(pt)-1.3* 01:35am blood pt-13.4* ptt-31.2 inr(pt)-1.2* 03:52am blood glucose-96 urean-18 creat-0.6 na-141 k-4.5 cl-105 hco3-29 angap-12 04:49am blood glucose-103* urean-16 creat-0.6 na-139 k-3.4 cl-99 hco3-33* angap-10 03:56am blood glucose-117* urean-12 creat-0.7 na-135 k-4.9 cl-97 hco3-28 angap-15 01:35am blood glucose-91 urean-10 creat-0.6 na-131* k-5.1 cl-99 hco3-26 angap-11 04:28am blood wbc-8.9 rbc-3.79* hgb-9.5* hct-30.6* mcv-81* mch-25.0* mchc-31.0 rdw-14.5 plt ct-398 04:28am blood pt-11.2 ptt-34.0 inr(pt)-1.0 04:28am blood glucose-90 urean-12 creat-0.7 na-140 k-4.7 cl-103 hco3-29 angap-13 06:11am blood alt-8 ast-13 ld(ldh)-191 alkphos-59 totbili-0.3 04:28am blood calcium-9.0 phos-4.8* mg-2.3 04:28am blood %hba1c-5.3 eag-105 03:41pm blood genta-0.8* 05:43am blood hct-29.1* 05:43am blood pt-33.8* inr(pt)-3.3* 05:43am blood urean-13 creat-0.5 na-135 k-4.4 cl-101 abd ultrasound (): findings: there is a large right and left pleural effusion identified. the hepatic architecture is unremarkable. no focal liver abnormality is identified. no biliary dilatation is seen and the common duct measures 0.6 cm. the portal vein is patent with hepatopetal flow. the gallbladder is normal. the pancreas is unremarkable. the spleen is borderline in size measuring 12.1 cm. no hydronephrosis is seen. the right kidney measures 11.8 cm and the left kidney measures 12.6 cm. the aorta is of normal caliber throughout. the visualized portion of the ivc is unremarkable. no ascites is seen in the abdomen. impression: 1. no findings to suggest a hepatic abscess. 2. bilateral pleural effusions. 3. no ascites. tee :conclusions (prelim) pre-bypass: the left atrium is moderately dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. a patent foramen ovale is present. a right-to-left shunt across the interatrial septum is seen at rest. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is moderately depressed (lvef= xx %). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to xx cm from the incisors. there is a large vegetation on the aortic valve. no aortic valve abscess is seen. severe (4+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is a moderate-sized vegetation on the mitral valve. severe (4+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is no pericardial effusion. post cpb#1 1. improved left and right ventricular systolci function with background inotropic support (epinephrine) 2. bileaflet maechanical valves seen in mitral aortic position. well seated and stable with good lealflet excursion with mild valvular regurgitation jets (washing jets) 3. minimal gradients across the prosthetic valves in aortic and mitral position. 4. progressive worsening of trisuspid regurgitation (central) after separation from cpb with associated systolic reversal of hepatic venous flow. no lealfelt avulsion/restriction visualized, but necessitated re-institution of cpb. post cpb#2 1, annuloplqasty ring seen in the tricuspid position. good leaflet excursion and mnimal gradient, with trace trisuspid regurgitation. 2. no ther change. echo left atrium: mild la enlargement. right atrium/interatrial septum: normal ra size. left ventricle: normal lv wall thickness and cavity size. mild regional lv systolic dysfunction. no resting lvot gradient. right ventricle: mildly dilated rv cavity. borderline normal rv systolic function. abnormal septal motion/position. aortic valve: bileaflet aortic valve prosthesis (avr). avr well seated, normal leaflet/disc motion and transvalvular gradients. mitral valve: bileaflet mitral valve prosthesis (mvr). tricuspid valve: tricuspid valve annuloplasty ring. moderate tr. pericardium: trivial/physiologic pericardial effusion. conclusions the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with septal hypokinesis. the right ventricular cavity is mildly dilated with borderline normal free wall function. there is abnormal septal motion/position. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. a bileaflet mitral valve prosthesis is present. a tricuspid valve annuloplasty ring is present. moderate tricuspid regurgitation is seen. there is a trivial/physiologic pericardial effusion. impression: no significant pericardial effusion. normal lv cavity size with hypokinesis of the septum. the movement of the septum appears abnormal - probably due to a combination of hypokinesis and post-pericardiotomy. the right ventricle is borderline dilated and borderline hypodynamic. mitral and aortic mechanical prosthesis are functioning normall. there is moderate tricuspid regurgitation compared with the prior study (images reviewed) of , the patient is post-op with avr, mvr and a tricuspid ring. ventricular function has improved, the amount of pericardial fluid has decreased. brief hospital course: she was admitted with enterococcus endocarditis sensitive to ampicillin and gentamicin. power picc was in place. her antibiotics started and first negative blood cultures were on . she had some dyspnea on exertion, and was requiring 2l-3 o2. ruq u/s demonstrates b/l pleural effusions (no abscesses). echo demonstrated severe 4+ aortic valve regurgitation, aortic veg and 3+ mr. surgery with dr. on and was transferred to the cvicu in stable condition on epinephrine and propofol drips. she was extubated the following morning and epinephrine weaned off. she was transferred to the floor on pod #2 to began to work with physical therapy to increase strength and mobility. coumadin was started for mechanical valves and was bridged with heparin until she was anticoagulated for inr goal 3.0-3.5. the infectious disease team was consulted and recommended 6 weeks of ampicillin and gentamicin from for enterococcus. chest tubes and pacing wires removed per protocol. she continued to progress well. gentamicin peak and trough were checked to assure proper dosing. by pod 6 she was ambulating with assistance, her incisions were healing well and she was tolerating a full oral diet. it was felt that she was safe for transfer to state hospital for continued antibiotics. medications on admission: home medications: depakote 250 mg daily zoloft 50 mg daily lexapro 20 mg daily . medications on transfer: depakote 250 mg daily acetaminophen 325 mg prn percocet q4h prn lactobacillis lovenox 40 mg daily ferrous sulfate 325 mg daily clotrimazole 1% cream gentamicin 70 mg/1.75 ml every 8 hrs ampicillin 2 gm q4h discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 4. divalproex 250 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 5. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 6. 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. 7. outpatient lab work labs q cbc with diff, lft, bun, cr, gent peak and gent trough, pt/inr labs qwed pt/inr labs qfriday pt/inr bun, cr gent peak and gent trough lab results to clinic phone ( office fax:( 8. warfarin 1 mg tablet sig: goal inr 3-3.5 tablets po once a day: to check inr in am for further dosing - had received between 2-6 mg see coumadin form . 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 10. ampicillin sodium 2 gram recon soln sig: two (2) recon soln injection q4h (every 4 hours): 2 gram q4h for 6 weeks thru follow up in clinic prior to completion . 11. gentamicin 40 mg/ml solution sig: fifty (50) mg injection q8h (every 8 hours): 50 mg q8h next trough and peak on for 6 weeks thru follow up in clinic prior to completion . 12. lexapro 20 mg tablet sig: one (1) tablet po once a day. 13. dilaudid 2 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. discharge disposition: extended care facility: discharge diagnosis: mssa endocarditis complicated by enterococcal endocarditis s/p avr/mvr/tv repair/pfo closure aortic valve regurgitation mitral valve regurgitation seizures hepatitis c ivdu depression anemia discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with dilaudid incisions: sternal - healing well, no erythema or drainage edema none 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. at 1:00 pm, bldg, cardiologist:dr. at 11:30 am 1- infectious disease with dr - please call to schedule for appointment in 4 weeks labs weekly - cbc with diff, lft - results to clinic labs biweekly bun, cr, gent peak and trough - results to clinic 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 and mitral valves goal inr 3-3.5 first draw friday please check , wednesday, and friday for 2 weeks then twice a week if inr and dosing stable rehab physician to manage coumadin until discharge from rehab **please arrange for coumadin/inr f/u prior to discharge from rehab* Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Open and other replacement of mitral valve Other and unspecified repair of atrial septal defect Open heart valvuloplasty of tricuspid valve without replacement Diagnoses: Anemia, unspecified Congestive heart failure, unspecified Unspecified viral hepatitis C without hepatic coma Mitral valve insufficiency and aortic valve insufficiency Depressive disorder, not elsewhere classified Ostium secundum type atrial septal defect Acute and subacute bacterial endocarditis Epilepsy, unspecified, without mention of intractable epilepsy Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Acute systolic heart failure Diseases of tricuspid valve Opioid abuse, unspecified |
allergies: penicillins / ibuprofen attending: chief complaint: lethargy, hypercapnic respiratory failure major surgical or invasive procedure: none history of present illness: 75 yo f with history of diastolic chf, sleep apnea, cad, dm, cri, 12 hospitalizations over past year, presented w/ dyspnea and decreased mental status. had just been discharged on after aggressive diuresis for acute on chronic diastolic chf during last admission and also tx for uti. . daughter called ems this am for progressive dyspnea and difficulty ambulating. on arrival ems found the patient to be somnolent. fs 66. per daughter, the patient had been at her recent baseline the night before, however with some weight gain and progressive dyspnea in last couple days. patient on ativan and percocet at home, per daughter, the patient not known to have taken increased doses. . in the ed, initial vs were: p 73 bp 205/60 100% o2 sat on 3l nc. her abg on arrival to the ed was 7.28/64/78. her respiratory rate peristed at 7-9. they pushed narcan 0.4mg x2 prior to possible intubation with significant response. pt then became somnolent again. she was then started on a narcan gtt. her bp improved in the ed to 168/58 without any intervention. labs in the ed were notable for worsening renal function with creatinine of 3.4 up from 2.9 on , wbc 12. serum/urine tox postive for benzos and tylenol. her probnp was mildly elevated at 1730. cxr was unchanged from prior. ekg stable. the pt was repeated falling asleep while being examined in the ed. . on arrival to the icu, the patient was arousable to voice, delirious, not oriented, moving all extremities. . review of systems: unable to obtain due to patient's mental status past medical history: cad s/p mi and stent chf diastolic htn dm2 uncontrolled with neuropathy hypothyroidism depression/anxiety rheumatoid arthritis h/o breast ca s/p mastectomy in 1083 osa on bipap 12/5 osteoarthritis s/p bilateral knee replacements in social history: very rare alcohol use. she for 5 years about 40 years ago. lives with her daughter who is her primary care giver. she also has vna. family history: father with chf; died in his 60s mother with cancer and "stomach problems"; died in her early 60s two brothers with prostate cancer one brother with dm one brother with mi s/p cabg one sister with breast cancer, currently blind 3 children, 2 with bilateral hip replacements due to osteoporosis, 1 with hypothyroidism s/p surgery physical exam: vitals: t: bp: p: r: 18 o2: general: obese, lethargic but arousable to voice, moving all extremities heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp difficult to evaluate lungs: difficult to assess, crackles at left lung base cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: 2+ pitting edema bilaterally to knees neuro: unable to perform pertinent results: 09:47am blood type-art po2-78* pco2-64* ph-7.28* caltco2-31* base xs-0 10:10am blood ck-mb-8 probnp-1730* 10:10am blood ctropnt-0.02* 01:25am blood ck-mb-13* mb indx-1.2 ctropnt-0.04* 04:39am blood ck-mb-10 mb indx-1.1 ctropnt-0.04* 10:10am blood alt-32 ast-32 ld(ldh)-305* ck(cpk)-423* alkphos-62 totbili-0.4 04:39am blood alt-29 ast-47* ld(ldh)-271* ck(cpk)-892* alkphos-50 totbili-0.6 10:10am blood wbc-12.4*# rbc-3.72* hgb-10.6* hct-33.4* mcv-90 mch-28.6 mchc-31.8 rdw-14.5 plt ct-251 04:39am blood wbc-6.7 rbc-3.29* hgb-9.7* hct-29.2* mcv-89 mch-29.6 mchc-33.3 rdw-14.8 plt ct-178 . head ct : findings: overall, evaluation is somewhat limited by motion, even after multiple attempts at acquisition, especially at the skull base. allowing for this, there is no acute intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarct. - white matter differentiation is preserved. ventricular and sulcal size appears age-appropriate. atherosclerotic calcifications involve the cavernous carotids and intracranial vertebral arteries bilaterally. the surrounding osseous structures are unremarkable. many ethmoid air cells are opacified bilaterally with small amounts of mucosal thickening noted in the maxillary sinuses bilaterally. the mastoid air cells appear well aerated. impression: no acute intracranial hemorrhage. . cxr : single ap chest radiograph: the lung volumes are low. the lungs are clear, with no consolidation, effusion, or pneumothorax. slight hazy opacity at the left base likely reflects soft tissue shadow and epicardial fat. heart size is top normal, unchanged from prior study, with no evidence for pulmonary vascular congestion. pleural surfaces are smooth. visualized bony thorax and surrounding soft tissues are unremarkable. impression: unchanged mild cardiomegaly with no evidence for volume overload. there is no consolidation to suggest pneumonia. : tte - pending at time of transfer to the floor brief hospital course: 75f with diastolic chf, sleep apnea, cad, dm, cri, ra with multiple recent hospitalizations over past year who presented to the ed with respiratory failure, arf, volume overload (wt 246 lbs). she was felt to suffer from encephalopathy from percocet, gabapentin and uremia. she received narcan and was admitted to the icu where she did well with conservative therapy. she was called out of the unit to the general medical floor. . # hypercapneic respiratory failure: hypercarbic on abg and decreased respiratory rate possibly related to narcotic usage given pt was sedated but woke up with narcan. this was stopped later the evening of admission. pt did not show signs of opioid withdrawal. no opioids on tox screen but oxycodone does not always show up on screen and tylenol level was elevated. -renally dosing gabapentin. patient with inadequate analgesia on tylenol alone. seems to do well with 1-2 percocet per day. she (and her daughter) have been counselled that she is not to take more than prescribed due to possible grave side effects. -continue albuterol and ipratropium nebs prn -continue cpap at night -diuresed over her hospitalization with discharge weight 236 lbs (dry weight 230 in the past) -no ace as history of hyperkalemia -tte --> preserved systolic function, moderate pulmonary hypertension - patient and her daughter report good home medication compliance, and home situation. . # constipation - patient's daughter attributes much of the patient's difficulties to chronic constipation with intermittent diarrhea associated with loose liquid stools passing around formed stool, leading to dehydration, pain and worsening renal function. --> continue miralax as this seems to be the best medication for this patient for prevention of constipation. --prn dulcolax, senna . # leukocytosis on admission --> resolved. bcx and ucx unrevealing . # acute on chronic renal insufficiency: --likely secondary to acute prerenal azotemia --improved with conservative treatment --continue to renally dose medications . # cad s/p mi and stent: pt cks trended up and then down. troponin peak at 0.04. mb index was positive. ekg was unchanged from prior. likely elevated in the setting of renal impairment, doubt acute cardiac ischemia. no events on telemetry through . telemetry d/c'd. -restarted asa, statin, beta blockers . # anemia: hct at baseline. . # dm2: --on lantus and iss . # depression: continued on citalopram. . # hypothyroidism: continued on synthroid. . # rheumatoid arthritis/neuropathy/shoulder pain: -see above for pain control . # ppx: heparin sq for dvt ppx and a ppi per home regimen. patient wishes to d/c ppi or use prn as she had initially been prescribed this in the setting of ibuprofen usage. . . # code: full code . # contact: daughter : medications on admission: medications: aspirin 81 mg daily multivitamin daily folic acid 1 mg daily cholecalciferol 800 u daily celexa 40 mg daily levothyroxine 112 mcg daily lorazepam 0.5 mg po qhs:prn prednisone 5 mg po daily calcium carbonate 500 mg po tid omeprazole 20 mg daily carvedilol 25 mg po bid amlodipine 10 mg daily hydralazine 50 mg po tid furosemide 80 mg po daily percocet 1-2 tabs po q6h:prn gabapentin 300 mg po bid gabapentin 600 mg po qhs ipratropium-albuterol 18 mcg q6h lantus 20 units qhs lidocaine patch daily discharge medications: 1. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 2. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q 4-6 hours prn as needed. 3. acetaminophen 500 mg tablet sig: two (2) tablet po three times a day as needed for pain. 4. levothyroxine 112 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 as needed. 6. hydralazine 50 mg tablet sig: one (1) tablet po tid (3 times a day). 7. carvedilol 12.5 mg tablet sig: two (2) tablet po bid (2 times a day). 8. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 9. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 10. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 11. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 12. gabapentin 300 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*0* 13. insulin please continue to take your lantus and your humalog as per your routine. see scale as given to you on discharge. 14. outpatient lab work bun, cr, k, na, cl, co3 please draw a chemistry profile on tuesday, and call the results in to dr at . 15. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 16. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po twice daily as needed for pain. disp:*60 tablet(s)* refills:*0* 17. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 18. polyethylene glycol 3350 100 % powder sig: one (1) po daily (daily): please take 1 heaping teaspoon daily (17 g) in oz of water/juice/soda. disp:*qs * refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: 1) hypercapneic respiratory failure 2) hypoxemia -moderate pulmonary hypertension -acute on chronic diastolic heart failure 3) acute renal failure 4) chronic kidney failure - stage iii 5) history of breast cancer s/p mastectomy 6) constipation with intermittent diarrhea 7) type 2 diabetes mellitus controlled with complications 8) cad s/p mi and stent 9) depression 10) hypothyroidism 11) rheumatoid arthritis 12) osteoporosis 13) neuropathy attributed to diabetes 14) hypertension 15) obesity 16) obstructive sleep apnea - on cpap at night 17) hyperlipidemia, hypertriglyceridemia discharge condition: good, ambulating independently, saturating normally on room air without complaints discharge instructions: you were admitted to the hospital with dehydration, acute kidney failure, confusion and difficulty breathing. ultimately, it was felt that you may have taken too much percocet and neurontin in the setting of kidney failure causing you to be confused and have trouble breathing. you did well after treatment in the icu. your kidney function improved. you received lasix (furosemide) to get off some of your water weight. . take all medications as instructed. . for pain, you may take tylenol (acetaminophen) 1000 mg by mouth three times daily. you can also take 1 or 2 tablets of percocet (total) per day. do not take more than this in tylenol or percocet as both contain acetaminophen. taking 4000 mg of acetaminophen in a 24 hour period of time can cause severe liver damage. . you should continue to take your neurontin (gabapentin), but at a lower dose than prior to this admission. you should take 300 mg by mouth twice daily. . you should take your lasix (furosemide) 40 mg by mouth tomorrow (, ) and weigh yourself every day. you should monitor your weight. do not take in more than 1-2 liters of fluid by mouth per day. if your weight increases by more than 2 or 3 lbs or is trending upward despite taking the lasix (furosemide) please call dr. , phone: or his coverage to discuss what you should do. . since you have trouble with constipation, you should take the miralax daily. if you do not have a bowel movement in three days time, you should take a dulcolax suppository or 2 tablets of senna. if you still cannot move your bowels, try repeating the suppository. if the you still cannot move your bowels, call dr. followup instructions: provider: , md phone: date/time: 11:20 provider: , md phone: date/time: 10:30 provider: ,bed six rooms date/time: 9:15 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Acute on chronic diastolic heart failure Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Percutaneous transluminal coronary angioplasty status Constipation, unspecified Chronic kidney disease, Stage III (moderate) Acute respiratory failure Obesity, unspecified Poisoning by aromatic analgesics, not elsewhere classified Accidental poisoning by anticonvulsant and anti-parkinsonism drugs Other malaise and fatigue Poisoning by other and unspecified anticonvulsants Accidental poisoning by aromatic analgesics, not elsewhere classified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p trauma, etoh intoxication major surgical or invasive procedure: endotracheal intubation history of present illness: 43m with no known medical history presents s/p assault. ems was called to the scene and discovered the patient intoxicated, unable to provide history. per ems report, the patient and a friend were drinking etoh all day. they had an argument over a woman and his friend hit him in the head three times with a closed fist. the patient fell to the ground and lost consciousness for an unknown period of time. when ems and police arrived, the patient was verbal, asking for water, but was not able to respond to other questions. he was observed to be intoxicated. on arrival to the ed, initial vs were 97 120 131/89 22 95% ra. he was unable to respond to questioning regarding pain or further medical history. he is not known to the system or to atrius, therefore no medical history is available. he was sedated with droperidol for agitation and combativeness. he became apneic and was intubated. ct head and ct c-spine were negative. on exam he had a small occipital hematoma without further traumatic injury evident. surgery was consulted and did not feel that his ams or respiratory failure had a traumatic component. labs revealed etoh level of 154 and was positive for benzos. cbc was normal, chem10 showed hypokalemia to 3.2 without other abnormality. following cts, it was not possible to extubate the patient, given hypoxic respiratory failure and concern for withdrawl from both etoh and benzos. vs prior to transfer: afebrile 150/101 80s 14 100% on 500/14/70%. on arrival to the micu, patient's vss. on fentanyl 50 and midaz 1, patient not responding to sternal rub, not following commands. perrl. review of systems: unable to obtain due to mental status past medical history: -schizophrenia, on risperdol and is seen at -alcoholism -homelessness social history: patient is homeless. otherwise unknown. claims to drink a fifth of tequilla and 6 beers occasionally. cage 0/4 family history: unknown physical exam: on admission: ------------- vitals: 97.3 131/87 89 18 100%on cmv peep 8 general: appears comfortable; does not open eyes to voice or follow simple commands heent: sclera anicteric, pupils 2mm and reactiv; mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: scattered crackles bilaterally abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding ext: warm, well perfused, 2+ pulses, 1+ edema to mid calf neuro: rass -2; pupils 2mm and reactive . on discharge: vss general: aaox3 in nad heent: sinus not ttp, head has some mild, minimally erythematous echymosis on the back of head, no nystagmus cv: rrr, no rmg lungs: ctab, no wrr abdomen: obese, nt, active bs x4, no hsm neuro: cn 2-12 grossly intact-eomi, perrla, sensation grossly intact, strength wnl, refused to ambulate with me, but witnessed multiple times ambulating in the without signs of imbalance . pertinent results: labs on admission: ------------------- 09:15pm blood wbc-7.6 rbc-4.61 hgb-14.1 hct-43.4 mcv-94 mch-30.7 mchc-32.6 rdw-13.4 plt ct-207 09:15pm blood neuts-86.7* lymphs-10.2* monos-2.2 eos-0.5 baso-0.4 09:15pm blood glucose-108* urean-8 creat-0.6 na-142 k-3.2* cl-107 hco3-19* angap-19 09:15pm blood alt-37 ast-30 alkphos-67 totbili-0.3 04:28am blood calcium-8.1* phos-4.4 mg-1.8 09:40pm blood type-art temp-36.1 rates-14/ tidal v-500 peep-8 fio2-60 po2-70* pco2-40 ph-7.32* caltco2-22 base xs--5 -assist/con intubat-intubated 02:35am blood lactate-2.5* labs prior to discharge: -all wnl on day of discharge . h-ct impression: no acute intracranial process. . c-spine ct impression: no acute fracture or malalignment. . cxr impression: no acute cardiopulmonary process. . tte the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is grossly normal (lvef ? 55%). the aortic valve is not well seen. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: suboptimal image quality. this examination is inadequate to exclude focal wall motion abnormalities of the left ventricle or any abnormality of the right ventricle . rib films impression: normal examination. no evidence of rib fracture or pneumothorax. . ekg sinus rhythm. findings are within normal limits. non-diagnostic q waves in the inferior leads. compared to the previous tracing of there is no significant diagnostic change. brief hospital course: 43 year old homeless man with pmhx of schizophrenia and alcoholism who presented to the ed s/p assault, who was transferred to the micu for hypoxic respiratory failure s/p intubation and was observed on the floor for signs of withdrawal # hypoxic respiratory failure: the patient was admitted to the hospital with shortness of breath after being found down, and was intubated with large a-a gradient (288). his respiratory failure was most likely caused by an aspiration pneumonitis given that he promptly improved. portable chest x-ray at the time of intubation showed possible aspiration in lll. alternatively, patient could have had pulmonary contusion/alveolitis, but had no further evidence of chest trauma. given substance abuse, he may also have had a component of hypoventillation as patient noted to have apenic episodes and somnolence prior to intubation, but would not account for a-a gradient. patient was able to be extubated after less than 12 hours. he was oxygenating well on room air. follow up cxr showed no signs of pneumonia and his antibiotics were stopped. . # altered mental status: patient presented with altered mental status, likely due to acute intoxication with etoh and benzodiazepines. there was no evidence of acute intracranial process on ct scan. there was no evidence of infection, cxr negative and uc was negative. . # etoh and benzo intoxication/abuse: patient admitted with etoh level 164 and positive urine benzos. the patient was followed for over 72 hours and monitored for signs of withdrawal with the ciwa scale. the patient was approached twice by social work and daily by the medical team encouraging alcohol abstinence. he insisted that he did not have an alcohol problem and refused to take literature of aa meetings and other resources available to him. . # ble edema the patient reports that this has been an issue for about 1 month. he also reported cp and sob during this admission. given these other symptoms, and tte was obtained which was a difficult study, but showed a normal ef. the patient had a bottle of lasix 20 mg qd from which i informed him he could continue. we re-started the lasix the day prior to discharge and check his electrolytes and they were wnl. i informed the patient that he can continue this medication until following up with his new pcp at on , at which time he should have his labs checked and defer further diuretic use to his pcp. . # cp and sob the patient cp was reproducible on pe and the suspicion for acs was low. serial tni's were done and negative. his ekg's were normal. his cp improved with tramadol and toradol. his sob was pleuritic and he was not tachycardia, hypoxic or tachypneic. the suspicion for pe was low. the patients got dedicated rib films and those were negative. his pain was thought to be due to pulmonary contusion and pleurisy from trauma. he was prescribed nsaid's and tramadol for pain upon discharge and an albuterol inhaler. . # headaches and dizziness the patient had the above complaints without any other neurologic signs or symptoms. h-ct was negative. he intermittently refused his medications and orthostatics vs, but when he finally agreed to doing them he was not orthostatic. he was seen ambulating the hallway without issues and pt/ot evaluated the patient and though he was stable for d/c. the patients h/a resolve and dizziness is thought to be due to post concussion syndrome. the medical team repeatedly discussed with the patient that some of these symptoms may take weeks to months to resolve. we emphasized follow up with a primary care physician. patient said he understood. . # cough with allergic rhinitis and post nasal drip the patient was advised to use nasal saline which he refused. he was also offered claritin, but he left without the prescription. he was treated symptomatically in house with tesselon pearles. . #homelessness the patient was repeatedly offered help with his housing situation. every time the medical team brought up discharge planning and assistance, the patient refused assistance. when attempting to discharge the patient he reports "not being ready". we again reinforced how important follow up was with a pcp. patient was pacing the prior to discharge and repeatedly asked for his lasix back. once he received this medication, he left without his discharge paper work. cm also checked to see if he had medication coverage and he does. . # transitional issues: -follow up with pcp 1 -2 weeks and assess the need for lasix, check basic metabolic panel -follow up with psyc in weeks and continued to reinforce alcohol cessation medications on admission: unknown discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: inhalation every six (6) hours as needed for shortness of breath or wheezing. disp:*qs for 2 weeks * refills:*0* 2. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for cough. disp:*30 capsule(s)* refills:*0* 3. sodium chloride 0.65 % aerosol, spray sig: sprays nasal q6h (every 6 hours). disp:*qs for 1 month * refills:*2* 4. risperidone 1 mg tablet sig: one (1) tablet po hs (at bedtime). 5. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 6. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 8. tramadol 50 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. disp:*20 tablet(s)* refills:*0* 9. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*14 tablet(s)* refills:*0* 10. ibuprofen 200 mg tablet sig: three (3) tablet po every six (6) hours as needed for pain. disp:*30 tablet(s)* refills:*0* 11. claritin 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: s/p assault with post concussive syndrome intoxication alcoholism schizophrenia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the icu at after being found intoxicated and being assualted. you had ct scans of your brain and cervical spine showed no acute changes but did show some mild shrinking of your brain possibly related to alcohol consumption. you were sent to the floor and treated for alcohol withdrawl. you also had a echocardiogram as a work up for your swelling. you heart appeared normal. you will sent to a shelter. we recommend that you stop drinking alcohol and follow up with your pcp and psychiatrist at in 1 week. . medication changes: 1) start albuterol inhaler for shortness of breath 2) start benzomatate for your cough 3) start sodium chloride nasally for your cough 4) start thiamine, folic acid and multivitamins to maximize your nutrition 5) start tramadol for moderate to severe pain 6) start ibuprofen for mild to moderate pain 7) continue lasix as prescribed to you at for 1-2 weeks until follow up with your primary care physician and get your electrolytes checked when seeing your pcp 8) start claritin for your allergies followup instructions: you are seen at the health group there contact number is . the office was unavailable and a message was left trying to confirm your appointment on . please call the office at the above number to do so. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Acidosis Obstructive sleep apnea (adult)(pediatric) Hypopotassemia Unspecified schizophrenia, unspecified Acute respiratory failure Unarmed fight or brawl Lack of housing Sedative, hypnotic or anxiolytic abuse, unspecified Acute alcoholic intoxication in alcoholism, unspecified Edema Allergic rhinitis, cause unspecified Concussion, with loss of consciousness of 30 minutes or less |
allergies: iodine / gluten attending: chief complaint: shortness of breath, weakness, malaise major surgical or invasive procedure: arterial line placement aortic valvuloplasty flexible sigmoidoscopy history of present illness: ms. is an 87 year old female who presented to this morning with complaint of dyspnea going on for several days, gradual in onset. she has a h/o critical as, is being considered for an avr. she presents with increasing shortness of breath and generalized weakness. additionally she had an episode of vomiting last night. does not know if she had any hematemesis or coffee-ground emesis . she reports that she has chronically black stools due to iron supplementation. noted to be hypoxic on arrival. her ros at was notably positive for orthopnea, cough, n/v, dysuria, and negative for chills/fever, abd pain, diarrhea. cxr was thought to be consistent with chf. her hct was found to be 22 down from a previous value of 27, with guaiac positive stools, and inr found to be 5. she was given vitamin k 10mg iv, 1 unit prbcs, lasix 10mg iv. hct bumped to 30 after 1 unit prbcs, and inr decreased to 3.9 after vit k. she was then transferred to for further management. ekg: rate: 63 bpm. axis left axis deviationst/t non-specific st changes rhythm: paced on arrival to our ed, initial vs were: 96.5 78 158/79 20 98% 6l nasal cannula, she eventually required nrb and desatted when weaning was attempted. protonix bolus + gtt was started; she was type and crossed, given 2 units ffp, given lasix 10mg iv. ekg was noted as vpaced rhythm. gi consulted but have not seen her yet. on arrival to the micu, patient's vs. t97.4 hr 75 bp 151/44 rr 21 sao2 87% on 100% nrb review of systems: unable to obtain patient's respiratory status and confusion. past medical history: 1. critical aortic stenosis, awaiting valve replacement in . 2. diastolic dysfunction, normal ef. 3. mild ar and moderate mr. 4. paroxysmal atrial fibrillation on coumadin. 5. status post permanent pacemaker. 6. tia in and left occipital stroke in . 7. status post right carotid endarterectomy in . 8. chronic kidney disease, stage 4, baseline creatinine around 2.2-2.4. 9. hypertension. 10. duodenal diverticulum and diverticulosis. 11. history of celiac disease. 12. history of chronic pancreatitis likely related to celiac disease. 13. status post cholecystectomy. 14. gerd. 15. bilateral renal artery stenosis. 16. history of acute renal failure during diuresis. 17. history of hyponatremia in the setting of chf. 18. status post total abdominal hysterectomy. 19. anemia of chronic disease, baseline hematocrit around 28-30. 20. hyperlipidemia. social history: mostly independent with adls. she was a l&d nurse for 40 years. no reports of alcohol, drugs or tobacco abuse. lives alone, independent adls. retired l&d nurse. family history: father with cardiac disease, otherwise non-contributory physical exam: admission exam: vitals: t97.4 hr 75 bp 151/44 rr 21 sao2 87% on 100% nrb general: in acute respiratory distress, somnolent, can state name and location but not year/date neck: jvd elevated 3cm above clavicle cv: difficult to auscultate, normal rate, loud systolic murmur lungs: diffuse crackles throughout all lung fields abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding ext: no apparent edema. warm, well perfused, 2+ pulses, no clubbing, cyanosis. neuro: oriented x2, somnolent skin: stage 2 on coccyx . discharge exam: general: intermittently confused, delerious neck: jvd elevated 3cm above clavicle cv: difficult to auscultate, normal rate, loud systolic murmur lungs: diffuse crackles throughout all lung fields abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding ext: no apparent edema. warm, well perfused, 2+ pulses, no clubbing, cyanosis. neuro: oriented x2, somnolent skin: stage 2 on coccyx pertinent results: admission labs: 03:15pm blood wbc-15.9* rbc-3.23* hgb-11.0* hct-30.9* mcv-96 mch-34.2* mchc-35.7* rdw-15.0 plt ct-248 03:15pm blood neuts-81.9* lymphs-11.5* monos-6.3 eos-0.2 baso-0.1 03:15pm blood pt-39.4* ptt-49.8* inr(pt)-3.9* 08:11pm blood fibrino-470* 08:11pm blood glucose-128* urean-63* creat-2.6* na-123* k-4.2 cl-83* hco3-22 angap-22* 08:11pm blood alt-25 ast-43* ck(cpk)-135 alkphos-103 totbili-1.3 08:11pm blood lipase-212* 03:15pm blood ck-mb-5 03:15pm blood ctropnt-0.27* 08:11pm blood albumin-4.3 calcium-9.1 phos-5.3* mg-2.6 08:11pm blood osmolal-275 08:11pm blood digoxin-2.2* 08:00pm blood type-art po2-61* pco2-45 ph-7.35 caltco2-26 base xs-0 08:00pm blood lactate-1.8 08:15pm urine color-yellow appear-clear sp -1.009 08:15pm urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-sm 08:15pm urine rbc->182* wbc-2 bacteri-few yeast-none epi-<1 transe-<1 08:15pm urine mucous-rare 08:15pm urine hours-random creat-18 na-54 k-48 cl-64 08:15pm urine osmolal-315 other pertinent labs: 03:15pm blood ctropnt-0.27* 08:11pm blood ck-mb-5 ctropnt-0.30* probnp-* 03:40am blood ck-mb-4 ctropnt-0.25* microbiology: blood culture : negative blood culture : negative urine legionella antigen : negative urine culture : negative imaging: cxr : worsening right lower lobe pneumonia and mild pulmonary edema 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. there is critical aortic valve stenosis (valve area <0.8cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the velocities across the aortic valve have increased slightly. the severity of aortic stenosis remains critical. the other findings are similar. brief hospital course: 87 year old female with critical as presenting with gradual-onset dyspnea and weakness, found to have anemia with guaiac positive stools, as well as new hypoxia and leukocytosis with likely pneumonia and acute congestive heart failure exacerbation. # goals of care: when the patient initially presented, she was considered a candidate for possible percutaneous aortic valve replacement (core valve). however given her tenous fluid status, refractory gi bleeding on anticoagulation and delerium, she was no longer considered a candidate. several family meetings were convened to assess her goals of therapy and care, and it was decided by all including her son and daughter , and the care team that further interventions would not be of benefit. she was discharged to a skilled nursing facility with the understanding that care will be aimed at maintaining her comfort and with the expectation that her condition will worsen in the near future and further hospitalization are not indicated. this was discussed with her health care proxy, her son, on : , and he agreed with this assesment. #perineal irritation: to gi bleed and constant oozing she has significant perineal pain. she requires frequent perineal cleanings and aquafor cream applications. topical lidocaine and prn 1mg dilaudid were also helpful for pain control. she has not required dilaudid since . # critical as: thought to be very likely to be contributing to her dyspnea and hypoxia. her cardiologists were contact and as she was being considered for aortic valve replacement in the near future, she was transferred to the ccu for evalution for prompt replacement vs. valvuloplasty on this admission. she went for valvuloplasty on during which time the initial gradient was a mean of 72 mm hg and this decreased to 20 mm hg translating into a valve area increase from 0.4 cm2 to 1.06 cm2 post-valvuloplasty. she is maintained on metoprolol and amlodipine predominantly to maintain a low heart rate and reduce her symptoms in the setting of atrial fibrillation. # acute hypoxemic respiratory failure: patient presented with dyspnea, orthopnea, and hypoxia, with worsening of hypoxia after receiving transfusion 1 unit prbcs and 2 units ffp for anemia and supratherapeutic inr. patient started on non-rebreather in ed, and on arrival to icu had o2 sats in mid-high 80s on nrb with 95% fio2 plus 6l nc. abg 7.35/45/61. differential diagnosis included pneumonia (leukocytosis, cough, rll infiltrate on cxr), acute pulmonary edema/chf exacerbation in setting of critical as and recent transfusions (diffuse crackles on exam, pulm edema on cxr, bnp ), possible flash pulmonary edema from htn, possible cardiac event (elevated troponins, normal ck mb), or trali. given concern for hcap (recent hospitalization), blood cultures were sent and patient was started on vanc/cefepime. she was cautiously diuresed with lasix boluses (10mg iv x2, followed by 20 mg iv x1), with 1.8l uop. given significant hypoxemia, was started on nippv overnight for 5 hours, with improvement in sats to mid-high 90s. a-line placed for repeated abgs and close monitoring. repeat abg 7.42/36/76. she was transitioned back to high flow face mask, and maintained sats in 90s overnight. a tte performed on showed worsening aortic stenosis. on , the patient was transferred to ccu, with plans for potential aortic valve replacement the following week, pending improvement in general clinical status. diuresis was continued in the ccu, and she continued to respond to iv lasix with improvement in her respiratory status. she remained on high-flow o2 face mask, and on , we began to wean the o2. her oxygen requirement decreased over her hospital course and on discharge her o2 sat was 97% on room air. she may require gentle diuresis with furosemide if she develops further pulmonary edema if she complains of shortness of breath. # rll pna: patient presented with dyspnea, cough, leukocytosis, and worsening rll infiltrate on cxr. blood culture sent, and patient started on empiric antibiotics with vanc/cefepime to cover potential hcap, given recent hospitalization. urine legionella antigen negative. patient remained afebrile, she completed an 8 day course of antibiotics and her sob resolved. # gib: h/h significantly decreased from most recent value on of 10.0/27.4, with baseline hcts over last couple of months between 25-28. likely slow gib given occult positive stool and h/o emesis (though no clear history of hematemesis or coffee ground emesis). of note also has recent history of hemorrhoidal bleeding. gi consulted and patient started on pantroprazole drip. given supratherapeutic inr, received 10mg iv vit k, rec'd 2 units ffp. warfarin was held. patient's hct bumped following transfusion 1 unit prbcs at , though trended down over next day back to 24. had 2 piv, and was typed and crossed for 4 units. in the setting of the patient's respiratory distress, gi decided to treat conservatively for gib given there are no signs of active bleeding. in the ccu, her hct was trended and stabilized between 23-25 on . gi was consulted and was performed which showed multiple gastric ulcers with no active bleeding. flex sig significant for internal hemorrhoids with no active bleeding. after discussing goals of care with mrs. family, it was decided to discontinue phlebotomy. in addition, heparin was discontinued continued gib and melanotic stools accepting the risk of cva. her last hct on was 24.7. she continues to have melanotic stools and requires frequent cleaning of her perineum. # leukocytosis: likely secondary to pneumonia given her cxr findings. ua not suggestive of uti, urine culture pending. blood cultures sent before intiation of antibiotics on the day of admission. vancomycin and cefepime were started on the day of admission for presumed hcap in the setting of her recent hospitalization at . lipase was checked in the setting of her chronic pancreatitis with concern for an acute-on-chronic picture; however, this was in the 200s and did not represent a change from her many recent values. her last wbc count was 12.6 on and her c-diff pcr was negative. there was no further workup performed as her goals of care shifted towards comfort measures. she was treated for a total of 8 days for hcap. # troponinemia: troponins were elevated to 0.24 at and rose to 0.27 in our ed. she did not have chest pain, and only nonsepcific st/t changes on ekg which are not significantly changed from prior. she had a recent cath showing no significant cad. on her third set trop rose to 0.3, but was decreased back to 0.25 the next morning. she was thought to be unable to clear troponin in the setting of her acute-on-chronic renal insufficiency. mb has been flat. there was a question of demand ischemia in setting of anemia. in the setting of this as well as her critical as, she was transferred to the ccu. it was felt this was likely demand ischemia and no further workup was performed. # hyponatremia: hyponatremic to 120 on admission which seemed to be at least partly chronic with na 124-128 since . she appeared volume up on lung exam, however did not have peripheral edema so there was thought to be less of an element of right heart failure. with high suspicion of volume overload in the setting of her additional hypoxia, she was diuresed with several doses of lasix and her sodium improved to 125 the next morning, which is at her recent baseline. her sodium improved to 135 and was 148 on , no further workup was performed given her shift in goals of care. . # acute on chronic kidney disease: h/o chronic kidney disease, stage 4 with baseline creat 2.2-2.4, up to 2.7 on admission. bun/cr ratio was 21, suggesting pre-renal etiology of acute-on-chronic picture in the setting of likely poor forward flow given her as. it was also thought her bun was possibly elevated due to gib. no acute interventions were taken for the and her creatinine was stable at 2.6 the following day. it bumped as high as 3.3 during the ccu stay, but came down to 2.9 prior to discharge. . # afib: she has sick sinus syndrome with ventricular pacer, and is additionally rate controlled on digoxin, metoprolol, amlodipine at home; these were held on admission. given her likely gib and elevated inr, warfarin was held. she received vitamin k and ffp with inr coming down to 1.3 on the day following admission. given that her chads2 score is 5, she does need anticoagulation but in the setting of gib this was not started initally. in the ccu, heparin was started and was continued even when her inr was no longer supra-therapuetic as we did not want to restart warfarin in the setting of possible cardiac catheterization. however, warfarin was restarted 24hr after the procedure at a lower dose of 3mg given her elevated inr on admission. warfarin was discontinued in the setting her her gib which is currenlty more symptomatic for ms , it is hoped that stopping anticoagulation may decrease the severity of her gib. (oozing from her gi tract is causing her much pain) given the change in goals of care, anticoagulation is no longer indicated. . # mental status: ms was delerious in the ccu and cleared some what after transfer to the floor. this was felt to her lack of sleep for several days while in the unit. it is hoped that transfer to a will improve her mental status. she was provided trazodone and seroquel for sleep during her stay at . transitional issues: # code status: comfort measures only medications on admission: preadmission medications listed are correct and complete. information was obtained from family/caregiver. 1. atorvastatin 20 mg po daily 2. amlodipine 5 mg po daily 3. digoxin 0.125 mg po every other day 4. magnesium oxide 400 mg po once duration: 1 doses 5. aspirin 81 mg po daily 6. gemfibrozil 600 mg po bid 7. creon 12 3 cap po tid w/meals 8. ferrous sulfate 325 mg po tid 9. metoprolol succinate xl 200 mg po daily 10. warfarin 2 mg po daily16 11. calcitriol 0.25 mcg po daily 12. cyanocobalamin 500 mcg po daily 13. calcium carbonate 600 mg po daily 14. vitamin d 1000 unit po daily 15. ascorbic acid 1000 mg po daily 16. omeprazole 20 mg po bid 17. furosemide 20 mg po daily discharge medications: 1. lidocaine jelly 2% 1 appl tp once duration: 1 doses 1 tube 2. amlodipine 5 mg po daily 3. ferrous sulfate 325 mg po tid 4. metoprolol succinate xl 200 mg po daily 5. acetaminophen 1000 mg po tid 6. aquaphor ointment 1 appl tp tid:prn sores 7. hydromorphone (dilaudid) 1 mg po q4h:prn pain hold for sedation, rr<10 8. ondansetron 4-8 mg iv q8h:prn nausea 9. simethicone 40-80 mg po qid:prn gas 10. trazodone 25 mg po hs:prn insomnia 11. omeprazole 20 mg po bid discharge disposition: extended care facility: healthcare & rehabilitation center - discharge diagnosis: critical aortic stenosis acute on chronic diastolic congestive heart failure lobar pneumonia acute on chronic renal failure anemia gastrointestinal bleed acute respiratory failure discharge condition: mental status: confused, waxing and mental status. paranoid. activity: requires assistance. discharge instructions: ms. , you were admitted to the hospital with a pneumonia and bleeding from your gi tract. your pneumonia was treated with antibiotics. the gi doctors performed (camera down into the stomach) which showed ulcers which are the likely source of the bleeding. you also had an aortic valvuloplasty (procedure to temporarily open up the aortic valve). you continue to have bleeding in your stool. because of all of your medical illnesses, you and your family have decided to focus on comfort. most of your medications were stopped and we stopped checking labs. you will be discharged to a skilled nursing facility where you can eventually get hospice services. you will not be hospitalized should you continue to get sicker. followup instructions: the nurses and doctors at the nursing home will be taking care of you. Procedure: Combined right and left heart cardiac catheterization Other endoscopy of small intestine Flexible sigmoidoscopy Percutaneous balloon valvuloplasty Diagnoses: Pneumonia, organism unspecified Acidosis Esophageal reflux Congestive heart failure, unspecified Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Hyposmolality and/or hyponatremia Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Acute on chronic diastolic heart failure Aortic valve disorders Other and unspecified hyperlipidemia Acute respiratory failure Cardiogenic shock Long-term (current) use of anticoagulants Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Cardiac pacemaker in situ Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Awaiting organ transplant status Chronic pancreatitis Delirium due to conditions classified elsewhere Epistaxis Internal hemorrhoids without mention of complication External hemorrhoids without mention of complication Candidal esophagitis Contact dermatitis and other eczema, unspecified cause |
allergies: no known allergies / adverse drug reactions attending: addendum: ms. was started on gabapentin for leg pain. her foley catheter may be removed when possible. discharge disposition: extended care facility: - md Procedure: Enteral infusion of concentrated nutritional substances Dorsal and dorsolumbar fusion of the anterior column, anterior technique Other excision of joint, other specified sites Excision of intervertebral disc Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Lumbar and lumbosacral fusion of the anterior column, anterior technique Insertion of interbody spinal fusion device Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Fusion or refusion of 9 or more vertebrae Fusion or refusion of 4-8 vertebrae Insertion of recombinant bone morphogenetic protein Insertion of recombinant bone morphogenetic protein Diagnoses: Other iatrogenic hypotension Unspecified essential hypertension Acute posthemorrhagic anemia Unspecified acquired hypothyroidism Other and unspecified hyperlipidemia Scoliosis [and kyphoscoliosis], idiopathic Delirium due to conditions classified elsewhere Lumbosacral spondylosis without myelopathy Degeneration of lumbar or lumbosacral intervertebral disc |
allergies: no known allergies / adverse drug reactions attending: chief complaint: back pain major surgical or invasive procedure: anterior l3-s1 fusion anterolateral t12-l3 fusion posterior t9-s1 fusion history of present illness: ms. has a long history of back pain due to scoliosis. she presents for surgical intervention. past medical history: hld, htn, depression, hypothyroidism social history: denies family history: n/c physical exam: a&o x 3; nad rrr cta b abd soft nt/nd bue- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact c5-t1 dermatomes; - , reflexes symmetric at biceps, triceps and brachioradialis ble- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, /fhl; sensation intact l1-s1 dermatomes; - clonus, reflexes symmetric at quads and achilles pertinent results: 01:39am blood wbc-7.9 rbc-3.74* hgb-11.2* hct-34.3* mcv-92 mch-29.9 mchc-32.6 rdw-13.6 plt ct-210 12:04am blood wbc-6.7 rbc-3.57* hgb-10.9* hct-31.7* mcv-89 mch-30.6 mchc-34.4 rdw-14.5 plt ct-148* 11:47pm blood wbc-4.5 rbc-3.57* hgb-11.0* hct-31.0* mcv-87 mch-30.9 mchc-35.6* rdw-14.0 plt ct-157 01:39am blood glucose-131* urean-11 creat-0.4 na-136 k-3.6 cl-100 hco3-30 angap-10 12:04am blood glucose-118* urean-8 creat-0.4 na-143 k-3.8 cl-107 hco3-32 angap-8 06:14pm blood glucose-199* urean-7 creat-0.6 na-141 k-3.2* cl-104 hco3-26 angap-14 brief hospital course: ms. was admitted to the spine surgery service on and taken to the operating room for l3-s1 interbody fusion through an anterior approach. please 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 given per standard protocol. initial postop pain was controlled with a pca. on hd#2 she returned to the operating room for a scheduled t12-l3 anterior release with as part of a staged 2-part procedure. please refer to the dictated operative note for further details. the second surgery was also without complication and the patient was transferred to the pacu in a stable condition. hospital day #3 she underwent a posterior t9-l1 posterior fusion. post-operatively she was transfered to the t/icu for hemodynamic monitoring. her course was uneventful. postoperative hct was low and she was transfused prbcs. she was kept npo until bowel function returned then diet was advanced as tolerated. the patient was transitioned to oral pain medication when tolerating po diet. foley was removed on pod#4 from the third procedure. she was fitted with a tlso brace for out of bed. 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. medications on admission: amlodipine citalopram dexilant levothyroxine losartan potassium pravastatin discharge medications: 1. acetaminophen 1000 mg po q 8h pain 2. amlodipine 10 mg po daily 3. bisacodyl 10 mg po/pr daily:prn constipation 4. citalopram 20 mg po daily 5. docusate sodium (liquid) 100 mg po bid 6. heparin 5000 unit sc bid 7. ipratropium bromide neb 1 neb ih q6h:prn wheezing 8. lansoprazole oral disintegrating tab 30 mg po daily 9. levothyroxine sodium 88 mcg po daily 10. losartan potassium 50 mg po daily 11. oxycodone (immediate release) 5-15 mg po q3h:prn pain hold if somnolent, rr < 12, sat < 92 12. oxycodone sr (oxycontin) 20 mg po q12h 13. pravastatin 20 mg po daily 14. senna 1 tab po bid:prn constipation 15. trazodone 25 mg po hs:prn insomnia discharge disposition: extended care facility: - discharge diagnosis: scoliosis acute post-op blood loss anemia discharge condition: good discharge instructions: you have undergone the following operation: anterior/posterior thoracolumbar 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: o2-3 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. olimit 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 have been given a brace. this brace is to be worn for comfort 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. no nsaids. -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. please call the office if you have a fever>101.5 degrees fahrenheit and/or drainage from your wound. physical therapy: activity: activity as tolerated in brace treatments frequency: please continue to change the dressing daily. followup instructions: with dr. in 10 days Procedure: Enteral infusion of concentrated nutritional substances Dorsal and dorsolumbar fusion of the anterior column, anterior technique Other excision of joint, other specified sites Excision of intervertebral disc Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Lumbar and lumbosacral fusion of the anterior column, anterior technique Insertion of interbody spinal fusion device Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Fusion or refusion of 9 or more vertebrae Fusion or refusion of 4-8 vertebrae Insertion of recombinant bone morphogenetic protein Insertion of recombinant bone morphogenetic protein Diagnoses: Other iatrogenic hypotension Unspecified essential hypertension Acute posthemorrhagic anemia Unspecified acquired hypothyroidism Other and unspecified hyperlipidemia Scoliosis [and kyphoscoliosis], idiopathic Delirium due to conditions classified elsewhere Lumbosacral spondylosis without myelopathy Degeneration of lumbar or lumbosacral intervertebral disc |
allergies: novocain attending: chief complaint: left sided weakness major surgical or invasive procedure: iv tpa before arrival at this hospital history of present illness: 87 yo rhf with past medical history of afib off coumadin for past week for colonoscopy, htn,hl,ar, chf p/w acute onset left sided weakness at 3:15 p.m. she was in usoh till 3:00 p.m. today and was seen by her son at 3:15 p.m. while eating to have acute onset weakness on the left side, noticed due to her food dribbling down on the left side of her face. ems was called and she was taken to at 3:26 p.m. and was found to have dense left hemiplegia, hemineglect and left visual field cut. head ct showed a dense rmca m1 thrombus extending up to m2. she received iv tpa starting at 4:29 p.m. and received the full dose. she then started complaining of mild right sided headcahe () which persisted. she was then transferred to for evaluation for possible neurointerventional procedure. on neuro ros, the pt denies headache, 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. denies difficulty with gait. on general review of systems, the pt denies recent fever or chills. no night sweats or recent weight loss or gain. denies cough, shortness of breath. denies chest pain or tightness, palpitations. denies nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denies arthralgias or myalgias. denies rash. past medical history: -afib previously on coumadin, but held for colonoscopy on (for 1 week now) -htn -hl -moderate aortic regurgitation -pda -chf ef 55-60% -h/o syncope -hypothyroidism -polymylagia rheumatica social history: lives independently and is fully functional at baseline. retired secretary, drives a car. has very involved children. denies tobacco, occasional alcohol. family history: father died at age 75 of cad, mother died at 95 of chf, brothers with cancer, daughter with lymphoma. physical exam: vitals: t: af p:86 (afib) r: 16 bp: 146/102 sao2: 99%ra general: eyes closed, arouses to voice, cooperative, 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 cta bilaterally without r/r/w cardiac: irregularly irregular. abdomen: soft, nt/nd extremities: wwp skin: bruises/ecchymoses noted in bilateral arms, with large skin tear on left elbow. neurologic: (if applicable) nih stroke scale score was: 14 1a. level of consciousness: 0 1b. loc question: 0 1c. loc commands: 0 2. best gaze: 2 3. visual fields: 2 4. facial palsy: 1 5a. motor arm, left: 3 5b. motor arm, right: 0 6a. motor leg, left: 2 6b. motor leg, right: 1 7. limb ataxia: 0 8. sensory: 1 9. language: 0 10. dysarthria: 0 11. extinction and neglect: 2 -mental status: alert, oriented to name, month, and . drowsy, and dozes off when not being questioned. speech is fluent in conversation. there were no paraphasias. only able to report "chair" and read the word "room" on stroke card, which are the farmost right items, demonstrating dense neglect vs hemianopia. speech was not dysarthric. able to follow both midline and appendicular one-step commands. dense visual, sensory, and auditory neglect. -cranial nerves: i: olfaction not tested. ii: perrl 4 to 2mm and brisk. does not btt in left visual field in either eye. funduscopic exam deferred. iii, iv, vi: forced gaze deviation to r that does not cross midline. no nystagmus noted. v: facial sensation intact to light touch. vii: left facial paresis w nlf and inability to close l eye. 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, decreased tone on left. moves lle in plane of bed but is unable to lift antigravity. withdrawal response to pain in lue. right sided extremities are antigravity. -sensory: senses light touch reliably on right; sometimes when left side is touched, she states she feels it on the right, othertimes she does not feel it at all. again sensory neglect is profound. -dtrs: tri pat ach l 1 1 1 1 0 r 1 1 1 1 0 plantar response was upgoing on the left. -coordination: no gross dysmetria when reaching out w right hand. -gait: deferred. ********** laboratory data: pertinent results: 02:58am blood wbc-8.1 rbc-4.12* hgb-12.6 hct-38.5 mcv-93 mch-30.6 mchc-32.7 rdw-15.4 plt ct-157 02:58am blood pt-11.2 ptt-25.2 inr(pt)-1.0 02:58am blood pt-11.2 ptt-25.2 inr(pt)-1.0 02:58am blood glucose-119* urean-15 creat-0.7 na-133 k-3.8 cl-99 hco3-26 angap-12 02:58am blood ck-mb-1 ctropnt-<0.01 02:58am blood triglyc-99 hdl-57 chol/hd-2.5 ldlcalc-66 02:58am blood %hba1c-5.6 eag-114 06:20am blood digoxin-0.4* ct/cta/ctp no acute intracranial hemorrhage. 2. ct perfusion study suggests acute infarctions in the superior right middle cerebral artery territory and in the right posterior cerebral artery territory. these are not yet detectible on the conventional ct images, with only a small focus of mild cytotoxic edema noted in the right anterior insula. 3. large thrombus extending from the distal right common carotid artery into the proximal right internal carotid artery with 99% stenosis. this thrombus also extends into and completely occludes the proximal right external carotid artery, which demonstrates distal reconstitution, most likely via retrograde filling through its branches. 4. occlusion of the superior division of the right middle cerebral artery. 5. bilateral fetal configuration of posterior cerebral arteries. the posterior communicating arteries appear patent bilaterally. 6. enlarged and multinodular thyroid. this may be further evaluated by , if not previously performed elsewhere. mri/mra head and neck 1. large acute infarctions involving the right frontal lobe, insula, and temporal lobe in the middle cerebral artery territory and the right occipital lobe in the posterior cerebral artery territory. 2. focal hemorrhagic transformation in the posterior right temporal lobe. 3. motion-limited mras of the head and neck demonstrate no appreciable change from the preceding ctas of the head and neck. there is a large thrombus extending from the distal right common carotid into the proximal right internal carotid and external carotid arteries, with 99% stenosis of the right internal carotid artery, better demonstrated on the cta, and complete occlusion of the proximal external carotid artery (with reconstitution via retrograde filling). persistent occlusion of the superior division of the right middle cerebral artery. bilateral fetal posterior cerebral arteries with bilateral patent posterior communicating arteries. echocardiogram: patent ductus arteriosus. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. moderate to severe tricuspid regurgitation. pulmonary artery hypertension. mild aortic valve stenosis. mild aortic regurgitation. dilated ascending aorta. cta neck :interval decrease in size of the thrombus in the right common carotid artery extending into both the internal and external branches. a small amount of thrombus is still present. 2. the previously seen occlusion of the superior division of the right mca is not completely included in the field of view of today's study given that the study is a neck cta. if there is any clinical concern for continued occlusion, recommend a dedicated cta of the head for further evaluation. 3. worsening pulmonary edema with bilateral pleural effusions. brief hospital course: the patient is an 87 y/o with past medical history of afib off coumadin for pastweek for colonoscopy, htn,hl,ar, chf p/w acute onset left sided weakness and found to have left hempiplegia and profound neglect consistent with r mca syndrome. neuro: at a dense mca sign was seen on imaging, and the pt received iv tpa at 90 min after onset of symptoms. nihss was slightly improved here to 14 from 17 at . the patient had a cta head and neck here which revealed recanalization of the r mca with cutoff seen at r m2 superior division and evidence of thrombus at the r cca occluding 99%, extending to r eca and r ica with recanalization distally. endovascular intervention was discussed with the neurointerventional attending as well as stroke attending, dr. and the decision was made that the risk of attempting recanalization of the r cca thrombus could potentially outweigh the benefit given the risk of distal embolization with manipulation, and relatively intact blood supply currently to circle of . the patient had a mri head which showed large acute infarctions involving the right frontal lobe, insula, and temporal lobe in the middle cerebral artery territory and the right occipital lobe in the posterior cerebral artery territory as well asa focal hemorrhagic conversion. the patient was briefly placed on a heparin drip despite this due to concern for the right carotid occlusion. this was later discontinued when the patient had a headache due to concern for bleed. ct head was obtained 24hours after tpa and showed no progression of hemorrhagic conversion noted on mri the previous day. the patient remained in the icu overnight and then was transferred to the floor the following day. she was started on aspirin and then restarted on coumadin. the patient regained some left sided strength and her left sided neglect improved slightly. while on the floor she began to open her eyes spontaneously and answered questions appropriately. a repeat cta of the neck showed decreased thrombus of the right common carotid. cardiac: the patient was monitored on telemetry and remained in atrial fibrillation. her cardiac enzymes were negative. she was continued on metoprolol at lower doses initially and home antihypertensives were held to allow for autoregulation. her heart rate trended up and her metoprolol was increased to her home dose. as above, she was started on aspirin bridge to coumadin. echocardiogram revealed a pfo. endocrine: her fingersticks were checked and she was placed on sliding scale insulin. glycohemoglobin was normal and ldl cholesterol was <100. fen: the patient was not able to swallow safely so a ng tube was placed and tube feeds begun on . on the patient was cleared to start ground solids and nectar thickened liquids. her tube feeds were held during the day and the plan is to continue nightly tube feed until she is able to take in an adequate number of calories. infection: the patient was noted to be delerious on and ua came back positive. she was started on ceftriaxone for uti, urine culture pending at this time. once antibiotics were started her delerium cleared. 1. dysphagia screening before any po intake? (x) yes - () no 2. dvt prophylaxis administered? (x) yes - () no 3. antithrombotic therapy administered by end of hospital day 2? (x) yes - () no 4. ldl documented? (x) yes 5. intensive statin therapy administered? (for ldl > 100) () yes - (x) no (if ldl >100, reason not given: ) 6. smoking cessation counseling given? () yes - () no (reason (x) non-smoker - () unable to participate) 7. stroke education given? (x) yes - () no 8. assessment for rehabilitation? (x) yes - () no 9. discharged on statin therapy? (x) yes - () no (if ldl >100, reason not given: ) 10. discharged on antithrombotic therapy? x() yes (type: (x) antiplatelet - (x) anticoagulation) - () no 11. discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) yes - () no - () n/a medications on admission: preadmission medications listed are correct and complete. information was obtained from family/caregiver. 1. simvastatin 40 mg po daily 2. lisinopril 40 mg po daily 3. warfarin md to order daily dose po daily16 2.5-5mg as directed 4. digoxin 0.125 mg po daily 5. levothyroxine sodium 75 mcg po daily 6. metoprolol tartrate 100 mg po bid 7. prednisone 1 mg po daily 7 tabs daily 8. docusate sodium 100 mg po bid 9. clobetasol propionate 0.05% ointment 1 appl tp discharge medications: 1. digoxin 0.125 mg po daily 2. docusate sodium 100 mg po bid 3. levothyroxine sodium 75 mcg po daily 4. prednisone 1 mg po daily 7 tabs daily 5. metoprolol tartrate 100 mg po bid 6. simvastatin 40 mg po daily 7. aspirin 325 mg po daily stop when inr 8. nystatin cream 1 appl tp 9. clobetasol propionate 0.05% ointment 1 appl tp 10. nitrofurantoin (macrodantin) 50 mg po q6h please continue through 11. warfarin 3 mg po daily16 discharge disposition: extended care facility: hospital - discharge diagnosis: right frontal, temporal and occipital lobe stroke patent foramen ovale discharge condition: oriented to date, does not believe we are at , thinks she's in hospital in . opening eyes. answers questions appropriately. naming intact. left facial droop, l hemineglect, l hemiparesis (antigravity). increased tone in left arm. localizes to pain on the left arm, withdraws to pain in left leg. toes up on left and down on right. bibasilar crackles in lungs, improved. discharge instructions: dear ms , you were admitted for a stroke. this was thought to be secondary to your atrial fibrillation. you were restarted on coumadin for stroke protection. your stroke risk factors were checked. you should continue to not smoke. your ldl cholesterol was 66. you were continued on a statin. you had a cardiac echocardiogram which demonstrated no cardioembolic source, but did show a patent foremen ovale. you were checked for blood glucose control with a hgb a1c. the level was 5.6 which is normal. you need to continue your blood pressure control. you should continue to eat a low fat healthy diet, and follow up with your primary care physician and stroke neurology as detailed below. it was a pleasure taking care of you. followup instructions: please follow up provider: , : date/time: 11:00 provider: (neurology) , md phone: date/time: 10:00 provider: , md phone: date/time: 1:30 md, Procedure: Enteral infusion of concentrated nutritional substances Diagnoses: Polymyalgia rheumatica Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Intracerebral hemorrhage Other and unspecified hyperlipidemia Do not resuscitate status Encephalopathy, unspecified Examination of participant in clinical trial Cerebral thrombosis with cerebral infarction Occlusion and stenosis of carotid artery with cerebral infarction Facial weakness Homonymous bilateral field defects Dysphagia, unspecified Flaccid hemiplegia and hemiparesis affecting nondominant side Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility |
allergies: no known allergies / adverse drug reactions attending: chief complaint: hematochezia, abdominal distension major surgical or invasive procedure: esophagogastroduodenoscopy colonoscopy with biopsies ultrasound guided paracentesis history of present illness: 47f with pmh of chronic depression, hemorrhoids x 20+ years presents with brbpr for past 2 weeks. patient states that 2 weeks ago, she drank tap water, which she normally does not do, and began to have diarrhea. since then, she has been going to the bathroom every hour, with small amounts of loose stool, until two days ago, when she became more constipated. she has noticed her hemorrhoids more recently, in the sense that when she uses the bathroom, she can feel them popping out from her sphincter, and finds blood on the toilet paper when she wipes. there is no pain associated with her hemorrhoids. at the same time, she has noticed worsened abdominal distension and her clothes no longer fit. she denies abdominal pain, nausea, or vomiting. yesterday, she had a fever of 100f with some sweats, but has not noticed any fevers since. she was also complaining of reflux symptoms over the past three days for which she had been taking an over the counter anti-acid. in the ed, initial vs were: 98.8, 106, 116/80, 18, 100% ra. labs were notable for an hct of 24.5 with an mcv of 122, plt of 109, ap of 204, t-bili of 3, ast of 62, alt of 18, amylase of 219, lipase of 123, inr of 1.7 and negative serum/urine tox screens. a ct of her abdomen/pelvis with contrast was notable for a thickened colonic wall consistent with colitis and a moderate amount of free fluid in the pelvis/paracolic gutters. she was given levofloxacin, with plans to start flagyl but did not receive this in the er. she was given 4g of mg and 40meq of potassium. gi was consulted with possible plans for a colonoscopy on monday, she had two 18 gauge iv's placed but was not transfused any prbc's in the er. she was admitted to the icu for frequent hct monitoring. vs on transfer were: t 98.4, bp 118/86, rr 17, o2 sat 100% ra. on arrival to the icu her initial vs were: t98, hr99, bp129/88, rr20, sat 100% (ra). she looks comfortable with no abdominal pain, nausea/vomiting. she does feel somewhat lightheaded, but no chest pain or sob. review of systems: positive per hpi. other review checked and unremarkable. past medical history: hemorrhoids depression (hx of si, insomnia) etoh abuse, in remission (last drink > 1 year ago, last heavy use approximately 4 years ago) anemia secondary to folate deficiency asthma hyperthyroidism s/p ablation, now hypothyroid htn low back pain secondary to djd s/p tubal ligation s/p fibroidectomy social history: unemployed, social support from mother but serious financial limitations - tobacco: 1 pack/day for 20 years - alcohol: former alcohol abuse (up to pink whisky/night), quit using alcohol last year, reports much less alcohol over the past four years - illicits: none family history: diabetes mellitus and cancer in members. no inflammatory bowel disease she knows about. physical exam: admission physical exam: vitals: t:98 bp:129/88 p:99 r:20 o2:100%(ra) general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: +bs, very distended, liver edge 4cm below costophrenic margin, tympanic to percussion, no tenderness to palpation gu: no foley ext: warm, well perfused, no edema discharge physical exam: all vital signs stable and within normal limits. pt appeared comfortable. mild jaundice. heart and lung exam within normal limits. abdominal exam notable for significantly diminished distension after u/s guided paracentesis. abdomen nontender and liver edge no appreciated. bowel sounds positive. no masses. otherwise exam notable for no asterixis. pertinent results: =================== laboratory results =================== admission labs: wbc-6.0 rbc-2.02*# hgb-8.4*# hct-24.5*# mcv-122*# rdw-15.2 plt count-109* --neuts-75.5* lymphs-15.1* monos-8.3 eos-0.7 basos-0.4 pt-18.6* ptt-32.7 inr(pt)-1.7* glucose-92 urea n-5* creat-0.7 sodium-139 potassium3.0* chloride-98 total co2-29 alt(sgpt)-18 ast(sgot)-62* ld(ldh)-204 ck(cpk)-103 alk phos-204* amylase-219* tot bili-3.0* albumin-3.8 calcium-8.7 phosphate-2.7 magnesium-1.3* lipase-123* ctropnt-<0.01 ck-mb-2 serum tox: asa-neg acetmnphn-neg ethanol-neg ucg neg, ua: blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-sm urobilngn-8* ph-6.5 leuk-sm rbc-1 wbc-3 bacteria-few yeast-none epi-33 urine tox: bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg discharge labs: wbc-7.9 rbc-2.52* hgb-9.8* hct-29.0* mcv-115* rdw-18.3* plt ct-85* pt-18.8* ptt-36.2* inr(pt)-1.7* glucose-83 urean-2* creat-0.6 na-133 k-3.6 cl-101 hco3-23 other important labs caltibc-221* ferritn-176* trf-170* vitb12-1123* folate-7.4 tsh-33* hbsag-negative hbsab-negative hbcab-negative hav ab-negative hcv ab-negative anti smooth muscle antibody- positive * -negative paracentesis: wbc-270* rbc-25* polys-3* lymphs-16* monos-73* mesothe-8* totpro-3.1 albumin-1.8 ============== microbiology ============== urine culture : no growth stool culture and c diff toxin assay: negative peritoneal fluid culture : gram stain (final ): 1+ (<1 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 (preliminary): no growth. anaerobic culture (preliminary): ============== other studies ============== ecg : sinus rhythm. poor r wave progression with low qrs voltage in the precordial leads and the limb leads. compared to the previous tracing of the qrs voltage has decreased and there is poor r wave progression. ct abdomen and pelvis w/ contrast : impression: 1. heterogeneously enhancing liver with a gastroesophageal varix and ascites; consider an acute inflammatory process of the liver. correlate for clinical presence of hepatitis. 2. thickened right colonic wall, with lesser thickening of the left colon wall and transverse colon sparing; this finding may be nonspecific in the setting of ascites; another consideration is colitis (infectious versus inflammatory etiologies). liver/ gb u/s : impression: 1. heterogeneous liver with patchy areas of increased echogenicity, finding suggestive of steatosis or possibly acute inflammation. no definite hepatic lesion is identified. 2. diffuse gallbladder wall edema, likely secondary to edema and/or underlying liver disease. no signs of acute cholecystitis. 3. no intra- or extra-hepatic biliary ductal dilatation. 4. moderate ascites, largest pocket in the right lower quadrant. brief hospital course: 47f with pmh of chronic depression, hypothyroidism, and alcohol abuse presenting with hematochezia and abdominal distension and signs of acute liver injury with secondary portal hypertension/ascites. 1) portal hypertension complicated by ascites due to acute or chronic hepatitis: pt presented with thromobocytopenia, increased transaminases with ast>alt, elevated bilirubin, and elevated inr that did not normalize with vitamin k. she also had ascites that was eventually revealed to have a saag of 1.3 suggestive of being due to portal hypertension. imaging revealed heterogeneous liver. overall picture is somewhat confusing. possible patient has chronic portal hypertension due to cirrhosis (most likely due to previous alcohol abuse) but imaging not strictly typical and though saag met criteria for being due to portal hypertension ascites albumin was relatively high. other possibility would be an acute hepatitis causing acute portal hypertension. most likely etiology of this would be alcoholic hepatitis but patient vehemently denies continued alcohol use to multiple individuals. extensive work up for causes of liver disease was unremarkable except for positive low titre anti-smooth antibody but with negative . she remained with an elevated bili, inr, and low platelets suggesting chronic cirrhosis but given she was otherwise stable she was discharged to follow up in liver clinic for further management and work up. she was cautioned about other manifestations of decompensated cirrhosis (i.e. encephalopathy) and warned to have a low threshold to seek medical care. she was started on 20 mg po lasix daily at time of discharge to help control ascites. 2) hematochezia: on presentation patient had bright red blood per rectum with major concern being for a hemorrhoidal bleed vs diverticular bleed vs bleeding from colitis (as ct seemed to suggest inflammation). never had large volume of blood and never with dark blood suggesting more likely from a lower gi source. the patient's hct on presentation was 24.5 and increased to around 30 after transfusion of one unit with stability thereafter. upper and lower endoscopy failed to reveal a clear source of bleeding though there were hemorrhoids, which could certainly explain blood that was seen. to complete work up should get a capsule endoscopy to evaluate for small bowel avms. gi elected to arrange this as an outpatient. at time of discharge hct stable >48 hrs w/o any transfusion. 3) ? fevers: pt reported low grade fevers prior to presentation. ed ct scan concerning for colitis so she was started on cipro/metronidazole though never febrile here. colonoscopy did not show any colitis and c diff negative so metronidazole stopped. sbp was also entertained as a source of fever but by time of paracentesis (deferred due to bedside procedure being technically infeasible and the deferred for endoscopies) she had received four days of antibiotics. therefore she completed five days of ciprofloxacin for possible sbp. no prophylaxis was started as diagnosis never confirmed and seemed unlikely. 4) anemia. patient has hx of anemia from folate deficiency. hct on presentation at 24.5 likely reflects baseline anemia with component of gi bleeding. labs suggested no current deficiencies. possible some degree of sequestration due to portal hypertension. she felt considerably better after transfusion and with higher hct. she will follow up for hct rechecks. 5) hypothyroidism: pt acknowledged taking levothyroxine irregularly at best. tsh 33 suggestive of very poor adherence. levothyroxine restarted in hospital. she will follow up with pcp for tsh rechecks. 6) depression. pt with significant history of depression and had not been taking meds regularly. she was restarted on fluoxetine and aripiprazole in house. 7) poor adherence: discussed with social work and largely due to very limited income and large debts for housing. patient discussed and reassured her that the infrastructure at clinic where she plans to be seen should be very helpful in working with financial issues and helping to make sure she does not miss care. patient was reassured. need for close follow up, particularly for hepatic issues was repeatedly emphasized. transitional issues: -pt will follow up with pcp to assess for signs of dehydration, tolerance of daily furosemide regime -pt will follow up with pcp and liver to assess resolution of ascites -pt will follow up with liver to discuss further work up of liver disease, trend labs, and discuss need for biopsy -pt will follow up with pcp to recheck anemia and trend as well as platelet count -final ascites culture results and serum ceruloplasmin pending at time of discharge. medications on admission: levothyroxine 200mcg daily - not taking everyday metoprolol 100mg daily - not taking hctz 50mg daily amlodipine 5mg daily fluoxetine 60mg daily - not taking regularly abilify 20mg daily - not taking everyday but thinks she should be calcium 1000mg vitamin d iron melatonin 3mg discharge medications: 1. fluoxetine 20 mg capsule sig: three (3) capsule po daily (daily). disp:*30 capsule(s)* refills:*1* 2. aripiprazole 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 3. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 6. furosemide 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. senna 8.6 mg tablet sig: 1-2 tablets po twice a day as needed for constipation. discharge disposition: home discharge diagnosis: primary diagnoses: acute decompensated cirrhosis complicated by ascites acute gi bleed (source unclear) secondary diagnoses: depression hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with gi bleeding and swelling of your abdomen. we think the swelling in the abdomen was due to liver disease, likely due to your previous heavy alcohol use (we have excluded viruses and some other common causes though the liver doctor you follow up might perform other investigations). despite using a camera to look at significant portions of your upper and lower gi tract we did not pinpoint a source of bleeding. nevertheless, the bleeding resolved on its own and it is likely a slow source so gi feels it can be worked up as an outpatient. your medications have been changed. you have been started on an acid blocking medication to help prevent further episodes of bleeding. your blood pressure medicines have been held as your blood pressure is normal without them. finally, you have been started on a diuretic called furosemide (lasix) to help you get rid of excess fluid on the body. followup instructions: department: post clinic when: thursday at 9:00 am with: dr building: sc clinical ctr south campus: east best parking: garage note: this appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. this visit, you will see your regular primary care doctor in follow up department: liver center when: thursday at 10:15 am with: , md building: lm campus: west best parking: garage Procedure: Other endoscopy of small intestine Percutaneous abdominal drainage Endoscopic polypectomy of large intestine Closed [endoscopic] biopsy of large intestine Diagnoses: Thrombocytopenia, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Other and unspecified alcohol dependence, in remission Unspecified acquired hypothyroidism Hypopotassemia Constipation, unspecified Blood in stool Other ascites Personal history of noncompliance with medical treatment, presenting hazards to health Benign neoplasm of colon Other and unspecified coagulation defects Internal hemorrhoids without mention of complication External hemorrhoids without mention of complication Chronic pulmonary heart disease, unspecified Folate-deficiency anemia |
allergies: penicillins attending: addendum: during the patient's operation, a moderate amount of hemorrhage was encountered due to raw surface bleeding from the surface of the hemangioma and the liever. the amount of blood loss resulted in an acute blood los anemia, which required blood product transfusions discharge disposition: home with service facility: all care va md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Arterial catheterization Transfusion of packed cells Transfusion of other serum Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Transfusion of platelets Other destruction of lesion of liver Transfusion of coagulation factors Diagnoses: Hemangioma of intra-abdominal structures Acute posthemorrhagic anemia Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Tachycardia, unspecified Cervicalgia Other acute postoperative pain Circumscribed scleroderma |
allergies: penicillins attending: chief complaint: neck pain, giant cavernous hemangioma major surgical or invasive procedure: exploratory laparotomy and enucleation of hepatic hemangioma. history of present illness: 49f transferred from where she presented with 1 day r neck pain radiating to back/ribs, cta chest to r/o pe revealed large r-sided liver lesion, possible hemangioma (15 cm). d-dimer was . transferred to for further evaluation and treatment. past medical history: pmh: h/o spontaneous r ptx psh: neck cyst and lymph node social history: lives with husband family history: n/c physical exam: vitals- t 97.1, hr 103, bp 124/90, rr 17, o2sat 100% gen- nad, alert head and neck- at, nc, soft, supple, no masses heart- rrr, no murmurs lungs- ctab, no rhonchi, no crackles abd- soft, nd, tender in ruq c fullness, dullness to percussion, no peritoneal signs ext- warm, well-perfused, no edema pertinent results: on admission: wbc-10.8 rbc-3.88* hgb-10.7* hct-32.7* mcv-84 mch-27.5 mchc-32.7 rdw-12.4 plt ct-376 pt-13.1 ptt-24.1 inr(pt)-1.1 glucose-144* urean-14 creat-0.6 na-138 k-4.1 cl-104 hco3-25 angap-13 at discharge: wbc-10.2 rbc-3.19* hgb-9.3* hct-27.1* mcv-85 mch-29.3 mchc-34.5 rdw-13.7 plt ct-626* glucose-124* urean-6 creat-0.5 na-138 k-3.9 cl-102 hco3-30 angap-10 alt-35 ast-25 alkphos-97 totbili-0.2 albumin-2.7* calcium-8.2* phos-3.5 mg-2.0 05:10am blood wbc-10.2 rbc-3.19* hgb-9.3* hct-27.1* mcv-85 mch-29.3 mchc-34.5 rdw-13.7 plt ct-626* 05:15am blood wbc-9.1 rbc-3.19* hgb-9.5* hct-27.0* mcv-85 mch-29.6 mchc-35.0 rdw-13.4 plt ct-505* 05:10am blood plt ct-626* 05:30am blood pt-13.4 ptt-25.7 inr(pt)-1.1 05:10am blood glucose-124* urean-6 creat-0.5 na-138 k-3.9 cl-102 hco3-30 angap-10 05:15am blood glucose-93 urean-5* creat-0.5 na-138 k-3.7 cl-103 hco3-30 angap-9 05:10am blood alt-35 ast-25 alkphos-97 totbili-0.2 05:15am blood alt-45* ast-26 alkphos-97 totbili-0.3 05:10am blood albumin-2.7* calcium-8.2* phos-3.5 mg-2.0 05:15am blood calcium-7.9* phos-2.8 mg-1.9 brief hospital course: 49 y/o female admitted from for further evaluation of liver mass thought to be hemangioma. ct from osh: incomplete cuts of upper abdomen, very large r-sided liver lesion c/w hemangioma with peripheral pooling of contrast she was admitted to the sicu with close monitoring of hct. ct repeated here showed: - large 12 x 14 cavernous hemangioma in the right lobe of the liver causing mass effect. - replaced common hepatic artery arising off the superior mesenteric artery. - cholelithiasis. - hypodense lesions within the bilateral kidneys, too small to characterize. - fundal uterine fibroid. - left adnexal cyst. if patient is premenopausal, this is likely physiological. she received two units of rbcs while in the icu, hct remained stable and she was taken to the or on with dr for exploratory laparotomy and enucleation of hepatic hemangioma. post op diagnosis was cavernous hemangioma. in the operation, the hemangioma which extended from the inferior margin of the right lobe all the way up to the right hepatic vein, pushed the entire right lobe medially to the left side. a moderate amount of hemorrhage was encountered that was just a raw surface bleeding from the surface of the hemangioma. essentially, segment vii from the liver and included the right hepatic vein was removed. during the operation, she received 7l of crystalloid, 13 units of rbcs, 9 units of ffp, 1 unit of cryoprecipitate, 2800cc of cell , and lost 5000cc of blood. she was admitted to the icu intubated and sedated. the patient was weaned off the vent and extubated on . her hct was checked q6h and was stable. her icu course was uneventful and she was transferred to the floor her pain was initially treated with an epidural and a pca. the epidural was removed pod4. her pca was removed and she was graduated to oral pain medications. we had to adjust her oral pain medications due to some discomfort, but achieved a regimen that worked well for the patient. she had some nausea that was treated with zofran. initially on the floor, the patient had a poor appetite which resolved by pod7. her foley was removed on pod5 and she voided afterward. she ambulated frequently with nursing staff and her husband. the nursing staff taught the patient and her husband proper care. she will have vna care to continue teaching and management. she has a follow up appointment with dr. . she is being discharged stable, in good condition. medications on admission: zyrtec 5', calcium, mvi discharge medications: 1. xyzal oral 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 10 days. disp:*20 capsule(s)* refills:*0* 3. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. disp:*80 tablet(s)* refills:*0* 4. multivitamin capsule sig: one (1) capsule po once a day. 5. calcium oral discharge disposition: home with service facility: all care va discharge diagnosis: hemangioma discharge condition: good discharge instructions: please call dr office at for fever> 101, chills, nausea, vomiting, diarrhea, inability to eat or keep down medications monitor for increased abdominal pain or increased drainage from the . also monitor for change in color or if the fluid developsa a foul odor monitor the incision for redness, drainage or bleeding. incision should be left open to air followup instructions: , md phone: date/time: 1:30 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Arterial catheterization Transfusion of packed cells Transfusion of other serum Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Transfusion of platelets Other destruction of lesion of liver Transfusion of coagulation factors Diagnoses: Hemangioma of intra-abdominal structures Acute posthemorrhagic anemia Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Tachycardia, unspecified Cervicalgia Other acute postoperative pain Circumscribed scleroderma |
allergies: penicillins attending: chief complaint: left groin bleeding major surgical or invasive procedure: leftt axilla-above knee poplteal bypass rightt iliac-above knee popliteal artery bypass excision of infected leftt-iliac-akpop bpg thrombectomy of left axillo-to-popliteal artery bypass history of present illness: 50y/o female one month s/p left external iliac to above-knee popliteal artery bypass -tex graft who now is transferred from an outside hospital for bleeding from her groin wound with concerns of an anastamotic disruption from a wound infection. she noted redness of her wound at 1 1/2 weeks postop. she also states there was drainage of green and brown discharge. the wound opened slightly and she was put on antibiotics. last night she noted large clumps of bright red blood come out of her wound. then she noted a burst of blood shoot into the air. following that she had a constant ooze of blood from her groin and she went to the ed at and osh. her wound was packed with fibrillar and a dressing applied. she was admitted to the icu overnight and she states there continued to be a constant bleed that just stopped prior to transfer. she has no current rest pain. she has not been ambulating too much since her recent surgery but does not have any pain in her le. she first noted redness from her wound at 1.5weeks post-op. past medical history: -htn -hypercholesterolemia -pad w/ h/o ischemic ulcerations rle and disabling claudication lle -sarcoid psh: r cia pta (), r cfa endarterectomy/patch angioplasty, left femoral to right above knee artery bypass -tex graft (), left external iliac to above knee artery -tex bypass () social history: +current tobacco use but has not smoked since surgery 1 mo ago. drinks etoh per week lives with husband, no children. currently works as a secretary family history: n/c physical exam: vitals 97.7 83 98/66 18 99% ra gen: a&o, nad cv: rrr lungs: cta-b abd: soft ntnd, abdominal wound staples in place with small hematoma. there is mild serosangous dranage from inferior aspect of wound. it does not appear to be infected. ext: graft site wounds are c/d/i. there is mild serous drainage from the left thigh incision. wound vac in place in left groin where previous infected graft site removed. all distal pulses have strong dopplerable signals pertinent results: 02:47am blood wbc-10.6# rbc-3.44* hgb-10.1* hct-28.8* mcv-84 mch-29.3 mchc-35.0 rdw-14.7 plt ct-281 02:47am blood plt ct-281 02:47am blood glucose-101* urean-4* creat-0.5 na-134 k-3.6 cl-102 hco3-26 angap-10 cta aorta/bifem/iliac runoff w/w&wo c and recons study date of 5:43 pm impression: 1. occlusion of the right external iliac, right common femoral and right superficial femoral arteries, with reconstitution of the right popliteal and three-vessel run-off by a patent left common femoral to right above knee popliteal bypass graft. 2. occlusion of the left superficial femoral artery with reconstitution of the left popliteal and three-vessel runoff by a patent left common femoral to left above knee popliteal bypass graft. 3. high-grade stenosis seen involving the distal left external iliac/proximal common femoral, just above the level of bypass graft anastamoses. 4. hematoma in the left groin compatible with known recent hemorrhage. there is no active extravasation and no retroperitoneal or intraperitoneal hematoma. 5. findings compatible with graft infection involving the left lower extremity bypass graft, including extensive rim-enhancing circumferential fluid and soft tissue standing tracking the length of the graft. ecg study date of 4:34:58 pm sinus rhythm. diffuse t wave flattening. no previous tracing available for comparison. chest (portable ap) study date of 9:59 pm comparison: no comparison available at the time of dictation. findings: the volume of the left and right hemithorax are normal. no evidence of focal parenchymal opacities suggesting pneumonia. minimal right basal atelectasis. no pleural effusions. normal size of the cardiac silhouette, no evidence of pulmonary edema. brief hospital course: mrs was initially transferred from an osh on for bleeding from groin at her goretex graft site in her left groin. she was brought to the cvicu for close observation of her wound given the potential severity of disruption of her anastamosis and graft site. her wound was initially packed and she was monitored. initially she had a cta which showed no obvious signs of extravastion or infection. iv antibiotics becan on hd 1 and cardiology was consulted for pre-op evaluation. who put her at average risk but given the urgency of this non-elective procedure, recommended that she continue with surgery. on the patient was brought to the operating room for planned left axillary to popliteal bypass and right iliac to popliteal bypass with excision of previous infected left iliac graft. intraoperative wound cultures were sent and the graft site was left open. please see full operative report for details. the patient was immediately started on a heparin drip in the pacu and when stable was transferred back to the cvicu. on the evening of pod0 the patient was found to have a cold left foot without dopplerable signals. the patient was immediately taken back to the operating room for exploration her her graft which had difuse clot. an intra-operative angiogram was performed proximal to the graft which demonstrated left subclavian stenosis, a stent was placed. please see full operative report for details. the patient was then transferred directly to the cvicu where she was extubated later that evening. she had no events overnight and on pod1 a wound vac was placed on the open wound where the infected graft was placed. she was transferred to the vicu later that evening and infectious disease was consulted regarding her wound infection. on pod3 the patient's diet was advanced to regular, she was restarted on her home medications and her simvastatin was increased to 100mg at the request of cardiology. she was started on coumadin 5mg while maintaining a heparin drip. on pod 5 the patient's inr was elevated to 4.5. her coumadin was stopped one day and restarted the next day at 1mg. she continued to have elevated inr >4.0 throughout her hospital course. the rest of her hospital course was uneventful. she worked with physical therapy on ambulating which she did well with. throughout her hospital stay, mrs. did not spike any fevers or develop an elevated wbc count. at the time of discharge the patient's systolic blood pressures were in the low 100's. her blood pressure medications were held and she was instructed to follow-up with her primary care doctor later that week regarding restarting her medications. her cultures grew out rare growth of mssa and coag negative staph. it was the final recommendation of the infecitous disease team that given her severe sequelae of another infection and her penicillin allergy that she complete a course of iv vancomycin for 6 weeks. she was also d/ced on 7 days of po flagyl given her diarrhea to stop any potential c. diff infection. on discharge her inr was 4.0 she was instructed to not take coumadin until instructed to do so by her pcp. will draw an inr 3x a week in order to manage her coumadin. she was instructed to call dr. office for a follow-up appointment in 2 weeks. medications on admission: asa 325; bupropion 150 tid; coreg 6.25 ; digoxin 250 mcg qdaily; gabapentin am/pm/hs; lorazepam 1 prn(rarely takes) colace 100 ; simvastatin 40 hs; torsemide 20 ; coumadin 12.5 qdialy; oxycodone 10 prn; lantus 100 ; humalog ss 80 units for bs 150; omeprazole 40 qdaily; fioricet prn discharge medications: 1. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous q 12h (every 12 hours). disp:*28 bags* refills:*1* 2. alcohol pads pads, medicated sig: one (1) box topical use as directed. disp:*1 box* refills:*2* 3. normal saline flush 0.9 % syringe sig: one (1) syringe injection three times a day: and before and after use. disp:*100 syringes* refills:*2* 4. outpatient lab work vanco through prior to 4th dose after a dose change. weekly cbc, esr, crp, chem 10 fax results to infectious disease:( attention: dr. 5. outpatient lab work inr three times a week. goal . fax/phone results to: dr. ,roann phone: fax: 6. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). 8. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 10. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 11. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 12. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 13. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 14. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 15. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 16. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 17. metronidazole 500 mg tablet sig: one (1) tablet po three times a day for 7 days. disp:*21 tablet(s)* refills:*0* 18. coumadin 1 mg tablet sig: one (1) tablet po once a day. disp:*60 tablet(s)* refills:*2* patient to dose coumadin with primary care doctor 19. hydrochlorothiazide 12.5 mg capsule sig: two (2) capsule po daily (daily). patient not to restart medication until cleared by pcp. 20. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). patient not to restart medication until cleared by pcp. 21. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). patient not to restart medication until cleared by pcp. discharge disposition: home with service facility: community discharge diagnosis: htn hypercholesterolemia pad w/ h/o ischemic ulcerations rle and disabling claudication lle, ?sarcoid psh: r cia pta (), r cfa endarterectomy/patch angioplasty, left femoral to right above knee artery bypass -tex graft (), left external iliac to above knee artery -tex bypass () discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: division of vascular and endovascular surgery lower extremity bypass discharge instructions activities: - ambulate essential distances untill fu with dr. - ace wrap leg from foot-knee when ambulating, to prevent swelling - your operated leg is expected to have some swelling and will resolve over time - elevate leg when sitting - no driving till fu - may shower, pat dry your incisions, no tub baths wound: - you were started on wound vac treatment to your left groin wound, - call for any problems with the machine and the dressing. - keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 - your staples will be removed on your fu with dr. diet: - diet as tolerated eat a well balanced meal - your appetite will take time to normalize - prevent constipation by drinking adequate fluid and eat foods in fiber, take stool softener while on pain medications medications: - you were started on coumadin, a blood thinner that required blood work to monitor inr levels. the goal inr should be between . - we will have your pcp take over the management of this medication and lab results. please discuss that you are on coumadin with your pcp. are being given a prescription for coumadin. do not take any coumadin until instructed to do so by your primary care physician. continue all medications as directed - take your pain medications conservatively - your pain will get better over time fu appointments: - keep all fu appointments 1. call dr. office for fu appointment. phone 2. infectious disease dr. phone: 3. dr. ,roann phone: followup instructions: -call dr. office for fu appointment. phone provider: , id west (sb) phone: date/time: 10:10 provider: . ,roann phone: call to make an appointment to be seen in weeks. Procedure: Venous catheterization, not elsewhere classified Other revision of vascular procedure Other revision of vascular procedure Angioplasty of other non-coronary vessel(s) Other (peripheral) vascular shunt or bypass Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Suture of artery Application of other wound dressing Cranial or peripheral nerve graft Insertion of one vascular stent Procedure on single vessel Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Sarcoidosis Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site 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 Other complications due to other vascular device, implant, and graft Infection and inflammatory reaction due to other vascular device, implant, and graft Stricture of artery Atherosclerosis of native arteries of the extremities with rest pain Chronic total occlusion of artery of the extremities Disruption of wound, unspecified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: mental status changes major surgical or invasive procedure: : right craniotomy and evacuation of subdural hematoma history of present illness: this is an 88 year old man with dementia who fell approximately 8 days prior to presentation in while visiting his daughter. was trying to use the bathroom and hit his head, started to experience some confusion and gait instability, was taken to the hospital where a ct was negative, but was found to have a uti and was admitted. on his second hospital day he fell out of bed, but it is unclear weather imaging was obtained. he returned to his facility, but was having considerable difficulty ambulating. he presents after a head ct at revealed an acute on subacute subdural hematoma. at baseline, the patient ambulates with a walker and is able to feed himself, but needs assistance with all other adls. past medical history: dementia, htn, pacer, esophageal strictures s/p release c/b gi bleed, right ca tract, prostate ca s/p radiation, renal adenocarcinoma s/p l nephrectomy. social history: lives at the arbors in the dementia unit, frequently goes to to stay with daughter. family history: nc physical exam: on admission: t:98.3 bp: 129/87 hr:70 r o2sats 95 4l gen: wd/wn heent: ncnt neck: supple. lungs: cta bilaterally. cardiac: rrr. paced abd: soft, nt, extrem: warm and well-perfused. neuro: mental status: lethargic but arousable. orientation: self, three daughters (number no), knows security number at baseline,but not at this time. language: some slurring cranial nerves: i: not tested ii: pupils right surgical, left 1 to .5mm iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hard of hearing ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: antigravity with all four extremities, difficult to asses drift and isolated muscle groups. physical exam upon discharge: eo spontaneous,non-verbal, right pupil surgical, left pupil brisk; purposeful left ue, right ue and bilat le withdraws antigravity pertinent results: ct head- impression: unchanged subacute right subdural and left parafalcine hematomas, with moderate mass effect on the right lateral ventricle and minimal leftward midline shift. no new hemorrhage or acute large vascular territorial infarction is detected. the examination is little changed since . ct head-postop status post evacuation of subdural hematoma with slight decrease in mass effect. no new hemorrhage seen. unchanged appearance of the falx subdural hematoma. cxr nasogastric tube ends in the upper stomach. transvenous right atrial and right ventricular pacer leads are unchanged in standard placements respectively. heart is top normal size, though increased compared to and there is also greater pulmonary vascular engorgement, so i see no edema or definite pleural effusion. cxr nasogastric tube and dual lead pacemaker are unchanged in appearance. the lungs appear well aerated. the heart is normal in size with normal cardiomediastinal silhouette. no effusion or pneumothorax is seen. lens there is normal compressibility, flow and augmentation of bilateral common femoral, superficial femoral, popliteal and calf veins. impression: no dvt. ct head slight decrease in pneumocephalus and sdh overlying the right cerebral hemisphere. decreased sdh in the left parafalcine region. unchanged minimal hemorrhage overlying both leaflets of the tentorium cerebelli. no change in minimal leftward midline shift. no new hemorrhage or acute large vascular territorial infarction cxr an ng tube is present, tip overlying fundus. a left-sided dual-lead pacemaker is present, with lead tips over right atrium and right ventricle. a patchy opacity at the right base seen on a film from at 8:19 a.m. is considerably improved; minimal residual opacity is present. this suggests resolving atelectasis. a focal pneumonic infiltrate or area of aspiration is considered much less likely. heart size is at the upper limits of normal or slightly enlarged, with left ventricular configuration and the aorta is unfolded. there is borderline upper zone redistribution, but no overt chf. there is minimal atelectasis at the left lung base. no gross effusion. : cxr: as compared to the previous radiograph, there is no relevant change. unchanged appearance of the lung parenchyma. no evidence of pneumonia. : lower extremity doppler ultrasound: negative for dvt ** bedside swallow evaluation:** history returned again today to reassess this 88 y/o man admitted to on after multiple week hx including fall in fl, confusion, gait instability, uti, fall out of bed at osh, difficulty ambulating at , etc. head cts revealed acute on subacute sdh and pt was txferred to for urgent r craniotomy and drain placement on . we have been following the pt during this admission, however pt consistently too lethargic to participate and with excess secretions making po intake unsafe. he's had ngt placement throughout this admission for nutrition, hydration, and medications. per chart and discussion with neurosurg, family is considering peg but is undecided. geriatrics is involved and per notes are concerned regarding prognosis given his pmh including moderate alzheimer's. pmhx: dementia, htn, pacer, esophageal strictures s/p release c/b gi bleed, right ca tract, prostate ca s/p radiation, renal adenocarcinoma s/p l nephrectomy. evaluation: the examination was performed while the patient was seated upright in the bed on 11. cognition, language, speech, voice: eyes open on arrival to room. once interacted with, begins moaning but no eye contact. response to questions. does withdraw to pain/discomfort with repositioning and placement of o2 monitor. once, mid-evaluation, pt turns head toward me, makes direct eye contact, and . only vocalizations heard are ah, humming, and moaning. teeth: intact in fair to good condition from what i can see secretions: congested cough intermittently at baseline. deep yankauer suctioning prior to pos (-) for return. dry/cracked tongue, but otherwise evidence of good oral care. oral motor exam: face grossly symmetrical. does not follow commands for eval. good jaw strength, as clamps down against spoon intermittently. gag present on deep suctioning. swallowing assessment: pt was offered ice chips (x2), thin liquid (tspn x3), nectar thick liquids (tspn x8-12), pureed solids (tspn x4-6). despite wakefulness and intermittent attentiveness, pt with limited interaction with pos. he often closes mouth against spoon, requires 10-30 seconds of encouragement before opening mouth. mouth opening is limited. oral phase appeared delayed/prolonged without overt oral cavity residue. laryngeal elevation delayed and reduced to palpation. pt had overt cough/sputter after tspns of thin liquid which was not observed with other consistencies, however intermittent congested cough increased during eval, concerning for intermittent aspiration of other consistencies. at end of eval, pt deep oropharyngeal suctioned via yankauer, (+) for return of moderate amounts of puree from posterior oropharynx. o2 sats stable at 94-97% throughout except when coughing on thin, at which time they dipped to 91% briefly and then returned. summary / impression: presents today with overt s/sx of aspiration of thin liquids and concern for intermittent (possibly silent) aspiration of nectar thick liquids and purees. pt also with documented upper airway congestion concerning for aspiration of oral secretions. safest recommendation based on today's evaluation remains npo with alternative means of nutrition, hydration, and medication. videoswallow study could provide more detailed/objective data, though due to pt's current mental status, not likely to participate and is, as such, not recommended currently. given pt's premorbid functioning and poor progress in the last week and a half since his neurosurgical intervention, would agree with md teams that further discussion of goals of care is warranted prior to pursuing peg placement. we are happy to participate in family meeting when one is scheduled. this swallowing pattern correlates to a functional oral intake scale (fois) rating of 1 out of 7. recommendations: 1. continue npo 2. continue q4 oral care 3. continue short term nutrition, hydration, and medication 4. family meeting encouraged regarding overall prognosis and goals of care as well as specifics of nutritional maintenance. 5. we will f/u. these recommendations were shared with the patient, nurse and medical team. ____________________________________ , m.s., ccc-slp pager # face time: 10:10-10:30 total time: 60 minutes addendum by , ms slp on at 1:44 pm: family meeting has been scheduled for this evening at 5:30pm, a time at which our department is unfortunately unavailable. today's results, as outlined above, have been discussed by phone with neurosurg pa and fellow. agree with fellow that further improvements in swallow function are likely to be seen on a period of weeks rather than days. d/c to ltach or other setting that can manage ngt while awaiting further recovery seems ideal if possible and if within family's/pt's goals of care. in the interim, pt can be receiving pt, cognitive-linguistic therapy, and swallow therapy to maximize recovery. to manage secretions optimally, would encourage continued q4 oral care with consideration of antibacterial such as chlorhexadine, as is available in the sage qcare kits here at . if the family has further specific questions regarding swallow function after the meeting this evening, please page and we'll be happy to speak with them tomorrow in person or by phone. updated recommendations 1. npo including no ice, no oral meds 2. continue q4 oral care with sage qcare kits, consider addition of chlorhexadine 3. continue short term nutrition, hydration, and medication via ngt pending further improvements in overall medical/neurological status. 4. continued pt, cognitive-linguistic tx, and swallow tx here as able and in rehab/ltach setting after d/c to maximize functioning. , ms, ccc-slp pager # brief hospital course: on the patient was admitted to the neurosurgery service. he was given one unit of platelets for his daily asa use. on he was taken to the or and underwent a craniotomy and evacuation of the sdh. this was without complication. he was extubated and transferred to the sicu. post op head ct revealed good evacuation. on he was lethargic but eo to voice and he moved all extremities. he was cleared for transfer to the stepdown unit. he remained stable overnight in the step down unit into . on his exam remained stable and he worked with pt/ot as well. his dressing was removed and his incision was clean dry and inntact with dissolvable sutures. he was started on tube feeds via ngt per nutritions recommendations. in the evening his incision was noted to be swollen,warm and red but he remained afebrile and there was no drainage, therefore it was recommended to apply ice packs and continue to monitor. a foley was replaced for urinary retention. on he was cleared for transfer to the floor. on he was febrile and a work up was initiated. chest x-ray showed small patchy left opacity. he was seen by nutrition and tf were djusted. his multi vitamin was stpopped when goal was reached per the nutrition team. he was again febrile on , ua was positive and cipro was started. lenis ruled out dvt. ct head was done for lethergy and this showed slight improvement in sdh. on , repeat cxr showed that the patchy opacity at the right base improved. his rr was 28, so chest pt/albuterol/atrovent were ordered prn. ivf were increased to 50cc/hr for hypernatremia and rf changes. on : tmax 100.8 ax. ivf to nss. on the overnight of into the patient was febrile to 101.5 axillary and a full fever workup was initiated. lower extremity doppler ultrasound was negative for dvt. cxr negative for clear pneumonia. blood and urine cultures were negative. his mental status began to improve and on and he was following simple commands. speech and swallow evaluation was performed however he was unable to consistently follow commands. the therapist noted delayed or prolonged oral phase and delayed laryngeal elevation. strict npo still recommended at this time. on the evening of a family meeting was held with neurosurgery, geriatrics and the hcp. it was decided at this time that it would be best to transfer the patient to rehab with an ngtube for an additional week or so. at that time the decision as to whether to place a peg tube or not could be re-visited. on he remained stable and afebrile. he was cleared for discharge to rehab facility pending bed availability. he was offered a bed at rehab and discharged to there on the afternoon of . medications on admission: namenda 10mg , allopurinol 100mg qd, citalopram 30mg qd, metoprolol tartrate 25mg qd, foltx 2.5/25/2 1 tab daily, asa 81mg qd, mvi, augmentin 500 for uti discharge medications: 1. docusate sodium 50 mg/5 ml liquid : one (1) po bid (2 times a day). 2. allopurinol 100 mg tablet : one (1) tablet po daily (daily). 3. citalopram 20 mg tablet : 1.5 tablets po daily (daily). 4. metoprolol tartrate 25 mg tablet : one (1) tablet po daily (daily). 5. folic acid 1 mg tablet : one (1) tablet po daily (daily). 6. pyridoxine 50 mg tablet : one (1) tablet po daily (daily). 7. cyanocobalamin (vitamin b-12) 100 mcg tablet : 0.5 tablet po daily (daily). 8. acetaminophen 650 mg/20.3 ml solution : po q6h (every 6 hours) as needed for fever or pain. 9. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily). 10. senna 8.8 mg/5 ml syrup : one (1) tablet po bid (2 times a day). 11. oxycodone 5 mg tablet : one (1) tablet po q4h (every 4 hours) as needed for pain. 12. heparin (porcine) 5,000 unit/ml solution : 5000 (5000) units injection tid (3 times a day). 13. hydralazine 25 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for sbp>160. 14. ciprofloxacin 250 mg tablet : one (1) tablet po q12h (every 12 hours) for 4 days: discontinue following final dose on . 15. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q4h (every 4 hours) as needed for wheeze/sob. 16. ipratropium bromide 0.02 % solution : one (1) neb inhalation q4h (every 4 hours) as needed for wheeze/sob. 17. nystatin 100,000 unit/ml suspension : five (5) ml po qid (4 times a day) for 5 days: d/c followign final dose on . 18. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 19. 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: for the aged - macu discharge diagnosis: subdural hematoma pleural effusion dysphagia uti hypernatremia discharge condition: mental status: confused - always. activity status: bedbound. level of consciousness: lethargic but arousable. 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 have dissolvable sutures you may wash your hair and get your incision wet. ?????? 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. followup instructions: follow-up appointment instructions ????????????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. Procedure: Incision of cerebral meninges Enteral infusion of concentrated nutritional substances Replacement of indwelling urinary catheter Diagnoses: Unspecified pleural effusion Urinary tract infection, site not specified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Personal history of malignant neoplasm of prostate Chronic kidney disease, unspecified Cardiac pacemaker in situ Hyperosmolality and/or hypernatremia Personal history of malignant neoplasm of kidney Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Fall from other slipping, tripping, or stumbling Unspecified deficiency anemia Other specified retention of urine History of fall Other dysphagia Dementia, unspecified, without behavioral disturbance |
allergies: bactrim / clindamycin / levaquin / pollen extracts / mold extracts / doxazosin attending: addendum: remained in hospital awaiting insurance clearance for rehab no change in clinical status since previous summary pertinent results: 11:00am blood hct-30.8* 11:00am blood pt-20.7* ptt-39.0* inr(pt)-2.0* discharge medications: 1. warfarin 2 mg tablet sig: as directed tablet po once a day: take as directed for goal inr between 2.0 - 2.5. daily dose may vary. take 1mg tonight. disp:*30 tablet(s)* refills:*2* 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day): hold for sbp < 100 and/or hr < 60 . 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. hydroxyurea 500 mg capsule sig: three (3) capsule po 2x/week (mo,th). 6. hydroxyurea 500 mg capsule sig: two (2) capsule po 5x/week (,tu,we,fr,sa). 7. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). 8. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 9. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 10. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 11. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 12. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 13. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 14. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 15. dofetilide 250 mcg capsule sig: one (1) capsule po q12h (every 12 hours): please administer same time each day. 16. lasix 40 mg tablet sig: one (1) tablet po twice a day for 7 days: please titrate accordingly(preop weight approx 105 kg). 17. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours) for 7 days: hold if k > 4.5 - please titrate and adjust with lasix accordingly. 18. tramadol 50 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*40 tablet(s)* refills:*0* 19. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing/sob. 20. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day) as needed for constipation. 21. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. disp:*1 ml(s)* refills:*0* 22. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: inhalation every six (6) hours. discharge disposition: extended care facility: senior healthcare - discharge diagnosis: aortic stenosis and coronary artery disease s/p aortic valve replacement and coronary artery bypass graft x 1 past medical history: -hypertension -atrial fibrillation/flutter, multifocal atrial tachycardia s/p -ablation -complete heart block -essential thrombocythemia -mild sleep apnea (does not require cpap) -copd/asthma, recurrent sinusitis (has been treated with various antibiotics and prednisone in the past) -prostate cancer s/p radiation, lupron therapy : rectal bleeding. colonoscopy revealing sigmoid diverticulosis as well as radiation proctitis s/p argon-plasma coagulator, internal hemorrhoids, diverticula. : recurrent bleeding requiring 1 unit prbc (setting of inr > 3, present goal is 2-2.5) no present bleeding. -nasal polyps -umbilical hernia -hypothyroidism -ventral hernia past surgical history -left distal fibula fracture s/p surgery -: bilateral inguinal hernia repair -knee surgery for meniscal tear - dual chamber sigma pacemaker implant followed by avj ablation, s/p generator change to adapta discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with tramadol incisions: sternal - healing well, no erythema or drainage edema: trace to 1+ 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. at 1:15p, cardiologist: dr. on at 1:40pm device clinic: at 12:30pm 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: atrial fibrillation, bioprosthetic aortic valve replacement goal inr: 2.0 - 2.5 first draw: ** please arrange coumadin followup prior to discharge from rehab ** patient was on coumadin prior to surgery and should resume follow up at the coumadin clinic @ and pcp . ** md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Obstructive sleep apnea (adult)(pediatric) Anemia, unspecified Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Personal history of malignant neoplasm of prostate Aortic valve disorders Personal history of tobacco use Atrial flutter Need for desensitization to allergens Pulmonary collapse Occlusion and stenosis of carotid artery without mention of cerebral infarction Hypotension, unspecified Long-term (current) use of anticoagulants Family history of ischemic heart disease Cardiac pacemaker in situ Chronic obstructive asthma, unspecified Personal history of irradiation, presenting hazards to health Other specified disorders of rectum and anus Umbilical hernia without mention of obstruction or gangrene Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Unspecified sinusitis (chronic) Ventral, unspecified, hernia without mention of obstruction or gangrene Essential thrombocythemia Personal history of traumatic fracture |
allergies: bactrim / clindamycin / levaquin / pollen extracts / mold extracts / doxazosin attending: chief complaint: worsening shortness of breath major surgical or invasive procedure: 1. aortic valve replacement 21-mm biocor apical tissue valve. 2. coronary artery bypass grafting times 1 of the left internal mammary artery graft to left anterior descending. history of present illness: 68 y.o. male with known as now with progressive dyspnea and fatigue. he can't walk up or down a flight of stairs, or go out to the mailbox at 50 feet, without experiencing moderate dyspnea. this resolves with rest. he denies any le edema. he states he cannot sleep on his back as he wakes up gasping for breath. he sleeps on his side without any difficulty. he has always slept with 2 pillows. he denies and chest pain, difficulty breathing at rest, dizziness, lightheadedness, palpitations, or presyncope. his last syncopal episode was over 25 years ago. overall he feels his energy level is not what it used to be and he is always tired and fatigued. recently has had rectal bleeding related to rectal proctitis from radiation treatments for his prostate ca in novemember . undergoing colonoscopies every few weeks for thermal therapy. brbpr and required blood transfusion in . in light of his worsening symptoms he was referred for right and left heart catheterization for further evaluation of his aortic valve in preparation of possible surgical intervention, which revealed 40% lad lesion. he is admitted today for heparin bridge with plans for avr/? cabg in am. past medical history: aortic stenosis and coronary artery disease s/p aortic valve replacement and coronary artery bypass graft x 1 past medical history: -hypertension -atrial fibrillation/flutter, multifocal atrial tachycardia s/p -ablation -complete heart block -essential thrombocythemia -mild sleep apnea (does not require cpap) -copd/asthma, recurrent sinusitis (has been treated with various antibiotics and prednisone in the past) -prostate cancer s/p radiation, lupron therapy : rectal bleeding. colonoscopy revealing sigmoid diverticulosis as well as radiation proctitis s/p argon-plasma coagulator, internal hemorrhoids, diverticula. : recurrent bleeding requiring 1 unit prbc (setting of inr > 3, present goal is 2-2.5) no present bleeding. -nasal polyps -umbilical hernia -hypothyroidism -ventral hernia past surgical history -left distal fibula fracture s/p surgery -: bilateral inguinal hernia repair -knee surgery for meniscal tear - dual chamber sigma pacemaker implant followed by avj ablation, s/p generator change to adapta social history: lives with:wife contact: (wife): cell occupation:previously worked in construction management cigarettes: smoked no yes last cigarette _____ hx: other tobacco use:smoked x 10 years, quit at age 30 etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use family history: premature coronary artery disease-brother with an mi in his 50s. father had several mis, dying suddenly at age 59. physical exam: pulse: 87 resp:18 o2 sat: ra 99% b/p right: 135/75 left: height: 5ft 10 weight:230lbs general: skin: dry intact left upper chest pacer pocket cdi heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade __3/6____ abdomen:large soft non-distended non-tender bowel sounds +, + ventral hernia extremities: warm , well-perfused edema _____ varicosities: none lower extremities neuro: grossly intact pulses: femoral right: +2 left:+2 dp right: doppler left:doppler pt :+2 left:+2 radial right:+2 left:+2 carotid bruit: right: referred murmur vs bruit left: referred murmur vs bruit pertinent results: echo: prebypass: no atrial septal defect is seen by 2d or color doppler. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. postbypass: biventricular systolic function remains normal. there is a well seated, well functioning bioprosthesis in the aortic position. there is trace valvular ai. the study is otherwise unchanged from prebypass. . cxr : unchanged left basilar atelectasis and small bilateral pleural effusions. unchanged moderate cardiomegaly. no pulmonary edema. . 07:01pm blood wbc-8.3 rbc-3.26* hgb-10.3* hct-32.0* mcv-98 mch-31.8 mchc-32.3 rdw-18.9* plt ct-401 04:15am blood wbc-8.9 rbc-2.73* hgb-8.8* hct-26.5* mcv-97 mch-32.2* mchc-33.2 rdw-17.9* plt ct-352 06:55pm blood pt-11.9 ptt-33.7 inr(pt)-1.1 04:15am blood pt-29.1* inr(pt)-2.8* 07:01pm blood glucose-137* urean-26* creat-1.0 na-136 k-4.6 cl-99 hco3-26 angap-16 04:15am blood urean-19 creat-0.8 na-137 k-4.1 cl-98 07:01pm blood alt-15 ast-21 ld(ldh)-555* alkphos-75 amylase-28 totbili-1.2 04:15am blood pt-29.1* inr(pt)-2.8* 04:10am blood pt-27.1* inr(pt)-2.6* 04:52am blood pt-18.3* inr(pt)-1.7* 07:05am blood pt-13.6* ptt-31.2 inr(pt)-1.3* 03:19am blood pt-12.6* ptt-29.3 inr(pt)-1.2* 04:15am blood urean-19 creat-0.8 na-137 k-4.1 cl-98 04:10am blood glucose-128* urean-20 creat-0.7 na-136 k-4.3 cl-99 hco3-27 angap-14 04:52am blood glucose-145* urean-19 creat-0.7 na-134 k-4.2 cl-100 hco3-28 angap-10 07:05am blood glucose-148* urean-17 creat-0.8 na-132* k-4.6 cl-99 hco3-24 angap-14 04:15am blood wbc-8.9 rbc-2.73* hgb-8.8* hct-26.5* mcv-97 mch-32.2* mchc-33.2 rdw-17.9* plt ct-352 04:10am blood wbc-8.9 rbc-2.74* hgb-8.7* hct-26.9* mcv-98 mch-31.7 mchc-32.2 rdw-18.4* plt ct-304 07:05am blood wbc-11.1* rbc-2.88* hgb-9.3* hct-28.0* mcv-97 mch-32.1* mchc-33.1 rdw-18.6* plt ct-326 03:19am blood wbc-9.9# rbc-2.98* hgb-9.4* hct-28.9* mcv-97 mch-31.5 mchc-32.5 rdw-18.4* plt ct-419 brief hospital course: mr. was admitted one day prior to surgery for heparin bridge and usual pre-operative work-up. prior to surgery, he was desensitized to aspirin. on he was brought to the operating room where he underwent an aortic valve replacement and coronary artery bypass graft x 1. please see operative report for surgical details. following surgery he was transferred to the cvicu for invasive monitoring in stable condition. pod 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. dofetilide and coumadin were resumed per dr. . 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. patient was complaining of fatigue with low hematocrit and was given blood transfusion with appropriate rise in hematocrit. by the time of discharge on pod five the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged of in good condition with appropriate follow up instructions. medications on admission: albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 puffs(s) inhaled four times daily as needed for shortness of breath budesonide - (prescribed by other provider) - 0.5 mg/2 ml suspension for nebulization - 1 (one) ampule inhaled via nebulizaiton prn for severe wheezing rarely uses diltiazem hcl - 180 mg capsule, ext release 24 hr - 1 (one) capsule(s) by mouth daily dofetilide - 250 mcg capsule - 1 capsule(s) by mouth twice a day fluticasone - 50 mcg spray, suspension - 2 sprays in each nostril daily fluticasone - 110 mcg/actuation aerosol - 1 aerosol(s) inhaled twice a day hydrocortisone acetate - (prescribed by other provider) - 30 mg suppository - one rectally at hs prn - no substitution hydroxyurea - 500 mg capsule - 3 capsule(s) by mouth on mondays and thursdays. 2 capsules by mouth on all other days of the week. ipratropium bromide - (prescribed by other provider) - 42 mcg spray, non-aerosol - 1 spray(s) each nostril daily prn - no substitution levothyroxine - 100 mcg tablet - 1 tablet(s) by mouth once a day montelukast - 10 mg tablet - one tablet(s) by mouth nightly nebulizer - dispense one nebulizer machine omeprazole - (prescribed by other provider) - 20 mg capsule, delayed release(e.c.) - 1 (one) capsule(s) by mouth daily hs spironolactone - 25 mg tablet - 1 tablet(s) by mouth once a day tamsulosin - 0.4 mg capsule, ext release 24 hr - 1 capsule(s) by mouth 1/2 hour after dinner, daily tiotropium bromide - 18 mcg capsule, w/inhalation device - 1 capsule(s) inhaled once a day warfarin - 5 mg tablet - tablet(s) by mouth daily as needed for inr (10mg 4day a week and 12.5mg other 3 days of week) - last dose 4 days ago () docusate sodium - (prescribed by other provider) - 100 mg capsule - 1 capsule(s) by mouth once a day discharge medications: 1. warfarin 2 mg tablet sig: one (1) tablet po once a day: take as directed for goal inr between 2.0 - 2.5. daily dose may vary according to pt/inr. 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day): hold for sbp < 100 and/or hr < 60 . 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. hydroxyurea 500 mg capsule sig: three (3) capsule po 2x/week (mo,th). 6. hydroxyurea 500 mg capsule sig: two (2) capsule po 5x/week (,tu,we,fr,sa). 7. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). 8. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 9. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation qid (4 times a day). 10. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 11. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 12. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 13. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 14. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 15. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 16. dofetilide 250 mcg capsule sig: one (1) capsule po q12h (every 12 hours): please administer same time each day. 17. lasix 40 mg tablet sig: one (1) tablet po twice a day for 7 days: please titrate accordingly(preop weight approx 105 kg). 18. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours) for 7 days: hold if k > 4.5 - please titrate and adjust with lasix accordingly. 19. tramadol 50 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. 20. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed for dyspnea. 21. ipratropium bromide 0.02 % solution sig: one (1) inhalation q8h (every 8 hours). 22. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing/sob. 23. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day) as needed for constipation. discharge disposition: extended care facility: senior healthcare - discharge diagnosis: aortic stenosis and coronary artery disease s/p aortic valve replacement and coronary artery bypass graft x 1 past medical history: -hypertension -atrial fibrillation/flutter, multifocal atrial tachycardia s/p -ablation -complete heart block -essential thrombocythemia -mild sleep apnea (does not require cpap) -copd/asthma, recurrent sinusitis (has been treated with various antibiotics and prednisone in the past) -prostate cancer s/p radiation, lupron therapy : rectal bleeding. colonoscopy revealing sigmoid diverticulosis as well as radiation proctitis s/p argon-plasma coagulator, internal hemorrhoids, diverticula. : recurrent bleeding requiring 1 unit prbc (setting of inr > 3, present goal is 2-2.5) no present bleeding. -nasal polyps -umbilical hernia -hypothyroidism -ventral hernia past surgical history -left distal fibula fracture s/p surgery -: bilateral inguinal hernia repair -knee surgery for meniscal tear - dual chamber sigma pacemaker implant followed by avj ablation, s/p generator change to adapta 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: trace to 1+ 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. at 1:15p, cardiologist: dr. on at 1:40pm device clinic: at 12:30pm 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: atrial fibrillation, bioprosthetic aortic valve replacement goal inr: 2.0 - 2.5 first draw: ** please arrange coumadin followup prior to discharge from rehab ** patient was on coumadin prior to surgery and should resume follow up at the coumadin clinic @ and pcp . ** Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Obstructive sleep apnea (adult)(pediatric) Anemia, unspecified Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Personal history of malignant neoplasm of prostate Aortic valve disorders Personal history of tobacco use Atrial flutter Need for desensitization to allergens Pulmonary collapse Occlusion and stenosis of carotid artery without mention of cerebral infarction Hypotension, unspecified Long-term (current) use of anticoagulants Family history of ischemic heart disease Cardiac pacemaker in situ Chronic obstructive asthma, unspecified Personal history of irradiation, presenting hazards to health Other specified disorders of rectum and anus Umbilical hernia without mention of obstruction or gangrene Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Unspecified sinusitis (chronic) Ventral, unspecified, hernia without mention of obstruction or gangrene Essential thrombocythemia Personal history of traumatic fracture |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache major surgical or invasive procedure: : left craniotomy/cranioplasty for excision of skull-based mass history of present illness: the patient was electively admitted for resection of a skull lesion. past medical history: unknown social history: lives with husband; from and speaks cantonese; works in a factory family history: non-contributory physical exam: exam upon discharge: chinese speaking only, but able to follow commands with prompts. pupils 4 to 3 mm bilaterally eomi face symetric no drift or droop full strength with motor exam. left sided cranial wound: c/d/i, closed with sutures. pertinent results: head ct : expected post-surgical changes after craniectomy and cranioplasty for a left frontoparietal calvarial lesion. mri head : since the previous study, the patient has undergone resection of left parietal skull mass. there is no residual nodular enhancement seen. there remains a small left-sided subdural collection and meningeal enhancement. there is no midline shift or hydrocephalus. no acute infarct seen. impression: status post resection of left parietal skull mass. no residual nodular enhancement is seen. no acute infarct. brief hospital course: the patient was electively admitted for resection of a skull-based lesion. she had a craniectomy and cranioplasty with mesh . the procedure went well and the patient was transferred to the icu for monitoring overnight. the patient's post-operative mri revealed complete resection of the lesion. she was neurologically stable and post-op imaging was consistent with total resection of the mass. the patient was transferred to the floor on . she worked with pt and ot but was slow to mobilize. she continued to work with pt and ot on and . she was re-evaluated on and was deemed safe for discharge home on with home services. the patient had lesions on her legs when she came into the or. dermatology was consulted and felt that she had chronic eczema for which she was discharged home with creams. she will follow-up with them in clinic. medications on admission: none discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain: no driving while on this medication. disp:*50 tablet(s)* refills:*0* 3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 4. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. levetiracetam 750 mg tablet sig: one (1) tablet po bid (2 times a day) for 9 days: continue for two weeks from the date of your surgery. disp:*10 tablet(s)* refills:*0* 6. cortisone 1 % cream sig: one (1) appl topical (2 times a day) for 10 days. disp:*1 tube* refills:*0* 7. triamcinolone acetonide 0.1 % ointment sig: one (1) appl topical tid (3 times a day) for 10 days. disp:*1 tube* refills:*0* discharge disposition: home with service facility: carecentrix discharge diagnosis: left skull-based mass - preliminary diagnosis is meningioma discharge condition: neurologically stable mental status: clear and coherent (with interpreter) level of consciousness: alert and interactive. activity status: ambulatory - requires assistance discharge instructions: - have a friend/family member check your incision daily for signs of infection. - take your pain medicine as prescribed. - exercise should be limited to walking; no lifting, straining, or excessive bending. - your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. -you may shower before this time using a shower cap to cover your head. -increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. -unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. -if you have been prescribed dilantin (phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. this can be drawn at your pcp??????s office, but please have the results faxed to . if you haven 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 in the brain clinic. it is located on the on 8. call . your appointment is at 4 pm. follow-up with dermatology in the clinic. call to schedule an appointment within 2 weeks. Procedure: Excision of lesion or tissue of cerebral meninges Pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance Excision of lesion of skull Other cranial osteoplasty Diagnoses: Other iatrogenic hypotension Benign neoplasm of cerebral meninges Contact dermatitis and other eczema, unspecified cause Other specified acquired deformity of head |
allergies: penicillins attending: chief complaint: transfer for pacemaker major surgical or invasive procedure: pacemaker placement history of present illness: patient is an 81 yo m with history of htn, hld, iddm, cad s/p cardiac catherization in , atrial fibrillation on coumadin who was transferred to from for pacemaker. per medical history and patient account, he was in his usoh until he friday morning when he felt lightheaded and dizzy while completing a crossword puzzle. initially though it was hypoglycemia but his fs was 150. patient then took his bp and found it to be 50/30 and his pulse was 28. he experienced orthostatic symptoms and felt dizzy while walking to bathroom and then fainted. at ed he was found to be hypotensive and with hrs in 20s, he was given atropine in the ed which raised his bp to 30s. patient was started on dopamine and given another amp of atropine and admitted to ccu. he was scheduled for a pacemaker but emergent interventions pushed his interventino back. patient was transfered to for planned pacemaker. 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, 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 absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations. in terms of his functional status, he used to be able to walk 3 miles without becoming sob though in recent years he has been more limited. he is able to walk about a mile slowly without becoming short of breath and he denies cp with exertion though does report some calf pain occasionally. he also has chronic for which he takes lasix though the patient denies it is related to chf and tte/c.cath with preseved lvefs in the past. past medical history: - cad - htn - a.fib: rate controlled and anti-coagulated - insulin dependent diabetes mellitus: a1c 5.8% - osa: uses cpap - hypothyroidism - glaucoma past surgical history: - laparoscopic cholecystectomy - c.cath - laminectomy social history: - tobacco history: + smoking history though quit in <5 pack-yr - etoh: glass wine per month - illicit drugs: nont - lives with wife in , ma. daughter lives in , has mr and lives in group housing in family history: - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - mi in uncle in his 70s physical exam: vs: afebrile, hr 40s, bps 134/60, rr 12, 98%ra general: pleasant, friendly, comfortable seated in bedside chair and 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 10cm. cardiac: bradycardic, s1s2 clear and of good quality, physiologic splite s2, no murmurs, rubs or gallops appreciated. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: obese, distended abdomen but soft and non-tender. no hsm, normoactive bowel sounds extremities: cold le bilaterally, faintly palpable pulses, 1+ pitting bilaterally to mid shin, chronic hyperpigmentation of le bilaterally. bilateral radial pulses 2+ and symmetric . pertinent results: labs on admission: 07:39pm blood wbc-7.7 rbc-3.81* hgb-12.5* hct-37.6* mcv-99* mch-32.9* mchc-33.4# rdw-15.5 plt ct-112* 07:39pm blood pt-22.0* ptt-43.5* inr(pt)-2.1* 07:39pm blood glucose-204* urean-41* creat-1.5* na-127* k-4.5 cl-93* hco3-21* angap-18 07:39pm blood alt-33 ast-41* alkphos-231* totbili-2.1* 07:39pm blood ck-mb-3 ctropnt-0.01 07:39pm blood calcium-9.0 phos-3.4 mg-2.1 09:42am blood caltibc-363 ferritn-183 trf-279 07:39pm blood tsh-0.52 imaging: ruq us 1. suboptimal exam due to portable technique. the liver echotexture may be coarse. hyperechoic lesions in the liver, may represent hemangiomas; however, hcc cannot be excluded in the setting of underlying liver disease. further assessment with dedicated cross-sectional imaging is recommended. 2. splenomegaly and ascites raising possibility of portal hypertension. 3. right renal cyst. chest x-ray: left chest wall pacemaker is seen with leads in the right atrium and apex of the right ventricle. there is no pneumothorax. there is no focal consolidation or pleural effusion. linear opacities at the bases are likely atelectasis. cardiomediastinal silhouette is stable. impression: pacemaker leads in right atrium and apex of the right ventricle. no pneumothorax. labs on discharge: 06:08am blood wbc-4.6 rbc-3.20* hgb-10.5* hct-31.6* mcv-99* mch-32.8* mchc-33.1 rdw-15.5 plt ct-112* 06:08am blood pt-23.8* ptt-50.3* inr(pt)-2.3* 06:08am blood glucose-134* urean-29* creat-1.2 na-138 k-4.5 cl-104 hco3-27 angap-12 06:08am blood alt-28 ast-36 ld(ldh)-173 alkphos-179* totbili-1.6* 06:08am blood albumin-3.8 calcium-8.5 phos-2.6* mg-2.0 09:42am blood caltibc-363 ferritn-183 trf-279 brief hospital course: mr. is an 81y/o gentleman with htn, cad, dm2 who presented initially to osh with syncope and bradycardia, and was found to have sick sinus syndrome with junctional escape rhythm, transferred to ccu for pacemaker implantation. # bradycardia/tachycardia: sick sinus syndrome, also with some his-purkinje disease. his disease is likely due to age-related fibrotic replacement of his conduction system, though other etiologies were considered. lyme negative ddi pacemaker (range 50-110). per pacemaker interrogation , the ra lead seemed to not be capturing correctly and on cxr, was dislodged. had revision of that lead . repeat chest x-ray confirmed lead was in place. initially, all nodal agents were held. after pacemaker implantation, patient was stable on metoprolol. discharged on metoprolol xl 25mg qd. also, d/c on keflex 500mg qid x7 days for prophylaxis (7 days because patient is at increased risk for icd pocket infection as he had the pocket re-opened) noted that patient had history of penicillin allergy (rash), so instructed patient to stop the keflex and call his pcp if he develops a rash. . # cad: stable.no recent episodes of chest pain, sob or doe though the patient reports his exercise capacity has been more limited in recent years though mainly due to hip pain. c.cath in showing diffuse vessel disease though no intervenable lesions. d/c on metoprolol as above and home dose lisinopril. not on aspirin because he is on coumadin. continued pravastatin. . # le edema : stable. no tte in omr but cath showed ef>55%. continued home lasix. . # atrial fibrillation: stable. chronic, rate controlled with labetalol at home, and on coumadin. inr 1.9. stopped labetalol while in house. started metoprolol low dose as above. continued coumadin. will have inr checked as outpatient. . # htn: chronic, well controlled on lisinopril and new metoprolol as above . # lft abnormality: ast 34, alt 34, ap 225, tbili 2.1 on . unclear etiology. he says he thinks this is baseline but he is not sure. no known h/o cirrhosis. ruq u/s demonstrated ? coarse echotexture, but no clearly defined biliary abnl. will likely need repeat exam s/p pacer placement. albumin 4.3. iron, ferritin and transferring nl. informed pcp about this and report. . # hematuria: patient with small amount of hematuria. ua negative for infection. urine culture ngtd. . # diabetes mellitus: stable. chronic, insulin dependent, well controlled with recent a1c of 5.8% per patient report. was on iss. . # osa: chronic, on cpap, continued in house. . # hypothyroidism: chronic, stable. tsh normal this admission. continued synthroid per home regimen. . # glaucoma: chronic, stable. continued home eye drop meds (except timolol) . # essential tremor: stable . transitional issues: - repeat ua; hematuria workup if still positive for rbcs - liver nodules on us and splenomegaly, small amount of ascites; will need f/u by pcp, report - will have inr checked as outpatient and results to pcp complete 7 day course of keflex 500mg po qid for prophylaxis for icd infection medications on admission: home medications: - pravastatin 40mg daily - lisinopril 40mg po daily - labetalol 200mg po bid - furosemide 60mg daily - primidone 50mg daily - warfarin 2.5mg x2days/week 5mg x5days/week - insulin - levothyroxine 137mcg daily (except sat and wed (274mcg)) - allopurinol 300mg daily - brimonidine both eyes - pilocarpine eye drops 2 drops both eyes - timolol one drop both eyes - bimatoprost 0.03% 1 drop right eye - finasteride 5mg daily . transfer medications: - dopamine 10mcg/kg/min iv drip discharge disposition: home discharge diagnosis: bradycardia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , you were transferred to from for pacemaker placement because you were having episodes of very low heart rates. one of the wires of the device became dislodged so you had to go back for a second procedure to have it fixed. you tolerated the procedures well. we are discharging you on a 1 week course of antibiotic called keflex to prevent infection around the pacemaker device. we know you have had a rash from penicillin in the past. there is an approximately 8% chance that you may develop a rash from this antibiotic, keflex. we are prescribing this one because it is the best choice for preventing infection without causing adverse effects. if you do develop a rash or any swelling in the mouth or trouble breathing, please stop taking it and let your primary care doctor know so that you can be started on a different antibiotic instead. again, the chance of you having an allergy to this medicine is small. we have made the following changes to your medications: -stop taking labetalol -start metoprolol 25mg daily -start keflex 500mg 4 times per day for 7 days (antibiotic to prevent infection) please have your inr checked on friday and the results to dr. (prescription included below) on discharge, please follow up with your primary care doctor (please call to make an appointment) and in cardiology device clinic as scheduled below. followup instructions: please call dr. , your primary care doctor, to schedule an appointment in the next week phone: department: cardiac services when: monday at 11:00 am with: device clinic building: sc clinical ctr campus: east best parking: garage md Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Non-invasive mechanical ventilation Revision of lead [electrode] Artificial pacemaker rate check Artificial pacemaker rate check Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Atrial fibrillation Personal history of tobacco use Unspecified glaucoma Other and unspecified hyperlipidemia Long-term (current) use of insulin Long-term (current) use of anticoagulants Obesity, unspecified Sinoatrial node dysfunction Mechanical complication due to cardiac pacemaker (electrode) Hematuria, unspecified Orthostatic hypotension Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Edema Nonspecific abnormal results of function study of liver Essential and other specified forms of tremor Atrioventricular block, unspecified Personal history of allergy to penicillin |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: esophageal adenocarcinoma major surgical or invasive procedure: 1. - esophagectomy. 2. buttressing of intrathoracic anastomosis with pericardial fat. 3. laparoscopic jejunostomy. 4. esophagogastroduodenoscopy. history of present illness: mr. is a 54-year-old male with an intramucosal adenocarcinoma of the esophagus seen while undergoing his routine 1 year endoscopy for surveillance of his gastric mucosa apc gene mutation. he was admitted for esophagectomy. past medical history: gerd hiatal hernia barretts apc gene mutation colonic adenoma social history: former smoker 40-50 ppy family history: nc physical exam: vs: t: 98.9 hr: 72 sr bp: 128/80 sats: 98% ra general: 64 year-old male in no apparent distress heent: normocephalic, mucus membranes moist neck: supple no lymphadenopathy card: rrr normal s1,s2 no murmur/gallop or rub resp; decreased breath sounds otherwise clear gi: bowel sounds positive abdomen soft non-tender/non-distended extre: warm no edema incision: right vats site clean, dry intact, well approximated. j--tube site clean dry intact neuro: non-focal pertinent results: wbc-11.3* rbc-5.18 hgb-16.1 hct-45.4 mcv-88 mch-31.1 mchc-35.6* rdw-13.2 plt ct-201 02:13am blood wbc-9.2 rbc-5.23 hgb-15.5 hct-46.4 mcv-89 mch-29.6 mchc-33.4 rdw-13.5 plt ct-206 02:13am blood wbc-9.9 rbc-4.88 hgb-15.2 hct-44.0 mcv-90 mch-31.2 mchc-34.5 rdw-13.7 plt ct-221 02:27am blood wbc-11.6* rbc-4.64 hgb-14.2 hct-41.3 mcv-89 mch-30.7 mchc-34.5 rdw-13.4 plt ct-205 07:45am blood wbc-8.5 rbc-4.18* hgb-12.9* hct-38.1* mcv-91 mch-30.9 mchc-34.0 rdw-13.5 plt ct-159 07:05am blood wbc-8.0 rbc-4.36* hgb-13.5* hct-39.9* mcv-92 mch-31.0 mchc-33.8 rdw-13.6 plt ct-190 07:15am blood wbc-7.5 rbc-4.54* hgb-14.5 hct-41.0 mcv-90 mch-31.9 mchc-35.3* rdw-13.9 plt ct-216 06:22pm blood glucose-174* urean-18 creat-0.8 na-138 k-3.9 cl-103 hco3-26 angap-13 02:13am blood glucose-160* urean-16 creat-1.0 na-133 k-8.0* cl-103 hco3-25 angap-13 02:27am blood glucose-119* urean-21* creat-0.8 na-138 k-4.3 cl-102 hco3-29 angap-11 07:45am blood glucose-119* urean-15 creat-0.6 na-139 k-3.5 cl-100 hco3-33* angap-10 07:05am blood glucose-110* urean-14 creat-0.7 na-141 k-3.5 cl-100 hco3-33* angap-12 07:15am blood glucose-119* urean-16 creat-0.6 na-139 k-3.9 cl-100 hco3-30 angap-13 06:22pm blood calcium-8.0* phos-4.0 mg-1.7 02:13am blood calcium-7.9* phos-4.2 mg-2.3 02:13am blood calcium-8.0* phos-3.4 mg-2.2 02:27am blood calcium-8.1* phos-2.2* mg-2.1 07:45am blood calcium-7.7* phos-1.8* mg-1.9 07:05am blood calcium-8.3* phos-3.4# 07:15am blood calcium-8.5 phos-3.4 mg-2.0 imaging: cxr endotracheal tube, the tip projects roughly 7 cm above the carina. normal course and position of the right-sided chest tube. no safe evidence of pneumothorax. no evidence of mediastinal widening. moderate perihilar haze on the right, likely due to the post-operative situation. mediastinal drains are in expected position. the lung bases show bilateral areas of atelectasis. post-operative subcutaneous gas inclusions. normal size of the cardiac silhouette. cxr right apical chest tube remains in place. nasogastric tube is in unchanged position with tip at the level of the hemidiaphragms. enlarged cardiomediastinal silhouette is stable. there is no evident pneumothorax. left lower lobe retrocardiac opacities have minimally increased, consistent with increasing atelectasis. drain projects midline. cxr 1. probably increased bilateral atelectasis or could be early pulmonary edema. 2. stable mild cardiomegaly with likely new small bilateral pleural effusion. cxr very small right apical pneumothorax with chest tube in place. improving bibasilar atelectasis and persistent small pleural effusions cxr small bilateral pleural effusions, including a right fissural component, have increased. tiny right apical pneumothorax is stable. moderate atelectasis at the lung base has worsened. upper lungs clear. heart size increased though normal. cxr barium swallow microbiology: none brief hospital course: the patient was admitted to the thoracic surgical service for elective esophagectomy for intramucosal adenocarcinoma of the esophagus. patient tolerated the operation well. he arrived in the icu npo, on iv fluids and antibiotics (3 doses total), with a foley catheter, jp drain, chest tube, epidural and pca dilaudid for pain control. patient was extubated and re intubated shortly after secondary to the respiratory distress in the icu. he was extubated once again shortly after, which he tolerated well. the patient was hemodynamically stable. neuro: the patient received epidural and pca dilaudid with good effect and adequate pain control. on pod 6, after patient passed the barium swallow study, the epidural was removed and pca was discontinued. when tolerating oral intake, the patient was transition ed to oral pain medications. cv: the patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. pulmonary: after the initial reintubation and successful re-extubation on pod 0 in the icu, the patient remained stable from a pulmonary standpoint. the chest tube was placed in the operating room. it was initially placed to suction and on pod 1 to water seal. it remained to water seal, with no air leak, until pod 6, when it was taken out. the chest x-rays were obtained daily. following the removal of the chest tube, there was tiny right apical pneumothorax seen on chest x-ray. patient was stable and his oxygen saturation was > 92% on room air. good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. gi/gu/fen: post-operatively, the patient was made npo with iv fluids. tube feeds were started at 20 cc/hr on pod 1 as per pathway, and advanced by 20 cc/hr daily, up to a goal of 125 cc/hr. patient tolerated the tube feeds well. the barium swallow study was obtained on pod 6. it demonstrated no leak. subsequently, the diet was slowly advanced to full liquid. patient's intake and output were closely monitored, and iv fluid was adjusted when necessary. electrolytes were routinely followed, and replete when necessary. id: the patient's white blood count and fever curves were closely watched for signs of infection. patient remained afebrile throughout the hospital stay. he received 3 doses total of intra and perioperative antibiotics. endocrine: no issues. hematology: the patient's complete blood count was examined routinely; no transfusions were required. prophylaxis: the patient received subcutaneous heparin and dyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating a full liquid diet, ambulating, voiding without assistance, and pain was well controlled on oral pain medications. patient was discharged with tube feeds at goal rate of 100 cc/hrs 12 hrs. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: omeprazole 20 mg daily discharge medications: 1. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*6* 2. roxicet 5-325 mg/5 ml solution sig: ml po every six (6) hours as needed for pain. disp:*500 ml* refills:*0* 3. colace 50 mg/5 ml liquid sig: ten (10) ml po twice a day as needed for constipation: while on narcotics. 4. tube feedings replete full strength at 125 ml/hr via j-tube cycled over 18 hours each day for nutritional support, s/ esophagectomy. flush feeding tube with 50 ml q 8 hr, and before and after use. do not put any crushed meds down j-tube, only liquids. pt will need feeding pump and tube feeding supplies. discharge disposition: home with service facility: area vna discharge diagnosis: esophageal cancer 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: -fever 101 or greater -increased shortness of breath, cough or sputum production -chest pain -difficult or painful swallowing. -nausea, vomiting, diarrhea or abdominal pain -chest tube site cover with a bandaid until healed -you may shower. no tub bathing or swimming -call immediately if feeding tube falls out. please bring the feeding with you so it can be replaced promptly. -no driving while taking narcotics. take stool softners with narcotics followup instructions: provider: , md phone: date/time: 10:30 on the clinical center chest x-ray radiology 30 minutes before your appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other enterostomy Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Partial esophagectomy Intrathoracic esophagogastrostomy Diagnoses: Esophageal reflux Personal history of tobacco use Diaphragmatic hernia without mention of obstruction or gangrene Barrett's esophagus Malignant neoplasm of cardia Arthropathy, unspecified, site unspecified |
allergies: quinine attending: chief complaint: septic shock and pneumatosis coli. major surgical or invasive procedure: exploratory laparotomy. history of present illness: the patient is a 61-year-old man with a personal history of prostate cancer and a diagnosis of pancreatic cancer with multifocal liver metastases on chemotherapy. he had an acute event and was transferred to our emergency room septic in shock. resuscitation and intubation failed to improve his status and he was noted to have pneumatosis coli on a ct scan. despite his poor prognosis from stage iv pancreatic cancer, his wife wished for all measures to be taken and he was taken to the operating room emergently for exploratory surgery with the presumptive diagnosis of ischemic bowel. past medical history: htn psh: lihr, radical prostatectomy, l fibula steel plate insertion. social history: lives with his wife. family history: nc pertinent results: small bowel: focal recent hemorrhage. no evidence of malignancy. brief hospital course: pt transferred to emergency room septic in shock. resuscitation and intubation failed to improve his status and he was noted to have pneumatosis coli on a ct scan. emergent exploratory surgery performed without evident cause of decompensation other than abdominal compartment syndrome without obvious causative factor. pt transferred to the icu on mechanical intubation, pressors. bcx with gnr, started cipro. dnr code statue per family meeting. insulin gtt. episode relative hypotension with increased pressor requirements - svv 14-17, gave fluid bolus. continued intubation, full icu support. patient made cmo after family meeting with dr . pt expired 3:22 p.m. was pronounced dead roughly 45 minutes after made cmo. family notified and offered autopsy. family declined autopsy. medications on admission: diltiazem, tylenol, milk of magnesium. discharge medications: does not apply discharge disposition: expired discharge diagnosis: death secondary to metastatic pancreatic cancer, sepsis, respritory failure. discharge condition: death discharge instructions: not applicable followup instructions: not applicable summary neither dictated nor read by me Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Exploratory laparotomy Arterial catheterization Suture of laceration of small intestine, except duodenum Diagnoses: Hypocalcemia Malignant neoplasm of liver, secondary Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Personal history of malignant neoplasm of prostate Accidental puncture or laceration during a procedure, not elsewhere classified Acute respiratory failure Septic shock Secondary malignant neoplasm of other digestive organs and spleen Nontraumatic compartment syndrome of abdomen Accidental cut, puncture, perforation or hemorrhage during surgical operation |
allergies: no known allergies / adverse drug reactions attending: chief complaint: liver failure major surgical or invasive procedure: : cardiac catheterization history of present illness: 52 m cambodian native w/ h/o hep b treated w/ ifn-a and adefovir followed by entecovir. the patient had been taking no medications for approximately 2 years. he was transferred from hospital, ri, with n/v, weakness and abdominal pain with associated jaundice for ~2weeks. at the time of transfer, the patient had worsening lfts to alt 928, ast 624, bili of 26.8 (direct 16.3), inr of 4.9 and cr of 1.7. on arrival at he had a meld of 41 past medical history: pmh: hep b, tuberculosis, htn, hl. psh: left lower lobectomy for tb, inner ear implant. social history: no tob, rare etoh, no illicits. lives at home w/ family family history: unknown pertinent results: admission labs: |101|19 ----------<53 5.2|23|1.8 7.2>37.9<136 alt 425 ast 321 ap 87 tbili 22.0 inr 4.6 pt 46.4 ptt54.2 brief hospital course: pt was admitted to where he underwent a transplant workup by the hepatology and transplant surgery services. on he was listed as a transplant candidate with a meld of 41. on he was transferred to the sicu in preparation for a possible iver transplant. unfortunately the procedure was unable to proceed due to poor donor graft. he remained in the sicu under the managment of the transplant surgery service and the sicu team. on he was once again prepared for a possible liver transplant but on the following morning he developed tachycardia with st depressions on ekg. the transplant was cancelled and an urgent cardiology consult obtained. they recommended urgent heart catheterization, however his elevated inr required correction w/ 9u ffp prior to procedure. cath identified 80% circumflex lesions that were deemed unstentable and cardiology recommended rate control. after receiving blood products the patient developed pulmonary edema requiring treatment with lasix and noninvasive ventilation (bipap). the following morning his respiratory status had improved and bipap d/c'd. he also received 2u prbcs for hcts 24 to maximize oxygen carrying capacity. on the afternoon of he developed a rapid drop in blood pressure requiring urgent iv fluids, placement of a central line, intubation, and initiation of pressors. an echo obtained at this time demonstrated hyperdynamic left ventricle and he was presumed to be septic and antibiotics were started. his urine output on this day was minimal and his creatinine had risen to 3.3. bladder pressure was 19 and the patient was not felt to have compartment syndrome. by his blood pressure had improved sufficiently to discontinue pressors but he remained intubated due to his mental status. his inr remained elevated (7.3) and he received ffp for correction. he underwent bronchoscopy and one of the bal samples grew mold which was eventually speciated to aspergillis for which he was started on voriconazole. his multisystem organ failure worsened over the next several days (): despite several days without sedation his neurologic status worsened until he was no longer withdrawing to painful stimuli and his pupillary reflexes became nonexistent. his hemodynamic status worsened as evidenced by the progression from intermittent pressors to requiring increasing doses of levophed. his course was further complicated by oliguric renal failure with rising creatinine, which peaked at 8.4. his liver failure likewise worsened with tbili's climing to 32 and coagulopathy marked by inrs > 7. in the setting of pulmonary aspergillosis, the patient was not a transplant candidate until he could receive at least two weeks of treatment and demonstrate clearing of the fungal infection. after consultation among the teams involved in the patient's care (transplant surgery, hepatology, sicu, infectious disease) consensus was reached that supporting the patient through multisystem organ failure for that amount of time was extremely unlikely. several conversations were had with the family explaining that the patient's accumulated physiologic insults had made further treatment futile. the family agreed to withdrawal of care and within half an hour of extubation the patient died on . medications on admission: cipro 500 mg daily losartan 50 mg daily zofran 4 mg prn pravastatin 40 mg daily vit d3 2000u daily discharge medications: none discharge disposition: expired discharge diagnosis: multisystem organ failure (liver failure, renal failure), pulmonary aspergillosis discharge condition: deceased discharge instructions: none followup instructions: none md, Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Coronary arteriography using two catheters Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Closed [endoscopic] biopsy of bronchus Diagnoses: Thrombocytopenia, unspecified Unspecified essential hypertension Acute and subacute necrosis of liver Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Acute respiratory failure Septic shock Hepatic encephalopathy Other and unspecified coagulation defects Surgical or other procedure not carried out because of contraindication Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta Aspergillosis Pneumonia in aspergillosis Acute edema of lung, unspecified Hypoglycemia, unspecified |
allergies: percocet / codeine / aspirin / nsaids (non-steroidal anti-inflammatory drug) attending: chief complaint: dizziness, lightheadedness major surgical or invasive procedure: egd history of present illness: 63 year old female with a past medical history of roux en y in who presented to the ed today with dizziness, lightheadedness, and black stools. she states that the black stools began about a week ago, initially resembling coffee grounds. she has had dark diarrhea since, and then had dark black stool today. for the past 2 days, she has also become increasingly lightheaded, dizzy, and short of breath, worse with standing. this morning, she had a syncopal episode during which she stood up, felt dizzy, fell to the floor, no head strike. her husband also states that she looks pale. no chest pain, abdominal pain, nausea, or vomiting. of note, she had a colonoscopy in which noted a sigmoid and ascending polyps, both found to be adenomas on pathology. there were no diverticuli noted. she took a two week course of ibuprofen in when she had her upper teeth extracted. she also tapered off of her omeprazole and has not been currently taking this. she denies any recent symptoms of early satiety (more than normal), pain with eating, or pain after eating. she takes a baby aspirin daily. in the ed, initial hr in the 70s and sbps in 110s-120s. stools were guiac + black, hct was 18.2 from baseline 37. she was type and crossed 2 units, however did not get the blood. she was also started on a protonix gtt. gi was notified. on arrival to the micu, patient is comfortable, alert, in nad. she notes a throbbing frontal headache, similar to prior but lasting longer. she denies any visual changes or neck pain. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, constipation, abdominal pain. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - laparoscopic roux-en-y gastric bypass with cholecystectomy on - gerd - hypertension - hyperlipidemia - cholelithiasis - osa on cpap - depression - breast atypia s/p excisional breast biopsy via wire localization on - melanoma s/p excision c/b mrsa infection in - hysterectomy in social history: she has been married for 14 years. she has one son. she is a former tobacco user and drinks approximately a cocktail with dinner. activities remain the same. she participates in water aerobics and swimming and always wears a seatbelt. family history: mother died at 88. father died at 62. she has no siblings. physical exam: on admission: vitals: 99.3 85 117/52 16 98% on ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: rrr, normal s1 + s2, no murmurs, rubs, gallops lungs: ctab, no wheezes, rales, ronchi abdomen: +bs, soft, non-tender, non-distended, no organomegaly gu: no foley ext: wwp, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities pertinent results: labs on admission: ====================== 12:48pm blood wbc-8.6# rbc-2.11*# hgb-5.9*# hct-18.2*# mcv-86 mch-27.7 mchc-32.2 rdw-16.3* plt ct-298 12:48pm blood pt-11.4 ptt-26.3 inr(pt)-1.1 12:48pm blood glucose-178* urean-31* creat-0.7 na-139 k-3.9 cl-107 hco3-23 angap-13 05:38am blood alt-13 ast-23 alkphos-31* totbili-0.5 05:38am blood calcium-8.1* phos-3.3 mg-2.1 12:48pm blood %hba1c-5.0 eag-97 labs prior to discharge: ========================== brief hospital course: assessment and plan 63 year old female with a history of roux en y in presenting with melena and acute blood loss anemia. # acute blood loss anemia: initially an ugib was suspected given melena and elevated bun. however egd this morning showed no source of bleeding. bleeding may have stopped prior to endoscopy or it may be a small bowel or lower gi source. there was concern for anastomotic ulcers since patient has a gastric bypass and she is off omeprazole but nothing was seen at the gj anastomotic site. the j-j anastomosis was not reached. patient was using ibuprofen but no gastric ulcers seen. metastatic melanoma is always a rare possibility in a patient with prior melanoma. colonoscopy was negative. cta abdomen pelvis showed no active bleeding. on discharge, she was hd stable with no sign of acutely active bleeding. her aspirin was held and she was discharged on pantoprazole and misoprostol per gi and bariatric surgery recs. she received a total of 4 units prbcs. she will follow up with gi in two weeks. # hypertension: metoprolol initially held, then restarted on discharge. # hl: continued simvastatin. # depression: continued sertraline. # osa: continued cpap medications on admission: preadmission medications listed are correct and complete. information was obtained from patientwebomr. 1. alprazolam 0.25 mg po bid:prn anxiety 2. metoprolol succinate xl 100 mg po daily 3. sertraline 100 mg po daily 4. simvastatin 20 mg po daily 5. trazodone 50 mg po hs:prn insomnia 6. aspirin 81 mg po daily 7. vitamin b complex 1 cap po daily 8. calcium carbonate dose is unknown po frequency is unknown 9. cod liver oil *nf* 1,250-135 unit oral daily 10. cyanocobalamin 1000 mcg po daily 11. docusate sodium 100 mg po bid 12. multivitamins w/minerals 1 tab po daily 13. vitamin e 400 unit po daily discharge medications: 1. alprazolam 0.25 mg po bid:prn anxiety 2. cyanocobalamin 1000 mcg po daily 3. docusate sodium 100 mg po bid 4. metoprolol succinate xl 100 mg po daily 5. multivitamins w/minerals 1 tab po daily 6. sertraline 100 mg po daily 7. simvastatin 20 mg po daily 8. trazodone 50 mg po hs:prn insomnia 9. vitamin b complex 1 cap po daily 10. vitamin e 400 unit po daily 11. misoprostol 100 mcg po qid give with meals, final dose at bedtime. rx *misoprostol 100 mcg 1 tablet(s) by mouth four times a day disp #*20 capsule refills:*0 12. calcium carbonate 500 mg po qd 13. cod liver oil *nf* 1,250-135 unit oral daily 14. pantoprazole 40 mg po q12h rx *pantoprazole 40 mg 1 tablet(s) by mouth twice a day disp #*60 capsule refills:*0 discharge disposition: home discharge diagnosis: primary: - gi bleed - acute blood loss anemia - iron deficiency secondary: - gastric bypass discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ms. , it was a pleasure taking care of you here at . you were admitted to the hospital because were dizzy and had dark stools. this was because you were anemic from bleeding in your digestive track. you had an upper endoscopy and a lower endoscopy (colonoscopy) which did not see any source of bleeding. however these studies are not able to visualize the areas in between. your blood counts stabilized and there were no signs that you were still bleeding. it is very important that you avoid all nsaids, including aspirin, ibuprofen, aleve, and advil. because your blood tests reveal an iron deficiency anemia, we gave you a dose of iv iron. you will continue to receive infusions of iv iron at the hematology clinic at the appointment listed below. followup instructions: iv iron transfusion, clinic: please call to schedule an appointment for iv iron next thursday . the infusion clinic is aware and should be contacting you as well. you will need to see dr. in the gastroenterology clinic in 2 weeks. you should receive a call from his office by monday to schedule an appointment, but just in case, the clinic number is . department: bidhc when: wednesday at 11:30 am with: , md building: (, ma) campus: off campus best parking: on street parking department: hematology/oncology when: friday at 10:30 am with: , md building: sc clinical ctr campus: east best parking: garage department: bariatric surgery when: thursday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage md Procedure: Other endoscopy of small intestine Colonoscopy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Esophageal reflux Unspecified essential hypertension Acute posthemorrhagic anemia Personal history of tobacco use Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Iron deficiency anemia, unspecified Headache Hemorrhage of gastrointestinal tract, unspecified Personal history of malignant melanoma of skin Other abnormal glucose Personal history of colonic polyps Bariatric surgery status Personal history of Methicillin resistant Staphylococcus aureus |
allergies: codeine / morphine / hydrocodone / oxycodone / ativan attending: chief complaint: lethargy major surgical or invasive procedure: none history of present illness: this is a 51 year old male with a history of cirrhosis secondary to alcohol use and possibly hemochromatosis who was admitted for unresponsiveness. per his family, he was found by the nursing staff to be unresponsive on the morning of , they were unable to arouse him. per his sister, the day prior they had seen him at the hospital after his elective egd, and he was doing well, talking, at his baseline. she came to visit him today with the rest of the family and states that he was able to recognize them, but definitely far from his baseline. she states that this seems like prior episodes when "his ammonia is high." he has had prior episodes of encephalopathy, last at from because he "couldn't speak" per the family. after receiving lactulose, he returned back to his baseline. he has since had 2 falls in - once on mother's day where he tripped and broke his right hip. no intervention was done. he then fell again, which per the family he doesn't remember. he had head strikes during both falls (one requiring stitches to the forward), but per the family, he was no different mentally after those falls. . on , he underwent an egd at hospital for a hct that was trending down of unclear etiology. he has been getting blood transfusions for this downtrending hct. over this time his edema has been getting worse and a foley catheter was placed days prior to admit as his scotal swelling prevented him from voiding effectively. per his family he has been taking all of his medications as prescribed. . on admission yesterday, he was noted to be in the 90s systolic, afebrile. a ruq us could not get great views of vasculature, but no ascites. a cxr was difficult to interpret but showed no obvious consolidation. he is guaiac negative and given a lactulose enema in the ed. in the micu, he received 3 doses of 30ml lactulose, and 1 dose of pr enema with ~ 3 bm's. he was placed on lasix 20mg iv bid and spironolactone 100mg po daily. he is net negative 2l during his micu stay. he seemed improved after lactulose enemas per the micu team. . on the floor, he is arousable to voice, able to answer a few questions, states his name. very poor attention. . ros: denies pain. otherwise unable to obtain given pt's mental status. but, per the family, he was not having any pain, fever, or other complaints the day prior. past medical history: 1. cirrhosis alcohol and hemochromatosis complicated by encephalopathy 2. recurrent cellulitis of left leg 3. dvt following trauma to left leg (mva) was on warfarin for 1 year. 4. chronic low back pain 5. depression 6. anxiety social history: no current tobacco use, former tobacco ~ 10 pack years (quit 3 years ago). former alcohol and klonopin abuse. patient lives in center, he does not work. he is separated from his wife. the patient's weekly exercise regimen consists of walking daily around the building. patient usually tries to adhere to a sensible diet and manages adls well with assistance. he is separated from his wife. has 3 grown children ages 31, 27 and 23 who live in . he quit smoking 3 years ago. family history: his father died of lung cancer and his mother has diabetes. he has 3 sisters and 1 brother who are healthy. his 3 children who are healthy. physical exam: admission: on the medicine floors, hod#2 vitals: t: 96.5 bp: 105/60 p: 79 r: 12 o2: 97%ra general: sleeping, arouses to voice, poor attention, appears very somnolent, able to only answer few questions with one word answers including stating his name and "no" to pain heent: ncat, perrl, ecchymoses over left eyelid, dry mm, unable to fully visualize oropharynx, no apparent tongue fasiculations neck: supple, obese, jvp not elevated lungs: no use of access mm, poor effort, no crackles or wheezes cv: rrr, nl s1 s2, no murmurs, rubs, gallops abdomen: +nabs, soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly, no fluid wave, no flank dullness gu: foley in place, dark yellow urine, diffusely edematous/tense scrotum ext: warm, diffuse anasarca up to his abdomen neuro: somnolent, poor attention, oriented only to self, able to follow limited commands, raise hands, unable to wiggle toes, 2+ dtr's in biceps & brachioradialis, downgoing toes, + asterixis discharge: vitals: 98.4 98.2 92-115/46-66 70-101 18 100%ra bg 133-228 24h 1750/inc, bmx4 8h 540/inc, large bm general: awake, lying in bed, able to follow commands, tremulous, nad, appears confused heent: ncat, mildly icteric sclera, dobhoff in place neck: supple, obese, jvp not elevated lungs: clear anteriorly without wheezes or crackles, no use of access mm cv: rrr, nl s1 s2, no murmurs, rubs, gallops abdomen: +nabs, soft, non-distended, non-tender, no rebound tenderness or guarding, no fluid wave, no flank dullness gu: in adult diaper, no foley ext: pitting edema to hip, left leg with 3+ edema in shin, stasis dermatitis, tender to palpation of shins bilaterally neuro: oriented to person, states he does not know, says "" for the date, says "i'm confused," +asterixis **pt's mental status fluctuates throughout the day. pt is always oriented to person, but occasionally not oriented to place or date. he seems to be better in the afternoon, frequently oriented to place and year but not exact date. pertinent results: admission labs: 02:38pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 12:50pm glucose-123* urea n-21* creat-0.8 sodium-138 potassium-4.6 chloride-104 total co2-30 anion gap-9 12:50pm alt(sgpt)-43* ast(sgot)-88* alk phos-143* tot bili-4.2* dir bili-0.9* indir bil-3.3 12:50pm lipase-26 12:50pm ctropnt-<0.01 12:50pm albumin-2.2* calcium-8.4 phosphate-3.3 magnesium-1.7 iron-187* 12:50pm caltibc-213* ferritin-1494* trf-164* 12:50pm ammonia-173* 12:50pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 12:50pm wbc-4.5 rbc-3.35* hgb-11.8* hct-34.2* mcv-102* mch-35.2* mchc-34.4 rdw-19.9* 12:50pm neuts-78.4* lymphs-13.3* monos-5.8 eos-2.1 basos-0.5 12:50pm plt count-50* 12:50pm pt-16.9* ptt-32.7 inr(pt)-1.5* 12:48pm glucose-116* lactate-1.9 na+-136 k+-4.4 cl--101 tco2-29 12:48pm hgb-12.0* calchct-36 12:40pm urine color-yellow appear-clear sp -1.017 12:40pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.5* leuk-tr 12:40pm urine rbc->182* wbc-3 bacteria-none yeast-none epi-0 trans epi-<1 12:40pm urine mucous-rare discharge labs: na 136 k 5.4 cl 99 hco3 36 bun 34 cr 1.3 bg 182 wbc 3.2 hgb 9.2 hct 27.3 plt 58 inr 1.5 alt 14 ast 29 ap 90 tbili 2.8 pertinent studies: urine hemosiderin: negative ammonia: 35 igg: 1323 qg6pd: 11.8 (normal) upep: no abnormalities spep: no abnormalities tsh: 2.4 freet4 1.2 ret-aut: 3.6 hfe gene: result: negative a1at: 122 (range 83-199 mg/dl) ceruloplasmin: 13 l (range 18-36 mg/dl) copper: 34 (low) : negative fsh: <1.0 lh: <1.0 testost: 19 shbg: 41 calcft: 3.6 tsh:4.3 free-t4:1.1 acth, plasma 12 ( pg/ml) cortisol, free results pending cortisol binding globulin (transcortin) results pending studies: cxr : findings: in comparison with the study of , there are lower lung volumes. increased opacification in the retrocardiac region most likely represents pleural fluid and atelectasis. in the appropriate clinical setting, the possibility of supervening pneumonia would have to be considered. ct head w/o : impression: 1. no acute intracranial abnormality. 2. global cerebral atrophy, disproportionate to the patient's age. 3. diffuse sinus inflammatory disease. 4. incidental note made of an arachnoid cyst in the left middle cranial fossa. liver u/s : findings: evaluation is limited due to patient's body habitus and overlying bowel gas. within the limitations the extremely limited portion of the liver that was imaged is unremarkable. the portal vein, common hepatic duct, spleen or pancreas could not be seen. a stone is noted in the gallbladder. the partially imaged gallbladder appears unremarkable. no ascitic fluid is noted. impression: gallstone noted. severely limited study cxr : findings: as compared to the previous radiograph, the pre-existing left basal opacity has decreased in extent and severity. otherwise, the radiograph is unchanged. no newly appeared focal parenchymal changes. ct abd : could not fully visualize hepatic vv due to contrast timing impression: 1. patent portal vein, although direction of flow cannot be evaluated with this study. 2. cirrhosis with evidence of portal hypertension, recanalized umbilical vein and splenorenal shunt. 3. cholelithiasis and choledocholithiasis without evidence for inflammation. tte : conclusions the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic arch is mildly dilated. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the report of the prior study (images unavailable for review) of , no change. ruq u/s : findings: note is made that this is a very limited ultrasound technically due to the patient's body habitus and his inability to hold his breath. no gross hepatic lesion is identified and no gross biliary dilatation is seen, although visualization of the liver is very limited. gallstones are again seen within the gallbladder. the spleen is enlarged measuring about 14.5 cm. no ascites is seen in the abdomen. doppler examination: color doppler and pulse-wave doppler images were obtained. within the right portal vein, flow is noted to be reversed. flow in the left portal vein is presumed to be patent and forward as there is a large patent umbilical vein. the main portal vein could not be identified. impression: extremely limited visualization of the anatomy due to the patient's body habitus. a large patent umbilical vein is identified. shadowing gallstones are again seen within the gallbladder. splenomegaly is also identified and there is no ascites seen. visualization of the remainder of the structures is extremely poor. leni left leg : no dvt in the left lower extremity. micro: urine cx : no growth. blood cx : no growth. stool cx, c diff : c. diff negative 7:39 am stool consistency: soft source: stool. **final report ** fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. ua : rbc 17 wbc 146 nitrite pos leuks few urine cx : urine culture (final ): yeast. 10,000-100,000 organisms/ml. blood culture , , , : no growth. brief hospital course: pt is a 51 year old male with etoh cirrhosis and possible hemochromatosis (still undergoing evaluation) who presented with increased confusion at home. he was initially taken to the icu for close monitoring. he had no active s/s infection. he was treated with lactulose for hepatic encephalopathy and mildly improved. he was transferred to the medicine service where he continued to improve with lactulose. however, several days into his stay he appeared more confused. infectious workup was resent, and pt was found to have a uti, and was treated for 14 day course. pt continued to be encephalopathic and was treated with vancomycin for cellulitis of his left leg. hospital course was complicated by hypotension, most likely due to diuresis and poor intravascular volume. he had mild renal insufficiency secondary to overiduresis. tube feeds were started for nutrition. eventually, pt was no longer able to be diuresed, and family meeting was , with the decision to be discharged to ltac for further care and pt. he will follow-up with hepatology on discharge. # hepatic encephalopathy: on admission to the icu, patient was arousable to pain and had asterixis, concerning for he. there was no evidence of infection. most likely precipitating factor was a medication effect from pain medicine and sedating medicine from the egd (at osh) or possibly medication noncompliance. ruq u/s was performed to look for thrombus but inconclusive for pvt. ct scan showed patent portal vein but unable to fully visualize hepatic vein given contrast timing. pt was transferred to the medicine liver service, where he continued to improve after increasing bowel movements with lactulose. however, as discussed below, course was complicated by complicated uti, cellulitis, and hypotension, all likely contributing to continued encephalopathy. on discharge, he was more alert than on admission, but his mental status continued to fluctuate throughout the day. he was always oriented to person, able to state facts (such as president, current events), but occasionally not oriented to place or date and had poor attention. he had no other sources of infection and no further etiologies to treat to improve encephalopathy. # cirrhosis: alcoholic (last drink 4 years prior) and possible hemochromatosis suspected initially (based on elevated ferritin and iron deposition on previous imaging). multiple decompensations in the past with hepatic encephalopathy. on rifaximin (only once daily) and lactulose (only 60ml daily), and had been taking these as directed per the family and facility. prior to admission, had started evaluation for transplant, but had not yet completed it. his continued decompensation was concerning for secondary process in addition to alcoholic cirrhosis. ferritin levels were elevated and previous imaging suggested possible hemochromatosis. pt had no family history but has received blood transfusions in the past. hfe gene mutation analysis was negative. additional studies for other etiologies for cirrhosis were sent, including igg, , a1at, copper, ceruloplasmin. igg was normal, negative, a1at negative, ceruloplasmin mildly low at 13, copper was low at 34, 24hour urine copper showed normal levels. he was continued on spironolactone 100mg daily, and his lasix was uptitrated given anasarca (see below). however, given hypotension, further diuresis was limited and for last several days prior to discharge. he was continued on rifaxamin, increased to twice daily as it was recorded only as once daily at facility. lactulose dose was uptitrated as well, and should maintain at least bowel movements per day. **at , he will need to have diuretics restarted and titrated as able. **need to ensure bowel movements per day. # macrocytic anemia: ddx included hemolysis vs. hypersplenism vs. bleeding vs. acd. hct had been reportedly been drifting down at osh, requiring blood transfusions, with egd without any bleeding and no varices seen, guaiac negative here on admission. hapto <5 and elevated ldh concerning for hemolysis. however, given that he has cirrhosis, not unexpected that haptoglobin would be low, and ldh to be mildly elevated. spep and upep were negative. hematolgoy was consulted, and reported that there were spherocytes in the peripheral smear, but no schistocytes. the dat was negative, making differential for coombs negative hemolysis hereditary spherocytosis (hs)/erythrocyte membrane defect (can also cause splenomegaly), g6pd, and paroxysmal nocturnal hemoglobinuria all possible. g6pd was normal. urine hemosiderin showed was negative. he was transfused one unit prbc's on with hct at 25.7, mostly for improvement in intravascular volume (no active bleeding), with appropriate increase in hct. he was found to have brown, guaiac positive stools the week prior to discharge, thought to be possibly due to gastritis seen on egd at osh. he had no melena or frank blood. his hct remained stable at 27-28 for one week prior to discharge. on discharge he will follow-up with hematology. # anasarca: most likely low albumin and cirrhosis with poor synthetic function. no protein seen in the urine. pt was diuresed with iv lasix 40mg , increased titration limited by sbp in 90s. he was continued on spironolactone 100mg daily. however, pt became hypotensive, requiring decreased diuresis. diuresis was attempted with albumin given back. however, pt had some mild arf as well, and further diuresis was . nutrition was consulted and while he was eating well, he was started on tf's to try to improve nutrition. **on discharge, the physicians at rehab will restart and titrate diuresis as able (limitations will be renal insufficiency and hypotension). # hypotension: ddx includes overdiuresis & dry intravascular volume, vs. sirs physiology vs. adrenal inusfficiency. diuretics stopped . midodrine uptitrated and given albumin. consulted endocrine given low cortisol on testing, though confusing picture given albumin only 2.1, therefore assay difficult to interpret. pt was treated with appropriate antibiotics for uti and cellulitis, and did not appear to be septic. diuresis was as above. he was started on midodrine. repeat ruq u/s and cxr were unremarkable. repeat urine cultures showed yeast, and the foley was discontinued. blood cultures on repeat showed no growth. endocrine followed and did not think the picture was consistent with adrenal insufficiency. lh, fsh were low, in addition to low testosterone. he was restarted on testosterone patch. his bp remained stable in the systolic 90s-100s for 48hrs prior to discharge. he was discharged to continue midodrine 10mg tid. # acute renal failure: pre-renal etiology given attempted diuresis, with cr bump to 1.4. diuresis was discontinued. his creatinine was stable at 1.3 for 2 days prior to discharge. # complicated uti: discovered on after pt appeared more confused, and infectious workup resent. he was treated with ceftriaxone for 14 day course. repeat urine culture showed yeast, but no bacterial growth. # left leg erythema: started on vancomycin to cover for possible cellutlitis. pt had already been on ctx for uti, and therefore was getting adequate coveraged accept for mrsa. completed a 7 day course with improvement. leni was checked to ensure no dvt, which was negative. he had some mild erythema of bilateral legs on discharge, attributed to stasis dermatitis. # depression: home abilify given concern for causing somnolence in addition to side effects of leukopenia in this patient who is already at risk. recommend follow-up with pcp after discharge for further management. # leukopenia: most likely hypersplenism, cirrhosis. no s/s infection. wbc remained stable. his wbc ranged from high 2s-3s consistently for the last 2 weeks prior to discharge. # back pain: chronic in nature. continued lidocaine patch and tramadol for pain. # recent avulsion fracture: conservative management. pt was consulted and recommended acute rehab. given tramadol for pain control. transitional care: 1. code: full 2. contact: sister (hcp) (c), (w); brother 3. ow-up: - liver transplant - pcp after discharge - hematology - endocrinology 4. medical management: - stopped lasix, abilify - increased lactulose, increased rifaximin, start miralax prn - start humalog sliding scale - nutrition with tube feeds 5. outstanding tasks: - tests: cortisol, free results pending , cortisol binding globulin (transcortin) results pending. pt will be seen by endocrinology on follow-up. medications on admission: -atrac-tain 10% cream apply to both lower extremities daily -nystatin 100000units/gm apply to skin folds -abilify 10mg daily -lidoderm 5% patch 12 hours on lower back -tramadol 50mg q6hrs prn pain -lasix 20mg 2 tabs daily -androderm 5mg/24hr patch for 24hr -benadryl 25mg q6hrs prn agitation -calcium+d 600-400 twice daily -ergocalciferol 50,000 units cap weekly for 12 weeks (end date ) -folic acid 1mg daily -lactulose 60ml daily -magnesium oxide 400mg po bid -mvi daily -omeprazole 20mg po bid -thiamine 100mg daily -vitamin b6 100mg daily -xifaxan 550mg daily discharge medications: 1. rifaximin 550 mg tablet sig: one (1) tablet po bid (2 times a day). 2. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): to lower back and hip. 3. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 4. testosterone 5 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal q24h (every 24 hours). disp:*2 patch 24 hr(s)* refills:*0* 5. calcium citrate + d 315-200 mg-unit tablet sig: one (1) tablet po twice a day. 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. pyridoxine 25 mg tablet sig: one (1) tablet po daily (daily). 10. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 11. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 12. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 1x/week (we) for 3 weeks: to be completed . 13. nystatin 100,000 unit/g powder sig: powder to skin folds topical twice a day as needed for rash. 14. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po qid (4 times a day). 15. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain: limit to 2g/24hrs. 16. polyethylene glycol 3350 17 gram/dose powder sig: seventeen (17) grams po daily (daily) as needed for <3 bm's day prior. 17. insulin lispro 100 unit/ml solution sig: as directed subcutaneous asdir (as directed): see humalog sliding scale. 18. midodrine 10 mg tablet sig: one (1) tablet po three times a day. discharge disposition: extended care facility: northeast - discharge diagnosis: primary diagnoses: 1. hepatic encephalopathy 2. anasarca 3. hypotension 4. macrocytic anemia 5. complicated urinary tract infection 6. cellulitis secondary diagnoses: 1. depression 2. chronic low back pain 4. avulsion hip fracture 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: dear mr. , it was a pleasure taking care of you during this admission. you were admitted with unresponsiveness. you were initially cared for in the icu. you were given lactulose, and you began to feel better. we sent off several tests to assess for your liver disease. however, we think the cirrhosis is mostly due to your previous alcohol use. you had a lot of swelling, and we had to increase the amount of diuretics you were getting. however, your blood pressure was a bit low, and we had to stop the diuretics. we had the endocrinologists see you to make sure there was problem with your adrenal glands. we restarted you on testosterone. your blood sugars were high, and we had to start you on insulin. we found two infections during this admission, a urinary tract infection and cellulitis. we treated both of these with antibiotics. we had the nutritionists see you because your albumin was low. they recommended tube feeds, which we started you on to improve your nutrition. you continued to be confused. we discussed with you and your family that perhaps more intensive would be the best for you. the following medications were changed during this admission: - stop abilify **this medication can cause sleepiness and also lower your blood counts. please discuss with your doctors whether there is a better medication for you. - stop benadryl, as this can cause confusion - stop magnesium oxide - stop lasix 20mg 2 tablets daily **the doctors need to restart diuretics when you are there. - increase the amount of lactulose you were taking from 60ml daily to 30ml four times daily to at least bowel movements per day. - increase the dose of rixafamin from 550mg daily to twice daily - change the pyridoxine dose from 100mg daily to 25mg daily - start insulin per the sliding scale provided - start midodrine 10mg by mouth three times daily - start acetaminophen 325mg by mouth every 6 hours as needed for pain (do not exceed 2grams/day) - start miralax 17g by mouth daily as needed for constipation please continue the other medications you were taking prior to this admission. followup instructions: please follow-up with the following appointments: department: cardiac services when: tuesday at 11:40 am with: , md building: campus: east best parking: garage department: hematology/oncology when: wednesday at 4:30 pm with: , md building: sc clinical ctr campus: east best parking: garage department: transplant center when: friday at 1 pm with: , md building: lm bldg () campus: west best parking: garage department: div of gi and endocrine when: wednesday at 2:00 pm with: , md building: ra (/ complex) campus: east best parking: main garage **your primary care doctor, dr. , need to get prior authorization so that you can see the endocrinologists before your appointment. Procedure: Insertion of other (naso-)gastric tube Insertion of (naso-)intestinal tube Diagnoses: Hyperpotassemia Thrombocytopenia, unspecified Other chronic pain Urinary tract infection, site not specified Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Other and unspecified alcohol dependence, in remission Personal history of tobacco use Dysthymic disorder Hypotension, unspecified Alkalosis Personal history of venous thrombosis and embolism Hepatic encephalopathy Lumbago Other and unspecified coagulation defects Splenomegaly Other abnormal glucose Unspecified deficiency anemia Other testicular hypofunction Leukocytopenia, unspecified Aftercare for healing traumatic fracture of hip Edema Other hemochromatosis |
allergies: codeine / morphine / hydrocodone / oxycodone / ativan attending: chief complaint: generalized weakness, diffuse abdominal pain, abnormal labs major surgical or invasive procedure: intubation history of present illness: patient is a 51 year old male with cirrhosis reportedly secondary to alcohol and hemochromatosis complicated by encephalopathy who presents to ed with concern for hyperkalemia noted on labs with outside provider. . in the ed, his potassium was noted to be normal though he appeared altered and reported generalized weakness and new diffuse abdominal pain without fever, chills, dysuria and headache. his physical exam was notable for sirs criteria with heart rate of 110 and map of 50. bedside tte showed normal ejection fraction though showed collapsed ivc whose diameter improved with 2 liters of ns resuscitation and 150 g of albumin resuscitation though no response to his map with cvp 8 - 12 and svco2 of 97%. rij line was placed and levophed was started with concern for septic shock. he was given vancomycin 1 gm iv x 1, ceftazidime 2 gm iv x 1 and flagyl 500 mg iv x 1 as empiric coverage and admitted to micu for management of septic shock with likely nidus of infection being sbp. . of note, fast in the ed showed trace free fluid without any ascites though abomdinal ultrasound later confirmed moderate ascites. labs notable for elevated creatinine to 3.9, lactate of 4.4, wbc of 3.8, elevated liver enzymes, inr of 2.09 and t.bili of 4.7. . cxr showed no acute cardiopulmonary process with satisfactory positioning of rij line. ua was wnl except for high specific gravity. ekg showed diffusely low voltage. he also has cellulitis. . vitals prior to tranfer were 133/92 on levo gtt. . on arrival to the micu, he was encephalopathic with somnolence but did arouse to voice and sternal rub. he answered questions with simple yes and no. he denied bloody bowel movements and vomiting blood although he had copious amounts of dried blood in his mouth. he was not making urine in the foley. past medical history: 1. cirrhosis alcohol, question of hemochromatosis given elevated iron levels (ferritin ~1500, tibc ~200). saw cardiology here in , who performed an mri and saw iron deposits in liver concerning for hemochromatosis. mild chf on last echo (lvef 50-55%) may be due to etoh vs. hemachromatosis. 2. recurrent cellulitis of left leg 3. dvt following trauma to left leg (mva) was on warfarin for 1 year. 4. chronic low back pain 5. depression 6. anxiety social history: no current tobacco use, former tobacco ~ 10 pack years (quit 3 years ago). former alcohol and klonopin abuse. patient lives in center, he does not work. he is separated from his wife. the patient's weekly exercise regimen consists of walking daily around the building. patient usually tries to adhere to a sensible diet and manages adls well with assistance. he is separated from his wife. has 3 grown children ages 31, 27 and 23 who live in . he quit smoking 3 years ago. family history: his father died of lung cancer and his mother has diabetes. he has 3 sisters and 1 brother who are healthy. his 3 children who are healthy. physical exam: vitals: temperature 91.1, bp 80s/40s, hr 130s, rr 8-10, o2 sats 100% 5lnc general: somnolent, arouses to voice and sternal rub, answers "yes" to some questions but not clearly appropriately heent: very mild scleral icterus, dried blood in the mouth neck: supple, difficult to assess jvp lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate, normal rhythm, soft heart sounds abdomen: firm, obese, diffusely tender with guarding, worse in the ruq ext: cold, left radial pulse 2+, right trace pulse, b/l dp trace pertinent results: 09:59am blood wbc-4.2 rbc-1.71* hgb-6.4* hct-21.0* mcv-123*# mch-37.5* mchc-30.5* rdw-16.9* plt ct-28* 09:29am blood wbc-4.4 rbc-1.95* hgb-7.2* hct-22.5* mcv-116* mch-36.8* mchc-31.8 rdw-17.1* plt ct-46* 05:01am blood wbc-4.2 rbc-2.26* hgb-8.4* hct-25.5* mcv-113* mch-37.3* mchc-33.1 rdw-17.0* plt ct-33* 09:40pm blood wbc-3.8* rbc-2.52* hgb-9.5* hct-28.6* mcv-114*# mch-37.7* mchc-33.2 rdw-17.0* plt ct-24* 09:59am blood plt smr-very low plt ct-28* 09:59am blood pt-24.1* ptt-88.5* inr(pt)-2.3* 09:29am blood plt ct-46* 09:29am blood pt-21.9* ptt-53.7* inr(pt)-2.1* 05:01am blood plt ct-33* 05:01am blood pt-22.0* ptt-65.2* inr(pt)-2.1* 11:05pm blood pt-22.0* ptt-150* inr(pt)-2.09* 09:59am blood glucose-513* urean-48* creat-3.3* na-135 k-4.1 cl-101 hco3-17* angap-21* 09:29am blood glucose-336* urean-48* creat-3.3* na-136 k-4.4 cl-100 hco3-17* angap-23* 05:01am blood glucose-304* urean-54* creat-3.5* na-134 k-4.3 cl-97 hco3-23 angap-18 09:40pm blood glucose-340* urean-57* creat-3.9*# na-134 k-5.0 cl-98 hco3-22 angap-19 09:59am blood ck(cpk)-76 05:01am blood alt-73* ast-112* ld(ldh)-277* ck(cpk)-65 alkphos-241* totbili-5.3* 09:40pm blood alt-83* ast-138* alkphos-282* totbili-4.7* 09:59am blood calcium-9.6 phos-7.0* mg-3.5* 09:29am blood calcium-8.3* phos-6.9* mg-2.4 05:01am blood calcium-9.0 phos-7.0*# mg-2.7* 10:43am blood lactate-8.1* 10:17am blood lactate-7.9* 09:43am blood lactate-5.4* 07:27am blood lactate-4.1* 03:17am blood lactate-3.5* 01:08am blood lactate-3.7* 11:07pm blood lactate-4.4* brief hospital course: mr. is a 51 year old male with a history of alcoholic cirrhosis and hepatic encephalopathy presented with new abdominal pain, altered mental status, and hypotension. . # septic shock: admitted to micu with map 58 after 2l ivf. etiology seemed to be sbp vs pneumonia, cxr was not c/w pneumonia. cardiac causes less likely given normal bedside echo in ed w/ fast negative for pericardial effusion. ruq showed some ascites but did not characertize hepatic vasculature well. he was continued on pressors to maintain his map >65, and treated per standard must protocol. he was also started on vancomycin and zosyn in the ed. despite aggressive goal-directed resuscitation and prompt antibiotic treatment, his septic physiology rapidly worsened and his lactate continued to rise and his blood pressure progressively fell. he subsequently went into pea arrest as described below. . # altered mental status: most likely a combination of his baseline hepatic encephalopathy with infection and superimposed delirium. there is also concern that his map is not high enough to maintain cerebral perfusion pressure at this point since he has had low map for >3 hours and is also not making urine. we continued aggressive fluid resucication and pressors to maintain map. he was also continued on lactulose and rifaximin, but ultimately had to be intubated for declining mental status. . # acute kidney injury: his creatinine is acutely elevated from baseline < 1. the possible etiologies include hrs versus atn. we had planned to obtain renal consult in the morning. patient had little to no urine output overnight, renal ultrasound in ed negative for obstruction or hydronephrosis. . # coagulopathy: patient with baseline coagulopathy and thrombocytopenia and presented with dried blood in his mouth. anesthesia also found blood in the oropharynx. he was not known to have varicies. given septic shock there was a concern for dic as his condition worsened. . # cirrhosis: known to be alcoholic and suspected also hemochromatosis. his synthetic function is poor now with increasing inr and decreasing albumin. his known decompensations include hepatic encephalopathy and sbp. . # cardiac arrest: despite continued aggressive intervention with pressors, antibiotics, and fluid resuscitation, the patient's condition continued to decline with decreasing blood pressure, increasing lactate, and no clinical improvement. bedside echo showed poor cardiac systolic function. he subsequently went into pea cardiac arrest for which standard acls protocol was initiated. he briefly return of spontaneous circulation, and showed mildly improved systolic cardiac function on repeat bedside echo. within one hour of rosc his blood pressure started to trend downward, and family meeting was initiated at the bedside. during this meeting the family decided not to continue resuscitation of the patient given poor prognosis on maximal support (he was on four pressors at that time). his family and the medical team were all in agreement with this decision. chaplain was called to the bedside, and supportive care was withdrawn. patient subsequently expired. medications on admission: - rifaximin 550 mg tablet po bid - lidocaine 5 %(700 mg/patch) adhesive patch, medicated topical to back and hip - tramadol 50 mg tablet po q6h prn pain - testosterone 5 mg/24 hr patch 24 hr q24h - calcium citrate + d 315-200 mg-unit - folic acid 1 mg tablet daily - thiamine hcl 100 mg tablet daily - multivitamin daily - pyridoxine 25 mg tablet daily - heparin (porcine) 5,000 unit/ml solution tid - omeprazole 20 mg - nystatin 100,000 unit/g twice a day as needed for rash -lactulose 10 gram/15 ml 30 ml po qid -acetaminophen 325 mg q6h prn pain: limit to 2g/24hrs -polyethylene glycol 17 gram/dose po daily -insulin lispro 100 unit/ml sliding scale. -midodrine 10 mg po tid discharge medications: not applicable discharge disposition: expired discharge diagnosis: septic shock discharge condition: expired discharge instructions: n/a followup instructions: n/a Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arterial catheterization Diagnoses: Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hepatorenal syndrome Unspecified septicemia Severe sepsis Personal history of tobacco use Depressive disorder, not elsewhere classified Anxiety state, unspecified Acute respiratory failure Long-term (current) use of insulin Septic shock Personal history of venous thrombosis and embolism Other ascites Hepatic encephalopathy Other and unspecified coagulation defects Other and unspecified alcohol dependence, unspecified Spontaneous bacterial peritonitis Other hemochromatosis Other pancytopenia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: new chest discomfort major surgical or invasive procedure: aortic valve replacement #23 tissue valve history of present illness: 81 year old male with known aortic stenosis who is followed closely by dr. . recent cardiac catheterization confirmed severe aortic stenosis and showed only mild coronary artery disease. he has been referred to dr. for consideration of aortic valve replacement. his symptoms included chest discomfort on exertion and occasionally at rest. he also admited to exertional shortness of breath. he denied syncope, orthopnea, pnd, and pedal edema. also admitted to intermittent palpitations from his chronic atrial fibrillation, and described occasional lightheadedness. despite above symptoms, he remains extremely active and performs routine adl without difficulty. he denies unsteady gait and recent falls. he recently recovered from a pneumonia in past medical history: aortic stenosis mild to mr tr pulmonary hypertension chronic af on warfarin renal insufficiency chronic thrombocytopenia dyslipidemia hypertension history of bladder cancer s/p tumor removal(no chemo or rad) recent pneumonia varicose veins arthritis, prior cortisone injections to left hip history of etoh abuse, sober for over 3 years psh: bilateral hernia repairs, hemorrhoidectomy, bilateral cataracts, bladder tumor removal, tonsillectomy social history: lives with:care giver contact: (son) occupation:retired saleman cigarettes: smoked no yes last cigarette 15yr__ hx: other tobacco use:n etoh: < 1 drink/week drinks/week >8 drinks/week stopped 3 yrs illicit drug use: none family history: family history:premature coronary artery disease physical exam: physical exam pulse: resp:16 o2 sat: b/p right:126/77 left:110/70 height:71" weight:103kg general:wdwn, nad skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds extremities: warm , well-perfused edema _____ varicosities: none bilat le varicosities neuro: grossly intact pulses: femoral right:2 left:2 dp right:1 left:1 pt :1 left:1 radial right:1 left:1 carotid bruit right:n left:n discharge exam: vs: t: 97.4 hr: 70-80's afib bp: 153/81 sats: 94% ra wt:101 kg (preop 103 kg) general: 81 year-old male in no apparent distress heent: normocephalic, mucus membranes moist card: irrgular. resp: decreased breath sounds otherwise clear throughout gi: obese, benign extr: warm with 1+ bilateral edema wound: sternal incision clean, dry intact no erythema or discharge neuro: awake, alert, oriented pertinent results: tee : conclusions pre-bypass: the left atrium is markedly dilated. mild spontaneous echo contrast is seen in the body of the left atrium. to severe spontaneous echo contrast is present in the left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). no thrombus is seen in the left atrial appendage. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is low normal (lvef 50-55%). tricuspid regurgitation.] there are focal calcifications in the aortic arch. there are simple atheroma in the descending thoracic aorta. the three aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). no ascending aortic aneurysm is seen. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. (2+) mitral regurgitation is seen. tricuspid regurgitation is seen. there is no pericardial effusion. post-bypass: the aortic bioprosthesis is well seated and functioning well with a residual mean gradient of 10 mm of hg across the valve. no peri valvular leaks seen. lvef 50%. mild to mr. mild to tr. dilated ivc like prebypass. rv function appears normal. intact thoracic aorta. cxr: : all the lines with the exception of the right internal jugular sheath have been removed. there is no pneumothorax. volume loss at the left lung base may be slightly worse. wbc-7.8 rbc-2.70* hgb-8.9* hct-26.8* mcv-99* mch-32.9* mchc-33.1 rdw-15.7* plt ct-92* wbc-8.9 rbc-3.59* hgb-11.5* hct-35.8* mcv-100* mch-32.0 mchc-32.1 rdw-15.0 plt ct-113* pt-13.5* ptt-28.1 inr(pt)-1.3* pt-13.3* inr(pt)-1.2* pt-12.1 inr(pt)-1.1 glucose-82 urean-27* creat-1.0 na-138 k-4.1 cl-103 hco3-26 glucose-178* urean-29* creat-1.4* na-140 k-3.8 cl-105 hco3-21 alt-23 ast-24 ld(ldh)-182 alkphos-48 totbili-0.5 mg-2.3 mrsa screen source: nasal swab. mrsa screen (final ): no mrsa isolated. brief hospital course: patient was admitted to the hospital on from osh long standing history of as. on he was brought to the operating room where the patient underwent aortic valve replacement. please see intraoperative note for further details.` overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. he initially required vasopressor and phenylephrine for blood pressure support. slow to wean from ventilator but eventually weaned and extubated without difficulty. on pod#1 he was extubated and off pressors. he has long history of rate control atrial fibrillation. low dose lopressor, diuretics and ace were initiated. his pre-operative dose of prednisone for thrombocytopenia was restarted. he was mildly confused post-operative and given his history of mild dementia his aricept was started and his mental status improved. he transferred to the floor in pod#2. pacing wires and chest tube were removed per protocol. anticoagulation therapy was started. he was evaluated by the physical therapy service for assistance with strength and mobility. he continued to make steady progress and was discharged to manor in nh on . he will follow-up as an outpatient. medications on admission: prednisone 10mg daily,lisinopril 2.5mg daily,donepezil 5mg daily,folate 1mg daily,coumadin 2.5mg daily(ld 5d),metoprolol succ 50mg daily,ecasa 81mg daily discharge medications: 1. donepezil 5 mg tablet sig: one (1) tablet po hs (at bedtime). 2. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 3. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 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). 6. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 7. mupirocin calcium 2 % ointment sig: one (1) appl nasal (2 times a day) for 4 days: last dose . 8. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever, pain. 9. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 10. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 12. furosemide 40 mg tablet sig: one (1) tablet po once a day for 5 days. 13. warfarin 2.5 mg tablet sig: one (1) tablet po once a day: inr goal 2.0-3.0. 14. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po once a day for 5 days: while take lasix. 15. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. discharge disposition: extended care facility: manor discharge diagnosis: aortic stenosis mild to mr tr pulmonary hypertension chronic af on warfarin renal insufficiency chronic thrombocytopenia dyslipidemia hypertension history of bladder cancer s/p tumor removal(no chemo or rad) recent pneumonia varicose veins arthritis, prior cortisone injections to left hip history of etoh abuse, sober for over 3 years psh: bilateral hernia repairs, hemorrhoidectomy, bilateral cataracts, bladder tumor removal, tonsillectomy discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics edema: 1+ edeam 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 followup instructions: please call to schedule appointments surgeon dr. , md phone: date/time: 1:15 in the building primary care dr. in weeks for a follow-up appointment. cardiologist dr. in weeks for a follow-up appointment. please call cardiac surgery if need arises for evaluation or readmission to hospital coumadin for atrial fibrillation: inr goal 2.0-3.0 coumadin follow-up with dr. as previous Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Thrombocytopenia, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Other chronic pulmonary heart diseases Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Mitral valve insufficiency and aortic valve stenosis Osteoarthrosis, unspecified whether generalized or localized, site unspecified Personal history of malignant neoplasm of bladder Dementia, unspecified, without behavioral disturbance |
allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: persistent encephalopathy major surgical or invasive procedure: intubation and mechanical ventilation endoscopy (osh) history of present illness: mr. is a 60y/o gentleman with etoh and hcv cirrhosis complicated by ascites, varices with bleeding in the past, hcc s/p tace who presented to hospital on after being found unresponsive requring intubation and is transferred to the micu due to continued encephalopathy. . his wife reports that on the evening of he was doing fine (oriented x3). early on at 2am he felt nauseated and had dry heaves. passed foul-smelling loose stools. was lethargic and confused, not answering questions appropriately so his wife gave him an extra dose of lactulose. later that morning at 10am she found him unresponsive with slow breathing. she called 911 and he was taken to hospital. . there, he was hemodynamically stable, was intubated for airway protection. head ct and ct abdomen/pelvis were unrevealing. he was noted to have maroon stools. his hospital course has been significant for gi bleed (hct 32 but was noted to pass some blood clots per rectum so received a total of 3u prbc, 2u ffp, vitamin k, and is on an iv ppi and octreotide gtt), fever to 102 of unclear source being covered empirically with ctx/flagyl then switched to zosyn/flagyl on when he developed a leukocytosis, and shaking episodes yesterday and today (head tilting to right with head jerking movements - received ativan yesterday). he was being sedated with a versed drip @8/hr for ~36hrs, but then he was switched to propofol. despite qid lactulose, his mental status is no more clear so he is transferred here for further workup/management. . on arrival to the micu, he is intubated and sedated. not responding to voice but withdrawing from pain. past medical history: past medical history: - etoh and hep c cirrhosis, hepatocellular ca, ascites, esld - s/p tace transarterial chemoembolization of hcc - 3 bands of grade 1 varices, last bleed () - failed treatment for hcv (ifn, ifn/ribavirin 10 yesrs ago) - gi bleed from duodenal ulcer - dilated cardiomyopathy with an ejection fraction of 55% - hypertension - hypogonadism - ibs . past surgical history: - herniorrhaphy x 3 - right wrist fracture s/p fixation - left toe surgery - knee arthroscopy x 4 social history: -home: lives with wife . they have an adopted daughter. 4 children from a prior marriage. -tobacco: none -etoh: prior history of heavy use, quit 6 yrs ago but relapsed and now has been sober again for 6 months -illicits: none family history: no history of cancer or hepatitis. physical exam: admission vitals: t: 100.1 bp: 125/62 p: 117 o2sat 100% on ps 10/5, rate 20, fio2 60% gen: well-nourished gentleman appearing his stated age, intubated, sedated heent: anicteric sclerae, mmm, normal oropharynx cvs: rrr, no mrg. resp: ctab, no rhonchi or crackles abd: obese but nondistended, no rebound or guarding ext: warm, 2+ dp and pt pulses bilaterally; no edema or cyanosis; right femoral cvl site with no erythema or hematoma neuro: withdraws to pain, vor intact, bracioradialis 2+ bilaterally, patellar reflexes 1+ bilaterally discharge: expired pertinent results: egd (osh) small esophageal varices without bleeding, no blood in the stomach, nodules in the gastric body, few gastric antral erosions . ct abdomen/pelvis w/o contrast (osh) 1. abnormality of the right hemicolon with mural thickening may be secondary to portal hypertension although the possibility of colitis is difficult to exclude 2. hepatic cirrhosis and new extensive abnormality in the right lobe of the liver suspicious for hcc 3. abdominal ascites 4. periportal lymphadenopathy 5. gallstones 6. right renal cyst unchanged and isodense nodule of right kidney also unchanged 7. colonic diverticulosis without acute diverticulitis 8. small right inguinal hernia containing fat 9. bibasilar atelectasis and/or infiltrates . ct head w/o contrast (osh) no evidence of acute intracranial abnormality. mucous retention cysts in maxillary sinuses. . liver u/s limited examination showing unchanged thrombosis of the anterior right portal vein. minimal/slow flow in the main portal vein noted, although this could be related to the limited examination. patent hepatic artery. no significant ascitic fluid noted. . cta abd/pelvis 1. hyperdense material within the cecum and small bowel resection anastomosis. these regions are potential candidates for a bleed source. no active extravasation is seen. 2. new, likely bland thrombus within the main portal (nearly occlusive) and right portal veins (occlusive)and origin of left portla vein (nearly occlusive) since the mr examination. 3. post-tace changes and small hypodense nodules, representing tumor thrombi, in segment 5. no definite arterially enhancing hepatic lesions identified. 4. varicose veins at the anterior abdominal hernia repair site and small bowel anastomosis. 5. cholelithiasis. 6. small amount of abdominal and pelvic ascites. brief hospital course: mr. is a 60y/o gentleman with etoh and hcv cirrhosis complicated by ascites, varices, hcc s/p tace who is transferred from an osh with continued encephalopathy, gi bleed, and fevers. . #. encephalopathy: likely multifactorial. acute onset of depressed level of consciousness at home could represent hepatic encophalopathy. has been taking lactulose qid but no report of if he has been stooling. precipitants could include upper gi bleed, medication effect (was on a versed drip at osh for ~36h), or infection (see "fevers" below). doppler and ct abdomen visualized portal vein thrombus which likely is contributing to current presentation of encephalopathy. switched to bolus sedation and continued lactulose and rifaximin without improvement of mental status. given his poor prognosis and absence of mental status, patient was terminally extubated on and transitioned to cmo. . #. bloody loose stools: lower gi bleed vs brisk upper gi bleed. has history of bleeding ulcers as well as esophageal varices. at the osh, he underwent egd showing portal gastropathy and small gastric nodules which were not bleeding; had "diminutive varices." patient had persistent hct drops during this hospitalization along with persistently bloody bowel movements. patient was transfused a total of 5units and cta was obtained showing sources of bleeding in the cecum and at a prior small bowel anastomosis, likely ectopic varices. initial plan was for colonoscopy but goals of care were discussed with family and as it was felt that this was a nonintervenable source of bleeding, supportive transfusions were discontinued and no further interventions were undertaken. ppi and octreotide drips were continued and patient was transitioned to cmo. . #. fevers: initially concerning for infection. had leukocytosis and had bandemia at osh. sources could include pna (especially concerning while intubated), uti, sbp. tap here was not suggestive of infection and cxr and urine were unremarkable. he was covered with zosyn and flagyl which were discontinued on hd #2 as there was no clear source of infection. . #. : prerenal with low urine na and fena. creatinine improved somewhat with fluids. . #. hcv and etoh cirrhosis: no response to lactulose and rifaximin so these were discontinued. his lasix and spironolactone were held. . # code status: given patient's persistent absence of mental status improvement, his poor prognosis given his underlying hcc and ongoing gi bleed, patient was made cmo on hd #2. medications on admission: - spironolactone 200 mg daily - furosemide 80 mg tablet daily - ursodiol 500 mg - lactulose 10 gram/15 ml 15-30 mls po qid - rifaximin 550 mg - gabapentin 300 mg tid - temazepam 30 mg qhs - citalopram 10 mg daily - sodium fluoride 1.1 % gel - pantoprazole 40 mg - b complex vitamins daily - magnesium oxide 400 mg daily - calcium 600 + d(3) 600 mg(1,500mg) -400 unit - testosterone 1 %(50 mg/5 gram) gel daily 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 Percutaneous abdominal drainage Central venous catheter placement with guidance Diagnoses: Other primary cardiomyopathies Unspecified essential hypertension Acute posthemorrhagic anemia Chronic hepatitis C with hepatic coma Alcoholic cirrhosis of liver Acute kidney failure, unspecified Acute respiratory failure Other sequelae of chronic liver disease Other encephalopathy Malignant neoplasm of liver, primary Do not resuscitate status Hemorrhage of gastrointestinal tract, unspecified Hyperosmolality and/or hypernatremia Leukocytosis, unspecified Portal vein thrombosis Alcohol abuse, in remission |
allergies: penicillins / morphine / iv dye, iodine containing contrast media / zestril / glucocorticoids (corticosteroids) / lipitor / ceftazidime attending: chief complaint: back pain respiratory distress major surgical or invasive procedure: - endotracheal intubation - t6 & t7 laminectomy for evacuation of epidural hematoma. - l hallux amputation history of present illness: mr. is a 56-year-old gentleman with a history of atrial fibrillation on coumadin, dm, cad s/p 3-vessel cabg & chronic back pain s/p spinal surgery in who complained of worsening "flank pain" after having a root canal on . the next day he was unable to stand & the pain was described as being much worse than his chronic back pain. he initially presented to hospital on with back pain that was radiating to the top of his thights. he was discharged but returned later that day. on his second presentation, labs were drawn which revealed an inr 17 (the patient had been taken antibiotics in association with his root canal). the patient was started on ceftriaxone for a possible toe infections that was noted on exam. the patient was transferred to for mri (he has an allergy to contrast). a repeat inr was 4.5 s/p vit k administration. in the ed, the patient was noted to be tachypneic & in respiratory distress s/p iv dilaudid & valium (for concern about possible etoh withdrawal) administration; he was subsequently intubated. he was started on broad-spectrum antibiotics (cefepime & vanco), and was admitted to the micu. in the ed, he was writhing in pain and was given dilaudid. he drinks 3-4 drinks per day, but had not in the last 3 days. given the posibility of withdrawal, he was given valium. he became hypoxic to the low 80s, tachypneic, and was intubated. a ct head was negative for an acute process. his inr here was 4.5. he was started on cefepime for a presumed l toe infection. he remained persistently tachycardic to high 120s/low 130s, even after intubation and sedation for which he was admitted to the icu. past medical history: - cad s/p cabg x3 in , s/p stents - bone graft - diabetes - carotid stenosis - anemia - atrial fibrillation - chronic back pain social history: - currently on disability from a job as a dispatcher - previously worked as an critical care nurse - denies tobacco use - drinks approximately drinks per day. he wife believes that he has had withdrawal symptoms in the past during previous hospital admissions, although he has never had seizures, nor has been been admitted for detoxication. - lives with his wife. family history: - not-contributory physical exam: admission exam: tmax: 37.2 ??????c hr: 130 bp: 115/86 rr: 22 spo2: 96% general: intubated, sedated heent: sclera anicteric, perrl, mmm cor: tachycardic, regular. normal s1s2, no m/g/r. pulm: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: obese, + nabs. soft, non-tender, non-distended. no rebound or guarding, no organomegaly. gu: foley in place ext: warm, well-perfused. 2+ pulses. large ulcers in bilateral great toes. the left leg has a necrotic center with pus draining. discharge exam: t 98.3 hr 54 bp 126/76 rr 18 sp02 97% gen: well-appearing, nad heent: no lymphadenopathy, mmm, perrl cv: irregularly irregular, no murmurs lungs: cta b/l abd: obese, +bs, soft, nt nd, no organomegaly ext: wwp, no cce, left hallux amputed with clean dry dressing back: well-healed midline scar over thoracic spine pertinent results: on admission: wbc-15.0* rbc-4.63 hgb-13.2* hct-39.9* plt ct-168 neuts-78* bands-1 lymphs-14* monos-5 eos-0 baso-0 atyps-2* pt-43.3* ptt-41.9* inr(pt)-4.5* glucose-126* urean-33* creat-0.9 na-139 k-4.4 cl-104 hco3-22 angap-17 alt-21 ast-27 alkphos-124 totbili-0.8 ctropnt-<0.01 art. blood gas rates-22/ tidal v-550 peep-5 fio2-100 po2-386* pco2-46* ph-7.34* caltco2-26 ct head impression: no acute intracranial process. specifically, there is no evidence of an acute hemorrhage cxr impression: et tube terminating 5.7 cm above the carina. vascular crowding is seen in the setting of low lung volumes, however, no acute intrathoracic process is detected. please note that the right costophrenic angle is completely excluded from the study. mr impression: 1. 5 cm x 13 mm x 9 mm left posterior epidural collection posterior to the t12 and l1 vertebral bodies is consistent with an epidural abscess with mild involvement of the left posterior paraspinal muscles. 2. anterior displacement of the nerve roots of the cauda equina with mild thickening and clumping is most consistent with arachnoiditis. mr l spine impression: status post evacuation of epidural abscess. except for tiny residual areas of fluid slightly above the level of the laminectomy site and also at t11-12 level majority of fluid seen within the epidural space is no longer visible. some residual enhancement of the epidural soft tissues is noted with considerable decrease in mass effect on the thecal sac. no abnormal signal seen within the spinal cord. mr findings: there is an area of slow diffusion in both occipital horns of the lateral ventricles. no corresponding abnormality is noted on the susceptibility t2 or t1-weighted images. no infarct, mass or mass effect is noted in the brain. there is no significant flair hyperintensity within the brain parenchyma. the paranasal sinuses and mastoid air cells show mild fluid in the right maxillary and sphenoidal sinuses. impression: small areas of slow diffusion in both occipital horns concerning for pus within the ventricles. a small amount of blood is a less likely possibility. echo impression: very suboptimal image quality due to body habitus. left ventricular systolic function is difficult to assess, ejection fraction is probably at least 45%. the right ventricle is not well seen. no significant valvular abnormality seen. on discharge: 05:45am blood wbc-8.1 rbc-3.61* hgb-10.2* hct-30.9* mcv-86 mch-28.3 mchc-33.0 rdw-17.1* plt ct-496* 05:48am blood pt-28.5* inr(pt)-2.8* 05:45am blood glucose-107* urean-11 creat-1.2 na-136 k-3.6 cl-100 hco3-28 angap-12 coags: - inr 1.9 (warfarin 3.5mg) - inr 2.9 (warfarin held) - inr 3.2 (warfarin held) - inr 2.8 (warfarin 3mg) brief hospital course: 56 yo male w/ cad s/p cabg & stents, afib on coumadin and etoh abuse here w/ acute on chronic back pain. pt was admitted to the micu after intubation in the ed for hypoxia. acute diagnoses: # epidural abscess & hematoma: the patient was intubated on admission to the micu. an mri was obtained which showed an epidural fluid collection concerning for infection or hematoma. he was started on vancomycin and piperacillin-tazobactam. neurosurgery was consulted and considered that the fluid was a hematoma consistent with his inr of 17 at presentation. his inr was partially corrected after ffp and vit k to an inr of 4.5. on hospital day 2, a repeat mri was ordered to help further identify the fluid collection. on hospital day 4, the patient had a brain mri due to a concern for his mental status (given that he was not responding off of sedation). after his inr was corrected to 1.4 in preparation for surgery, he underwent a t5-t8 laminectomy and hematoma evacuation, during which purulent material was also found in the space. the culture from the epidural mass showed pan-sensitive e-coli as well as group b strep. as per id recs, the pip-tazo was changed to ceftazadime, which was then changed to ciprofloxacin because of a drug rash presumed to be secondary to the ceftazidime. id recommends continuance of the vancomycin and ciprofloxacin for a duration of 6 weeks (vanc started on , cipro started on ). # supratherapeutic inr: the patient presented to osh with an inr of 17. his inr decreased to 4.5 after treatment with fresh frozen plasma & vitamin k. the patient states that he had recently been on a cephalosporin in preparation for his root canal procedure. his coumadin was resumed on after his podiatric surgery. due to the ciprofloxacin, his coumadin was held for a few days with a slightly high inr. he was restarted at a lower dose of 3mg daily, but will need consistent monitoring while being treated with cipro. # ? ventriculitis: the patient's mri brain revealed "small areas of slow diffusion in both occipital horns concerning for pus within the ventricles. a small amount of blood is a less likely possibility." the patient will be on antibiotics for 6-8 weeks and neurosurgery did not feel that this finding required intervention. however, this radiographic finding will be followed up with a repeat head ct without contrast in weeks. # atrial fibrillation & tachycardia: the patient had occasional tachycardia of unclear etiology. possibilities included hypovolemia, atrial flutter, discomfort, or infection. after the mri, the pt became agitated and developed afib with rvr with a heart rate in 110's. rate control was achieved with diltiazem 10 and 10 of metoprolol; the pt remained normotensive throughout. he had one further episode of rapid atrial fibrillation on the floor, which ultimately responded to 15 mg iv diltiazem. # encephalopathy: following his laminectomy, extubation, and weaning off sedation, the patient had episodes of aggression, cursing, and agitation. he appeared to be talking to people who were not present in the room. psych was consulted, and it was felt that it was likely due to delirium. he was treated with seroquel and haldol, and his mental status steadily improved. while alcohol withdrawal remained a possibility, his lengthy hospitalization made the timeline for withdrawal unlikely. upon transfer to the floor, the patient was alert & oriented to person, place, & time with a clear mental status. he had no further bouts of aggression or confusion # congestive heart failure: the patient's volume status & i/o's were monitored throughout hospitalization. he occasionally required some diuresis with lasix while he was on the floor. his home spironolactone & metoprolol were held until the patient was able to take medications by mouth. #foot ulcers: the patient was noted to have bilateral toe ulcers on admission; he had necrotization with purulent discharge of the left hallux. podiatry was consulted and the patient underwent a left hallux amputation on . he will f/u with podiatry as an outpatient. chronic diagnoses: # depression & hypothyroidism: the patient was continued on his home levothyroxine & citalopram. # diabetes: the patient's metformin was held during hospitalization and an insulin sliding scale was instituted. transitional issues: # follow-up: the patient has several follow-up appointments with neurosurgery, infectious disease, & podiatry. he will need a head ct without contrast in weeks (prior to his outpatient neurosurgery appointment). # lab work: the patient will need weekly lab draws while he is on iv vancomycin. he will have services established upon discharge to arrange his weekly cbc, bun/cr & vanco level checks. he will also need consistent inr monitoring while on cipro. medications on admission: - celexa 10mg daily - vitamin e 400 units daily - colace 100mg - levoxyl 250mcg daily - omeprazole 20mg daily - spironolactone 25mg daily - naprosyn 500mg daily prn - metoprolol 100mg - coumadin - asa 81mg - crestor 10mg daily - proair 90mcg 2 puffs q6hrs - metformin 500mg - potassirum er 20 meq discharge medications: 1. multivitamin tablet sig: one (1) tablet po daily (daily). 2. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 3. spironolactone 25 mg tablet sig: one (1) tablet po bid (2 times a day). 4. levothyroxine 125 mcg tablet sig: two (2) tablet po daily (daily). 5. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 6. omeprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 7. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). 8. vancomycin 500 mg recon soln sig: 1250 (1250) mg intravenous q 12h (every 12 hours) for 6 weeks. 9. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 10. metformin 500 mg tablet sig: 0.5 tablet po twice a day. 11. celexa 10 mg tablet sig: one (1) tablet po once a day. 12. vitamin e 400 unit tablet sig: one (1) tablet po once a day. 13. naproxen 500 mg tablet sig: one (1) tablet po once a day as needed for pain. 14. warfarin 3 mg tablet sig: one (1) tablet po once a day. 15. dilaudid 2 mg tablet sig: one (1) tablet po three times a day as needed for pain. 16. ciprofloxacin 750 mg tablet sig: one (1) tablet po twice a day for 6 weeks. discharge disposition: home with service facility: all care vna of greater discharge diagnosis: primary diagnoses: - spinal abscess - left hallux infection - atrial fibrillation secondary diagnoses: - cad s/p cabg x3 in , s/p stents - bone graft - diabetes - carotid stenosis - anemia - atrial fibrillation - chronic back pain discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: mr. , it was a pleasure to participate in your care while you were at . you came to the hospital because of back pain that worsened after some dental treatment. while you were here, you were admitted to the icu. an mri of your back showed that you had an area of infection with bleeding resting on your spine. you were taken to the operating room on to have this area of infection removed. you also had your left big toe amputated due to infection. the neurosurgeons & infectious disease doctors followed throughout your hospitalization. the infectious disease specialists recommended that you have 6-8 weeks of iv antibiotics to fight your infection. medication changes: - medications added: iv vancomycin 1250 mg twice a day for at least 6 weeks, oral ciprofloxacin 750 mg every 12 hours for at least 6 weeks - medications changed: warfarin dose was lowered to 3mg daily, but will fluctuate with your inr - medications stopped: none. followup instructions: department: podiatry when: friday at 3:30 pm with: , dpm building: ba ( complex) campus: west best parking: garage name: midha,salil address: , , phone: when: friday, , 2:30pm department: infectious disease when: tuesday at 9:50 am with: , md building: lm campus: west best parking: garage department: infectious disease when: tuesday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage department: radiology when: wednesday at 8:30 am with: cat scan building: cc clinical center campus: west best parking: garage department: neurosurgery when: wednesday at 9:30 am with: , md building: lm campus: west best parking: garage Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Amputation of toe Arterial catheterization Other exploration and decompression of spinal canal Nonexcisional debridement of wound, infection or burn Biopsy of bone, other bones Central venous catheter placement with guidance Diagnoses: Obstructive sleep apnea (adult)(pediatric) Abnormal coagulation profile Tobacco use disorder Unspecified pleural effusion Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Depressive disorder, not elsewhere classified Alcohol abuse, unspecified Ulcer of other part of foot Acute respiratory failure Long-term (current) use of anticoagulants Rash and other nonspecific skin eruption Hypoxemia Encephalopathy, unspecified Intraspinal abscess Chronic diastolic heart failure Arthrodesis status Unspecified osteomyelitis, ankle and foot Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B Meningitis, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fatigue, weakness, dyspnea on exertion major surgical or invasive procedure: coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein grafts to the posterior left ventricular branch artery and the obtuse marginal artery history of present illness: 56 year old male with known coronary artery disease status post stents to right coronary artery and left anteriopr descending artery who now has complaints of fatigue and weakness. several weeks ago he presented to hospital with complaints of chest pain, ruled out for myocardial infarction, and was sent home for outpatient stress test which was abnormal. he presented on for cardiac catheterization which revealed three vessel coronary artery disease. now presents for surgical revascularization. past medical history: coronary artery disease s/p cypher stents to rca and lad , s/p lad stent in hypertension hyperlipidemia copd chronic cough/bronchitis bipolar disease diverticulitis recent "spot on liver"-found on imaging study for abdominal pain ***episodes of epistaxis. stopped asa but continued plavix and epistaxis stopped. left ankle bullet wound injury, s/ s/p tonsillectomy ear surgery as child social history: race: caucasian last dental exam: many years lives with: wife occupation: on disability tobacco: 1ppd x45 years etoh: rare recreational drugs: marijuana daily family history: father died of mi age 59 physical exam: pulse:83 resp:16 o2 sat: 100%ra b/p right:130/83 left: 151/94 height: 5'7" weight:260 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema +2 varicosities: none neuro: grossly intact pulses: femoral right: dressing left: +2 dp right: +1 left: +1 pt : +1 left: +1 radial right: +2 left: +2 carotid bruit right: 0 left:0 pertinent results: echo: pre bypass the left atrium is moderately dilated. the left atrium is elongated. mild spontaneous echo contrast is seen in the body of the left atrium.. no thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is moderate global left ventricular hypokinesis. in addition, the distal lateral, anterolateral, and anterior walls seem more hypokinetic than the other segments. the overall ejection fraction is about 35%. the right ventricle displays borderline normal free wall function. the aortic root is mildly dilated at the sinus level. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 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. trivial mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results in the operating room at the time of the study. postbypass the patient is atrially paced on a phenylephrine infusion. global left ventricular function is now slightly improved (overall ejection fracture about 40-45%) although global left ventricular hypokinesis persists. the distal lateral, anterolateral, and anterior walls continue to be more hypokinetic than the other segments. valvular function is essentially unchanged. thoracic aorta is unchanged after decannulation. brief hospital course: mr. was a same day admit after undergoing his cardiac cath and pre-admission testing during previous hospital visit. on he was brought directly to the operating room where he underwent a coronary artery bypass graft x 3. please see operative report for surgical details. following surgery he was transferred to the cvicu for invasive monitoring. within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. on post-op day one his chest tubes were removed and he was transferred to the telemetry floor for further care. beta blockers and diuretics were started and he was diuresed towards his pre-op weight. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 7 the patient was ambulating freely, the wound was healing well and his pain was controlled with oral analgesics. the patient was discharged to home in good condition with appropriate follow up instructions. medications on admission: albuterol 90mcg inhaler-2 puffs prn plavix 75mg po daily diltiazem 120mg po q12 hrs advair diskus 1 puff ih furosemide 20mg po daily atrovent 2 puffs ih four times a day risperidone 2mg po qhs sertraline 200mg po qhs simvastatin 80mg po daily mvi 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:*90 tablet, delayed release (e.c.)(s)* refills:*2* 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 4. zocor 80 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 5. risperidone 2 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 6. zoloft 100 mg tablet sig: two (2) tablet po at bedtime. disp:*60 tablet(s)* refills:*2* 7. carvedilol 6.25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: 1 puff disk with device inhalation (2 times a day). disp:*1 disk with device(s)* refills:*2* 9. atrovent hfa 17 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation four times a day. disp:*1 mdi* refills:*2* 10. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation four times a day as needed for shortness of breath or wheezing. disp:*1 mdi* refills:*2* 11. lasix 20 mg tablet sig: take 2 tabs daily for 7 days, then decrease dose to 20mg daily. tablet po qam: take 2 tablets (40mg) daily with 20meq potassium for 7 days, then decrease dose to 20mg daily without potassium supplement. disp:*30 tablet(s)* refills:*2* 12. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po qam for 7 days: take for 7 days with lasix and then stop. disp:*7 tab sust.rel. particle/crystal(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 3 past medical history: hypertension hyperlipidemia s/p cypher stents to rca and lad , s/p lad stent in copd chronic cough/bronchitis bipolar disease diverticulitis recent "spot on liver"-found on imaging study for abdominal pain ***episodes of epistaxis. stopped asa but continued plavix and epistaxis stopped. left ankle bullet wound injury, s/ s/p tonsillectomy ear surgery as child discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with percocet prn incisions: sternal - healing well, no erythema or drainage. no instability. leg right/left - healing well, no erythema or drainage. edema 1+ bilaterally discharge instructions: 1. please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage 2. please no lotions, cream, powder, or ointments to incisions 3. each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4. no driving for approximately one month until follow up with surgeon 5. no lifting more than 10 pounds for 10 weeks please call with any questions or concerns 6. take lasix 40mg (2 - 20mg tablets) once daily in the morning for 1 week, then decrease dose to 1 tablet (20mg) daily thereafter as per prior to surgery. you will take a potassium supplement 20meq daily with your lasix dose of 40mg for for 1 week and then stop. 7. 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 at 1:00pm please call to schedule appointments with your primary care dr. in weeks cardiologist dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Acidosis Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Other and unspecified angina pectoris Family history of ischemic heart disease Obesity, unspecified Bipolar disorder, unspecified Obstructive chronic bronchitis without exacerbation |
allergies: no known allergies / adverse drug reactions attending: chief complaint: pedestrian struck by mvc while crossing street major surgical or invasive procedure: 1. c3 bilateral hemilaminotomy. 2. laminectomy, c4-c7. 3. bilateral hemilaminotomy, t1. 4. posterior spinal instrumentation, c3-t1. 5. open treatment, cervical fracture/dislocation posterior. 6. posterolateral fusion, c3-t1. 7. application of local autograft for fusion. 8. allograft for fusion. right ac picc history of present illness: 72m pedestrian struck by car on right side while crossing the street (?25mph). denies loc. notes inability to move his legs after accident. brought in by to . on imaging, patient has l sided posterior rib fractures, small l pulmonary laceration and small pneumothorax, c5-c6 retrolisthesis and question of cord injury. past medical history: pmh: hld psh: tonsillectomy; maxillary surgery with likely screw placed for intractable nose bleed. social history: patient now retired, lives alone at home. smokes 1ppd. occasional etoh use. family history: non-contributory physical exam: temp: 97.1 hr: 63 bp: 106/56 resp: 23 o(2)sat: 100 normal constitutional: comfortable heent: normocephalic, atraumatic, pupils equal, round and reactive to light, extraocular muscles intact oropharynx within normal limits chest: decreased bs at bases cardiovascular: regular rate and rhythm, normal first and second heart sounds abdominal: soft, nontender, nondistended extr/back: no cyanosis, clubbing or edema, + pulses skin: no rash, warm and dry pertinent results: 01:35pm blood wbc-14.9* rbc-4.00* hgb-13.4* hct-38.0* mcv-95 mch-33.5* mchc-35.2* rdw-13.0 plt ct-217 04:38am blood wbc-8.6 rbc-2.86* hgb-9.4* hct-26.6* mcv-93 mch-32.9* mchc-35.4* rdw-13.1 plt ct-194 04:38am blood glucose-96 urean-13 creat-0.5 na-137 k-4.1 cl-104 hco3-25 angap-12 ct c-spine 1. no fracture. 2. grade 1 retrolishesis of c5 on c6 with widening of the c5/6 interspace anteriorly and a small amount of prevertebral fluid concerning for anterior ligament injury/disruption. 3. posterior disc osteophyte complexes at c5-6 and c6-7 causing severe and moderate canal narrowing, respectively. 4. calcified left thyroid nodule. please correlate with exam findings. thyroid ultrasound may be obtained nonemergently if indicated. ct head - no acute intra-cranial process ct chest - 1. left posterior eighth through twelfth rib fractures, segmental from ninth through eleventh ribs, with small left pulmonary laceration and pneumothorax. 2. left-sided calcified thyroid nodule. 3. no aortic dissection, vertebral fractures, or free pelvic fluid. no evidence of traumatic injuries to the abdomen or pelvis. brief hospital course: the patient was admitted to the icu upon admission. on , the patient went to the or spine for decompression with c3-c7 laminectomy, c3-t1 fusion. postoperatively the patient was hypotensive likely from cord injury, otherwise he was hemodynamically stable. he required intermittent pressor with neo gtt, and this was unable to be weaned until . on , the patient was started on full liquid diet and transitioned to po pain medications. however, on patient was noted to have difficulty with swallowing and failed a speech and swallow study. he was kept on regular pureed solid diet. the patient's had a drain in place after his procedure, which was removed on . his r arm laceration was closed with a penrorse drain on . he was started on ancef when the penrose drain was placed. on , the patient was hemodynamically stable off pressors, his pain was well controlled, and he was afebrile with stable vital signs. he was transferred to the floor. following transfer to the surgical floor he was evaluated by the physical therapy and occupational therapy service for full evaluations. rehab was recommended to help in learning compensation techniques. he was also evaluated again by the speech and swallow therapist and a video swallow was done which showed some aspiration of thin liquids and his diet currently remains pureed with nectar thick liquids. he underwent vigorous pulmonary toilet and has remained free on any pulmonary complications. his right elbow laceration is draining serous fluid but there is surrounding erythema and needs to be watched. the penrose is out and keflex will remain until . after an unfortunate accident he was transferred to rehab on with the hopes of returning home soon, able to compensate for his deficits. his upper extremities are improving daily but his lower extremities are without movement. medications on admission: atorvastatin discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po every six (6) hours. 2. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 3. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 4. gabapentin 300 mg capsule sig: one (1) capsule po q8h (every 8 hours). 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 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). 8. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 9. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 10. oxycodone 5 mg tablet sig: 1-2 tablets po q 3 hrs as needed for pain. 11. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a day). 12. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours). 14. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every 6 hours) for 5 days. dc discharge disposition: extended care facility: hospital - discharge diagnosis: s/p mvc 1. left posterior rib fractures 2. cervical spinal cord injury. 3. c5-c6 fracture-dislocation. 4. cervical spinal stenosis. 5. small left pulmonary laceration and pneumothorax 6. large laceration ?avulsion r elbow (no obvious joint involvement) 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 with multiple injuries after your motor vehicle accident including fractured ribs, a spinal cord injury and an elbow laceration. you have improved daily but need acute rehab to try to increase your mobility. * wear your cervical collar when out of bed. * continue to use your incentive spirometer, cough and deep breath to improve your lungs and prevent pneumonia. * work hard with physical and occupational therapy to get your muscles conditioned. * continue to eat pureed foods and the speech and swallow therapist at rehab will re evaluate you to hopefully increase your diet. * please call your doctor or return to the ed if you develop fever > 101.5, chills, nausea, vomiting, worsening pain not controlled by pain medications, decreased sensation/movement in any or extremities, chest pain, or sob. followup instructions: call the acute care clinic at for a follow up appointment in weeks. call the clinic at for a follow up appointment in 4 weeks. Procedure: Closure of skin and subcutaneous tissue of other sites Repair of vertebral fracture Other cervical fusion of the posterior column, posterior technique Fusion or refusion of 4-8 vertebrae Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Other iatrogenic hypotension Tobacco use disorder Hyposmolality and/or hyponatremia Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Other and unspecified hyperlipidemia Traumatic pneumothorax without mention of open wound into thorax Closed fracture of five ribs Open wound of elbow, without mention of complication Degeneration of cervical intervertebral disc Shock, unspecified Laceration of lung without mention of open wound into thorax Closed fracture of C5-C7 level with central cord syndrome |
allergies: penicillins attending: chief complaint: endocarditis/ perivalvular abscess major surgical or invasive procedure: :mediastinal exploration and chest closure/ cormatrix patching of the pericardium. :redo sternotomy and redo bentall procedure and ascending aortic and hemi-arch replacement under deep hypothermic arrest with a 25 mm homograft and a 28 mm gelweave tube graft. : l femoral thrombectomy/lle fasciotomy : rle fasciotomies : l leg debridement and vac placement : l leg debridement : exploratory lap history of present illness: 42 year old gentleman well known to the cardiac surgery service as he is s/p bentall(29 stjude mech ao valved graft) on with dr.. he was evaluated at on for right facial numbness and concern for posiible tia-however his symptoms resolved and he was not admitted at that time. he presented to on complaining of lower back pain, left hip pain and a low grade temp for which he was admitted for presumed endocarditis. at osh a ct of abdomen and pelvis were done, as well as mri which were unremarkable. his inr>6 and he was given 5mg vitamin k. he spiked a temp to 103 and was cultured. he was empirically placed on vancomycin and rocephin. cardiology was consulted and there was a question of perivalvular abscess.he was admitted for suspected endocarditis with perivalvular abscess and peripheral stigmata/recent suspected tia on /and supratherapeutic inr. was contact and the pt was transferred for further workup and tee. past medical history: past medical history: bicuspid aortic valve aortic insufficiency dilated ascending aorta hyperlipidemia hypertension past surgical history: eye surgery social history: lives with: wife contact: wife phone # occupation: hvac cigarettes: smoked no yes last cigarette hx: other tobacco use: denies etoh: < 1 drink/week drinks/week >8 drinks/week - 2 drinks/day illicit drug use: denies family history: family history: father with cad and stent at age 60. gf underwent cabg. mother and brother without issues. physical exam: pulse:94 resp:18 o2 sat: 97% r/a b/p 109/68 height: 70" weight: general: a&ox3, appears uncomfortable lying flat 2' back pain skin: warm dry intact heent: ncat perrla eomi neck: supple full rom chest: (r)basilar crackles heart: rrr irregular murmur (+)valvular click abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema u/le splinter hemorrhages/osler nodes varicosities: none neuro: grossly intact pulses: femoral right: left: dp right: 2+ left: 2+ pt : left: radial right: 2+ left: 2+ carotid bruit: right: - left: - pertinent results: echocardiography report , portable tee (complete) done at 1:51:15 pm final referring physician information , r. , division of cardiothorac , , c. , status: inpatient dob: age (years): 42 m hgt (in): 70 bp (mm hg): 94/74 wgt (lb): 175 hr (bpm): 101 bsa (m2): 1.97 m2 indication: endocarditis. icd-9 codes: 424.90 test information date/time: at 13:51 interpret md: , md test type: portable tee (complete) 3d imaging. son: doppler: full doppler and color doppler test location: west cath/ep lab contrast: none tech quality: adequate tape #: 2012w000-0:00 machine: e9-1 sedation: versed: 4 mg fentanyl: 50 mcg patient was monitored by a nurse throughout the procedure echocardiographic measurements results measurements normal range findings multiplanar reconstructions were generated and confirmed on an independent workstation. right atrium/interatrial septum: no asd by 2d or color doppler. left ventricle: overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. aorta: abnormal ascending aorta tube graft. normal descending aorta diameter. normal abdominal aorta diameter. no thoracic aortic dissection. aortic valve: mechanical aortic valve prosthesis (avr). mitral valve: normal mitral valve leaflets. mild to moderate (+) mr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. pericardium: no pericardial effusion. general comments: written informed consent was obtained from the patient. informed consent was obtained. a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was monitored by a nurse e throughout the procedure. the patient was sedated for the tee. medications and dosages are listed above (see test information section). local anesthesia was provided by benzocaine topical spray. the posterior pharynx was anesthetized with 2% viscous lidocaine. no glycopyrrolate was administered. no tee related complications. resting tachycardia (hr>100bpm). patient. conclusions the ascending aorta tube graft appears abnormal. there is dehiscence of the proximal aortic graft/valve apparatus with the intervalvular fibrosa, with a false lumen in communication with the left ventricular outflow tract. color doppler confirms flow in systole and diastole through the communication. the maximal diameter of the false lumen measures 1.6cm. the false lumen is bordered by the adjacent pulmonary artery and pericardium. no pericardial effusions seen elsewhere. the distal end of the false lumen could not be visualized. there are multiple lobulated structures at the proximal end of the false lumen, which may represent vegetations or thrombi. the distal anastomosis of the aortic graft appears normal. mechanical valve appears well seated within the graft with no paravalvular leak within the graft. no evidence of masses/vegetations on aortic valve. 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. no thoracic aortic dissection is seen. a mechanical aortic valve prosthesis is present. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. there is no evidence of thoracic or descending aortic dissection. impression: dehiscence of the composite aortic root valved conduit with an extensive aortic root abscess, as described above. dr. was notified in person of the results on at 1:40pm. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 17:22 echocardiography report , (complete) done at 9:20:48 am final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 42 m hgt (in): bp (mm hg): / wgt (lb): hr (bpm): bsa (m2): indication: abnormal ecg. h/o cardiac surgery. icd-9 codes: 424.90 test information date/time: at 09:20 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 #: 2012aw-3: machine: ie33 echocardiographic measurements results measurements normal range left ventricle - stroke volume: 60 ml/beat left ventricle - peak resting lvot gradient: 5 mm hg <= 10 mm hg aortic valve - peak velocity: 1.8 m/sec <= 2.0 m/sec aortic valve - peak gradient: 14 mm hg < 20 mm hg aortic valve - mean gradient: 7 mm hg aortic valve - lvot vti: 19 aortic valve - lvot diam: 2.0 cm findings right atrium/interatrial septum: moderately dilated ra. a catheter or pacing wire is seen in the ra and extending into the rv. normal interatrial septum. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness. normal lv cavity size. normal regional lv systolic function. no lv mass/thrombus. no resting lvot gradient. right ventricle: normal rv free wall thickness. normal rv chamber size. borderline normal rv systolic function. mild global rv free wall hypokinesis. aorta: normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. aortic valve: normal aortic valve leaflets (3). pericardium: no pericardial effusion. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions patient was brought to or for chest closure. repeat tee was performed. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. no masses or thrombi are seen in the left ventricle. the right ventricular free wall thickness is normal. right ventricular chamber size is normal. with borderline normal free wall function. there is invaginateion of the ias into la with a cvp of 24mmhg. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is a small probably vegetation on the anterior leaflet of the mitral valve. not pedunculated, affecting the mv apparatus functionally. surgeons aware. there is no pericardial effusion. probe was placed and removed uneventfully and atraumatically i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 09:37 . conclusions no atrial septal defect is seen by 2d or color doppler. left ventricular systolic function is hyperdynamic (ef>75%). the aortic valve appears to be a homograft. the aortic valve prosthesis appears well seated, with normal leaflet motion. no masses or vegetations are seen on the aortic valve. a large, extensive aortic annular abscess is seen, involving the entire extent of the anterior mitral continuity and full extention into the anterior fibrous skeleton. no aortic regurgitation is seen. there is a large vegetation involving the anterior mitral leaflet with leaflet abscess and mutliple areas of perforation (including one large perforation and partial flail). severe (4+) mitral regurgitation is seen, with reversal of flow in the right superior pulmonary vein. the regurgitant jet is principally posteriorally directed through a large perforation of the anterior mitral valve leaflet, but additional regurgitation is seen through poor leaflet coaptation. the tricuspid valve leaflets are normal, with no masses or vegiations seen. there is mild to moderate (+) tricuspid regugitation. impression: large vegetation/abscess involving the anterior mitral valve leaflet and extending throughout the anterior fibrous skeleton and aortic root. extensive destruction of the anterior mitral valve leaflet with multiple sites of perforation and secondary severe, eccentric mitral regurgitation. preliminary report developed by a cardiology fellow. not reviewed/approved by the attending echo physician. . was notified in person of the results on at 1615. . conclusion: 1. normal-appearing liver without focal abnormalities. 2. patent portal and hepatic venous system with pulsatile flow suggesting right heart failure or tricuspid insufficiency. 3. bilateral pleural effusions, left greater than right. 4. gallbladder sludge without evidence of cholecystitis. brief hospital course: 42 year old male s/p bentall(29 stjude mechanical aortic valve graft) on with dr.. he presented to on complaining of lower back pain, left hip pain and a low grade temp. he was admitted for presumed endocarditis and transferred to the for further workup. on his admission on , he was admitted to 6,id consulted,empiric vancomycin/ceftriaxone were started,blood cxs obtained, reversal of inr for tee to evaluate paravalvular abscess/endocarditis with cardiology and a ct torso was done. pain service was consulted for his chronic lower back pain likely of multifactorial etiology: myofascial vs neuropathic vs infectious, however his chronic back pain is complicated by infectious processes on his aortic valve, high grade fevers, cerebral emboli hemorraghic and possibly septic. as such there was concern that his severe lower back pain could be a result of a disseminated infection to vertebral body or epidural space. mri of the spine was done on , per radiology showed: no evidence of spinal infection. small midline l5-s1 disc protrusion. neurosurgery and neurology was consulted and mri/mra of the brain performed. per radiology it showed: multiple bilateral punctate infarctions, acute-to-subacute in chronicity,most compatible with embolic infarcts.some of these infarcts are noted with small intraparenchymal hemorrhage,small amount of subarachnoid hemorrhage in the adjacent sulci and no evidence of developing hydrocephalus or significant edema. mra brain shows no vascular occlusion. during mr. testing in the ct scanner his left antecubital fossa was infiltrated with 75cc of ct contrast. hand surgery was consulted and found his arm had soft compartments without threatened overlying skin. recommendations were appreciated. opthamology was consulted due to new blurry vision. his visual acuity and anterior exam were found to be normal. during intermittent episodes of extreme back pain, the pt was incontinent. neurology was contact for evaluation of caudus equinus. neuro felt it was narcotic induced. due to mr. worsening pain and mental status waxing and , he was transferred to the cvicu to undergo a controlled intubation and intensive monitoring prior to surgery. was informed on by the osh, the blood cxs from the outside institution grew aspergillus. as previously stated, repeat imaging at the was done on admission. it showed a dehiscence of the proximal suture line of the valve to the anulus with a contained pseudoaneurysm or abscess. he also suffered from multiple embolization. dr. discussed, numerous times, with mr. and his family, that he is presenting for a very high risk undertaking of reoperative root most likely with the homograft in the setting of fresh embolic strokes seen on ct scan and an inadequately treated fungal infection. on mr. was taken to the operating room and underwent redo sternotomy and redo bentall procedure and ascending aortic and hemi-arch replacement under deep hypothermic arrest with a 25 mm homograft and a 28 mm gelweave tube graft. please see operative report for further surgical details. he was transferred to the cvicu intubated, sedated, requiring multiple pressors and inotropic support to augment his cardiac function. he was received in the cvicu in very critical condition. postoperative bleeding occurred and aggressive resuscitation with multiple blood products ensued. he was taken back to the operating room for exploration. hemodynamic stability was obtained. at the completion of the rexploration, it was noted that mr. left leg appeared mottled. he returned to the cvicu paralyzed with an open chest. due to the extensive surgery, crrt was initiated for and volume removal. renal was consulted. postop night the left lower extremity became cool with no pulses distal to femoral artery. vascular surgery reevaluated. on he was taken to the angiosuite with vascular and underwent a left femoral common artery thrombectomy and lateral and medial left lower leg fasciotomies. later that day it was noted that his right lower extremity was now cool and larger in appearance with associated elevated pressures. vascular performed a fasciotomy on the right lower extremity, with wound vac placed. the following day his hemodynamics allowed for weaning off of inotropic support. pressors were decreased as tolerated. on mr. returned to the operating room and exploration of the mediastinum showed no active bleeding. there was no collection of fluid anywhere. all the surgical sites were free of any active bleeding. the heart size was small enough for chest closure to be accomplished. his fasciotomies were debrided. postoperatively he developed persistent heart block with nonfunctional epicardial pacing wires after his redo bentall/aortic homograft procedure. despite his weaning off pressors with a stable heart rate in the 50s, his ekgs suggest an escape focus with alternating conduction down the anterior and posterior fascicles. ep was consulted and it was felt that he will eventually require a permanent pacemaker, but still being critically ill and actively being treated for fungemia, a pacemaker implantation would be premature at this time. ep therefore placed a temporary pacemaker with the use of a temporary screw-in lead. due to the patients prolonged postop course, physical therapy was consulted while he was in the cvicu to evaluate his strength and mobility. it was noted that he moved all extremities to verbal commands except for his left lower extremity. neurology reassesed.a repeat head ct scan on showed:resolving right frontal subarachnoid hemorrhage/ no new hemorrhage/ stable appearance of right frontal embolic infarct. apparent new right cerebellar hemisphere infarct, likely also embolic. his cultures returned positive for c-difficile. flagyl was added to his antibiotic regimen, id continued to follow. mr. left upper extremity was noted to be larger than his right. a lue u/s was done: acute deep vein thrombosis seen in the left subclavian vein with non-occlusive thrombus seen surrounding the vascular line in the left internal jugular vein. hematology was consulted for recommendations. iv heparin continued and his result was hit negative. on vascular intervened for compartment syndrome of the right lower extremity. a three-compartment fasciotomy of the right lower extremity was performed. please see operative report for further surgical details. the following day he was taken to the operating room by vascular surgery for acute left lower extremity ischemia.he underwent left lower extremity angiogram/ femoral embolectomy/ four-compartment fasciotomy of the lower leg. please see operative report for further surgical details. he continued to have leukocytosis and he was cultured regularly. all lines were changed and he was given a line 'holiday'. on he was panscanned and found no obvious source of leukocytosis. a repeat bronch was performed and a bal sent for culture. all lines were changed in ir. a repeat tee was done which revealed: interval development of cavitary space surrounding the bioprosthetic aortic root and aortic graft compared with post bypass images obtained intraoperatively. severe thickening of the aortic root was noted. the following day he was taken back to the or by vascular for a bilateral lower extremity debridement. on ep reevaluation felt that mr. rhythm would recover. the temporary rv pacing lead was discontinued. he weaned to extubate. he remains anuric and cvvh continues. her continued to improved and was advanced to a soft solid diet. he was found to have vre in his leg and was started on linezolid. he also complained of some vision loss in his r eye and was evaluated by opthamology and neurology. they was a dulling of the optic nerve on the r and could have been from his embolic issues. he had another leg debridement on and had a tunnelled hd line and picc placed on . on he became acutely short of breath and was reintubated. he became hypotensive and acidotic and was restarted on cvvh. he had a rising lactate and wbc up to 40,000. he had an abdominal and pelvic ct which was unremarkable. general surgery was consulted and he had a negative exploratory lap on . he continued to have an increased pressor requirement and remained acidotic. he also received large amounts of bicarb and volume. there was a family meeting on to communicate the gravity of the situation to them. echo on revealed 4+mr. after extensive thought, discussion and family meetings, it was decided that mr. condition was not survivable. this was explained to the family in detail and they understand. the patient was made dnr, then cmo. pressors were discontinued and ventillatory settings minimized. the patient died with his family at the bedside at 12:06pm. medications on admission: ambien 5 (1)/hs prn, asa 81(1), diltiazem cd 120 (1),chlorzoxazone 500 (3) prn, warfarin daily, deltasone 5 (1), dilauded 2-4 mg q4h prn, meds on tx from osh: ambien 5(1)hs prn, ditiazem cd 120(1), colchicine 0.6 mg qhs (pericarditis), amiodarone 200 mg daily, tylenol prn, vanco 1250 q 12h, ceftriaxone 2g q 24h, prednisone 5 mg daily,diazepam 10q6h prn, protonix 40(1),warfarin-4mg-held due to supratherapeutic inr discharge medications: . discharge disposition: expired discharge diagnosis: procedure:: bentall(29 stjude mech ao valved graft)-on coumadin -postop afib (on coumadin) -postop pericarditis -bicuspid aortic valve -recently seen at osh for right facial numbness/ likely tia on -aortic insufficiency -dilated ascending aorta -hyperlipidemia -hypertension -fungal endocarditis -bilat lower extremity compartment syndrome with vre infection -respiratory failure with prolonged intubation -renal failure -hepatic failure -sepsis discharge condition: expired discharge instructions: . followup instructions: . Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Other revision of vascular procedure Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Hemodialysis Arteriography of femoral and other lower extremity arteries Venous catheterization for renal dialysis Exploratory laparotomy Excision or destruction of other lesion or tissue of heart, open approach Open and other replacement of aortic valve Insertion of temporary transvenous pacemaker system Reopening of recent thoracotomy site Fasciotomy Closed [endoscopic] biopsy of bronchus Incision of vessel, lower limb arteries Nonexcisional debridement of wound, infection or burn Other myectomy Other repair of heart and pericardium Central venous catheter placement with guidance Diagnoses: Acute posthemorrhagic anemia Acute and subacute necrosis of liver Acute kidney failure, unspecified Severe sepsis Cardiac complications, not elsewhere classified Atrial fibrillation Subarachnoid hemorrhage Hemorrhage complicating a procedure Acute respiratory failure Defibrination syndrome Atrioventricular block, complete Cellulitis and abscess of leg, except foot 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 Other specified septicemias Septic shock Intestinal infection due to Clostridium difficile Infection with microorganisms without mention of resistance to multiple drugs Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other ascites Infection and inflammatory reaction due to other vascular device, implant, and graft Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Cerebral embolism with cerebral infarction Congenital insufficiency of aortic valve Arterial embolism and thrombosis of lower extremity Aspergillosis Displacement of lumbar intervertebral disc without myelopathy Ischemic optic neuropathy Infection and inflammatory reaction due to cardiac device, implant, and graft Nontraumatic compartment syndrome of lower extremity Septic arterial embolism Acute pericarditis in diseases classified elsewhere Acute venous embolism and thrombosis of subclavian veins Personal history of (corrected) congenital malformations of heart and circulatory system |
allergies: penicillins attending: chief complaint: asymptomatic major surgical or invasive procedure: : bental(29 stjude mech ao valved graft) history of present illness: 42 year old gentleman with a known bicuspid aortic valve and a dilated ascending aorta which has been followed by serial echocardiograms. his most recent echocardiogram showed mild to moderate aortic insufficiency however his ct scan showed his aortic root to measure 6.0cm. given the size of his aorta, he has been referred for surgical evaluation. he denies any chest pain, dyspnea, palpitations, edema or syncope but does admit to mild fatigue. past medical history: past medical history: bicuspid aortic valve aortic insufficiency dilated ascending aorta hyperlipidemia hypertension past surgical history: eye surgery social history: race: caucasian last dental exam: yrs ago lives with: wife contact: wife phone # occupation: hvac cigarettes: smoked no yes last cigarette hx: other tobacco use: denies etoh: < 1 drink/week drinks/week >8 drinks/week - 2 drinks/day illicit drug use: denies family history: family history: father with cad and stent at age 60. gf underwent cabg. mother and brother without issues. physical exam: physical exam pulse: 69 resp: 16 o2 sat: 100% b/p right: 116/69 left: 136/70 height: 70" weight: 196 general: well-developed male 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 sys/diastolic 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: 02:55am blood wbc-6.3 rbc-3.36* hgb-10.5* hct-29.5* mcv-88 mch-31.2 mchc-35.6* rdw-13.3 plt ct-191 02:55am blood pt-26.3* ptt-60.3* inr(pt)-2.5* 02:55am blood glucose-98 urean-16 creat-0.9 na-138 k-5.1 cl-102 hco3-28 angap-13 03:46am blood wbc-7.3 rbc-3.37* hgb-10.3* hct-29.4* mcv-87 mch-30.6 mchc-35.0 rdw-13.1 plt ct-148*# 03:46am blood plt ct-148*# 03:46am blood pt-18.2* ptt-34.3 inr(pt)-1.7* 03:46am blood glucose-98 urean-16 creat-1.0 na-138 k-4.8 cl-102 hco3-29 angap-12 03:46am blood mg-2.0 05:31am blood glucose-108* k-4.4 tee conclusions pre-bypass: 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 root is moderately dilated at the sinus level. the ascending aorta and arch are moderately dilated. the aortic valve is bicuspid. moderate (2+) aortic regurgitation is seen. there is no aortic stenosis. the mitral valve appears structurally normal with trivial mitral regurgitation. post-bypass: the patient is in sinus ryhthm on a phenylephrine infusion. #29 st. mechanical aortic valve graft appears well seated. there are no apparent peri-valvular leaks. washing jets are present. normal left ventricular function - ef50-55% trace mr remains. remainder of exam is unchanged. 02:55am blood wbc-6.3 rbc-3.36* hgb-10.5* hct-29.5* mcv-88 mch-31.2 mchc-35.6* rdw-13.3 plt ct-191 02:55am blood pt-26.3* ptt-60.3* inr(pt)-2.5* 02:55am blood glucose-98 urean-16 creat-0.9 na-138 k-5.1 cl-102 hco3-28 angap-13 brief hospital course: the patient was admitted to the hospital and brought to the operating room on where the patient underwent bental with #29 mechanical aortic valve. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. he was initially hypertensive and required a nicardipine gtt. he was started on lopressor and lasix. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable. on pod#1 he transferred to the floor. chest tubes and pacing wires were discontinued without complication. post opertatively he was noted to have a new lbbb which has since resolved. the patient was evaluated by the physical therapy service for assistance with strength and mobility. he was started on anticoagulation therapy his goal inr 2.5-3.5. he was given the following coumadin doses -5mg/7.5mg/7.5mg/7.5mg/5 mg with inr 2.5 at the time of discharge. 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 to home with visiting nurse services in good condition with appropriate follow up instructions. his first vna inr draw is to be done . medications on admission: preadmission medications listed are correct and complete. information was obtained from webomr. 1. lisinopril 5 mg po daily 2. levitra *nf* (vardenafil) unknown oral unknown 3. clindamycin 150 mg po frequency is unknown prn dental discharge medications: 1. aspirin ec 81 mg po daily rx *aspirin 81 mg 1 tablet(s) by mouth daily disp #*100 tablet refills:*0 2. furosemide 20 mg po q12h rx *furosemide 20 mg 1 tablet(s) by mouth daily disp #*5 tablet refills:*0 3. hydromorphone (dilaudid) 2-4 mg po q4h:prn pain rx *hydromorphone 2 mg tablet(s) by mouth q 4 hrs disp #*30 tablet refills:*0 4. metoprolol tartrate 50 mg po bid hold for hr < 55 or sbp < 90 and call medical provider. *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*1 5. ranitidine 150 mg po bid rx *ranitidine hcl 150 mg 1 tablet(s) by mouth twice a day disp #*30 tablet refills:*0 6. warfarin md to order daily dose po daily mechanical avr take as directed for inr goal 2.5-3.5 for mechanical valve rx *warfarin 5 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 7. lisinopril 2.5 mg po daily rx *lisinopril 2.5 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 8. milk of magnesia 30 ml po hs:prn constipation discharge disposition: home with service facility: amedisys discharge diagnosis: bicuspid aortic valve aortic insufficiency dilated ascending aorta hyperlipidemia hypertension eye surgery 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 minimal discharge instructions: shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions no lotions, cream, powder, or ointments to incisions no driving for approximately one month and while taking narcotics no lifting more than 10 pounds for 10 weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: wound check at cardiac surgery office on at 10:30a surgeon dr. on at 1:00p cardiologist: dr. on at 1:45pm please call to schedule the following: primary care dr in weeks coumadin for prosthetic aortic valve inr goal: 2.5-3.5 coumadin follow-up with dr. confirmed fax next inr draw: **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Resection of vessel with replacement, thoracic vessels Diagnoses: Anemia, unspecified Unspecified essential hypertension Thoracic aneurysm without mention of rupture Other and unspecified hyperlipidemia Other left bundle branch block Congenital insufficiency of aortic valve |
allergies: no known allergies / adverse drug reactions attending: chief complaint: polytrauma status post fall major surgical or invasive procedure: : 1. open reduction internal fixation left distal femur fracture with plate. 2. open reduction internal fixation right distal femur with plate. 3. open reduction internal fixation right hip fracture with tfn devices, 11 x 170 x 130. 4. hemiarthroplasty left hip with cemented unipolar stem, 44 mm head, 0 mm neck, #8 cemented. 5. closed treatment right proximal humerus fracture. : insertion of inferior vena cava filter : percutaneous tracheostomy; percutaneous endoscopic gastrostomy tube. history of present illness: 72f with a history of ms transferred from osh after fall from wheelchair sustaining bilateral femoral head/neck fx as well as sah/sdh. reported mechanical fall, in wheelchair d/t ms. + headstrike and loc. bps dropped to 80s systolic, intubated electively w/etomidate and succinylcholine. transfer via , recv'd fentanyl during xport. rec'vd 1700cc and 4u prbcs for hypotension w/bp in 120s on arrival to ed. past medical history: pmh: hypothyroid, hyperlipidemia, htn, ms, psh: unknown meds: tylenol, baclofen, amantadine, lasix, provigil, copaxone, lasix, lexapro 40', asa 81', simvastatin social history: wheelchair bound pre-admission. patient w no living relatives. attorney as executor of estate. taken care of by care giver, . tobacco/etoh/recreational drugs: denies family history: non-contributory physical exam: p/e on d/c: vs: 101.0 98 123/57 29 100% 0.5fm gen: wd bedbound f in nad heent: +large r frontal subgaleal hematoma; eomi; perrla; +tracheostomy w no erythema/drainage cv: rrr pulm: coarse breath sounds b/l abd: s/nt/nd; +peg tube in luq w no erythema/drainage; +suprapubic catheter in place ext: 2+ b/l lower extremity edema; b/l multipodus boots; l knee w staples at anterior incision; b/l lateral thigh incisions w staples in place; all incisions c/d/i w no erythema or drainage neuro: a&ox0; opens eyes spontaneously; does not track; does not follow commands; does not vocalize; b/l le 0/5 strength; ue 1+/5 b/l pertinent results: laboratories: admit: 04:40pm blood wbc-40.9* rbc-4.06* hgb-12.8 hct-36.2 mcv-89 mch-31.5 mchc-35.3* rdw-16.2* plt ct-105* 04:40pm blood pt-13.7* ptt-22.0 inr(pt)-1.2* 04:40pm blood glucose-151* urean-21* creat-0.6 na-143 k-4.0 cl-111* hco3-20* angap-16 04:40pm blood alt-36 ast-54* alkphos-85 totbili-0.7 08:00pm blood ck-mb-8 ctropnt-<0.01 04:40pm blood albumin-3.4* calcium-7.4* mg-1.8 discharge: 01:42am blood wbc-17.4* rbc-2.26* hgb-7.0* hct-20.7* mcv-92 mch-31.0 mchc-33.8 rdw-16.1* plt ct-413 01:42am blood glucose-115* urean-53* creat-1.0 na-141 k-4.4 cl-111* hco3-23 angap-11 01:42am blood calcium-8.1* phos-2.7 mg-2.3 12:00am blood heparin dependent antibodies- negative microbiology: : mini-bal: staph aureus coag +. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ <=0.5 s : ucx: yeast. >100,000 organisms/ml.. imaging: ct pelvis : 1. complex fracture of the right femoral neck and intertrochanteric region. 2. complex fracture of the left femoral neck. 3. bilateral complex supracondylar fractures. 4. bilateral hemarthrosis of the knees. 5. subcutaneous soft tissue hematoma tracking along bilateral thigh. 6. severe osteopenia. 7. degenerative changes in the lower lumbar spine, si and hip joints. 8. suprapubic foley catheter in the urinary bladder and air in the urinary bladder, presumably from catheter placement; correlate clinically. 9. nonspecific fat stranding about the rectum; correlate clinically. ct max/sinus : 1. multiple maxillofacial fractures including the posterior sphenoid sinus, anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial wall of the right maxillary sinus and anterior wall of the left maxillary sinus and nasal bones . the bones are diffusely demineralized which makes identification of any additional fractures difficult to exclude. 2. paranasal sinuses are filled with hyperdense material, likely blood. 3. small foci of pneumocephalus posterior to the right frontal sinus. an underlying dural tear and csf leak cannot be excluded. 4. diffuse intracranial hemorrhage better characterized on concurrent head ct. ct head : 1. slightly increased small extra-axial hematoma overlying the left frontal lobe convexity and possible small secondary frontal hematoma noted on the right. 2. stable bilateral subarachnoid hemorrhage layering around the bifrontal and temporal lobes and extending into the suprasellar, prepontine and interpeduncular cisterns with indentation on the pons. 3. likely anterior maxillary and nasal bone fractures better evaluated on subsequent maxillofacial ct. opacification of the paranasal sinuses likely related to blood. 4. subgaleal hematoma overlying the right frontal bone. ct head : no significant change compared to study performed approximately 12 hours prior. multifocal subarachnoid, subdural, or intraventricular hemorrhage is redemonstrated, as is a contusion involving the left inferior frontal lobe. extensive facial fractures with blood in the paranasal sinuses was better characterized on prior dedicated facial bones ct. there is again no midline shift or evidence of central brain herniation. mri c-spine : 1. no obvious focus of marrow edema in the cervical vertebrae. multilevel, multifactorial degenerative changes, with adequate assessment is significantly limited on the axial images, due to motion-related artifacts. vague areas of cord signal intensity are noted, inadequately assessed on the present study. areas of altered signal intensity in the thecal sac may relate to blood products/pulsation artifacts or a combination of both given the presence of subarachnoid and intraventricular hemorrhage on prior ct head study. ct t/l spine : 1. acute compression fracture of the t3 vertebral body, with buckling of the posterior cortex, the inferior aspect of which is displaced posteriorly by approximately 3 mm. suspected t2 vertebral body fracture (seen on concurrent cervical spine mri) is not apparent by ct. 2. compression deformities involving the t11, t12, and l1 vertebral bodies. while as detailed above these may be chronic, given the concurrent acute injury in the upper thoracic spine, it is difficult to exclude an acute component. mr t/l spine : 1. areas of marrow edema in the t2 and t3 vertebral bodies, with mild contour irregularity of the posterior cortex of t3 which is seen to indent the ventral thecal sac and the ventral surface of the cord. osseous details are better assessed on the prior ct. mild diffuse disc bulge, with small-to-moderate sized disc extrusion, on the right side deforming the right side of the cord at t7/8. small central protrusion at t6-t7 level indenting the ventral thecal sac and ventral cord. moderate loss of height t12 vertebral body with schmorl's nodes, likely chronic. mild-to-moderate loss of height of the l1 vertebral body, with a schmorl's node with an acute component of marrow edema in the l1 vertebral body. multilevel disc and facet degenerative changes in the lumbar spine with mild foraminal narrowing at l4 and l5 levels. 2. diffusely altered signal intensity in the thecal sac, may relate to pulsation artifacts; however, blood products cannot be completely excluded given the presence of subarachnoid and intraventricular hemorrhage on the prior ct head study. 3. vague areas of increased signal intensity in the thoracic cord, nature of which is uncertain. assessment of cord lesions is limited due to artifacts. attention on followup can be considered. 4. diffuse hypointense signal of the marrow- correlate with hematology labs. 5. bilateral pleural effusions and distended gall bladder -correlate with dedicated imaging. ct head : 1. minimal increase of the intraventricular hemorrhage layering in the occipital horns. otherwise, no change of the intraparenchymal, subarachnoid and subdural hemorrhage. 2. no shift of midline structures and no intracranial herniation. 3. stable minimal dilatation of the ventricles. pathology: : bone, left femoral head, hemiarthroplasty: - bone and cartilage with changes consistent with fracture site. - bone marrow with an atypical lymphoid infiltrate, consistent with known history of chronic lymphocytic leukemia. current labs: 04:27am blood wbc-21.4* rbc-2.94* hgb-8.8* hct-27.6* mcv-94 mch-29.7 mchc-31.7 rdw-16.1* plt ct-546* 04:45am blood wbc-20.1* rbc-2.89* hgb-8.6* hct-26.6* mcv-92 mch-29.9 mchc-32.5 rdw-16.6* plt ct-473* 04:27am blood plt ct-546* 04:45am blood plt ct-473* 04:27am blood gran ct-2573 04:45am blood gran ct-3618 04:27am blood glucose-116* urean-46* creat-0.9 na-142 k-5.6* cl-110* hco3-23 angap-15 01:38pm blood na-144 k-5.6* cl-112* 04:45am blood glucose-119* urean-47* creat-0.9 na-144 k-5.4* cl-112* hco3-21* angap-16 12:51am blood glucose-133* urean-51* creat-1.0 na-143 k-4.7 cl-112* hco3-20* angap-16 04:27am blood calcium-8.5 phos-3.4 mg-2.5 04:45am blood calcium-8.6 phos-3.2 mg-2.5 brief hospital course: patient was transferred from osh via intubated and sedated. stat trauma protocol was initiated on arrival to ed. evaluation was carried out by acs trauma team and ed trauma. imaging was obtained as per above. patient was tachycardic/hypotensive despite crystalloid fluid resuscitation. 4 units prbc were given in trauma bay. patient was then stabilized and admitted to the tsicu for further management. neuro: at baseline patient is wheelchair bound secondary to ms. cognitive baseline is described as mentally sharp with ability to do crossword puzzles. on arrival to ed patient was not seen to be spontaneously moving extremities and not following commands. this mental status persisted throughout admission. ct head obtained on admission demonstrated traumatic brain injury (left frontal subdural hematoma and scattered frontotemporal subarachnoid hemorrhage). this was found to be grossly stable on interval imaging during admission. seizure prophylaxis was administered per neurosurgical recommendation. patient will follow up with neurosurgery with interval imaging per instructions. throughout hospital course patient was given pain medication with good effect and adequate relief. tylenol and narcotics initially administered via iv and then transition to enteral with good effect. cv: patient demonstrated sinus tachycardia on admission to tsicu. this was minimally responsive to fluid resuscitation. beta blockade was initiated following confirmation of adequate pain control and stable hematocrit. this was titrated up with good effect. at time of discharge patient is on stable dose of metoprolol with no cardiac issues. vital signs were routinely monitored. pulmonary: patient was admitted intubated. respiratory support was continued. patient was febrile with desaturations. bronchoscopy was performed that demonstrated thick secretions and treatment was initiated for vap. given inability to wean from ventilatory support a tracheostomy was placed . procedure was tolerated well and remains in good position at time of discharge. at time of discharge patient tolerating t-piece supplemental oxygen with persistent requirement for q2-3 hour suctioning/pulmonary toilet. gi/gu: patient was npo with ivf at time of admission. enteral feeding was initiated with appropriate recommendations made by nutrition service. these were well tolerated and bowel regimen was given with good effect. enteral access via peg tube was obtained given expectation for long term inability to tolerate po intake. this was noted to be in good position and functioning well. at time of discharge patient on stable enteral feeding regimen and passing flatus/bms appropriately. patient was admitted with suprapubic catheter in place related to ms. this was continued throughout admission. following initial resuscitation lasix was utilized to assist in diuresis of massive volume previously required for cardiovascular support. at time of discharge patient with adequate urine output via pre-existing suprapubic catheter. intake and output were closely monitored. msk: patient sustained bilateral proximal and distal fractures of the femur that were repaired by orthopedics as per above . patient is discharge with recommendation to be non-weight bearing at bilateral hips but may have full range of active/passive motion at knees. multipodus boots used throughout admission per pt recommendations. patient was seen early by physical therapy who continued to work with patient throughout admission. patient was noted to have thoracic spine fractures as above. a brace was recommended by ortho spine. this was obtained during admission. she should wear this at all times when not in bed. in bed patient may be without brace on logroll precautions. facial fractures were evaluated by plastic surgery. nasal bone fracture was reduced at the bedside . other fractures non-operative per plastic surgery with no need for plastics follow up. heme: patient has a history of which was demonstrated via wbc in 40s on admission. patient was transfused 4 prbc prior to arrival in tsicu related to refractory hypotension at osh. patient was further transfused 3 prbc, 1 ffp and 1 platelets while in operating room with orthopedics. hematocrit was persistently low without appropriate increases seen on prior day's transfusions. three additional units of prbc were transfused and patient's hematocrit remained stable in the low to mid 20s for remainder of admission. hematology/oncology were consulted during this admission for considerations of in trauma patient. they recommended further workup of hematologic malignancy if patient manifested symptoms of hematologic dysfunction which she did not. an ivc filter was placed given likelihood of protracted immobility and multiple orthopedic injuries. lenis had been obtained prior to this () and these were negative. a hit panel was sent for concern of low platelets during this admission and this was found to be negative. heparin products were briefly held related to this but resumed when negative test was found. id: patient had recently completed a course of antibiotics for uti at time of admission. patient was febrile on and pan cultures were obtained. given desaturations and cxr findings at this time vap protocol was initiated with triple antibiotic therapy (vancomycin, cefepime and cipro). bal specimens demonstrated mrsa on and . antibiotics were tailored appropriately. cipro was discontinued and fluconazole started for finding of yeast in bal and ucx. cefepime was discontinued . at time of discharge patient is completing 14 day course of vancomycin and fluconazole and had been afebrile for over 72 hours. vancomycin and fluconazole have been discontinued. prophylaxis: see heme. disposition: patient was actively screened for appropriate post-hospital care and was accepted to facility. regarding code status health care proxy has stated that patient is full code. discussions prior to injury hcp states that patient never wanted to discuss things of this nature. at the time of discharge on , the patient was doing well, afebrile with stable vital signs, tolerating enteral feeding, bedbound, voiding via suprapubic catheter, and pain was well controlled. of note: borderline potassium of 5.6 reported on . 15 gm kayexalate given. please repeat potassium and patient was not started on home lasix dose while hospitalized because of borderline creatinine. please resume 40 mg lasix daily ( records unclear as to home dose....40 mg daily or 40 mg ) continue to monitor lytes/creat.) medications on admission: : copaxone, lasix, lexapro 40', asa 81', simvastatin discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 2. amantadine 100 mg capsule sig: one (1) capsule po daily (daily). 3. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 5. glatiramer 20 mg kit sig: one (1) kit subcutaneous daily (). 6. baclofen 10 mg tablet sig: one (1) tablet po q am (). 7. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 8. insulin regular human 100 unit/ml solution sig: one (1) per sliding scale injection asdir (as directed). 9. glucagon (human recombinant) 1 mg recon soln sig: one (1) mg recon soln injection q15min () as needed for hypoglycemia protocol. 10. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 12. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection (2 times a day). 13. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 14. metoprolol tartrate 50 mg tablet sig: two (2) tablet po q6h (every 6 hours): hold for systolic bp <110, hr <60. 15. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 16. dextrose 50% in water (d50w) syringe sig: 12.5 g intravenous prn (as needed) as needed for hypoglycemia protocol. 17. neutra-phos sig: one (1) packet once a day: please continue to monitor phos. 18. lasix 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: hospital - discharge diagnosis: 1. traumatic brain injury (left frontal subdural hematoma, scattered frontotemporal subarrachnoid hemorrhage) 2. bilateral intertrochanteric fractures 3. bilateral distal femur fractures 4. multiple maxillofacial fractures including the posterior sphenoid sinus, anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial wall of the right maxillary sinus and anterior wall of the left maxillary sinus and nasal bones discharge condition: mental status: confused - always. level of consciousness: lethargic and not arousable. activity status: bedbound. discharge instructions: you were admitted to the acute care surgery service for management of polytrauma secondary to fall. general discharge instructions: please resume all regular home medications, unless specifically advised not to take a particular medication. please take any new medications as prescribed. please take the prescribed analgesic medications as needed. you may also take acetaminophen (tylenol) as directed, but do not exceed 4000 mg in one day. please also follow-up with your primary care physician within three weeks of discharge. continue nursing care, enteral feeding, physical therapy per attached. followup instructions: please follow up in clinic in approximately two weeks. call ( at time of discharge to arrange appointment. clinic located at , medical office building, . please follow up with dr. , neurosurgeon, in approximately one month. call ( at the time of discharge to arrange an appointment to be seen and to have a non-contrast ct scan of the head on the day of your appointment. please follow up with dr. . , orthopedic surgeon, in two to four weeks. call ( at the time of discharge to arrange an appointment. please follow up with dr. , orthopedic spine surgeon, in four weeks. call ( at time of discharge to arrange an appointment. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Interruption of the vena cava Enteral infusion of concentrated nutritional substances Other bronchoscopy Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Partial hip replacement Closed [endoscopic] biopsy of bronchus Open reduction of fracture with internal fixation, femur Open reduction of fracture with internal fixation, femur Closed reduction of nasal fracture Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Unspecified essential hypertension Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism 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 Alkalosis Pressure ulcer, lower back Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Multiple sclerosis Ventilator associated pneumonia Accidents occurring in residential institution Closed supracondylar fracture of femur Chronic lymphoid leukemia, without mention of having achieved remission Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration Closed fracture of nasal bones Pressure ulcer, stage I Closed fracture of intertrochanteric section of neck of femur Other accidental fall from one level to another |
allergies: erythromycin attending: chief complaint: atrial flutter, etoh withdrawl major surgical or invasive procedure: ablation of atrial flutter drainage of molar abscess history of present illness: mr. is a 65m with a pmh s/f etoh abuse and a tachyarrhythmia in the past that the patient cannot identify who is presenting with atrial flutter and etoh withdrawl. the patient has been an alcoholic for 40 years off and on, where he intermittently consumes ~1 quart of vodka daily, of note he denies any prior history of withdrawl seizures. his last drink was on monday at 8pm. on tuesday he was at a dental appointment for a tooth extraction, where he was noted to be tremulous. the dentist took his pulse and noted him to be tachycardic. he was sent to ed. from there he was medically cleared to be transferred to for etoh detox. at the patient was placed on an ativan sliding scale. at 8pm on , the on-call physician was called for a rapid hr to 144 despite three doses of ativan. he was otherwise hemodynamically stable. he was transferred to for further evaluation. . in the emergency department initial vitals were 96.8, 142/107, 146, 18, 100% on 2l. ciwa score on arrival to the ed was 21 he recieved a total of 30mg iv diazepam. vagal maneuvers were unsuccessful. after 18mg of iv adenosine (6mg followed by 12mg), his rate slowed down to 110s and revealed 3:1 atrial flutter. at that time he recieved a total of 3l of ns, and 3 10mg iv diltiazem doses. a diltiazem drip was started at 10mg/hr with minimal effect. he was transferred to the icu for further monitoring. . ros is negative for any changes in vision, headache, chest pain, palpitations, dyspnea, light-headedness, abdominal pain, or weakness. ros is notable only for tremor and nausea past medical history: htn gerd s/p multiple cva's: last one seven months ago, where the patient presented with dysarthria obstructive sleep apnea etoh abuse: no history of withdrawl seizures social history: 40 year history of etoh abuse, off an on since his 20s. during active periods, he consumes ~8 drinks/day. he has been smoking 2 packs per day over the past 30 years. he denies any other substance abuse. family history: non contributory physical exam: t=98.6... bp=140s systolic... hr=140s... rr=13... o2=97% ra . . physical exam general: alert and oriented x3, tremulous, able to answer questions appropriately. nad heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. dry mucous membranes. op clear. neck supple, no lad, no thyromegaly. neck: no carotid bruits cardiac: regular rhythm, tachycardic, unable to auscultate any murmurs secondary to rapid rate lungs: inspiratory and expiratory wheezes diffusely. abdomen: nabs. soft, nt, nd. no hsm extremities: no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout. psych: listens and responds to questions appropriately, pleasant pertinent results: ================== admission labs ================== wbc-7.6 rbc-3.98* hgb-13.2* hct-37.2* mcv-93 mch-33.0* mchc-35.4* rdw-13.8 plt ct-170 pt-13.1 ptt-26.3 inr(pt)-1.1 glucose-114* urean-15 creat-1.0 na-140 k-4.1 cl-107 hco3-24 angap-13 ck(cpk)-72, ctropnt-<0.01, calcium-8.3* phos-3.4 mg-1.3* ===================== transthoracic echo () ===================== the left atrium is mildly dilated. mild spontaneous echo contrast is seen in the body of the left atrium. no thrombus is seen in the left atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. impression: mild spontaneous echo contrast in the left atrial appendage. no thrombus in the left atrial appendage. normal left ventricular function. mild mitral regurgitation. ============= chest x-ray ============= the cardiomediastinal silhouette is within normal limits. there is no pneumothorax, consolidation, or pleural effusion. the pulmonary vasculature is normal. the osseous structures appear within normal limits. impression: no acute cardiopulmonary process. ================== discharge labs ================== wbc-6.7 rbc-3.82* hgb-12.5* hct-36.0* mcv-94 mch-32.8* mchc-34.8 rdw-14.1 plt ct-188 pt-13.9* inr(pt)-1.2* glucose-97 urean-13 creat-0.9 na-140 k-3.6 cl-107 hco3-26 angap-11 calcium-9.3 phos-3.9 mg-1.6 blood tsh-1.4 brief hospital course: mr. is a 65m with a pmh s/f etoh abuse and atrial flutter in the setting of alcohol withdrawal, status post ablation. below is a problem based summary of this hospitalization: . #. atrial flutter: likely related to underlying un-diagnosed copd given smoking history. patient was placed on heparin drip and electrophysiology consultation was obtained. patient was taken to radiofrequency ablation of atrial flutter which was found to be typical counter-clockwise at rate of 220 msecs. hv intervals and sa nodes were normal, and no atrial flutter was inducible after ablation. patient will be anticoagulated for 4 weeks, with coumadin (inr goal ) with lovenox bridge. on discharge, inr was 1.8 and he had been on 3 days of coumadin 5 mg daily. patient will also be maintained on atenolol per pre-admission medications. this information was relayed to his pcp, . who will follow his inr. clinic appointment was also arranged for the patient. . #. etoh withdrawal: patient was closely monitored and maintained on diazepam per ciwa scale > 10. patient was also maintained on mvi, thiamine, folate. . # dental abscess: pt had abscess involving molar #19. he was seen by omfs and underwent drainage of abscess. he was discharged on 7 days po clindamycin and can follow-up with his outpatient dentist prn. . #. history of cva: we continued home asa but discontinued his plavix as it was deemed no longer necessary. . #. htn: patient had good bp control on atenolol. . #. gerd: we continued home regimen of omeprazole . fen: patient tolerated a cardiac healthy diet ppx: -dvt ppx: on systemic anticoagulation -bowel regimen: colace -pain management: tylenol as needed. access: piv's code status: patient remained full code during this admission. medications on admission: plavix 75mg daily atenolol 50mg daily omeprazole 20mg daily asa 325mg daily lipitor 40mg daily mvi daily thiamine 100mg daily folic acid 1mg daily ativan taper -lorazepam 1mg on -lorazepam 1mg x1 on am of discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 2. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*30 patch 24 hr(s)* refills:*2* 7. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours) for 1 weeks. disp:*120 tablet(s)* refills:*0* 8. enoxaparin 60 mg/0.6 ml syringe sig: one (1) subcutaneous (2 times a day) for 4 days. disp:*8 syringe* refills:*1* 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. warfarin 5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). disp:*30 tablet(s)* refills:*2* 11. atenolol 50 mg tablet sig: 1.5 tablets po daily (daily). 12. clindamycin hcl 150 mg capsule sig: one (1) capsule po four times a day for 7 days. disp:*28 capsule(s)* refills:*0* discharge disposition: home facility: - discharge diagnosis: primary: atrial fibrillation alcohol withdrawal dental abscess discharge condition: hemodynamically stable, with sinus rhythm and with ongoing alcohol withdrawal symptoms. discharge instructions: you were admitted to the hospital with a rapid heart rate after you stopped alcohol intake. we helped to control your withdrawal and were able to perform a procedure to keep this type of fast heart rate from happening. you will need to continue anticoagulation for 4 weeks, with a medication called coumadin. dr. will check your coumadin level on monday. you also had an abscess in your tooth which was removed by the oral surgeon. please follow up with your dentist after this procedure. you should take an antibiotic called clindamycin for 7 days to prevent infection after your operation. please keep all doctors and take medications as prescribed. if you experience any nausea, vomiting, fevers, chest pain, palpitations, or any other symptoms that concern you, please seek medical attention immediately. please stop smoking. information was given to you on admission regarding smoking cessation. followup instructions: primary care: please attend the appointment at dr. office with nurse, on monday at 1:40pm for your coumadin level checked and coumadin teaching. . you also have an appointment with dr. phone: ( date/time: monday at 2:45pm. . please call to make an appointment with your regular dentists for follow-up. . cardiology: provider: . , , phone: ( date/time: office will call you with an appt md Procedure: Diagnostic ultrasound of heart Excision or destruction of other lesion or tissue of heart, endovascular approach Cardiac mapping Extraction of other tooth Diagnoses: Other primary cardiomyopathies Obstructive sleep apnea (adult)(pediatric) Esophageal reflux Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrial flutter Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Other and unspecified alcohol dependence, continuous Alcohol withdrawal Periapical abscess without sinus |
allergies: penicillins / arterial line in right radial attending: chief complaint: s/p failed gallstones removal c/b gallbladder perforation major surgical or invasive procedure: ir guided attempted removal of gallstones and fragmented cholecystostomy tube (failed attempt), complicated by perforation of the gallbladder. history of present illness: mr. is a 61 y/o male with h/o htn, copd, chronic renal disease on hd, s/p aaa repair and cholecystitis who was admitted to the micu after a failed attempt to remove stones/biliary dilation and removal of previous catheter fragment that was complicated by gallbladder/cystic duct perforation. the patient presented with acute cholecystitis on and underwent percutaneous cholecystostomy; at that time as based on his comorbidities he was not felt to be a good surgical candidate. since then he has undergone ercp x 2 with sphincterotomy as well as failed laparoscopic cholecystectomy because of adhesions on . his cholecystostomy tube came out accidentally and a new percutaneous tube was replaced on . unfortunately this cholecystostomy tube was severed by vna, leaving him with a cathetar fragment at his ostomy site. . of note, all of his prior care has been at . he was referred to ir (dr. for a cholangiogram via his existing cholecystostomy tube +/- stone extraction, catheter fragment removal and sphincteroplasty. the procedure performed yesterday was unsuccessful in removing the gallbladder stones or the catheter fragment, and was also complicated by gallbaldder/cystic duct perforation. pt was hemodynamically stable, complaining only of ruq pain (). . this morning pt had episodes of hypotension with sbp's to the 70's prior to dialysis. pt was mentating well, tmax of 100.1. pt not currently complaining of abdominal pain. pt was transferred to the micu because of concern for sepsis following perforation. past medical history: -hypertension -copd on home oxygen (2l) -chronic renal disease on hd (t,th,sat schedule. last hd on saturday ) -open aaa repair in c/b abdominal wall hernia repaired with mesh. -thoracic aortic aneurysm, s/p endograft repair -s/p lue avf -cholelithiasis -sleep apnea -hypercholesterolemia -cva -recent (diagnosed via mri) -arthritis social history: - tobacco: 2-3packs/day x 40 years - alcohol: very heavy drinker x 15 years - illicits: none family history: - no family history of gallstones - kidney stones: brothers physical exam: vitals: t:97.5 bp:90/50 p:79 r:12 o2:99% 2l general: alert, interactive, oriented, no acute distress heent: sclera anicteric, mucus membranes , oropharynx clear, eomi neck: supple cv: regular rate and rhythm, normal s1 + s2, gii systolic and diastolic murmer at rusb, gii holosystolic and diastolic murmer at lsb, no rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, mild distension, ostomy site clean with bandage in place and cholecystostomy drain with serosanguinous drainage in bag, +bs ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema micu admission exam: vitals: t: 99.5 bp: 83/48 p: 85 r:9 18 o2: 100% on ra general: alert, oriented, no acute distress heent: sclera anicteric, dry mucous membranes, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, mild tenderness to palpation in the ruq, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact pertinent results: admission labs: 09:40pm blood wbc-11.1* rbc-3.57* hgb-9.7* hct-29.4* mcv-82 mch-27.1 mchc-32.9 rdw-16.0* plt ct-309 10:40am blood neuts-79* bands-0 lymphs-9* monos-10 eos-1 baso-0 atyps-1* metas-0 myelos-0 10:40am blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-normal microcy-1+ polychr-1+ ovalocy-1+ schisto-occasional tear dr 09:40pm blood glucose-102* urean-29* creat-4.6* na-138 k-4.0 cl-102 hco3-23 angap-17 05:35am blood calcium-8.2* phos-6.2* mg-2.1 05:35am blood alt-5 ast-10 ld(ldh)-158 alkphos-65 totbili-0.2 09:40pm blood pt-12.5 ptt-34.0 inr(pt)-1.2* 03:24am blood cortsol-8.7 03:24am blood vanco-18.6 micro: bcx pending bcx negative ucx negative 9:58 am bile bile. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): enterococcus sp.. rare growth. enterococcus sp.. rare growth. second morphology. sensitivity testing performed by sensititre. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | enterococcus sp. | | ampicillin------------ <=2 s 0.5 s penicillin g---------- 4 s 2 s vancomycin------------ 1 s <=1 s anaerobic culture (final ): no anaerobes isolated. imaging: ct abd/pelvis (): 1. phlegmonous change within the gallbladder fossa with one intact pigtail catheter in place. there is also a fragment present laterally within no drainable collection identified. adjacent inflammatory fat stranding and pericholecystic fluid. 2. moderate duodenal diverticulum. 3. simple cysts within both kidneys. 4. multiple stable subcentimeter hepatic hypodensities which are too small to characterize. 4. intrahepatic ductal dilation with enhancement of the intrahepatic duct suggestive of cholangitis. 5. stable aneurysmal aorta and right common iliac artery. 6. sigmoid and ascending colon diverticulosis, without evidence of acute diverticulitis. . tte (): the left atrium is mildly dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . rue ultrasound (): no evidence of deep venous thrombosis in the right upper extremity. . cxr (): normal size of the cardiac silhouette. no lung parenchymal disease. brief hospital course: 61yom with h/o htn, copd, chronic renal disease on hd, s/p aaa repair and cholecystitis who was admitted after failed attempts by ir to remove stones and previous catheter fragment, complicated by gallbladder/cystic duct perforation and sepsis. . # hypotension/perforated gallbladder/common bile duct: the patient was admitted on following a failed ir attempt to remove gallstones and a cholecystostomy catheter fragment, which was complicated by gallbladder/cystic duct perforation with contrast seen extravasating from the gallbladder. post procedure bps were in the 90s from a baseline of 120-140 systolic, attributed to sedation with slow clearance in the setting of liver failure. he was covered with ceftriaxone and flagyl. however, he then became hypotensive with sbp 70's-80's the following morning on with low grade fever and increasing white count, and he was broadened to vanc/ for concern for early peritonitis and sepsis. blood pressures did not respond to several boluses of ivf and he was transferred to the micu, where he received 8l ns. his blood pressures stablilized and white count down-trended, fever resolved on vanc/. ct was concerning for cholangitis, but lfts did not show a cholestatic picture. ercp was consulted and did not have plans to intervene unless the patient developed a cholestatic hepatitis. surgery was consulted and is planning to perform an open cholecystectomy when he becomes medically stable. gb was determined to be adequately decompressed with his cholecystostomy tube at this time, and lfts were wnl. he was discharged with a plan to continue vancomycin/meropenem for a 2 week course. bile culture grew enterococcus sensitive to vancomycin. the patient was given acetaminophen and oxycodone was increased for pain control. gemfibrozil was discontinued, as this can precipitate gallstone formation. the day of discharge, there was question of whether the patient's insurance would cover his vancomycin and meropenem as an outpatient, but the patient refused to remain in-house to wait for confirmation of insurance approval. he will follow-up with his pcp as an outpatient regarding this, as he was refusing to remain in-house for this issue, despite knowing the risks of leaving. the day after discharge, on , the patient was called and he confirmed that the vna just finished giving him the iv antibiotics and confirmed that his insurance would cover enough antibiotics for 10 days, for a full course. . # anemia: the patient had hct 29 on initial presentation that slowly down-trended to 24 post-op. likely dilutional in the setting of missing hd due to hypotension vs slow blood loss from ostomy vs anemia of esrd without epo repletion given recent initiation of hd. he was transfused 2 units prbc in the micu with subsequent increased and stable hcts. he will receive epo with hd per renal. . # r hand ischemia: while in the micu, the patient developed cyanosis of the right hand, which was attributed to a-line insertion in the setting of visualized small caliber vessel. perfusion returned s/p removal of the line. surgery/hand consulted, felt there were no concerning findings. ??????s test normal. . # hd dependent esrd: the patient was initially on a t/th/sat hemodialysis schedule but while in the micu, his schedule was switched to m/w/f. he received an extra dose of hd in-house after being called out to the floor, as he initially missed hd while in the micu for sepsis. continued sodium bicarb 650 mg tid, sevelamer 1600 mg tid with meals. renal was following in-house. . # hypertension: patient was recently hypotensive in the setting of sepsis, and his home lisinopril and metoprolol were held until follow-up with his pcp. . # copd on home oxygen (2l): patient is currently asymptomatic, with no shortness of breath or wheezing. the patient is on 2l at home chronically but has been non-compliant with his oxygen use at home. he was intermittently on 2l nc in-house. his home regimen of tiotropium and albuterol were continued in-house. . #hypercholesterolemia: pt currently on simvastatin 40mg daily, continued in-house. . #cva: recent (diagnosed via mri). continued home aspirin 81mg daily. . . # code: full code transitions of care: - vancomycin, to be continued until - needs confirmation that insurance will cover outpatient medication - meropenem to be continued until - needs confirmation that insurance will cover outpatient medication - f/u bp; re-start lisinopril and metoprolol as bp tolerated - tamsulosin was stopped for hypotension; follow up pcp or nephrologist prior to re-starting this medication - furosemide was stopped for hypotension; follow up with nephrologist prior to re-initiation - percocet was increased in frequency temporarily for pain control post-procedure - gemfibrozil was stopped, as this can cause gallstones - genasyme was held; follow up with nephrologist or pcp before medications on admission: -aspirin 81mg daily -flovent (1puff twice daily) -furosemide 40mg -genasyme -lisinopril 20mg qd -metoprolol 100mg -gabapentin 100mg tab x 2 tabs tid -ursodiol 300mg -sevelemer 800mg tid -meclizine 12.5mg -darbepoetin injections on thursday -oxycodone/acetaminophen prn -simvastatin 40mg dialy -spiriva daily -budesonide 2 puffs twice daily -gemfibrizol 600mg -tamsulosin -sodium bicarbonate 325mg x 2 tabs three times daily discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. fluticasone 110 mcg/actuation aerosol sig: one (1) puff inhalation (2 times a day). 3. gabapentin 100 mg capsule sig: two (2) capsule po three times a day. 4. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). 5. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 6. meclizine 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). 7. darbepoetin alfa in polysorbat injection 8. oxycodone-acetaminophen 2.5-325 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain for 7 days: you should not drive or do anything that requires alertness while taking this medication. you should avoid drinking alcohol while taking this medication. . disp:*20 tablet(s)* refills:*0* 9. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 10. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 11. budesonide 90 mcg/actuation aerosol powdr breath activated sig: two (2) puffs inhalation twice a day. 12. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 13. sodium bicarbonate 325 mg tablet sig: two (2) tablet po three times a day. 14. meropenem 500 mg recon soln sig: five hundred (500) mg recon soln intravenous q24h (every 24 hours) for 10 days: last dose on . disp:*5000 mg recon soln(s)* refills:*0* 15. vancomycin in d5w 1 gram/200 ml piggyback sig: 1000 (1000) mg intravenous hd protocol (hd protochol) for 10 days: last dose on . disp:*5000 mg* refills:*0* 16. normal saline flush 0.9 % syringe sig: one (1) injection injection twice a day: 10 cc of normal saline flush- before and after meropenem infusion. disp:*20 injections* refills:*0* discharge disposition: home with service facility: acclaim discharge diagnosis: perforated gallbladder/common bile duct sepsis acute on chronic renal failure 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 while you were at . you came to the hospital to have interventional radiology remove stones and a catheter fragment from your gallbladder. unfortunately the procedure was very difficult and it was not possible to remove the stones nor the catheter fragment. during the procedure your gallbladder was perforated and you had to be admitted to the hospital for observation. while you were in the hospital, your blood pressure dropped most likely due to your body reacting to a bacteria in the blood. your antibiotics were switched and you were in the intensive care unit until your blood pressure stabilized. you will be discharged on a course of antibiotics to be taken at home. you will have the vna who will be doing the antibiotic infusion daily. the infusion company called home therapy will be calling you tomorrow in the morning to set up the delivery time of your antibiotic. however, we were not able to get it approved by your insurance today given it is , we do not know the cost of your copay. we have recommended that you stay inpatient until this is cleared tomorrow morning, but you have refused. it is extremely important that you get the antibiotic- meropenem tomorrow in the afternoon. if you have any problems please call our floor at . while in the hospital, your kidney function was found to be abnormal, likely due to ****dehydration**** and your kidney function improved after receiving intravenous fluids. please call your dialysis unit on monday morning at 06:00 am to make sure if you will need to go on monday or back to your regular schedule tues/thurs/sat schedule. the following changes were made to your home medications: - vancomycin was started, to be continued until - meropenem was started, to be continued until - nephrocaps was started - sevelamer was increased - percocet was increased in frequency temporarily - gemfibrozil was stopped, as this can cause gallstones - tamsulosin was stopped; please follow up with your kidney specialist or your primary care physician before this medication - furosemide was stopped; please follow up with your kidney specialist or your primary care physician before this medication - genasyme was held; please follow up with your kidney specialist or your primary care physician before this medication -lisinopril was stopped; please follow up with your kidney specialist or your primary care physician before this medication -metoprolol was stopped; please follow up with your kidney specialist or your primary care physician before this medication followup instructions: department: hemodialysis please call your dialysis unit on monday morning at 06:00 am to make sure if you will need to go on monday or back to your regular schedule. please call your primary care physician, . , , and arrange to follow up with him within 5 days of discharge from the hospital. please call dr. in the surgery department at at ( and arrange to follow up with him within weeks after discharge to discuss removing your gallbladder. Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Removal of other therapeutic device Endoscopic retrograde cholangiography [ERC] Diagnoses: Other iatrogenic hypotension Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Renal dialysis status Pure hypercholesterolemia Tobacco use disorder Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage 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 Long-term (current) use of insulin Mechanical complication due to other implant and internal device, not elsewhere classified Other sequelae of chronic liver disease Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Personal history of noncompliance with medical treatment, presenting hazards to health Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Unspecified sedatives and hypnotics causing adverse effects in therapeutic use Obstruction of bile duct Calculus of gallbladder and bile duct without cholecystitis, without mention of obstruction Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft Arthropathy, unspecified, site unspecified Other dependence on machines, supplemental oxygen Alcohol abuse, in remission Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use Calculus of bile duct with other cholecystitis, with obstruction Perforation of gallbladder Other digestive system complications |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cardiac cath coronary bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to posterior descending artery and distal circumflex artery. history of present illness: 62 year old male reports about a two year history of intermittent chest pressure that has no exertional component. he describes his discomfort as a very mild mid sternal pressure that occurs randomly and at rest several times a week, lasting about five to ten minutes before resolving spontaneously. about three to four weeks ago he went for an appointment with his new pcp. did an ekg and compared it to one from a few years ago and told him that there were significant changes and evidence of a possible mi. he was then referred to dr. for stress testing. imaging revealed a large fixed inferior defect with mild to moderate peri-infarction ischemia and an lvef of 31%. he was started on aspirin, lipitor and coreg and is was referred for cardiac catheterization. he was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. past medical history: borderline hypertension dyslipidemia mild glucose intolerance arthritis/ spinal stenosis chronic back pain/leg numbness possible sleep apnea (wife has witnessed periods of apnea) anxiety s/p hemorrhoid surgery hx of remote back surgery social history: race:caucasian last dental exam:edentulous lives with:wife contact: (wife) occupation:disabled from work cigarettes: smoked no yes last cigarette , quit 2 years ago and started smoking again 3 months ago, 1ppd x 20 years other tobacco use:denies etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use:denies family history: premature coronary artery disease- brother died in his late 50's from complications of heart disease and diabetes physical exam: pulse:86 resp:18 o2 sat:98/ra b/p right:179/88 left:172/91 height:5'7" weight:234 lbs temp: 99.9 general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema _____ varicosities: none neuro: grossly intact pulses: femoral right: (s/p cardiac cath, no bleed/hematoma) left: palp dp right: palp left: palp pt : palp left: palp radial right: palp left: palp carotid bruit right: none left: none pertinent results: cath: 1. selective coronary angiography of this right dominant system demonstrated severe three vessel coronary artery disease. the lmca had no significant stenoses. the lad had an 80% proximal lesion. the lcx was occluded proximally. the rca was occluded at mid-vessel with heavy calcification. 2. limited resting hemodynamics revealed severe systemic systolic arterial hypertension with an sbp of 176mmhg. . carotid u/s : 1. less than 40% stenosis of the right internal carotid artery. 2. 50-69% stenosis of the left internal carotid artery. . echo : pre-cpb: 1. the left atrium is moderately dilated. the left atrial appendage emptying velocity is depressed (<0.2m/s). no thrombus is seen in the left atrial appendage. 2. no atrial septal defect is seen by 2d or color doppler. 3. left ventricular wall thicknesses are normal. 4. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is moderately depressed (lvef= 30 %). the inferior wall is severely hypokinetic. 5. the right ventricular free wall is hypertrophied. the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. 6. there are simple atheroma in the ascending aorta. there are simple atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. 7. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. 8. the mitral valve leaflets are moderately thickened. mild (1+) mitral regurgitation is seen. 9. there is a trivial/physiologic pericardial effusion. dr. was notified in person of the results. post-cpb: on infusion of epi, phenylephrine briefly. a paced. improved biventricular systolic function on inotropic support. lvef = 45%. inferior hypokinesis remains. mr remains 1+. the aortic contour is normal post decannulation. 04:45am blood wbc-11.3* rbc-4.00* hgb-11.5* hct-34.3* mcv-86 mch-28.8 mchc-33.7 rdw-13.5 plt ct-311 02:44pm blood wbc-8.9 rbc-4.83 hgb-14.0 hct-41.7 mcv-86 mch-29.0 mchc-33.6 rdw-13.3 plt ct-183 06:00am blood pt-13.0* ptt-30.9 inr(pt)-1.2* 07:25pm blood pt-12.4 ptt-33.6 inr(pt)-1.1 04:45am blood glucose-124* urean-22* creat-1.2 na-135 k-4.3 cl-96 hco3-31 angap-12 02:44pm blood glucose-105* urean-12 creat-1.0 na-135 k-4.0 cl-100 hco3-25 angap-14 brief hospital course: mr. was admitted following his cardiac cath which revealed severe three vessel coronary artery disease. he underwent surgical work-up and on he was brought to the operating room where he underwent a coronary artery bypass graft x 3 (left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to posterior descending artery and distal circumflex artery). cross-clamp time:61 minutes.pump time:74 minutes.please see operative report for surgical details. following surgery he was transferred to the cvicu for invasive monitoring in stable condition. within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. he weaned off pressor support. beta-blocker/statin/aspirin and diuresis was initiated. all lines and drains were discontinued per protocol. pod#1 he transferred to the step down unit for further monitoring. physical therapy was consulted for evaluation of strength and mobility. the following day he went into rapid atrial fibrillation which was treated with amiodarone. he converted into normal sinus rhythm. postoperatively serosanguinous drainage was evident from his sternal incision and iv abx was started. aggressive diuresis was continued. the remainder of his hospital course was essentially uneventful. his sternal drainage and edema improved and by pod# 7 only a scant amoune of sternal drainage was able to be expressed. his sternum remains stable with no or click. he was placed on oral abx for a 10 day course upon discharge. he was cleared for discharge to home with vna. wound check will be done in 1 week following discharge. mr. was advised of signs and symptoms of concern and advised to contact the cardiac surgery department if any of these changes occur. all follow up appointments were advised. medications on admission: alprazolam 0.25 mg, 1-2 times a day as needed atorvastatin 40 mg daily carvedilol 6.25 mg percocet 1 tablet every six hours as needed for back pain aspirin 325 mg daily aleve 220 mg capsule - 2 capsules a day as needed for pain discharge medications: 1. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 6. carvedilol 6.25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. furosemide 40 mg tablet sig: 1.5 tablets po twice a day for 10 days: then decrease to 1 tab twice daily until reevaluated by md. :*30 tablet(s)* refills:*0* 8. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po twice a day. :*120 tablet extended release(s)* refills:*2* 9. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): x 7 days then decrease to 2 tabs (400 mg)once daily x 7 days, then decrease to 1 tab (200 mg) daily until md advises differently. :*120 tablet(s)* refills:*2* 10. keflex 500 mg capsule sig: one (1) capsule po four times a day for 10 days. :*40 capsule(s)* refills:*0* 11. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. :*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 3 past medical history: borderline hypertension dyslipidemia mild glucose intolerance arthritis/ spinal stenosis chronic back pain/leg numbness possible sleep apnea (wife has witnessed periods of apnea) anxiety s/p hemorrhoid surgery hx of remote back surgery discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesia incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema + 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 1pm in the building cardiologist: dr. please call for a follow-up appointment in 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 (Aorto)coronary bypass of two coronary arteries Left heart cardiac catheterization Diagnoses: Obstructive sleep apnea (adult)(pediatric) Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Tobacco use disorder Mitral valve disorders Other postoperative infection Unspecified pleural effusion Atrial fibrillation Other and unspecified hyperlipidemia Anxiety state, unspecified Hypotension, unspecified 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 Family history of ischemic heart disease Urinary complications, not elsewhere classified Spinal stenosis, unspecified region Oliguria and anuria Other abnormal glucose Arthropathy, unspecified, site unspecified Elevated blood pressure reading without diagnosis of hypertension Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status. major surgical or invasive procedure: stereotactic brain biopsy on . history of present illness: per mr. wife, mr. has been acting "strangly" for the last month. he was staying at work all night or going into work early. he was unable to hold conversations or talking about things that did not make sense. prior to that his wife denies any changes in his mental status. he has been seeing his primary physcian who sent him for a neurology consult at the . he was found to be hypotensive by the neurologist and told to stop his blood pressure meds. he continued to have low blood pressure and mental status changes, and his pcp recommended coming to the emergency room at . past medical history: hypertension asthma incisional hernia social history: the patient drinks 3 to 5 beers weekly. he does not smoke cigarettes. he works at the . family history: he denies any family history of heart disease or cancer. physical exam: vital signs: temperature 98.3 f, blood pressure 82/58, pulse 80, respiration 20, and oxygen saturation 94% in room air. general: wd/wn, comfortable, nad. heent: pupils: bilaterally eoms full neck: supple. lungs: cta bilaterally. cardiovascular: rrr, s1/s2. abdomen: soft, nt, bs+ extremities: warm and well-perfused. neurological examination: mental status: awake and alert, cooperative with exam, flat affect. orientation: oriented to person, place, and had difficulty with date with time he was able to state than said . 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 or tremors. strength full power throughout. no pronator drift sensation: intact to light touch reflexes: b t br pa ac right 2+ 2+ left 2+ 2+ toes downgoing bilaterally coordination: normal on finger-nose-finger pertinent results: mr head w & w/o contrast : findings: there is a large frontal lobe mass identified extending from corpus callosum to both frontal lobes with central area of low t1 and high t2 signal with areas of low signal on susceptibility images indicating small areas of chronic blood products. there is an extensive enhancement identified in the mass. the location and the appearance of the mass are suggestive of a glioma or less likely a lymphoma. additionally, there is enhancement seen in the left frontal sulci as well as in the basal cisterns and internal auditory canals indicative of leptomeningeal spread of the neoplasm. there is mass effect on the anterior horns of both lateral ventricles. a prominent flow voids are identified adjacent to the inferior aspect of the neoplasm indicative of hypertrophic blood vessels or draining veins. impression: large bifrontal neoplasm extending through the corpus callosum likely a primary neoplasm such as glioma or lymphoma. hypertrophic vessels are visualized in the inferior aspect of the tumor, indicating vascular supply and whatever the diagnosis of glioma. leptomeningeal extension of the neoplasm is identified through the basal ganglia and internal auditory canal. ct torso : findings: chest: there are no pathologically enlarged thoracic lymph nodes. there is no pericardial or pleural effusion. there is mild dilatation of the esophagus. lung windows demonstrate no nodules or masses. the central airways are patent, without endobronchial lesions. there are no suspicious osseous lesions. abdomen: the liver, spleen, kidneys, adrenal glands, pancreas, and gallbladder are normal. there are no pathologically enlarged lymph nodes. there is an umbilical hernia containing fat and small bowel, without evidence of obstruction. there is no free fluid in the abdomen. delayed images demonstrate normal contrast excretion of the kidneys bilaterally. pelvis: the bladder is decompressed with a foley catheter. the pelvic bowel loops are unremarkable. there is no free fluid. there are no pathologically enlarged lymph nodes. bone windows demonstrate a lytic lesion in the posterior left iliac bone with a thick sclerotic border. no other focal lesions are identified. there are minimal degenerative changes of the spine. impression: 1. no evidence of mass in the chest, abdomen or pelvis. 2. umbilical hernia containing fat and small bowel. 3. nonaggressive-appearing lesion within the posterior left iliac bone, unlikely to represent a metastatic lesion. 4. mild esophageal dilatation. ct head w/o contrast : findings: again noted is extensive hypodensity involving both frontal lobes and the genu of the corpus callosum. there is persistent mass effect on the bilateral frontal horns. allowing for differences in slice selection, there may be slight interval increase in the diameter of the lateral ventricles. the left lateral ventricle measures 14 mm compared to 10 mm previously and the right lateral ventricle measures 14 mm compared to 12 mm previously. there is no shift of normally midline structures or evidence of uncal or transtentorial herniation. the 3rd and 4th ventricles are preserved. there is no evidence of hemorrhagic conversion. the -white matter differentiation is otherwise preserved without evidence of infarction. the visualized portion of the paranasal sinuses and mastoid air cells are well aerated. no osseous abnormality is identified. impression: extensive hypodense lesion in the bilateral frontal lobes with slight interval increase in the diameter of the lateral ventricles. third and fourth ventricles remain patent and basilar cisterns preserved. pathology examination from steriotactic biopsy : diagnosis: 1. brain, target point, stereotactic biopsy (a): glioblastoma multiforme, (who grade iv); see note. 2. brain, -4, stereotactic biopsy (b): glioblastoma multiforme, (who grade iv); see note. 3. brain -8, stereotactic biopsy (c): glioblastoma multiforme, (who grade iv); see note. 4. brain, -12, stereotactic biopsy (d): white matter infiltrated by glioma. 5. brain, -16, stereotactic biopsy (e): white matter with reactive gliosis and rare atypical cells. 6. brain, -20, stereotactic biopsy (f): white matter with reactive gliosis and rare atypical cells. note: the tumor displays hypercellularity, vascular proliferation, necrosis, and mitotic figures. gross: the specimen is received in the o.r. in 11 parts, all labeled with the patient's name, " " and the medical record number. each part consists of a 0.1 x 0.1 x 0.1 cm fragment of white soft tissue, except for the target point. part 1 is additionally labeled "target point" and measures 0.6 cm x 0.1 cm and is red in color. it is entirely submitted in cassette a. part 2 is additionally labeled "-2" and is consumed entirely by intraoperative smear diagnosis. smear diagnosis by dr. is: "malignant glioma". part 3 additionally labeled "-4", and is entirely submitted in cassette b. part 4 is additionally labeled "-6", and is consumed entirely by intraoperative smear diagnosis. smear diagnosis by dr. is: "malignant glioma". part 5 additionally labeled "-8", and is entirely submitted in cassette c. part 6 is additionally labeled "-10", and is consumed entirely by intraoperative smear diagnosis. smear diagnosis by dr. is: "malignant glioma". part 7 is additionally labeled "-12", and is entirely submitted in cassette d. part 8 is additionally labeled "-14" and is consumed entirely by intraoperative smear diagnosis. smear diagnosis by dr. is: "white matter with reactive gliosis and rare atypical cells". part 9 is additionally labeled "-16", and is entirely submitted in cassette e. part 10 is additionally labeled "-18", and is consumed entirely by intraoperative smear diagnosis. smear diagnosis by dr. is: "reactive gliosis with scattered atypical cells". part 11 is additionally labeled "-20", and is entirely submitted in cassette f. ct head without contrast post-op : findings: there is a new left frontal burr hole for stereotactic biopsy. there is a small focus of new hemorrhage along the biopsy path in the left frontal lobe (2:18). extensive vasogenic edema is again seen in association with the known mass involving both frontal lobes and the genu of corpus callosum, with unchanged mass effect on the frontal horns of the lateral ventricles. overall, the ventricles are stable in size. mild rightward shift of the anterior falx is stable. there is a large mucus retention cyst in the right maxillary sinus and a possible polyp in the left nasal cavity, as before. impression: small amount of blood along the left frontal biopsy path. no change in mass effect from the bifrontal mass. mri head () findings: study is slightly limited due to patient motion during examination. again demonstrated is a heterogeneous mass located within bilateral frontal lobes, and crossing the corpus callosum, compatible with biopsy proven glioblastoma multiforme. this mass measures grossly 6.5 cm x 4.6 cm, with central areas of susceptibility, particularly within the left frontal region, likely reflecting intratumoral hemorrhagic products from recent biopsy. the mass is situated in the expected location of the a2 segments of the anterior cerebral arteries, which are not clearly visualized. there is associated significant vasogenic edema of bilateral frontal lobes. significant mass effect on the adjacent frontal horns of the lateral ventricles and a rightward shift of normally midline structures by approximately 7 mm are not significantly changed. increased flair signal and enhancement surrounding the left lateral ventricular ependymal surface is noted. abnormal enhancement is also evident within the basal cisterns and in the region of the thalamus/tectal junction. these findings suggest subarachnoid spread of tumor with a differential diagnosis of infection, if clinically appropriate. no other foci of hemorrhage are identified. there is no infarct, without evidence of diffusion-weighted abnormality. mucus-retention cyst in the right maxillary sinus with mucosal thickening of the ethmoid sinuses is noted. impression: 1. large butterfly glioma in the frontal lobes, compatible with known glioblastoma multiforme, with associated significant mass effect and vasogenic edema, unchanged. 2. post-biopsy changes, including a small amount of intratumoral hemorrhage. 3. abnormal enhancement of the left lateral ventricular ependymal surface, in the basal cisterns, and in the thalamo-tectal junction. these findings could indicate subarachnoid spread of tumor. however, a concomitant infection could have a similar appearance and needs clinical correlation . an mri of the spine is recommended to assess for leptomeningeal involvement of the spinal axis. 4. incomplete visualization of the a2 segments of the anterior cerebral arteries. a dedicated mra or cta is recommended to assess for vascular patency. ct head () findings: again demonstrated is a large bifrontal mass, compatible with biopsy-proven gbm, with significant mass effect on the adjacent frontal horns of the lateral ventricles and rightward shift of midline by approximately 7 mm. surrounding low attenuation in bilateral frontal lobes is compatible with vasogenic edema, with a track of high density in the left frontal lobe compatible with post-biopsy hemorrhagic tract. these findings are not significantly changed from the prior study. the size of the ventricular system is stable, without evidence of new hydrocephalus. there are no other foci of intracranial hemorrhage. no major vascular territorial infarction is identified. visualized paranasal sinuses and mastoid air cells are normally aerated. osseous structures reveal biopsy burr hole in the left frontal bone. impression: no significant change in large bifrontal mass, compatible with biopsy-proven gbm, and associated significant mass effect on the adjacent lateral ventricles and rightward shift of midline. brief hospital course: the patient was admitted to the icu for q1 hour neuro checks after he was found to have a very large bifrontal brain mass. he had been given 1 dose of steroids at the outside hospital but they were not continued here in anticipation of a steriotactic brain biopsy. the patient had a ct torso that did not show evidence of metastatic disease. on his neurological examination changed and he was unable to speak. a stat head ct showed increased edema in the frontal region. at that time he was started on steroids due to his worsening examination and increased edema. afterwards, he improved significantly and was oriented x 3 and following commands. on , the patient had a steriotactic brain biopsy. the pathology revealed that the mass was a glioblastoma who grade iv. post-operatively the ct scan showed a new small hemorrhage at the surgical bed. he was transferred back to the icu still intubated. the patient was started on mannitol. on , the patient was extubated and his neurological examination was improved. his mannitol and steroids were weaned and he was transferred to the neuro step-down unit. he continued to be stable as the weaning of both mannitol and steroids continued and was transferred out of step-down to the floor on . in the afternoon of (after radiation planning appointment), he was found to have significant aniscoria (right greater than left) and sixth cranial nerve palsy. head ct was repeated; and found to have significantly worsened edema. he was given a one time dose of mannitol 50 gm, re-loaded with decadron 10 mg, and continued on decadron 4 mg every 6 hours. given his marked neurological decline, palliative care was again urgently consulted to assist with appropriate planning. at this time, the family changed his code status to include no cardiac compressions, defibrillation, or cpr; they agree to chemical code only. in subsequent hours, his neurological examination significantly improved to the point that he could possibly be discharged. in the setting of his progressive decline, and sensitivity to increasd steroids, emergent whole brain radiation was sought. pursuant to this plan, he was transferred to the 7 under the neuro-oncology service on to make arrangements for this to occur. from to , he received 5 of 22 total treatments of whole brain radiation. he also began temozolomide while in-house. he was started on bactrim prophylaxis since he was on both radiation and temozolomide. his neurological examination remained stable during this time with mild right greater than left anisicoria (1 mm difference), with brisk pupillary reflexes. he remained oriented x 2 (difficulty with date) and with 1/3 recall after 5 minutes. he had poor attention and poor comprehension of his disease. he was discharged on decadron 4 mg every 6 hours, with proton pump inhibitor, bowel regimen, and instructions to ambulate frequently in an attempt to prevent dvt. he was also discharged on . he is scheduled for follow-up on . medications on admission: albuterol sulfate 90 mcg hfa aerosol inhaler - 2 puffs q4 prn fluticasone 50 mcg spray 2 sprays each nostril qd flovent 110 mcg 2 puffs ; hctz lisinopril 1 qd; simivastatin; aspirin - 81 mg qd discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q6h (every 6 hours) as needed for wheezing. 2. fluticasone 50 mcg/actuation spray, suspension sig: one (1) spray nasal (2 times a day). 3. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. dexamethasone 4 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*100 tablet(s)* refills:*0* 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*14 tablet, delayed release (e.c.)(s)* refills:*0* 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 7. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 8. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 9. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. disp:*30 tablet(s)* refills:*0* 10. polyethylene glycol 3350 100 % powder sig: one (1) dose po daily (daily) as needed for constipation. disp:*1 month supply* refills:*0* 11. zofran odt 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po three times a day as needed for nausea. disp:*30 tablet, rapid dissolve(s)* refills:*0* 12. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 13. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 14. 1,000 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: visiting nurse discharge diagnosis: primary diagnosis: glioblastoma multiforme discharge condition: neurologically stable; r sided anisicoria, oriented x 2. discharge instructions: you were admitted to the hospital on with confusion. you were found to have a brain tumor. you had a brain biopsy on . the sutures have already been removed. you had 5 treatments of radiation so far and you have gotten 3 days of temozolomide chemotherapy. you can take zofran odt as needed for nausea. you are being discharged on steroids because of the swelling in your brain. you must take omeprazole to avoid stomach irritation with steroids. you must take a bowel regimen to make sure you have a bowel movement everyday while you are on steroids. if you do not have a bowel movement in two days call your doctor. you must also be sure to walk around at least 5 times per day to avoid clots in your legs. you are also being discharged on , anti-seizure medication, as you may be more prone to seizures now that you have a brain tumor. you are being discharged on bactrim to prevent infection now that you are getting radiation and chemotherapy. do not drive. do not do any heavy lifting. you are at an increased risk for falling with your brain tumor and confusion. you are being sent home with a vna for help with your medications and for a home safety evaluation. you will be contining your radiation and chemotherapy as an outpatient. general instructions and information: ?????? 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 have been discharged on (levetiracetam) as anti-seizure medication. ?????? you are being sent home on steroid medications, so 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. ?????? do not drive ?????? make sure to continue to use your incentive spirometer while at home. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: follow-up appointment instructions you have an appointment in the brain clinic on at 9:30 a.m. the brain clinic is located on the of , in the building on the . their phone number is . please call if you need to change your appointment, or require additional directions. when you go to radiation treatment on monday, please talk to the nurses about seeing a social worker so can be set up. Procedure: Closed [percutaneous] [needle] biopsy of brain Injection or infusion of cancer chemotherapeutic substance Other radiotherapeutic procedure Other immobilization, pressure, and attention to wound Diagnoses: Unspecified essential hypertension Asthma, unspecified type, unspecified Sixth or abducens nerve palsy Intracerebral hemorrhage Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Cerebral edema Other encephalopathy Iatrogenic cerebrovascular infarction or hemorrhage Anisocoria Memory loss Malignant neoplasm of frontal lobe |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cabg x4 (lima>lad, svg>diag, svg>om, svg>pda) history of present illness: 69 year old male with a history of coronary artery disease s/p remote mi, stent placement in the late 's and a positive stress test around 6 months ago. in , he presented to the emergency room with crushing substernal chest pain at rest with associated nausea and diaphoresis. he ruled in for mi and underwent cardiac catheterization which revealed 3 vessel coronary artery disease. cardiac surgery was consulted and preoperative evaluation was performed. the patient was discharged home to recover from his mi prior to surgical revascularization. he presents for elective cabg. past medical history: hypertension dyslipidemia coronary artery disease -- s/p multiple pci -- () s/p inferior mi no intervention -- () mid and distal rca stenting with three ps1530 -- () diag and multiple om branch disease on cath -- () rotational atherectomy of rca after exertional angina diabetes mellitus glaucoma social history: race:caucasian last dental exam:edentulous lives with: sister occupation:retired tobacco:quit friday , smoked 1 pack per week for 50years etoh:denies family history: brother with mi in his 50s, mother had mi physical exam: admission physical exam pulse:56 resp:16 o2 sat:98% ra b/p right:140/62 left: 160/67 height:5'5" weight:180 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr no murmur abdomen: soft non-distended non-tender bowel sounds + , obese extremities: warm , well-perfused + (b)le edema; no varicosities; neuro: grossly intact pulses: femoral right: left: dp right: 2+ left: 2+ pt : left: radial right: 2+ left: 2+ carotid bruit none pertinent results: 03:00pm blood wbc-6.9 rbc-1.85*# hgb-5.9*# hct-17.4*# mcv-94 mch-32.2* mchc-34.1 rdw-13.6 plt ct-48*# 04:50pm blood wbc-8.9 rbc-2.43*# hgb-7.9*# hct-22.9*# mcv-94 mch-32.7* mchc-34.7 rdw-13.8 plt ct-74*# 08:59pm blood wbc-10.6 rbc-3.05*# hgb-9.8* hct-27.9*# mcv-92 mch-32.3* mchc-35.3* rdw-13.9 plt ct-78* 12:58am blood wbc-8.5 rbc-3.04* hgb-9.4* hct-27.1* mcv-89 mch-31.1 mchc-34.8 rdw-14.0 plt ct-84* 04:40am blood wbc-6.0 rbc-3.02* hgb-9.8* hct-27.7* mcv-92 mch-32.4* mchc-35.2* rdw-14.1 plt ct-109* 04:30am blood wbc-6.1 rbc-3.01* hgb-9.6* hct-27.8* mcv-92 mch-31.7 mchc-34.4 rdw-13.8 plt ct-138* 03:00pm blood pt-16.9* ptt-33.1 inr(pt)-1.5* 03:00pm blood plt ct-48*# 04:50pm blood plt ct-74*# 08:59pm blood plt ct-78* 12:58am blood plt ct-84* 04:40am blood plt ct-109* 04:30am blood plt ct-138* 03:00pm blood fibrino-127* 04:50pm blood urean-23* creat-1.0 na-141 k-5.4* cl-116* hco3-22 angap-8 12:58am blood glucose-107* urean-21* creat-1.0 na-139 k-4.5 cl-110* hco3-23 angap-11 04:40am blood glucose-162* urean-23* creat-1.3* na-141 k-5.2* cl-107 hco3-27 angap-12 04:30am blood glucose-72 urean-29* creat-1.1 na-141 k-4.7 cl-106 hco3-28 angap-12 04:35am blood urean-25* creat-1.0 na-137 k-4.2 cl-100 introp tee : conclusions the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35 cm from the incisors. 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 no pericardial effusion. post bypass the patient is now s/p 4 vessel cabg,on an neosynephrine drip at 0.3mcg/kg/min and av sequentially paced lv function and ejection fraction are preserved with no new regional wall motion abnormalities there are no dissection flaps visible in the proximal ascending aorta there is persistent mild mitral regurgitation. cxr findings: there is residual small right apical pneumothorax which is similar-appearing compared to most recent prior. mild cardiomegaly is unchanged. there is minimal stable pulmonary vascular congestion. small bilateral pleural effusions are seen. impression: unchanged small right apical pneumothorax. brief hospital course: the patient was electively brought to the operating room on where the patient underwent cabg x4 lima>lad, svg>diag, svg>om, svg>pda). please see operative report for full details. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. postoperatively, he received a total of 3 units of prbcs for postoperative blood loss with a hct of 17. his hematocrit bumped appropriately to 27. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. on pod 3, the patient had a brief burst of rapid atrial fibrillation and beta blockade was increased. by the time of discharge on pod 4, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged on in good condition with appropriate follow up instructions. medications on admission: crestor 20mg daily metoprolol xl 50mg daily glyburide/metformin 5/500 2 tab actos 30mg daily doxyzosin 2mg daily lisinopril 40mg daily fenofibrate 160mg daily aspirin travatan z 0.004% 1 drop qhs ntg sl (but does not use) discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 2. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 5 days. disp:*5 tablet, er particles/crystals(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): please take stool softeners while taking narcotic pain medication. . 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain for 2 weeks: please do not drive or operate machinery while taking this medication. take stool softeners to prevent constipation. wean yourself off as tolerated. disp:*40 tablet(s)* refills:*0* 6. rosuvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 8. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime): per home regimen. 9. fenofibrate micronized 145 mg tablet sig: one (1) tablet po once a day. 10. doxazosin 2 mg tablet sig: one (1) tablet po at bedtime: per home regimen. 11. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 12. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 13. glyburide-metformin 5-500 mg tablet sig: two (2) tablet po twice a day: per home regimen. do not restart actos. please log your blood sugars and f/u with pcp. . discharge disposition: home with service facility: homecare discharge diagnosis: coronary artery disease hypertension hyperlipidemia diabetes mellitus discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage le edema: trace-1+ discharge instructions: discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: you are scheduled for a wound check on 6 with a midlevel provider on at 10am. surgeon dr. , md phone: date/time: 1:15 pcp/cardiologist dr. at 3:00pm **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Subendocardial infarction, subsequent episode of care |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: prostate cancer major surgical or invasive procedure: radical prostatectomy history of present illness: 57 y/o male with t2dm, htn, osa, and prostate cancer (recent psa 4.2, gl 6+7 disease comprising up to 90% of the cores on the right, ; h/o colovesical fistula/repair. got 10.0l ebl: 1.5l. difficult intubation requiring fiber optic scope - took 15 minutes. per anesthesia, would like monitoring overnight in unit before attempting extubation. ros: unable to obtain as patient is intubated and sedated past medical history: diverticulitis s/p exploratory laparotomy, sigmoid and left colectomy with mobilization of the splenic flexure, repair of bladder, and primary anastomosis s/p repair of his bladder from a fistula anti-platelet antibodies with chronic thrombocytopenia osa s/p palatal surgery t2dm htn hypothyroidism physical exam: vitals: t 101 bp: 100/65 hr: 107 gen: no acute distress, intubated heent: intubated, pupils small but reactive neck: no jvd cor: rrr, no m/g/r, normal s1 s2, radial pulses +2 pulm: rhonchorous throughout abd: soft, nt, jp drain in place draiing serosanguinous fluid ext: no , 2+ dp pulses bilaterally neuro: sedated skin: no rashes pertinent results: 07:06pm glucose-143* urea n-13 creat-1.0 sodium-139 potassium-4.3 chloride-108 total co2-22 anion gap-13 07:06pm calcium-7.9* magnesium-1.5* 07:06pm wbc-13.7* rbc-3.67* hgb-11.4* hct-32.5* mcv-89 mch-31.1 mchc-35.1* rdw-13.4 10:57pm lactate-3.7* 02:34pm type-art tidal vol-800 o2-100 po2-227* pco2-46* ph-7.30* total co2-24 base xs--3 aado2-440 req o2-76 intubated-intubated vent-controlled 05:10pm type-art temp-35.3 rates-10/ tidal vol-1100 peep-5 o2-60 po2-95 pco2-43 ph-7.34* total co2-24 base xs--2 intubated-intubated vent-controlled 10:57pm type-art temp-37.6 rates-/18 tidal vol-865 peep-5 o2-100 po2-153* pco2-44 ph-7.32* total co2-24 base xs--3 aado2-516 req o2-86 intubated-intubated vent-spontaneou imaging: cxr: no evidence of consolidation, ? blunting on cp angles bilaterally brief hospital course: 57 yo m with prostate ca 2/p radical prostatectomy with difficult intubation requiring fiber optic scope. admitted to icu for monitoring now s/p extubation. # difficult intubation: patient with fiber optic intubation, per anesthesia, needed monitoring overnight. required increased fentanyl for sedation. was sucessfully extubated and was on cpap overnight for osa. this morning was satting well on ra. # oliguria: the patient postoperatively had oliguria and was given lr boluses. this resolved with ivf. # anemia: hct decreased from 29.9 to 26.6 this am, on recheck was 26.3, likely secondary to dilution from ivf and intraoperative blood loss, ebl 1.5l. recheck pm hct, if continues to decrease would have a low threshold to scan his abdomen/pelvis with a ct to rule out rp bleed. # lower extremity numbness: patient had new onset numbness in her lower extremities b/l overnight which was improving this am. no motor deficits. unclear cause, possible related to how he was laying for the operation (possible nerve compression?). # positive ua: patient had trace le, pos nit, but >1000 rbc's. has colovesicular fistula in past. difficult to interpret ua in this setting. was on cefazolin post surgically, wihch has some urine pathogen coverage. per urology, expected to have dirty ua, no tx indicated at this time. # fever: the patient spiked a fever to 101 on and was cultured. unclear source, could be post-op vs infectious, slighly tachy to 100's with the fever. wbc elevated at 14.9, but decreased to 11.9 today. cx have been ngtd except for the dirty ua as above. no fever for the last day. # tachycardia: patient has been in the 90??????s to 100??????s; was on verapamil as an outpatient and this was held, so may be reflex tachycardia from this. received ivf yesterday without much response. his home verapamil was added back and ****. # prostate ca: t3n0m0, s/p radical prostatecomy. his jp tube continued to put out a large amount of serosanguinous fluid. # htn: patient is on verapamil and diovan as an outpatient. his pressures have been well-controlled, but he??????s been tachycardic. these medications were initally held perioperatively, however verapamil was restarted the day he left the micu. #hypothyroidism: the patient was continued on his home levthyroxine. he was admitted to urology after undergoing radical prostatectomy. no concerning intraoperative events occurred; please see dictated operative note for details. he received ancef for perioperative prophylaxis. he was transferred to the icu from the pacu in stable condition. on pod0 he remained intubated with large urine output from his jp. he was extubated on pod 1 and transferred to the floor on pod 2. his pain was well controlled on pca , hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis. a physical therapy consult was obtained who recommended home with vna. on pod3, he was restarted on his home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from pca to oral analgesics, diet was advanced to a regular diet with start of colace. jp removed pod5 without difficulty after drainage was <10 for the past 2 days. the remainder of the hospital course was relatively unremarkable. he was discharged in stable condition on pod1, ambulating independently, eating well, and with pain control on oral analgesics. on exam, his incision was clean, dry, and intact, with no evidence of hematoma collection or infection. he was given explicit instructions to follow-up in clinic with dr. in 1 week, and that the urethral catheter (foley) would be removed during the follow-up appointment. he was instructed to start 3 day course of ciprofloxacin on day prior to foley removal. medications on admission: diovan verapamil sr 240 mg po daily metformin 500 mg po bid levothyroxine 0.225mg daily discharge medications: 1. 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* 2. verapamil 240 mg tablet sustained release sig: one (1) tablet sustained release po q24h (every 24 hours). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): use while taking narcotics. disp:*60 capsule(s)* refills:*0* 4. levothyroxine 200 mcg tablet oral 5. cipro 500 mg tablet sig: one (1) tablet po twice a day for 3 days: start day before appointment. disp:*6 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: prostate cancer discharge condition: stable discharge instructions: -you may take motrin and narcotic together for pain control -you may shower 2 days after surgery, but do not tub bathe, swim, soak, or scrub incision for 2 weeks. -allow bandage strips to fall off over time, remove all remaining dressings in 2 days -no heavy lifting for 4 weeks (no more than 10 pounds) medical attention for fevers (temp>101.5), worsening pain, drainage or excessive bleeding from incision, chest pain or shortness of breath. -follow up in 1 week for wound check/foley removal -please do not drive or consume alcohol while taking pain medications. -take first dose of ciprofloxacin 1 day prior to foley catheter removal and for subsequent 2 days. - wear large foley bag for majority of time, leg bag is only for short-term when leaving house. followup instructions: 1-2 weeks Procedure: Division or crushing of other cranial and peripheral nerves Regional lymph node excision Radical prostatectomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified acquired hypothyroidism Malignant neoplasm of prostate Urinary complications, not elsewhere classified Oliguria and anuria |
allergies: morphine / ativan attending: addendum: discharged with the following meds. discharge medications: 1. simvastatin 40 mg tablet sig: 0.5 tablet po hs (at bedtime). 2. multivitamin tablet sig: one (1) tablet po daily (daily). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 4. zinc sulfate 220 mg capsule sig: one (1) capsule po bid (2 times a day). 5. amiodarone 200 mg tablet sig: 0.5 tablet po daily (). 6. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 7. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 8. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 11. gabapentin 100 mg capsule sig: one (1) capsule po daily (daily). 12. verapamil 120 mg tablet sig: one (1) tablet po q24h (every 24 hours). 13. lisinopril 2.5 mg tablet sig: one (1) tablet po daily (daily). 14. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 15. lantus insulin 8 (eight) units subcuatneous injection every evening. 16. regular insulin sliding scale breakfast lunch dinner bedtime glucose insulin dose 0-70 mg/dl proceed with hypoglycemia protocol 71-150 mg/dl 0 units 0 units 0 units 0 units 151-200 mg/dl 2 units 2 units 2 units 2 units 201-250 mg/dl 4 units 4 units 4 units 4 units 251-300 mg/dl 6 units 6 units 6 units 6 units 301-350 mg/dl 8 units 8 units 8 units 8 units 351-400 mg/dl 10 units 10 units 10 units 10 units > 400 mg/dl notify m.d. 17. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 18. metformin 500 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 19. menthol-cetylpyridinium 3 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed) as needed for sore throat. 20. ipratropium bromide 0.02 % solution sig: one (1) inhalation q4h (every 4 hours) as needed for shortness of breath. 21. warfarin 2 mg tablet sig: one (1) tablet po once a day. 22. zinc sulfate 220 mg tablet sig: one (1) tablet po twice a day. 23. milk of magnesia 400 mg/5 ml suspension sig: thirty (30) ml po once a day as needed for constipation. 24. multivitamin with iron-mineral tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: - md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Endarterectomy, other vessels of head and neck Transfusion of packed cells Procedure on single vessel Diagnoses: Anemia, unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Atrial fibrillation Peripheral vascular disease, unspecified Occlusion and stenosis of carotid artery without mention of cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Other toe(s) amputation status Other alteration of consciousness |
allergies: morphine / ativan attending: chief complaint: menatl status changes major surgical or invasive procedure: left carotid endarterectmoy history of present illness: 86 f transfered from ed s/p r toe amputation and fem bypass in mid who presents now with ms changes concerning for tia. pt has been recooperating in nursing home being treated for chronic infection. today she developed acute episode of altered mental status- she was reported to be sitting in a chair and subsequently felt lightheaded. pt was noted to have mom garbled speech. thought to be either delirium s/p infection vs mutiple tias. she was brought to the ed where she was noted to have elevated wbv, uti. inr was subtherapeutic 1.6. creatinin at 1.2 baseline <1. pt was transfered to for further evaluation. past medical history: -pvd s/p fem bypass and toe amputation -dm2 -chf -a-fib -copd -bilateral carotid stenosis social history: former tobacco use, no etoh use, no drugs, lives with son and daughter in law. recently d/c;d from rehab after fall with no major injuries family history: n/c physical exam: vs: 98.4 79 121/52 20 96% ra neck, left with incision intact, steri stripped rrr ctab soft nt/nd, no pulsitile masses no le edema, b/l feet warm rle - 2+ fem, mp pt, dp - 2+ fem, mp pt, dp rle: toes necrotic changes rle wound on shin : blister like lesion on shin pertinent results: 06:30am blood wbc-9.4 rbc-3.08* hgb-9.4* hct-27.8* mcv-90 mch-30.7 mchc-33.9 rdw-16.0* plt ct-214 06:30am blood plt ct-214 06:30am blood glucose-79 urean-15 creat-1.1 na-140 k-4.4 cl-100 hco3-33* angap-11 02:46am blood glucose-79 urean-12 creat-0.7 na-139 k-3.9 cl-104 hco3-29 angap-10 brief hospital course: patient was transferred from osh for mental status changes, admitted to vascular surgery/dr. service. concerning for tias in the setting of bilateral carotis stenosis. head/brain ct was done-negative for ich w/ severe narrowing of the common carotid artery bifurcation and proximal cervical internal carotid arteries, right more than left, started heparin drip. she was scheduled for l cea on , remained on heparin drip over the weekend. she was pre-oped and consented for l cea. patient was taken to the or and underwent l cea, patient tolerated procedure well, transferred to pacu for recovery. in the pacu, patient became unresponsive, needing to be intubated and transferred to the icu where she stayed intubated oevrnight. she was also placed on neo drip to keep her sbp above 150 mmhg. neurology consulted, head ct repeated-no stroke. patient was weaned and extubated, weaned off pressors, alert and oriented and neurologically intact. by the end of the day patient was transferred to floor. patient recieved blood transfusion for hct 21.4 <- from 27, also given lasix. physical therapy evaluated rehab (which is patient's baseline). /overnight patient had episodes of wheezing, started albuterol nebs prn. resolved by morning. patient is now stable, ambulating w/ assistance, eating and voiding. discharged back to her rehab (lifecare center in ) in good condition. will fu w/ dr. in weeks. medications on admission: coumadin 2 mg po qd celexa 10 mg po qd lisinopril 2.5 mg po qd verapamil 120 mg po qd neurontin 100 mg po qd metformin 500 mg po qd lasix 40 mg po qd amiodarone 200 mg po qd lantus 100 unit/ml 16 units injection once daily discharge disposition: extended care facility: - discharge diagnosis: bilateral carotid stenosis with tia's now s/ , need rxea in the near future anemia-acute on chronic, hct drop from 27->21+, transfused w/ 1 u pc history of: -pvd s/p fem bypass and toe amputation -dm2 -chf -a-fib -copd past surgical history: right lower extremity diagnostic angiogram right femoral-below knee popliteal bypass w/nrsvg right 2nd toe amputation discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - needs assistance discharge instructions: division of vascular and endovascular surgery carotid endarterectomy surgery discharge instructions activities: - shower, pat dry your incision, no tub baths - no driving till seen in fu by dr. - no lifting heavy objects, suddent neck turns or excessive neck bending and rotating - resume activities as tolerated, slowly incraese activiy as tolerated - expect your activity level to return to normal slowly diet: - diet as tolerated, eat a well balanced meal - your appetite will take time to normalize - prevent constipation by drinking adequate fluid and eat foods in fiber, take stool softener while on pain medications wound: - you may have some swelling and feel a firm ridge along the incision, slightly red and raised - keep your incision open to air - keep wound dry and clean, call if noted to have redness, draining, or swelling, or if temp is greater than 101.5 when to call: - call the office or go to ed if you experience severe headache that is not relieved by tylenol, signs of tia or stroke (weakness/paralysis of any or all extremities, difficulty of speech, facial drooping), difficulty of speaking, or swallowing. others: - you may have a sore throat and/or mild hoarseness - try warm tea, throat lozenges or cool/cold beverages medications: - continue all medications as instructed followup instructions: call dr. office for fu appointment. phone: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Endarterectomy, other vessels of head and neck Transfusion of packed cells Procedure on single vessel Diagnoses: Anemia, unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Atrial fibrillation Peripheral vascular disease, unspecified Occlusion and stenosis of carotid artery without mention of cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Other toe(s) amputation status Other alteration of consciousness |
allergies: iodine attending: chief complaint: abdominal pain major surgical or invasive procedure: endovascular aneurysm repair with bilateral groin cutdowns history of present illness: 70 year old male presented with abdominal pain. the pain started the afternoon of afternoon he laid down. pt reported dizziness when he stood up. he had similar abdominal pain approximately 4 days prior, and at that time, he had a ct scan without iv contrast that demonstrated a non-leaking 4 cm abdominal aortic aneurysm. the patient was then sent to the va for admission and further evaluation. he reports he was discharged 2 days ago from the va with a negative work-up for his abdominal pain. he had been pain free the day prior to admission but he also had nothing to eat until this afternoon. he denied fever, chills. no nausea or vomiting. no diarrhea. blacked out at home and went to caritas hc where a ct without contrast showed leaking aneurysm and creatinine up to 5.8 from baseline 1.8. he was hydrated and flighted to to have emergent evar of aaa by dr. . past medical history: past medical history: coronary artery disease s/p myocardial infarction, hypertension, hyperlipidemia, gerd, reflux esophagitis, constipation, cataract, blepharitis, cri, copd, ventral hernia, renal cancer, low back pain, renal cell ca, pvd, elevated psa, . past surgical history: status post nephrectomy for renal cancer, right femoral bypass in and s/p thrombolysis of his graft, right below the knee amputation, cabg x 4 in 93, appendectomy, exploratory laparotomy with lysis of adhesions -internal hernia, biliary stenting evar for ruptured aaa social history: lives by himself. ex-smoker and quit 8 years ago. he drinks about 3 alcoholic drinks per week. family history: non-contributory physical exam: vs: 98.3, 97.7, 91/47, 105, 20, 94%2l gen: nad, a&ox3, ngt in place heent: anicteric sclera, neck supple, no lad cv: rrr, nl s1 and s2 lungs: decreased bs b/l abd: soft, distended, reducible large ventral hernia, diffusely tender to palpation, +tympany ext: r bka site well healed, l dp is 2+ palp b/l groin sites with slight erythema but no active drainage pertinent results: please see omr brief hospital course: pt was admitted on transferred from an osh for ruptured abdominal aortic aneurysm. an urgent cat scan with iv contrast performed at demonstrated a contained, leaking abdominal aortic aneurysm. due to prohibitive surgical risk, the pt underwent an endovascular aneurysm repair with bilateral groin cutdowns on emergent basis on . bp during the procedure was initially 90-100s over 40-50s (one value to 80/40) then 110/80s. postoperatively, the pt was transferred to the cvicu intubated on pressors. he required fluid boluses and prbc as well as albumin. bp stabilized. he was extubated. due to increase in creatinine from baseline of 1.8 to 5.0, nephrology was consulted on . arf on crf felt to hypotension and poor perfusion. hd was not indicated. avoidance of all nephrotoxins was advised as well as keeping map >65. on , surgeon was consulted for concern for ischemic bowel as the patient had an episode of watery diarrhea. a flex sig was performed at the bedside which revealed no evidence of either mucosal slough or transmural ischemia. the colon was entirely normal up to 45 cm. no further episodes of diarrhea occured following the sigmoidoscopy. on ,he was kept npo, an ngt was placed for vomiting and a kub was done to eval for free air. urine was positive for pan sensitive enterobacter cloacae. cipro was started. ct abdomen on demonstrated findings consistent with ileus. status post aortobifemoral graft with no interval change in the size of extensive right retroperitoneal hematoma. cholelithiasis was noted. of note, there were gas locules noted in the aneurysmal sac and in the retroperitoneal region likely post-surgical in nature. although, there was concern for possible fistula. hepatobiliary was reconsulted on . on , hepatobiliary surgery was reconsulted for concerns for obstruction as he had abdominal pain and distention since without bm. the ngt output was 1l to 1.5l of gastric contents on a daily basis for the past 72 hours. after review of the mri and ct scans from the va, the pancreatic mass was felt to likely be either a primary pancreatic adenocarcinoma or potential renal cell carcinoma metastasis. because the mass was obstructing the distal common bile duct, the patient underwent ercp and stent placement. brushings obtained during the ercp were negative for malignancy, and biopsy obtained during a subsequent eus of the mass was an insufficient sample and thus a proper diagnosis could not be made. gi was consulted on for possible egd. this was not felt to be indicated and recommendations to assess the pancreatic stent were recommended given elevated t.bili and alk phos (6.5 and 272). on , he was started on vanco, zosyn and flagyl for possible small perforation. of note, patient's other current major issue is progressive renal dysfunction. ***no summary from - . on , the patient was noted by nephrology to have altered mental status concerning for uremia, and so he received a tunnelled hemodialysis cathether. on he was started on hemodialysis but became hypotensive to 40s and so dialysis was stopped early. on ams, hypoxic, transferred to sicu, intubated, became tachy/brady then asystolic, pulse returned w/ cpr found to have massive mi by echo put on pressors and taken to cath lab. pt had stent placed in left main coronary and required iabp support, which was problem given recent aaa repair. pt required 4 pressors and transient cpr. iabp was removed shortly due to distal skin mottling thought to be due to emboli from his aorta. he continued to deteriorate with ph on abg of <7, and potassium at 6.7. pt's family was contact and decision was made to be dnr/dnr, and soon after cmo. pt's medications were all stopped, including pressors and morphine drip started for comfort. pt passed away within 30 minutes from cardiopulmonary arrest. pt was warm, with no heart sounds or breath sounds. negative gag reflex, neg corneal reflex and neg oculocephalic reflex. pt's family was notified and appropriate death certificate and autopsy paperwork was filed. primary cause of death: cardiopulmonary arrest secondary cause of death: nstemi medications on admission: tylenol prn, lisinopril 5', senna 8.6", omeprazole 20', lubricating oph ointment qhs, carboxymethylcellulose 1% 0.4ml gtts"', colace 100", flunisolide 0.025%", loratiadine 10', lopressor 25", simvastatin 80', tamsulosin 0.4', ketotifen 0.025 gtts ou prn: qd, doxepin 50' discharge disposition: expired facility: - discharge diagnosis: cardiopulmonary arrest nstemi partial small bowel obstruction pancreatic mass right lobe pneumonia urinary tract infection. acute on chronic renal failure. abdominal aortic aneurysm ileus discharge condition: expired discharge instructions: none followup instructions: none Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of non-drug-eluting coronary artery stent(s) Parenteral infusion of concentrated nutritional substances Left heart cardiac catheterization Coronary arteriography using a single catheter Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Exploratory laparotomy Implant of pulsation balloon Angiocardiography of right heart structures Other open incisional hernia repair with graft or prosthesis Flexible sigmoidoscopy Endovascular implantation of other graft in abdominal aorta Transfusion of packed cells Other cholangiogram Other percutaneous procedures on biliary tract Infusion of vasopressor agent Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Urinary tract infection, site not specified Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Chronic airway obstruction, not elsewhere classified Coronary atherosclerosis of autologous vein bypass graft Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other and unspecified hyperlipidemia Acute respiratory failure Incisional hernia without mention of obstruction or gangrene Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Cardiogenic shock Old myocardial infarction Paralytic ileus Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Obstruction of bile duct Personal history of malignant neoplasm of kidney Unspecified intestinal obstruction Below knee amputation status Abdominal aneurysm, ruptured Hemoperitoneum (nontraumatic) Neoplasm of uncertain behavior of other and unspecified digestive organs |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: asymptomatic major surgical or invasive procedure: cardiac cath aortic valve replacement (21mm st. porcine) aortic root enlargement (pericardial patch) history of present illness: 69 yo male with hx of aortic stenosis followed by serial echos. recent echo shows severe as with 0.54 cm2 and mild lvh. known heart murmur for 10 years. referred for pre-op cath and surgery. past medical history: gout obesity aortic stenosis non-insulin depenedent diabetes mellitus hypertension hypercholesterolemia benign left parotid mass nephrolithiasis social history: works an an engineer never used tobacco occasional etoh drink lives alone family history: non-contrib. physical exam: hr 71 rr 12 145/60 5'3 " 168# nad, obese skin unremarkable large firm left parotid mass neck supple, full rom ctab rrr 4/6 sem with radiation throughout precordium to carotids abd + bs warm,well-perfused, no peripheral edema or varicosities noted mae strengths, grossly intact 1+ bil. femorals 2+ bil. dp/pt/radials pertinent results: cardiac catheterization comments: 1. coronary angiography of this right dominant system demonstrated no angiographically apparent flow-limiting coronary artery disease. the lmca was a short vessel. the lad had mild diffuse plaquing to 25% in the mid-vessel. the distal lad wrapped around the apex. there was slight pulsatile flow. the high diagonal-1 and the diagonal-2 branches had mild plaquing. the lcx was patent and supplied small om1 and om2 branches and a major, slightly tortuous lpl and distal av groove lcx. the rca had minimal diffuse plaquing and bifurcated into large rpda and rpl systems. 2. resting hemodynamics revealed severe elevations in right and left sided filling pressures with a rvedp of 24 mmhg and a lvedp of 29 mmhg. there was mild pulmonary arterial hypertension with a pa pressure of 42/23 mmhg. there was mild systemic arterial systolic hypertension with a central aortic pressure of 158/76 mmhg. the mean gradient across the aortic valve was 50 mmhg. the calculated aortic valve area was 0.5 cm2. the cardiac index was 1.8 l/min/m2. final diagnosis: 1. no angiographically apparent flow-limiting coronary artery disease. 2. severe aortic stenosis. 3. severe biventricular diastolic dysfunction. 4. mild pulmonary arterial hypertension. 5. mild systemic arterial systolic hypertension. attending staff: , echo conclusions pre-bypass: 1. no atrial septal defect is seen by 2d or color doppler. 2. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). 3. right ventricular chamber size and free wall motion are normal. 4. there are simple atheroma in the aortic root. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 5. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). mild (1+) aortic regurgitation is seen. 6. trivial mitral regurgitation is seen. post-bypass: for the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being av paced. 1. a well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 16-22 mmhg). no aortic regurgitation is seen. 2. aorta appears intact post decannulation 3. biventricular function is normal. 4. mr appears slightly worse, no is seen. it is mild to moderate in severity dr. was notified in person of the results. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, echocardiography report , portable tte (complete) done at 2:00:00 pm final referring physician information , division of cardiothoracic , status: inpatient dob: age (years): 69 m hgt (in): 63 bp (mm hg): 159/70 wgt (lb): 191 hr (bpm): 84 bsa (m2): 1.90 m2 indication: evaluate for pericardial effusion. recent aortic valve prosthesis. icd-9 codes: 423.9, 424.1 test information date/time: at 14:00 interpret md: , md test type: portable tte (complete) son: , rdcs doppler: full doppler and color doppler test location: / 6 contrast: none tech quality: adequate tape #: 2009w000-0:0 machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: 3.3 cm <= 4.0 cm left atrium - four chamber length: *5.3 cm <= 5.2 cm right atrium - four chamber length: *5.3 cm <= 5.0 cm left ventricle - septal wall thickness: *1.3 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.6 cm <= 5.6 cm left ventricle - ejection fraction: 55% to 60% >= 55% aorta - sinus level: *3.8 cm <= 3.6 cm aorta - ascending: 3.0 cm <= 3.4 cm aortic valve - peak velocity: *2.4 m/sec <= 2.0 m/sec aortic valve - peak gradient: *23 mm hg < 20 mm hg aortic valve - mean gradient: 13 mm hg mitral valve - e wave: 0.7 m/sec mitral valve - a wave: 0.9 m/sec mitral valve - e/a ratio: 0.78 mitral valve - e wave deceleration time: 209 ms 140-250 ms tr gradient (+ ra = pasp): 21 mm hg <= 25 mm hg pericardium - effusion size: 1.3 cm findings this study was compared to the prior study of . left atrium: elongated la. right atrium/interatrial septum: mildly dilated ra. left ventricle: mild symmetric lvh with normal cavity size. suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. aorta: mildly dilated aortic sinus. normal ascending aorta diameter. aortic valve: bioprosthetic aortic valve prosthesis (avr). avr well seated, normal leaflet/disc motion and transvalvular gradients. no ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. tricuspid valve: normal pa systolic pressure. pulmonic valve/pulmonary artery: pulmonic valve not well seen. mild pr. pericardium: small to moderate pericardial effusion. effusion circumferential. no ra or rv diastolic collapse. sgnificant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. conclusions the left atrium is elongated. 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. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. 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. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small to moderate (1.3 cm) sized pericardial effusion. the effusion appears circumferential. no right atrial or right ventricular diastolic collapse is seen. there is accentuated respiratory variation in mitral valve inflows, consistent with impaired ventricular filling. this may be secondary to etiologies other than pericardial tamponade (lung disease, etc..). compared with the prior study (images reviewed) of , an aortic valve bioprosthesis is now present. the aortic root appears thickened, consistent with aortic root enlargment. the pericardial effusion is new. the estimated pulmonary artery pressure is lower. electronically signed by , md, interpreting physician 17:10 radiology report chest (pa & lat) study date of 1:34 pm reason: assess for effusions preliminary report !! pfi !! 1. enlargement of the cardiac silhouette relative to both the most recent prior and the pre-operative chest x-ray without evidence of chf. these findings could represent interval development of a pericardial effusion and a cardiac echo may be obtained for further characterization. 2. small bilateral pleural effusions and improved aeration of the left lung base. dr. 04:55pm urine color-yellow appear-clear sp -1.019 04:55pm urine blood-lg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 04:55pm urine rbc-* wbc-0 bacteria-few yeast-none epi-0-2 03:32pm glucose-132* urea n-23* creat-0.9 sodium-139 potassium-4.7 chloride-104 total co2-23 anion gap-17 03:32pm alt(sgpt)-30 ast(sgot)-26 ld(ldh)-188 alk phos-64 amylase-57 tot bili-0.5 03:32pm lipase-61* 03:32pm albumin-4.3 calcium-9.4 magnesium-1.8 03:32pm %hba1c-6.6* 03:32pm wbc-15.6* rbc-4.65 hgb-13.6* hct-38.8* mcv-83 mch-29.2 mchc-35.0 rdw-13. , m 69 03:32pm plt count-452* 03:32pm pt-12.6 ptt-21.4* inr(pt)-1.1 05:35am blood wbc-23.6* rbc-3.46* hgb-10.1* hct-29.2* mcv-84 mch-29.3 mchc-34.7 rdw-15.2 plt ct-446*# 05:35am blood plt ct-446*# 05:35am blood pt-13.7* ptt-26.3 inr(pt)-1.2* 05:35am blood glucose-86 urean-24* creat-1.2 na-137 k-3.9 cl-101 hco3-25 angap-15 brief hospital course: admitted and underwent cardiac cath. this did not reveal any significant coronary disease. underwent surgery with dr. on . transferred to the cvicu in stable condition on titrated insulin, phenylephrine, and propofol drips. extubated later that day. transferred to the floor on pod #2 to begin increasing his activity level. rapid a fib treated with amiodarone and metoprolol, converted to sinus rhythm. low grade fever prompted ua which showed a uti, started on cipro for a three day course. chest tubes and pacing wires removed per protocol. remainder of hospital stay uneventful. cleared for discharge to home with vna on pod 6. medications on admission: colchicine 0.6 mg colace 100 mg tenormin 50 mg daily glucophage xr 1000 mg diovan 320 mg daily hctz 25 mg daily zocor 20 mg daily glipizide 2.5 mg asa 81 mg daily amlodipine 5 mg daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 4. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 5. colchicine 0.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*1* 6. glipizide 5 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 7. amiodarone 200 mg tablet sig: two (2) tablet po once a day: 400mg qd x7 days then 200mg qd. disp:*35 tablet(s)* refills:*0* 8. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 9. potassium chloride 10 meq tablet sustained release sig: two (2) tablet sustained release po twice a day: 20meq x 1 week then 20meq qd x 2 weeks. disp:*60 tablet sustained release(s)* refills:*0* 10. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day): 20mg x 1 week then 20mg qd x 2 weeks. disp:*28 tablet(s)* refills:*0* 11. glipizide 5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 12. glucophage xr 500 mg tablet sustained release 24 hr sig: two (2) tablet sustained release 24 hr po twice a day: resume preop schedule. tablet sustained release 24 hr(s) discharge disposition: home with service facility: home health and hospice discharge diagnosis: aortic stenosis postop atrial fibrillation pmh: hypercholesterolemia hypertension non-insulin dependent diabetes mellitus h/o nephrolithiasis left parotid mass (benign) gout obesity discharge condition: good discharge instructions: please shower daily including washing incisions, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month, and while taking narcotics no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: dr. in 4 weeks () dr. ,sudarshan in 1 week please call for appointments wound check appointment 6 as instructed by nurse () md Procedure: Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Open and other replacement of aortic valve with tissue graft Repair of blood vessel with tissue patch graft Diagnoses: Anemia, unspecified Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Cardiac complications, not elsewhere classified Gout, unspecified Atrial fibrillation Aortic valve disorders Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Obesity, unspecified Hypovolemia |
allergies: percocet attending: chief complaint: chemotherapy with hypertomic saline administration major surgical or invasive procedure: none history of present illness: 61 y/o with stage squamous cell carcinoma of the right piriform sinus presenting for c2d1 of tpf (taxotere, cisplantin, 5-fluorouriacil). he originally presented with neck pain and in underwent direct laryngoscopy with a biopsy of a pyriform sinus mass diagnostic of ssc. . mr started cycle 1 of tpf on on c1d13 he presented with na of 120 and was hospitalized from to . he na nadir was 118 and patient experienced decreased concentration at that time. he has a h/o chronic hyponatremia with na 126 dating back to . labs were consistent with siadh, with the acute exacerbation thought to be a consequence of his platinum based chemotherapy. his sodium improved with 1l fluid restriction and nacl tablets to 126 on discharge. he is followed by , nephrology. . given mr hyponatremia with the last cycle chemotherapy admission for close na monitoring and ppx hypertonic saline is planned. past medical history: past oncologic history: mr. presented with a pain in his right neck after holding in a sneeze. a lump developed in the area and he was referred to dr. and laryngoscopy demonstrated a post-cricoid hypopharyngeal lesion and was referred to have a ct scan of the neck. the ct scan of the neck revealed an enhancing mass in the right pyriform sinus with extensive conglomerate adenopathy in the right level 2 and level 3 nodes. biopsy of the mass was positive for squamous cell carcinoma. on he underwent direct laryngoscopy and biopsy of right pyriform sinus lesion and rigid esophagoscopy. pathology from this procedure revealed squamous cell carcinoma, moderately differentiated. he was hpv negative. port was placed . he started c1d1 tpf on . . other past medical history: - history of prostate cancer status post radical prostatectomy with dr. in . he had a biochemical recurrence in , status post salvage radiation therapy and has since followed with dr. with anundetectable psa in . - hypertension - acid reflux disease with hiatal hernia - hernia repair in - appendectomy in social history: social history: lives in . the patient is married with five children, all local. he smoked half a pack per day for 10 years but quit smoking 30 years ago. he drank alcohol heavily in the past mostly associated with his job as a bar tender but has been sober for the last two and half years. he is retired navy and currently works as a doorman/security, which he enjoys. family history: family history: his mother died of chf. father died of a heart attack. he has four siblings. his children are healthy. physical exam: tmax=97.5=tcurrent, hr=50s-60s, bp=100s-150s/60s-80s, rr=13-22, pox=93% general: alert, nad heent: nc/at cv: rrr, no m/r/g appreciated resp: cta bilaterally abd: s/nt/nd; bs present ext: trace pitting edema in the le??????s bilaterally pertinent results: 01:05pm glucose-86 urea n-22* creat-0.7 sodium-123* potassium-4.8 chloride-89* total co2-23 anion gap-16 01:05pm calcium-9.0 phosphate-3.6 magnesium-1.7 01:05pm wbc-14.4*# rbc-3.52* hgb-11.0* hct-31.6* mcv-90 mch-31.2 mchc-34.8 rdw-13.6 01:05pm neuts-85.7* lymphs-7.1* monos-6.8 eos-0.2 basos-0.2 01:05pm plt count-480*# 01:05pm pt-12.3 ptt-21.7* inr(pt)-1.0 brief hospital course: this is a 61 year old male with stage iv squamous cell carcimona of the right pyriform sinus presenting for his second cycle of tpf requiring an elective icu admission for hypertonic saline because his previous cycle was complicated by acute on chronic hyponatremia. . # squamous cell carcinoma of right pyriform sinus: pt was discharged on c2d2 of tpf (taxotere, cisplatin, 5-fu). he received taxotere 75 mg/m2 and cisplatin 100 mg/m2 on admission. he was also set up with a 5-fluorouracil pump at 1000 mg/m2/24 hours x 96 hours via continuous infusion on the day of discharge. the patient says that he feels well after the chemo which he attributes to the cisplatin being infused over 8 hours instead of 5 hours like his previous treatment. he received hypertonic saline while the chemo was administered and his sodium remained above 123. he received the following antiemetics per oncology recommendations: emend 125mg po and zofran 8mg iv 1 hr prior to chemo on . he also received emend 80mg po on and was continued on zofran 8mg po q8h standing. he also took dexamethasone 8mg prior to arrival and was continued on 8mg with a plan to take 4mg daily while getting the 5-fu infusion. ativan and compazine were continued for breakthrough nausea. he will start cipro prophylaxis when his 5-fu infusion is complete. he will also use clotrimazole troches qid prn mouth pain. . # hyponatremia: he completed a regimen of normal saline and hypertonic saline per renal recs. sodium was 127 on discharge and was never below 123. he will continue a 1 liter fluid restriction and start lasix 20mg po to keep his sodium up at home. . # leukocytosis: likely related to patient??????s recent steroid administration and improved on discharge. he did not spike a fever. . # htn: his home atenolol was continued and his home enalapril was decreased to 5mg from 10mg. . # gerd: his home omeprazole was continued. medications on admission: emend dose pack (on hold) atenolol 50mg daily dexamethasone 4-8mg as directed (has taken 8mg last two days) enalapril 10mg hydrocodone- acetaminophen 5/500mg tab q6h prn (on hold) lidocaine - diphenhyd--mag- mouthwash tid (on hold) lorazepam 0.5mg po q6h prn (on hold) omeprazole 40mg po daily ondansetron 8mg q8h prn (on hold) prochlorperazine 10mg q6h ( on hold) viagra 100mg po prn tolvaptan 15mg po dailyl (currently on hold, never started) multivitamin daily discharge medications: 1. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 2. dexamethasone 4 mg tablet sig: 1-2 tablets po q12h (every 12 hours): take two tablets twice daily on then reduce to one tablet once daily on and then stop. 3. furosemide 20 mg tablet sig: one (1) tablet po once a day: take in the morning. disp:*30 tablet(s)* refills:*2* 4. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 5. clotrimazole 10 mg troche sig: one (1) troche mucous membrane four times a day as needed for mouth pain. disp:*100 troches* refills:*0* 6. zofran 8 mg tablet sig: one (1) tablet po every eight (8) hours: on and , take every 8 hours. then, can take every 8 hours as needed for nausea. 7. emend 80 mg capsule sig: one (1) capsule po once a day: take on . 8. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 9. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 10. enalapril maleate 5 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 11. multivitamin tablet sig: one (1) tablet po daily (daily). 12. fluorouracil 500 mg/10 ml solution sig: 1800 (1800) mg intravenous continuous infusion: until . 13. vicodin 5-500 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 14. lidocaine-diphenhyd--mag- 200-25-400-40 mg/30 ml mouthwash sig: ten (10) ml mucous membrane three times a day: as needed. discharge disposition: home discharge diagnosis: stage iv sqaumous cell carcinoma of the pyriform sinus hyponatremia from siadh . secondary diagnoses: -hypertension -gerd discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to for chemotherapy and concentrated saline administration. you tolerated the chemotherapy well and your sodium levels remained at your baseline. you are being discharged on a 5-fu chemotherapy pump. be sure to continue to restrict your fluid intake to 1 liter a day. in addition try to eat salty foods. the following changes were made to your medication regimen: - lasix was started to help keep your sodium level normal - enalapril was decreased to 5mg twice a day. - clotrimazole as needed for mouth pain - you should start cipro as directed on saturday when your 5-fu chemo pump is stopped be sure to follow up with your doctors as listed below. followup instructions: please follow-up with all of your outpatient medical appointments listed below: . heme/onc: provider: , rn phone: date/time: 9:30 . renal: provider: , m.d. phone: date/time: 4:30 Procedure: Injection or infusion of cancer chemotherapeutic substance Diagnoses: Esophageal reflux Unspecified essential hypertension Personal history of malignant neoplasm of prostate Personal history of tobacco use Other disorders of neurohypophysis Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck Malignant neoplasm of pyriform sinus Encounter for antineoplastic chemotherapy |
allergies: percocet attending: chief complaint: cough, confusion, hyponatremia --> cycle 3 tpf major surgical or invasive procedure: cycle 3 tpf (taxotere, cisplantin, 5-fluorouriacil) chemotherapy history of present illness: the patient is a 61 yo m with h/o prostate cancer and currently undergoing treatment for piriform scc who presents from home with non-productive cough and mental slowing. pt reports a repeated sensation of abd cramping followed by coughing, only when supine. the cough is nonproductive and does not reaccure when sitting upright. per the wife over the last few days mr has seemed slow with his thinking. he was not disoriented. no fevers, however 2 days ago he had rigors. no ns. no cp. + loose bm, no abd pain. no dysuria. . in the ed, initial vs were: t 97 p72 bp 108/72 r16 o2 sat 100. bp droped to 89/64 but improved to 101/69 following resusitation with 3.5l ns. a chest xray showed a possible rll pna and crackles were heard in that area. patient was given ceftriaxone, azithro and flagyl. his was admitted to the icu given his transient hypotension. . on the floor, he is without complains other than pain at the finger tips from his chemo. past medical history: oncologic history: # head and neck cancer: - mr. presented with a pain in his right neck. a lump developed in the area and he was referred to dr. and laryngoscopy demonstrated a post-cricoid hypopharyngeal lesion and was referred to have a ct scan of the neck. the ct scan of the neck revealed an enhancing mass in the right pyriform sinus with extensive conglomerate adenopathy in the right level 2 and level 3 nodes. biopsy of the mass was positive for squamous cell carcinoma. on he underwent direct laryngoscopy and biopsy of right pyriform sinus lesion and rigid esophagoscopy. pathology from this procedure revealed squamous cell carcinoma, moderately differentiated. he was hpv negative. port was placed . he started c1d1 of cisplatin, docetaxel, 5-fu on . # prostate cancer: status post radical prostatectomy with dr. in . he had a biochemical recurrence in , status post salvage radiation therapy and has since followed with dr. with anundetectable psa in . non-oncologic history: - hypertension - acid reflux disease with hiatal hernia - hernia repair in - appendectomy in social history: lives in . the patient is married with five children, all local. he smoked half a pack per day for 10 years but quit smoking 30 years ago. he had extensive second hand smoke exposure working in a tavern. no alcohol use for the last 2 years. previous drinking history. he is retired navy and currently works as a doorman/security. . family history: his mother died of chf. father died of a heart attack. he has four siblings. his children are healthy. . physical exam: general: alert, orientedx 3, no acute distress. slightly tangential and perseverating speech. heent: sclera anicteric, pale conjuctiva, mmm, oropharynx clear (no visible mouth lesions) neck: supple, jvp not elevated, no lad lungs: crackles rll. no rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: 05:46pm glucose-110* urea n-16 creat-0.8 sodium-125* potassium-4.3 chloride-91* total co2-26 anion gap-12 05:46pm calcium-8.5 phosphate-2.1* magnesium-1.9 11:00am urine hours-random urea n-454 creat-38 sodium-63 potassium-31 chloride-80 11:00am urine osmolal-386 11:00am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 10:14am hct-22.2* 10:14am fibrinoge-501* 10:14am ret aut-4.3* 08:05am glucose-91 urea n-24* creat-0.7 sodium-120* potassium-3.5 chloride-90* total co2-26 anion gap-8 08:05am ld(ldh)-185 08:05am calcium-7.1* phosphate-1.7* magnesium-1.5* uric acid-4.9 08:05am haptoglob-220* 08:05am wbc-6.2 rbc-2.22*# hgb-7.2* hct-19.8* mcv-89 mch-32.5* mchc-36.4* rdw-14.9 08:05am neuts-66 bands-2 lymphs-17* monos-8 eos-0 basos-0 atyps-0 metas-4* myelos-3* 08:05am plt smr-normal plt count-221 03:53am lactate-2.9* 03:40am glucose-109* urea n-28* creat-0.9 sodium-122* potassium-3.0* chloride-89* total co2-26 anion gap-10 02:16am lactate-2.2* 11:45pm glucose-102* urea n-33* creat-1.1 sodium-119* potassium-3.6 chloride-82* total co2-31 anion gap-10 11:45pm alt(sgpt)-43* ast(sgot)-30 ck(cpk)-117 alk phos-112 tot bili-0.3 11:45pm ctropnt-<0.01 11:45pm wbc-7.4 rbc-2.98* hgb-9.6* hct-26.4* mcv-89 mch-32.3* mchc-36.4* rdw-16.8* 11:45pm plt count-242 . cxr : findings: in comparison with study of , there is little change in the appearance of the heart and lungs. there are some bilateral areas of opacification most likely representing atelectasis. in the appropriate clinical setting, the possibility of pneumonia would have to be considered. continued mild cardiomegaly. the port-a-cath remains in place. definite vascular congestion. central catheter. . ekg : sinus tachycardia. non-specific st-t wave abnormalities. compared to the previous tracing of heart rate has increased and q-t interval prolongation is no longer seen. brief hospital course: this is a 61 year old male with pmh of scc of the pryiform sinus s/p c2 of tpf (taxotere, cisplatin, 5-fu) on presenting with cough and confusion and found to have a possible rll pna on imaging, worsening of his known chronic siadh hyponatremia, and anemia with a hct=19.8. . # pyriform sinus squamous cell carcinoma: # stage squamous cell carcinoma of the right piriform sinus: s/p cycle 2 of tpf (taxotere, cisplatin, 5-fu) on . due to patient's hyponatremia, confusion and generally complex medical condition, he stayed in-house for his third cycle of tpf once his cough, confusion and anemia had improved. he required special preparations of his 5-fu with normal saline, not d5w given his hyponatremia. discontinued dexamethasone 2 days early given steroid psychosis. he completed the cycle with no significant complications, although he did have some emotional lability with the steroids. the patient was discharged with antibiotic prophylaxis (cipro) as well as emend. . # anemia: his hematocrit was down to 19.8 on from 31.9 on . he reports 2 days of brbpr. he may have gi oozing secondary to mucositis or underlying diverticulosis which may be amplified by aggressive fluid repletion. his hematocrit was trended closely and he received 2 unit of prbcs. . # hyponatremia: the patient has a long history of hyponatremia which has been extensively evaluated by renal and found to be consistent with siadh with unclear underlying cause, possibly due to his malignancy and worsened in the past (and this admission) with chemotherapy session. cisplatinum chemo is also known to worsen hyponatremia and therefore the patient has been repeatedly admitted for hyponatremia. during his last admission, he was treated with lasix, salt tabs, and fluid restriction. on admission his sodium was 119 and he was last discharged with a na=120. he was once again treated with lasix, salt tabs, and fluid restriction (although patient occasionally found drinking fluids in the nutrition room with question of ability to comply). his sodium was trended closely and was quite labile. renal followed the patient in-house. . # cxr findings: he has a small infiltrate on imaging suggestive of rll pna vs. atelectasis. given his recent chemotherapy, as well as current bandemia, chills, and cough with rll crackles, he was given azithromycin, ceftriaxone, and flagyl in the ed. this regimen was changed to cefepime and azithromycin in the icu. he does not have a history of chronic cough, but he claims to have "aspiration" due to cough with lying flat consistent with gerd. after monitoring the patient overnight, it was felt that pneumonia was very unlikely, and antibiotics were stopped. the patient remained stable from a pulmonary standpoint for the remainder of this hospital course. # altered mental status: likely multifactorial from hyponatremia and possibly toxicity from his chemotherapy may be contributing. he was near his recent baseline per his wife who has noted subtle memory changes since he started his chemo regimen. recent mri head imaging had not revealed a likely cause. it was later felt, also, once the patient started his next cycle of chemotherapy that the steroids (dexamethasone) made him emotionally labile, alternatively frustrated, anxious, tearful. the patient wandered off the floor once looking for coffee. this emotional lability improved once the steroids were discontinued. # gerd: he described abdominal cramping followed by a feeling of regurgitation and cough while supine which is consistent with gerd. he was started on a ppi with improvmenet in his symptoms. # htn: his home atenolol was held given hypotension. as his pressures normalized, the patient's home beta blocker was resumed. it was felt that the patient has a tendency to develop vasovagal hypotension and bradycardia when his port site is accessed. the patient has had vagal episodes in the past during accessing his port. when the patient was prepared prior to port site access, it is well tolerated. medications on admission: 1. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 3. clotrimazole 10 mg troche sig: one (1) troche mucous membrane qid (4 times a day). 4. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. 5. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 6. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 7. multivitamin tablet sig: one (1) tablet po daily (daily). 8. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 9. lidocaine-diphenhyd--mag- 200-25-400-40 mg/30 ml mouthwash sig: ten (10) ml mucous membrane four times a day. 10. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 11. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 12. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for de-accessing port. 13. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 10 days. disp:*20 tablet(s)* refills:*0 discharge medications: 1. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. clotrimazole 10 mg troche sig: one (1) troche mucous membrane qid (4 times a day) as needed for pain. disp:*30 troche(s)* refills:*0* 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. lorazepam 0.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for insomnia, anxiety. disp:*30 tablet(s)* refills:*0* 7. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. disp:*30 tablet(s)* refills:*0* 8. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 9. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 10. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 9 days. disp:*18 tablet(s)* refills:*0* 11. compazine 10 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. 12. multivitamin tablet sig: one (1) tablet po once a day. 13. hydrocodone-acetaminophen 5-500 mg capsule sig: capsules po every six (6) hours. 14. lidocaine-diphenhyd--mag- 200-25-400-40 mg/30 ml mouthwash sig: ten (10) ml mucous membrane four times a day. 15. enalapril maleate 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 16. sodium chloride 1 gram tablet sig: two (2) tablet po three times a day. disp:*180 tablet(s)* refills:*2* 17. atenolol 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: expired discharge diagnosis: primary: stage squamous cell carcinoma of the right piriform sinus, hyponatremia, slow lower gi bleed, altered mental status secondary: hypertension, gerd discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with mental slowing and cough. you were initially in the icu because of concerns about your low sodium and a slow bleeding in your gi tract. you were treated briefly with antibiotics for possible pneumonia and closely monitored for the gi bleeding, which stopped. you also underwent your third cycle of chemotherapy, which you tolerated well. . -it is important that you continue to take your medications as directed. we made the following changes to your medications during this admission: --> resume atenolol 50mg daily --> increase lasix 20mg twice daily to 40mg twice daily --> decrease your atenolol 50mg daily to 25mg daily --> continue ciprofloxacin 500mg twice daily for 9 more days --> start taking enalapril 10mg daily --> start sodium chloride (salt) tablets 2mg three times daily --> start clotrimazole troches 10mg four times daily -as we suspect you have bleeding in your intestinal tract, it is very important that you see a gastroenterologist about getting a colonoscopy. this can be set up through your primary care doctor. the number of the gastroenterologist office here is . -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. followup instructions: please follow-up with dr. and dr. . their office will contact you with date/time of your appointments next week in hematology/ clinic. you also have an appointment with dr. (kidney doctor) to follow up with your low sodium level. that appointment will be on at 430pm. his office is located on the of the clinical center. it is very important that you go to this appointment. as we suspect you have bleeding in your intestinal tract, it is very important that you see a gastroenterologist about getting a colonoscopy. this can be set up through your primary care doctor. the number of the gastroenterologist office here is . provider: , rn phone: date/time: 10:30 provider: , rn phone: date/time: 10:30 md, Procedure: Injection or infusion of cancer chemotherapeutic substance Diagnoses: Pneumonia, organism unspecified Esophageal reflux Unspecified essential hypertension Adrenal cortical steroids causing adverse effects in therapeutic use Iron deficiency anemia secondary to blood loss (chronic) Personal history of malignant neoplasm of prostate Hypotension, unspecified Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Hemorrhage of gastrointestinal tract, unspecified Hypovolemia Other disorders of neurohypophysis Precipitous drop in hematocrit Personal history of irradiation, presenting hazards to health Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck Unspecified drug-induced mental disorder Malignant neoplasm of pyriform sinus Mucositis (ulcerative) due to antineoplastic therapy |
allergies: percocet attending: chief complaint: watery, nonbloody diarrhea major surgical or invasive procedure: intubation and mechanical ventilation arterial line central venous line history of present illness: mr. is a 61-year-old man with history of head and neck cancer. he is currently on docetaxel, cisplatin, and 5-fu who presented with diarrhea. the night before admission, he started having multiple bowel movements with watery, non-bloody diarrhea. per his wife, he was also increasingly lethargic and nodding off while sitting on the toilet. he denies fevers, chills, or abdominal pain. in ed, t 98.1, hr 110, bp 116/92, rr 16, 99% ra. exam revealed a macular rash on upper chest. wbc was 2.6 with 35% neutrophils, 21% lymphs, and 28% bandemia. urinalysis was negative, and cxr was reported as unremarkable. (however, subsequent of cxr revealed lll opacity.) he received empiric levofloxacin and metronidazole. review of systems: no recent weight change, fevers, chills, headache, visual changes, shortness of breath, cough, chest pain, abdominal pain, constipation, melena, brbpr, hematuria, dysuria, weakness, numbness, tingling past medical history: oncologic history: # head and neck cancer: - mr. presented with a pain in his right neck. a lump developed in the area and he was referred to dr. and laryngoscopy demonstrated a post-cricoid hypopharyngeal lesion and was referred to have a ct scan of the neck. the ct scan of the neck revealed an enhancing mass in the right pyriform sinus with extensive conglomerate adenopathy in the right level 2 and level 3 nodes. biopsy of the mass was positive for squamous cell carcinoma. on he underwent direct laryngoscopy and biopsy of right pyriform sinus lesion and rigid esophagoscopy. pathology from this procedure revealed squamous cell carcinoma, moderately differentiated. he was hpv negative. port was placed . he started c1d1 of cisplatin, docetaxel, 5-fu on . # prostate cancer: status post radical prostatectomy with dr. in . he had a biochemical recurrence in , status post salvage radiation therapy and has since followed with dr. with anundetectable psa in . non-oncologic history: - hypertension - acid reflux disease with hiatal hernia - hernia repair in - appendectomy in social history: lives in . the patient is married with five children, all local. he smoked half a pack per day for 10 years but quit smoking 30 years ago. he had extensive second hand smoke exposure working in a tavern. no alcohol use for the last 2 years. previous drinking history. he is retired navy and currently works as a doorman/security. . family history: his mother died of chf. father died of a heart attack. he has four siblings. his children are healthy. . physical exam: vitals: t 97.3, bp 122/90, hr 125, rr 16, 98%ra gen: elderly caucasian man in no acute distress, awake, alert, oriented x 3 but slightly confused about recent history, very talkative heent: eomi, moist mucus membranes with punctate oral sores under tongue and on bilateral oral cavity, chocolate milk/boost on lips, ruddy complexion (unchanged from last admission) neck: supple, no lad, reticular/erythematous rash with clear margins on chest cv: regular rate/rhythm, normal s1/s2, no murmur/gallops/rubs, port site c/d/i lungs: ctab, no wheezing/rhonchi/rales abd: soft, nontender, nondistended, bowel sounds present, no hepatosplenomegaly ext: no c/c/e - previous admissions' edema of bilateral lower extremiteis much improved pertinent results: 12:00am plt smr-normal plt count-254 12:00am hypochrom-normal anisocyt-1+ poikilocy-occasional macrocyt-1+ microcyt-occasional polychrom-normal 12:00am neuts-35* bands-28* lymphs-21 monos-9 eos-0 basos-0 atyps-2* metas-3* myelos-2* nuc rbcs-1* 12:00am wbc-2.6*# rbc-3.99* hgb-12.1* hct-35.7* mcv-90 mch-30.3 mchc-33.8 rdw-17.4* 12:00am calcium-8.9 phosphate-3.6 magnesium-1.6 12:00am lipase-13 12:00am alt(sgpt)-34 ast(sgot)-16 alk phos-135* tot bili-0.7 12:00am urea n-24* creat-1.0 12:05am freeca-1.07* 12:05am glucose-125* lactate-2.6* na+-131* k+-3.2* cl--94* tco2-23 12:05am ph-7.42 comments-green top 01:10am urine mucous-rare 01:10am urine hyaline-* 01:10am urine rbc-0-2 wbc-0-2 bacteria-few yeast-none epi-0 01:10am urine blood-tr nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-5.5 leuk-neg 01:10am urine color-yellow appear-clear sp -1.025 . = = = = = = = = ================================================================ micro data: sputum from bal _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s 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 . . sputum: gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram positive cocci in pairs. respiratory culture (final ): commensal respiratory flora absent. staph aureus coag +. moderate growth. sensitivities performed on culture # 298-6523s . . . sputum: 11:53 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive cocci. in pairs and clusters. 1+ (<1 per 1000x field): gram positive rod(s). 1+ (<1 per 1000x field): budding yeast. respiratory culture (final ): commensal respiratory flora absent. staph aureus coag +. heavy growth. . = = = = = = = = ================================================================ imaging cxr - 1. focal opacity at the left lung base, could be focal consolidation; however, cannot exclude nodule in a patient with cancer history, although less likely. d/ son . 2. nonspecific bowel gas pattern, with a few scattered air-fluid levels in the right upper abdominal quadrant. . : chest x ray impression: increase of the left lung opacity consistent with worsening pneumonia. . chest x ray: findings: as compared to the previous radiograph, the endotracheal tube projects 4 cm above the carina with its tip. the course of the nasogastric tube is unchanged. also unchanged is the course of the right pectoral port-a-cath. newly appeared bilateral parenchymal opacities, notably in the perihilar areas, suggest pulmonary edema rather than pneumonia. progressing retrocardiac atelectasis, the presence of a small left pleural effusion cannot be excluded. no other relevant changes. . chest x ray: comparison is made with multiple prior studies including all performed the day before. cardiac size is top normal. lines and tubes remain in place in standard position. there is no pneumothorax or enlarging pleural effusions. extensive bilateral parenchymal opacities worse in the left lung have minimally improved in the right lower lobe. these are a combination of pulmonary edema and preexisting left lung pneumonia. . chest x ray: impression: worsening multifocal consolidation and increased left lower lobe atelectasis. . chest x ray: diffuse bilateral extensive opacities have minimally improved in the left lower lobe. cardiomediastinal contours are unchanged. cardiac size is top normal. lines and tubes remain in place in standard position. there is no evident pneumothorax or large pleural effusion. . trans thoracic echocardiogram: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is severe global left ventricular hypokinesis (lvef = 20%). there is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. the estimated cardiac index is depressed (<2.0l/min/m2). the right ventricular cavity is markedly dilated with severe global free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. there is probably moderate pulmonary artery systolic hypertension. . there is a trivial/physiologic pericardial effusion. impression: severe left ventricular systolic dysfunction in the setting of rapid atrial fibrillation. markedly dilated and severerly hypokinetic right ventricle with relative apical sparing, consistent with acute pulmonary hypertension with a chronically untrained rv (due to pulmonary embolism, hemorrhage, ards, etc.). moderate to severe tricuspid regurgitation. at least moderate pulmonary hypertension. brief hospital course: mr. was a 61-year-old man with head and neck cancer who presented with diarrhea. he ultimately developed a pneumonia and passed due to complications of sepsis. septic shock: mr. was admitted on . he was initially started on levofloxacin for empiric coverage for a pulmonary infection. later that day his antibiotic coverage was increased to vancomycin and cefepime. the following morning he became hypoxic after eating/drinking. a respiratory code was called. he was satting well on a non-rebreather. the decision was made to intubate on the floor to prevent further decompensation. after intubation, multiple secretions/food were suctioned from his airway. he was transferred to the icu for further care. his antibiotic coverage was broadened to vancomycin and zosyn. the following day his blood pressures began to decrease. he was started on norepinephrine, phenylephrine, and vasopressin. he received several fluid boluses. on micafungin was added for fungal coverage due to persistent fevers. mrsa grew from bal sputum on and on subsequent sputums on and . on zosyn was discontinued. meropenem and linezolid were started based on id recommendation. his primary source was felt to be from mrsa pneumonia. the infectious disease team followed his course and offered recommendations. despite aggressive fluid resuscitation, multiple pressors, and appropriate antibiotic coverage, he had signs of end organ damage. an echo showed an ef of 15%, he had elevated lft's, elevated lactate to 12.1, increasing coags and decreasing platelets indicating dic, increasing wbc, and increasing creatinine. multiple family discussion were held discussing mr. poor prognosis. his family wanted an aggressive approach. he lost his pulse and a code was initiated. cpr was started, but his wife asked us the team to stop the code. thrombocytopenia: mr. was admitted with a platelet count of 254. this decreased to a low of 25. a hit antibody test was sent and was negative. all heparin products were temporarily discontinued pending results of the test. his thrombocytopenia was ultimately thought to be due to his overwhelming infection and possible medication effects. increased creatinine: mr. kidney function remained intact for most of his icu stay with a creatinine of 0.9. the day of his death his creatinine increased to 1.3 indicating renal failure from his sepsis. the renal team was consulted. there was no indication to for dialysis. his worsening renal function was attributable to overwhelming infection. elevated lft's: on the patient's lft's were significantly elevated. this was thought to be due mainly to hypoperfusion of the liver. also in the differential was amiodarone toxicity as this was recently started prior to the increase in lfts. the lfts were monitored closely and continued to increase as we were unable to maintain adequate tissue perfusion. head and neck cancer: no active treatment was given during this hospitalization. atrial fibrillation with rvr: mr. went into atrial fibrillation with rvr. his heart rate was initially in the 200's. he was given metoprolol which slightly decreased his rate to the 150-160's. his blood pressures then decreased to systolics of 70-80's. he was cardioverted initially with 100 j, then 200 j. each cardioversion resulted in a return to sinus rhythm. however, his heart rate went back into atrial fibrillation after a few minutes. he was then loaded with amiodarone. after a loading dose, an amiodarone gtt was started. he was then successfully cardioverted. he maintained this rate for several hours. however, throughout the next couple of days he again went into atrial fibrillation with rvr. each time his blood pressure would drop. he was cardioverted multiple times throughout the next 2-3 days. however, each time he remained in sinus rhythm for a shorter period of time. his blood pressure rebounded less often. an esmolol gtt was briefly started, but this was discontinued for hypotension. diarrhea: his episode of diarrhea was thought related to a chemotherapy side effect. c. diff and stool cultures were all negative. he was given intravenous fluids to maintain volume status. medications on admission: atenolol 50 mg po daily omeprazole 40 mg po daily clotrimazole 10 mg troche 4 times a day ondansetron 4 mg po q8h as needed for nausea lorazepam 0.5 mg po q6h as needed for nausea prochlorperazine 10 mg po q6h as needed for nausea multivitamin hydrocodone-acetaminophen 5-500 mg 1-2 tablets po q6h as needed for pain lidocaine-diphenhyd--mag- 200-25-400-40 mg/30 ml mouthwash 10 ml four times a day furosemide 20 mg po bid * had just completed 10 day course of cipro ppx discharge disposition: expired discharge diagnosis: septic shock mrsa pneumonia/ards discharge condition: expired discharge instructions: none followup instructions: none Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Arterial catheterization Atrial cardioversion Atrial cardioversion Closed [endoscopic] biopsy of bronchus Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acidosis Unspecified essential hypertension Acute and subacute necrosis of liver Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Severe sepsis Atrial fibrillation Paroxysmal ventricular tachycardia Acute respiratory failure Defibrination syndrome Pneumonitis due to inhalation of food or vomitus Cardiogenic shock Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Diarrhea Other disorders of neurohypophysis Neutropenia, unspecified Methicillin resistant Staphylococcus aureus septicemia Methicillin resistant pneumonia due to Staphylococcus aureus Malignant neoplasm of pyriform sinus Stomatitis and mucositis, unspecified |
allergies: bactrim attending: chief complaint: splenic marginal zone lymphoma major surgical or invasive procedure: laparoscopic converted to open splenectomy history of present illness: 81-year-old woman who has been evaluated originally for abnormal blood smear. she was further worked up with a bone marrow biopsy and cat scan and diagnosed with a low-grade lymphoma and thought most consistent with a splenic marginal zone lymphoma. in terms of symptoms, she has had right lower abdominal "pressure pain" which is more prominent at night when just prior to bed. otherwise, she has had no symptoms, no nausea, vomiting, no exacerbating or alleviating symptoms. past medical history: pmh: 1. headaches. 2. thalassemia minor. 3. degenerative joint disease. 4. question of tuberculosis. psh: 1. total abdominal hysterectomy and bilateral salpingo- oophorectomy for bleeding. 2. cataract surgery, left eye. 3. cesarean section x1. 4. bartholin cyst surgery. 5. thumb surgery. social history: she is a former smoker but quit years ago. she does not drink or use drugs. she is retired. she lives with her husband, daughter, and son. she has eight grandchildren. family history: family history is significant for her father having had kidney cancer. her children have thalassemia, brother had thyroid cancer, another brother had and prostate cancer. physical exam: vs: 97.0, 76, 126/52, 20, 96% ra gen: a&o, nad cv: rrr no m/r/g pulm: ctab abd: soft, ttp over incision site, non-distended, incision c/d/i with staples ext: warm, 2+dp/pt, 1+le edema pertinent results: 11:50am blood wbc-12.9* rbc-3.71* hgb-9.1* hct-29.2* mcv-79* mch-24.6* mchc-31.2 rdw-17.0* plt ct-840* 11:50am blood pt-34.2* ptt-35.2* inr(pt)-3.4* 11:50am blood glucose-107* urean-10 creat-0.5 na-137 k-3.8 cl-97 hco3-32 angap-12 07:20am blood alt-34 ast-22 alkphos-74 totbili-0.4 11:50am blood calcium-8.3* phos-3.2 mg-1.8 brief hospital course: date of admission: date of discharge: procedures: laparoscopic converted to open splenectomy, epidural placement x2 imaging: cxr (): no acute infiltrate. bilateral lower lobe atelectasis with small left pleural effusion. no cardiomegaly. no pulmonary edema. abdominal u/s (): 1. markedly abbreviated study due to poor patient noncompliance. 2. limited findings are concerning for portal vein thrombus versus undetectable flow, but cannot be further clarified with ultrasound at the present time. a contrast enhanced liver ct is advised to further evaluate. ct abd/pelv (): occlusive pv thrombus in intrahepatic r and l branches of the pv. non-occlusive thrombus in the main pv. thrombus in splenic vein remnant. colonic wall thickening, likely due to underdistention, but could represent colitis in the right clinical setting. multiple hepatic and renal cysts. bilateral pleural effusions, greater on the left than the right. cxr (): ij is in proper position in the lower svc. otherwise, bilateral pancake atelectasis with small pleural effusions are unchanged. cxr (): neg for pna or effusions pending labs: spleen for pathology medication changes: none the patient was admitted for observation after laparoscopic splenectomy that was converted to open. an epidural was placed by the acute pains service (aps) post-operatively for pain control which provided moderate pain relief. this was removed and was briefly started on a dilaudid pca. however, she developed confusion and this was d/c'd and started on vicodin with iv morphine for breakthrough. aps was re-contact and another epidural was placed. pod#2 she developed low grade temperature with leukocytosis of 15,000 with a hct drop from 29.6 to 26.8 and worsening abdominal pain. there was concern for possible venous thrombosis so an abdominal u/s was performed. however, this was suboptimal study limited views due to pain but did demonstrate lack of flow through the portal vein. a follow-up ct scan demonstrated an occlusive thrombus in the portal vein and non-occlusive thrombus in the splenic vein remnant. aps was paged and the epidural was removed and she was transferred to the sicu for observation and was started on heparin drip. a right ij cvl was placed for access. her hct continued to drop to 22.4 and she was transfused 2 units prbcs, she responded appropriately with a hct of 30. id was consulted who recommend checking blood cultures and ua which were negative. she received pre-splenectomy vaccinations in . heme/onc was consulted to assist with management and transfusion requirements in patient post-splenectomy with history of thalassemia minor. their recommendations were to keep hct greater than 21 and to follow up as an outpatient with her oncologist and her scheduled f/u ct scan. pod#4 she was transferred to the floor and was started on coumadin. she was placed on regular diet and a morphine pca for pain control. pod#5 the foley was removed and she was voiding without difficulty. she was transitioned to oxycodone and the pca was stopped. pt was consulted who recommend rehab upon discharge. pod#6 the heparin drip was stopped and she continued on coumadin. pod#7 her inr returned as 6.6 and all anticoagulation was held to allow her to drift back down. her r ij was removed and sent for culture which was negative. she continued to have mild o2 requirements via nasal cannula likely due to decreased ambulation. is was continued to be encouraged and the o2 was then weaned. the oxycodone was stopped because she was overly sedated and she was placed on scheduled tylenol and prn tramadol of which she only needed 1 dose. pod#8 she did have temperature of 101.0, cxr was negative for infiltrate and ua was negative. she remained afebrile therafter, her wbc continued to trend down and her inr trended down to 3.4, and she developed post-splenectomy thrombocytosis with platelet count of 840 on discharge. she was ambulating, tolerating a regular diet, voiding, and having bm's. she was discharged to rehab with appropriate follow up appointments with dr. from surgery and her oncologist. she is going to receive 1mg coumadin tonight and should have her inr checked at rehab to titrate coumadin. medications on admission: prilosec 20', ca-vit d 600 mg-400'', mvi' discharge medications: 1. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 2. calcium with vitamin d 600 mg(1,500mg) -400 unit tablet sig: one (1) tablet po twice a day. 3. m-vit 27-1 mg tablet oral 4. tylenol 325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. 5. coumadin. titrate to goal inr of . discharge disposition: extended care facility: nursing center - discharge diagnosis: splenic marginal zone lymphoma portal vein thrombosis splenic vein thrombosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: call the surgery clinic () or go to the emergency department for the following: temperature greater than 101.4; increasing redness, pain, swelling, or discharge from the incision sites; blood in your stool or black tarry stools; inability to tolerate food or drink; worsening abdominal pain; or any other concerns. general discharge instructions: please resume all regular home medications, unless specifically advised not to take a particular medication. please take any new medications as prescribed. please take the prescribed analgesic medications as needed. you may not drink alcohol, drive or operate heavy machinery while taking narcotic analgesic medications. you may also take acetaminophen (tylenol) as directed, but do not exceed 4000 mg in one day. please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. please also follow-up with your primary care physician. incision care: *please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until cleared by your surgeon. *you may shower and wash incisions with a mild soap and warm water. gently pat the area dry. *if you have staples, they will be removed at your follow-up appointment. followup instructions: provider: , md phone: date/time: 2:15 provider: scan phone: date/time: 11:00 provider: , md phone: date/time: 10:00 Procedure: Total splenectomy Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Diagnoses: Thrombocytopenia, unspecified Iron deficiency anemia secondary to blood loss (chronic) Personal history of tobacco use Drug-induced delirium Unspecified sedatives and hypnotics causing adverse effects in therapeutic use Splenomegaly Laparoscopic surgical procedure converted to open procedure Portal vein thrombosis Essential thrombocythemia Sickle-cell trait Marginal zone lymphoma, unspecified site, extranodal and solid organ sites |
allergies: no known allergies / adverse drug reactions attending: chief complaint: pt is a 49 yo male transferred via med flight from osh s/p gsw. pt was brought directly to the or. major surgical or invasive procedure: operation: 1.median sternotomy, multiple cardiac repairs as dictated by dr. , repair of right upper lobe parenchymal laceration, exploratory laparotomy,chromic suturing and argon beam coagulation of 4 liver lacerations,abdominal packing, vac closure of abdomen. 2. emergency median sternotomy. 3. evacuation cardiac tamponade. 4. repair of bullet injury to the right ventricle free wall. 5. tricuspid valve replacement with a size 29 mosaic tissue valve. 6. repair of ventricular septal defect caused by the bullet with dacron patch. 7. left ventriculotomy to remove the bullet. 8. laparotomy and repair liver lacerations and also lung parenchymal injury by dr. as seen in her operation dictation note. 9. mediastinal exploration and washout. 10. mediastinal exploration and closure of the sternotomy. 11.exploratory laparotomy/reopening of recent laparotomy, washout of the abdomen and closure, as well as exploration of the right arm wounds, debridement and packing 12.exploratory laparotomy and abdominal washout. abdominal wall debridement.liver biopsy. abdominal wall closure with retention sutures. history of present illness: this is a 49-year-old patient who sustained a gunshot injury to the right chest. he was apparently very unstable in the field with multiple arrests resuscitated successfully and on reaching the outside hospital at he was apparently reasonably stable. there, further investigations with x-rays revealed the bullet had traversed through the right hemithorax(chest tubed placed) across the heart and lodged itself into the left heart border and he was transferred emergently to the hospital for further exploration and repair. on arrival to the hospital, he was actively resuscitated to maintain reasonable hemodynamics and emergency surgery was carried out by , and the trauma surgeon, dr. , and initially explored by dr. as well. past medical history: +etoh, dm, htn, ? methadone user, s/p hit by train social history: heroin addict family history: non-contributory physical exam: admission physical deferred- rushed emergently to o.r. pertinent results: tee focused study for chest closure and ongoing pressor requirement: left ventricular wall thicknesses and cavity size are normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is a muscular ventricular septal defect (vsd) just below the prosthetic tricuspid valve with left to right flow. this is approximately 1 cm superior to the vsd observed on that was repaired. the remaining left ventricular segments contract normally. right ventricular chamber size and free wall motion are normal.. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. a bioprosthetic valve is seen in the tricuspid position. there is a very small pericardial effusion. dr. was notified in person of the results on at 0830. following chest closure overall systolic function was unchanged from prior. chest and abd ct scan: 1.small apical right pneumothorax. 2.small bilateral pleural effusions with overlying atelectasis; however, infection cannot be excluded, especially at the left lung base. chest tube in appropriate position. 3.small fluid collection inferior to the cecum with high density material concerning for extravasation of oral contrast. associated focal wall thickening of the cecum which may be due to colitis: infections or inflammatory. 3. wedge-shaped hypodense lesion within segment of the liver, likely representing repaired liver laceration. small amount of perihepatic free fluid. 4. open anterior abdominal wall wound with a small amount of fluid or stranding inferiorly in the anterior abdominal wall. 5. fractured left 1st and 2nd ribs. discharge labs: 06:18am blood wbc-9.5 rbc-2.98* hgb-8.4* hct-27.0* mcv-91 mch-28.3 mchc-31.1 rdw-16.5* plt ct-381 06:18am blood glucose-68* urean-28* creat-1.8* na-126* k-4.8 cl-93* hco3-23 angap-15 04:51am blood wbc-10.0 rbc-2.94* hgb-8.4* hct-26.8* mcv-91 mch-28.4 mchc-31.2 rdw-16.7* plt ct-401 05:19am blood wbc-12.9* rbc-2.99* hgb-8.6* hct-26.8* mcv-90 mch-28.8 mchc-32.1 rdw-16.6* plt ct-431 04:51am blood plt ct-401 05:19am blood plt ct-431 02:53am blood pt-15.0* ptt-42.0* inr(pt)-1.4* 04:51am blood glucose-78 urean-30* creat-2.1* na-125* k-4.2 cl-93* hco3-25 angap-11 05:19am blood glucose-96 urean-34* creat-2.2* na-122* k-4.0 cl-89* hco3-23 angap-14 05:50am blood alt-72* ast-131* alkphos-108 amylase-87 totbili-1.9* 02:01am blood alt-62* ast-170* ld(ldh)-378* alkphos-97 tbili-2.6* 05:50am blood lipase-49 02:07am blood lipase-204* 04:51am blood mg-2.2 05:19am blood mg-2.1 10:58 am stool **final report ** c. difficile dna amplification assay (final ): negative for toxigenic c. difficile by the illumigene dna amplification assay. (reference range-negative). 9:52 pm sputum source: endotracheal. gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. stenotrophomonas (xanthomonas) maltophilia. sparse growth. identification and sensitivities performed on culture # . 3:12 pm blood culture source: line-ij 2 of 2. blood culture, routine (final ): serratia marcescens. identification and sensitivities performed on culture # 353-3223v . anaerobic bottle gram stain (final ): gram negative rod(s). aerobic bottle gram stain (final ): gram negative rod(s). radiology report chest port. line placement study date of 2:54 pm final report: in comparison with study of , there has been placement of a left subclavian picc line that extends to the lower portion of the svc. continued low lung volumes with bibasilar effusions and atelectasis. no definite pulmonary edema. left apical pleural cap again is seen, representing a loculated, possibly extrapleural fluid collection related to the recent rib fracture. brief hospital course: the patient was admitted from an outside hospital and went emergently to the or after sustaining gunshot wound to the chest. he underwent extensive surgery to repair trauma sustained to chest. he was brought from the or after undergoing median sternotomy, tvr/vsd closure/rv repair by dr. , repair of right upper lobe parenchymal laceration, exploratory laparotomy, chromic suturing and argon beam coagulation of 4 liver lacerations,abdominal packing, vac closure of abdomen .please see multiple operative notes for further details. he arrived from or intubated, sedated, paralyzed on epi/levo/vasopressin, open chest. he was bleeding from his chest tubes and required multiple blood products and returned to the or for abd and chest washout, repair of diaphragmatic bleeder. returned from or continued to be hypotensive, elevated transaminases, chest and abd open and wound vac in place. he developed rapid afib and received amiodarone with good effect. he returned to the or on pod#2 for chest closure which he tolerated well. abdominal wound remained open and packed. after chest closure pressors were weaned slowly over the course of several days. on pod# 4 his abd was closed. his sedation was weaned off, he remained neurologically intact and his c-spine was cleared by acs. he spiked fevers and became bacteremic. he grew serratia from his blood and stenotrophomonas and enterobacter from sputum on . he was covered with broad coverage antibiotics, (vanc, fagyl, cefepime) id were consulted and bactrim was added. he developed drainage upper aspect of abd wound and was brought back to the or by acs. the abd was opened and packed. he returned a few days later for abd wound closure but the skin remained open. he was extubated on pod#7 but was reintubated 3hr later 2nd to resp distress. left chest tube was placed for moderate to large effusion. he was again reextubated on pod#10. due to his current drug history he was seen by the acute pain service for management of meds. he continued to progress slowly and was transitioned off tube feeds, seen by speech and swallow and cleared to eat regular diet. appetite is poor and he is on supplements. his tranaminases have continued to improve. he developed acute renal failure peak creatinine 2.5. and was therefore gently diuresed. his creat continues to be above normal. he was noted to have developed a pressure sore to the back of his head for which he was seen by wound nurse and place in foam mattress. chest tubes and pw were remove without incident. he eventually transitioned to the floor on pod#12. on the floor he continued to progress. he has remained very weak and deconditioned. he developed c-diff and was started on po vanco which he had completed. he became hyponatremic which has been slowly improving and was placed on fluid and free water restriction and meds were adjusted. he has remained afebrile and will continue on bactrim until . the patient was evaluated by the physical therapy service for assistance with strength and mobility. at the time of discharge on pod 24 the patient was requiring max assist and was screened for rehab. he is able to sit and stand at the bedside he has a continued flat affect requiring encouragement to partake in physical therapy. all his wounds are healing well, his abdominal wound has several retention sutures and a vac in place to assist with wound healing. he was noted to be lethargic a few days prior to discharge and pain meds were adjusted, he has tolerated the adjustment and noted to be less lethargic. the patient was discharged to sianai in in good condition with appropriate follow up instructions. medications on admission: none discharge medications: 1. acetaminophen 650 mg po/pr q4h:prn temperature >38.0 2. amiodarone 200 mg po daily 3. aspirin 81 mg po daily 4. bisacodyl 10 mg pr hs:prn constipation 5. docusate sodium 100 mg po bid 6. furosemide 20 mg po bid 7. heparin 5000 unit sc tid 8. metoprolol tartrate 12.5 mg po bid hold and call ho for sbp<90 hr<55 9. milk of magnesia 30 ml po daily:prn constipation 10. nystatin cream 1 appl tp groin 11. oxycodone (immediate release) 2.5 mg po q4h:prn pain rx *oxycodone 5 mg 0.5 (one half) tablet(s) by mouth every four (4) hours disp #*40 tablet refills:*0 12. oxycodone sr (oxycontin) 10 mg po q12h rx *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours disp #*60 tablet refills:*0 13. ranitidine 150 mg po daily 14. tizanidine 0.5 mg po bid:prn pain 15. sodium chloride 1 gm po tid discharge disposition: extended care facility: at medical center discharge diagnosis: 1)gunshot wound to chest with resultant injuries to heart, diaphragm, lung and liver resulting in massive hemorrhage and pericardial tamponade. 2)bleeding from diaphragm. 3)fascial dehiscence and evisceration 4)serratia bacteremia pmh: htn, dm discharge condition: alert and oriented x3 nonfocal bed to chair with assist(per pt)full assist-lift(per nursing) pain managed with oral narcotics extremities:warm well perfused-no edema abd wound:with vac, incision-clean occiput: pressure ulcer-keep on sponge pillow discharge instructions: look at your incisions daily no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and in the evening take your temperature, these should be written down on the chart vab dressing chnage to abdomin q 72hrs (last change ) no driving for one month or while taking narcotics. do not drive until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: recommended follow-up: you are scheduled for the following appointments surgeon: dr phone: date/time: 1:00 in the medical office building cardiologist:needs referral please call to schedule appointments with your: acute care surgery(acs): call to schedule f/u appt in 2 weeks primary care dr., in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Enteral infusion of concentrated nutritional substances Closed (percutaneous) [needle] biopsy of liver Cardioplegia Other repair of chest wall Other repair of abdominal wall Nonexcisional debridement of wound, infection or burn Closure of laceration of lung Closure of laceration of liver Excision or destruction of lesion or tissue of abdominal wall or umbilicus Open and other replacement of tricuspid valve with tissue graft Hypothermia (systemic) incidental to open heart surgery Suture of laceration of diaphragm Other repair of heart and pericardium Diagnoses: Other postoperative infection Cellulitis and abscess of trunk Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Severe sepsis Atrial fibrillation Alcohol abuse, unspecified Laceration of heart with penetration of heart chambers with open wound into thorax Injury to liver without mention of open wound into cavity, laceration, minor Pressure ulcer, other site 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 Opioid abuse, unspecified Traumatic shock Disruption of external operation (surgical) wound Personal history of sudden cardiac arrest Cardiac tamponade Acute respiratory failure following trauma and surgery Septicemia due to serratia Secondary and recurrent hemorrhage Pressure ulcer, unstageable Traumatic pneumohemothorax with open wound into thorax Assault by other and unspecified firearm Open wound of upper arm, complicated Laceration of lung with open wound into thorax Injury to diaphragm, with open wound into cavity |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: admitted for repair of hernia. major surgical or invasive procedure: 1. exploratory laparotomy with biopsy of mesenteric nodule. 2. lysis of adhesions greater than 2 hours. picc line placement history of present illness: mr. has the history of multiple abdominal surgeries including hernia repairs with mesh. he presented with very large abdominal wall hernias with intermittent and recurrent obstruction. he was able to lose weight preoperatively with the aid of the lap-band procedure and now he required surgical repair of his hernias. past medical history: right bundle branch block ---stress test in normal osteoporosis hypothyroidism s/p thyroid resection for thyroid nodule of undetermined significance sigmoid diverticulitis s/p hartmann's with small bowel resection () and takedown () ventral hernia repaired with component separation () social history: the patient quit tobacco 20 years ago, does drink one glass of wine per night. no drugs. works as mail carrier, lives with wife. family history: non-contributory -- as per hpi no h/o blood clots, coagulaopathies, or miscarriages physical exam: the bp is 116/74 and his pulse is 72 and regular. resp is 14 and unlabored after walking down the hallway. the temp is 98.2 orally. there are no acute skin lesions. the hair and nails are normal for his age. the ear canals are clear with benign tms. the sclera are anicteric and w/o pallor. perrl and a. the oral mucosa has no lesions; dentition is in good repair. the neck is supple, and the thyroid is w/o enlargment or nodularity. the neck veins are flat when he is about 30 degrees from the fully supine position. the trachea is midline. there is no pain with percussion of the vertebral bodies or the cvas. the thorax is resonant, and the bs are clear and symmetric in all lung fields, including the apices, rml and the lingula. the precordium is quiet and there is a soft and regular s1 and s2 and no murmurs, no s3 or s4 when he is upright and supine. there are no carotid bruits. no cardiac rubs. the abdomen has active bs. the liver is 9 cm in span by percussion and scratch. he has at least 2 very large ventral hernias. no abdominal masses. no peripheral edema, and no acute joint pathology. he is alert and orientated. pertinent results: 09:25pm blood wbc-6.2 rbc-3.34* hgb-11.2* hct-33.6* mcv-101* mch-33.7* mchc-33.5 rdw-13.2 plt ct-302 03:07am blood wbc-6.3 rbc-3.29* hgb-10.6* hct-32.6* mcv-99* mch-32.4* mchc-32.6 rdw-13.5 plt ct-277 08:13pm blood glucose-183* urean-13 creat-0.8 na-140 k-4.4 cl-107 hco3-26 angap-11 03:07am blood glucose-144* urean-13 creat-0.9 na-139 k-4.4 cl-107 hco3-27 angap-9 08:13pm blood calcium-8.2* phos-4.7* mg-1.5* 03:07am blood calcium-8.4 phos-4.8* brief hospital course: pt underwent open heria repair on with dr. and then dr. from plastics did the reconstruction. procedure lasted over 10 hours and so pt was transfered to icu after surgery. three jp drains were placed. pt did well, made good urine, vital signs were stable and so on pt was transfered to the floor. on foley was removed diet was advanced. laboratory results and vital signs remained stable. jp drainage was reduced. neuro - patient's pain was well controlled with a dilaudid pca until the patient was tolerating pos at which point he was transitioned to percocet which offered good relief for his pain. cv - the patient's vital signs were monitored per routine on the floor after surgery. he was hemodynamically stable throughout the entirety of his hospital course. pulm - after surgery the patient was encouraged to use his incentive spirometer 10 times/hour; the patient was compliant and had not postoperative complications with his pulmonary function. he maintained his oxygen saturations in the mid-90s on room air at the time of discharge. gi - the patient underwent an open hernia repair on by dr. and dr. (plastic surgery). his post-operative course was complicated by an ileus secondary to narcotics whichw as relieved by a suppository. prior to discharge the patient was passing gas, defecating, and tolerating a stage v diet without nausea or vomiting. integumentary - the patient's incision was monitored for cellulitis on a daily basis and showed no signs of infection during his postoperative stay. he was kept on ancef for prophylaxis while his jp drains were in. all jps and the ancef were discontinued on the day of discharge. medications on admission: 1. verapamil 80 mg tablet sig: one (1) tablet po q8h 2.levothyroxine sodium 150 mcg 3. multivitamin tablet sig: one (1) tablet po once a day discharge medications: 1. verapamil 40 mg tablet sig: two (2) tablet po q8h (every 8 hours). 2. levothyroxine 100 mcg tablet sig: 1.5 tablets po daily (daily). discharge disposition: home with service facility: homecare discharge diagnosis: ventral hernia discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: you are being discharged on medications to treat the pain from your operation. these medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. you must refrain from such activities while taking these medications. please call your doctor or return to the emergency room if you have any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. activity: no heavy lifting of items pounds for 6 weeks. you may resume moderate exercise at your discretion, no abdominal exercises. wound care: you may shower, no tub baths or swimming. if there is clear drainage from your incisions, cover with clean, dry gauze. your steri-strips will fall off on their own. please remove any remaining strips 7-10 days after surgery. please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. followup instructions: please follow up with dr. in 2 weeks. please call his office at to make an appointment. please follow up with dr. , please call his office at to make an appointment. please make an appointment with your primary care provider in the next month to review your current health status. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Excision or destruction of peritoneal tissue Other lysis of peritoneal adhesions Other open incisional hernia repair with graft or prosthesis Diagnoses: Obstructive sleep apnea (adult)(pediatric) Cellulitis and abscess of trunk Peritoneal adhesions (postoperative) (postinfection) Right bundle branch block Osteoporosis, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Paralytic ileus Personal history of venous thrombosis and embolism Obesity, unspecified Incisional ventral hernia with obstruction Bariatric surgery status Postsurgical hypothyroidism Acquired absence of intestine (large) (small) |
allergies: coconut oil attending: chief complaint: altered mental status, hiatal hernia, hepatitis of unknown etiology major surgical or invasive procedure: 1. several intubations for respiratory failure 2. laparoscopic reduction of hiatal hernia, repair of diaphragmatic defect with pledgeted sutures, pexy of stomach to diaphragm, and laparoscopic liver biopsy history of present illness: ms. is a 52 year old female with a history of mental retardation and migraine headaches who is transfered from hospital for further management of hepatitis. she originally presented to hospital on with an increase in the frequency of falls and confusion. her sister and noted subtle changes in her behavior as far back as that became increasingly pronounced over the following months, viral hepatitis work-up was reportedly negative. at hospital, the patient had a prolonged and complicated course with extensive evaluation of her elevated lfts. she was noted to have hyperammonemia and was treated with lactulose for hepatic encephalopathy with some improvement in mental status. mri abdomen was unremarkable. ceruloplasmin, , ama, were all normal. viral hepatitis serologies were negative as was cmv pcr. alpha-1 antitrypsin was elevated at 385. she underwent a liver biopsy on that showed "ongoing severe liver injury with extensive hepatocyte damage and resulting collapse. she underwent endoscopy that demonstrated a 10 cm hiatal hernia and gastric volvulus with edema and erythema of the stomach and an erosion at the ge junction. colonoscopy showed grade iv internal hemorrhoids and 2 colonic ulcerations that were ischemic in nature and a 2 mm polyp that was resected. she required antibiotics (vancomycin and zosyn) to treat hap and aspiration pna. her lfts remained abnormal with ast of 146 and alt 103. ap peaked at 457. she was transferred, at the request of her family, to on for further evaluation as they were still seeking a diagnosis for her illness. the patient was admitted to the medicine service on to evaluate her liver disease. while on the medicine service, her hospital course was complicated by ongoing aspiration events felt to be a result of her large hiatal hernia and esophageal dysmotility. on , she was intubated and transferred to the micu for increasing dyspnea and acute respiratory failure. she was extubated soon after on and was treated for hap/aspiration pneumonia, but antibiotics were stopped on . on , the patient was transferred to the thoracic surgery service and underwent laparascopic hiatal hernia reduction with percutaneous liver biospy. past medical history: - mental retardation of unknown etiology (some work-up at hosp of that was of unclear consequence) - history of migraine headaches that are associated with nausea and vomiting and can be debilitating. - hypercholesterolemia, was formerly on lipitor. - history of self-mutilization characterized by picking at skin. - s/p right inner ear surgery x 2 with implant, and - atn, ain at hospital recent medical history during this hospitalization: - recurrent aspiration pneumonia ( - 18 intubated for ards) - hiatal hernia s/p repair - gastric volvulus s/p repair - right upper extremity phlebitis/cellulitis associated with picc - nash with grade iii-iv fibrosis - ards and intubation post operatively /10 - atn, cvvh with oliguric renal failure (cr peaked at 3.5) - coagulase negative staphylococcal bacteremia () - persistent leukocytosis of unclear etiology - elevated alpha 1 antitrypsin social history: she lives with her sister , her , and a burmese mountain dog. she used to work at a daycare program where she did manual labor but then was switched to a group that manages dementia patients as it was thought she might be developing dementia. she has had diminished ability to perform her adls over the past few months. she has never smoked, no alcohol, and no drug use. family history: - mother: breast ca at 76 - father: colorectal ca in his 60s, mi - 4 siblings: diabetes, hypertension, migraine headaches, vertigo/meniere's disease physical exam: vitals: t 99.1, bp 149/89, hr 80, rr 20, o2 sat 96% ra general: morbidly obese, middle-aged, caucasian female in nad, voice is difficult to understand heent: dysmorphic facies, atraumatic, sclera anicteric, disconjugate gaze, unable to completely assess eom d/t non-cooperation with exam, op clear, mmm neck: supple, no lymphadenopathy or thyromegaly heart: rrr, normal s1 and s2, no murmurs lungs: cta anteriorly, laterally, and superiorly in the back. no w/r/r. breathing comfortably without accessory muscle use. abdomen: +bs, soft, obese, mild ruq tenderness without rebound or guarding extremities: 3+ edema in feet and ankles bilaterally. neurological: alert, oriented to self and family. moves all 4 extremities. difficult to assess due to lack of cooperation with exam. pertinent results: admission labs: 09:32pm blood wbc-14.5* rbc-3.89* hgb-10.6* hct-34.4* mcv-88 mch-27.2 mchc-30.9* rdw-15.8* plt ct-236 05:53am blood neuts-85.2* lymphs-7.8* monos-4.6 eos-2.1 baso-0.2 09:32pm blood pt-15.6* ptt-32.5 inr(pt)-1.4* 09:32pm blood glucose-101* urean-7 creat-1.0 na-140 k-3.9 cl-108 hco3-22 angap-14 09:32pm blood alt-90* ast-145* ld(ldh)-229 alkphos-532* totbili-0.8 09:32pm blood albumin-2.6* calcium-8.3* phos-3.3 mg-1.8 labs on transfer to micu: 04:58am blood wbc-22.5* rbc-3.51* hgb-10.0* hct-31.6* mcv-90 mch-28.5 mchc-31.7 rdw-15.9* plt ct-288# 12:48pm blood neuts-91.5* lymphs-5.0* monos-2.9 eos-0.2 baso-0.4 04:58am blood pt-16.2* ptt-30.6 inr(pt)-1.4* 04:58am blood glucose-124* urean-15 creat-1.5* na-146* k-3.6 cl-111* hco3-21* angap-18 04:58am blood alt-94* ast-132* ld(ldh)-312* alkphos-505* totbili-0.8 04:58am blood albumin-2.8* calcium-8.1* phos-3.9 mg-1.9 10:26am blood type-art po2-65* pco2-30* ph-7.48* caltco2-23 base xs-0 10:26am blood lactate-3.4* barium esophagram (): 1. severe esophageal dysmotility and reflux. 2. moderate hiatal hernia. liver biopsy, pathology (): 1. advanced fibrosis (stage 3-4) with extensive bridging, multifocal incomplete nodule formation (with a rare focus suggestive of complete nodule formation) and a prominent sinusoidal component. 2. moderate lobular neutrophilic inflammation and mild portal mixed inflammation (score 2). 3. foci of hepatocyte ballooning degeneration with associated intracytoplasmic hyalin (score 2). 4. minimal steatosis (involving <5% of the core biopsy; score 0) 2d echo (): mild regional left ventricular systolic dysfunction consistent with coronary artery disease. mri abdomen & pelvis (): 1. no evidence of biliary obstruction. 2. small amount of perihepatic ascites. 3. significant dependent body wall edema indicative of "third-spacing". renal ultrasound (): essentially normal renal ultrasound. no evidence of hydronephrosis. duplex dopp abd/pel; liver or gallbladder us (): major intrahepatic vasculature patent with normal direction of flow. slightly coarsened and echogenic liver compatible with the history of autoimmune hepatitis. no intrahepatic or extrahepatic biliary ductal dilatation. ct chest/abdomen/pelvis (): 1. improved aeration of lung parenchyma, with persistent predominantly basal consolidations and perihilar ground-glass opacities. 2. small bilateral pleural effusions. 3. diffuse body wall edema with mild abdominal and pelvic ascites without focal fluid collection. 4. persistent geographic area of hypoattenuation involving the medial aspect of segment ii and iii of the liver of uncertain etiology. edema or infarcts could be considered. when clinically appropriate, if the patient can have a contrast-enhanced ct or mr examination, depending patient factors, this appearance could be investigated further. alternatively, a short-term follow-up with ultrasound might be able to provide some information and could provide a baseline for follow-up of the abnormality, if it is later visualized. doppler features could also be reassessed in light of persistence of this abnormality. 5. left picc ends in the left brachiocephalic vein. 6. thickening of the distal colon, involving the sigmoid and through the upper rectum, even allowing for underdistension. differential considerations include colitis in the appropriate setting or sequelae of portal congestion. since the upstream colon is mildly prominent, the fact that the distal is mild to moderately narrowed may be causing slight obstruction, although contrast passes entirely through the area. the whole segment was collapsed on the last examination, limiting assessment and comparison. correlation with clinical factors is recommended. duplex dopp abd/pel port; liver or gallbladder us (): 1. patent hepatic vasculature 2. no focal liver lesion and no biliary dilatation seen. 3. minimal ascites. ct abd/pelvis (): 1. no evidence of abscess. moderate amount of ascites, which has increased since the previous study. 2. small bilateral pleural effusions, which have decreased in size since the previous study. adjacent bibasilar atelectasis in addition to diffuse ground-glass and patchy opacities at the bases have improved. 3. small areas of hypoenhancement within segment ii and iii of the liver with slight decrease in size of these segments likely reflects evolving infarct and subsequent scarring corresponding with the area of hypodensity noted on the previous noncontrast ct studies. 4. possible bowel wall thickening of the cecum, new since the previous study. while this may be due to underdistended bowel, focal colitis cannot be excluded. previously described thickening of the distal colon is not seen on today's study and may have been due to underdistension on the previous study. mr head w/ & w/o contrast (): non-specific, nonenhancing focus of high signal on flair and t2 weighted images in the left parietal lobe. the differential considerations are demyleination, vasculitis or sequlae of small vessel disease. microbiology: hd catheter - coag neg staph hd catheter - coag neg staph blood cultures - vre multiple sputum and urine cultures showing undifferentiated yeast. brief hospital course: hospice care: ms. was initially admitted to the hospital from after being diagnosed with hepatitis that was found to be end stage liver disease (cirrhosis) from nash. briefly, her hospitalization course was complicated by intubation for aspiration pneumonia with subsequent respiratory arrest. she also underwent a hiatal hernia repair to help decrease the risk of aspiration, she was in the icu for transient shock liver and renal dysfunction. she also developed vre sepsis and was finally extubated several prior to her transition to the floor. unfortunately her course continued to deteriorate, she was noted to again be in respiratory distress likely a combination of aspiration from secretions and a hypervolemic state. she was also not tolerating oral, ng tube feeds. following the onset of ngt feeding her abdomen would become distended, she would have a fever. after a discussion with health care proxy and family members the decision was made for her to be comfort measures only. all non-essential, non-comforting medications were discontinued. pt was started on oral morphine for pain, oral ativan for anxiety, scopolamine patch to minimize secretions from the morphine. - please continue with 5-10mg po morpine every 4 hours as needed for comfort, this may need to be increased pending her discomfort - please continue with 1mg ativan po every 4 hours for anxiety - please continue with 3 scopolamine patches to the neck to decrease secretions - please continue with bisacodyl 10mg pr as needed if the pt does not have a bowel movement for several days and seems uncomfortable from constipation - please continue with acetaminophen pr as needed for any fevers prior to transfer to thoracic surgery service/micu: # elevated liver enzymes: liver biopsy pathology slides were obtained from hospital and reviewed by pathology. full findings are above. pathology was consistent with stage 3-4 fibrosis thought to be secondary to nash. # dysphagia, hoarse voice: barium study evaluation revealed a large hiatal hernia, and osh upper endoscopy showed possible gastric volvulus. patient was continued on ppi and thoracic surgery was consulted. # respiratory distress, aspiration pneumonia: a respiratory code was called when patient became increasingly dyspneic and hypoxic to 85% on the non-rebreather on . patient was then transferred to the micu and started on hap coverage with vancomycin and zosyn. she was extubated on . bronchoscopy specimens only grew yeast. # coag negative staph bacteremia: on bottle grew gpcs which turned out to be coag negative staph. surveilance cultures were negative, and this was felt to be likely a contaminant. patient was initially covered with vancomycin, but this was stopped on . # candiduria: patient grew from urine, as well as bronch specimen. patient received fluconazole iv x 3 days, and foley catheter was changed. # nutrition: after above mentioned aspiration event, patient was made npo. initial speech and swallow found esophageal dismotility on barium swallow, without coughing and patient was placed on diet of thin liquids and pureed solids. # cellulitis: she presented to the hospital from hospital with a right arm cellulitis at the site of her previous picc. we completed her 7-day course of antibiotics. there were no further issues. from transfer to thoracic surgery service/sicu (): key events: : hepatology rec likely volume down, supportive care. renal recs likely atn from hypotension. renal us no source. tpn. vanco inc 1gm q48. : placement of r subclavian cvl, started levo for sbp support, adequate uo, one dose of lasix 20 mg iv in am, improved liver function, rising creatinine : continues with minimal uop. started albumin 25g tid and lasix drip with improvement in uop, low dose levophed started to increase renal perfusion. fever, sent u/a, ucx, blood cx, cxr. ordered for ruq ultrasound with doppler. started cvvh, ct torso, placed hd line, bedside echo cvvh at bedside, cr / bun / weight trending down, inr stable at 1.5. started vanco, , fluc. continues on cvvh. now on psv 10/10 with plan to extubate off cvvh since am, minimal urine production, improving past midnight, no vasopressors, febrile to 103.2 -> blcx, uclx, sputum, on cpap. sputum gram stain no organisms. : paracentesis done, 1.5 l of transudative fluid removed. right sc removed and new triple lumen placed in left subclavian. ct torso without obvious etiology of fevers. increasing stools overnight, c. diff sent. : had hd performed at bedside with 1.5 l removed. sbt with 5/0 settings. patient did well for ~45 minutes, then became tachypnic with desaturation. no extubation. became febrile to 104 and received ice packs and fan. : hd was cancelled fever, hd planned for , may not need renal recs albumin and lasix in interim; we gave lasix 40 mg once with adequate response, hepatology - f/u lfts, no acute events, afebrile > 24 hours, d/c'ed rij hd line. patient extubated. : vancomycin started for coag neg staph on right ij hd catheter. uop improving, lasix prn. overall, pt clinically improving. : urine output continues to improve. received lasix with good output, however, afternoon lytes with hypernatremia (147). evening lasix held. : we d/ced fluconazole given completion of course for yeast cultures. she was cleared for thin liquids and pureed foods with swallow eval. : repeat swallow study was performed demonstrating poor interest in intake, no aspiration or mechanical issue with deglutition. : last dose of vancomycin was given in the am. blood cultures were drawn x 2. from transfer to micu on : # respiratory failure: pt was transferred to the micu on for hypoxic respiratory failure and was intubated. multiple sputum cultures and a mini-bal were negative except for undifferentiated yeast. her respiratory failure was multifactorial, with contributions from her deconditioning after a long hospital stay, increased intraabdominal pressure from ileus and ascites, a component of ards during her immediate post-op period, and significant fluid overload from aggressive rehydration. she was initially >14l positive on arrival to the micu. with aggressive diuresis with lasix and metolazone her respiratory status improved tremendously and she was extubated to face mask on and transferred to the floor on on nasal cannula. # fevers and persistent leukocytosis: patient had multiple infectious workups including repeat negative blood/sputum/urine/catheter tip cultures, negative ct chest/abdomen/pelvis, negative ct neck, cardiac echo negative for vegetations. she did have one positive blood culture for vre early in her micu stay. she received a long course of multiple broad-spectrum antibiotics, including vancomycin, meropenem, daptomycin, linezolid, flagyl and micafungin. it was noted that her fevers appeared related temporally to tube feeds and her fevers seemed to resolve when she was transitioned to tpn. # renal failure: patient's creatinine was 1.2 upon admission to the micu and improved without intervention. # constipation/ileus/abdominal distension: patient had difficulty with high residuals and persistent fevers seemingly associated with tube feeds. she had intermittent increased abdominal distension which was evaluated on multiple abdominal kubs, ultrasounds, ct scans which did not show acute abdominal processes. diagnostic paracenteses x2 did not demonstrate sbp and ascites did not increase drastically during her micu stay. thought likely due to ileus and the distension improved with tpn (tube feeds held,) and erythromycin. initially lactulose was effective but this was also held as it was given per ngt and was poorly absorbed. # ams: presumably hepatic encephalopathy was the cause of altered ms that led to pt's initial presentation to osh in mid , when pt was found to have elevated lfts for the first time. apparently pt able to communicate with her sister at baseline, but level/sophistication of this communication unclear. had repeat negative head cts and an mri negative for acute abnormalities. her mental status improved only slightly after extubation; however she never fully regained the ability to communicate at her reported baseline. # anemia: first established at osh, where egd/ negative. fe studies consistent with anemia of chronic disease. did decrease once during her micu stay requiring 1u prbc but remained stable throughout the rest of her stay in the low/mid 20s. had one episode of blood in ett but no overt signs of significant hemorrhage. # liver fibrosis/nash: transaminitis relatively stable during micu course, actually improved while in the micu. paracentesis on and negative for sbp. she was continued on ursodiol and rifaximin for hepatic encephalopathy. she was initially receiving lactulose, but this was discontinued due to high residuals in her tube feeds and concern for worsening abdominal distension. # coagulopathy: inr generally 1.5-1.8 with peak 2.1. platelet counts normal. patient most likely had vit k deficiency from chronic antibiotics, npo status, and malabsorption/ileus. there was no need for reversal of anticoagulation during her micu stay. medications on admission: medications (pre-admission): - propranolol 20mg qday - atorvastatin 20mg qday - fluoxetine 80 mg qday - nortriptyline 75mg qday - ativan 1mg prn anxiety . medications (on transfer to micu ) - miconazole powder 2% 1 appl tp tid:prn yeast - nortriptyline 75 mg po/ng hs - acetaminophen 325-650 mg po/ng q6h:prn pain or fever - olanzapine (disintegrating tablet) 5 mg po tid:prn anxiety - albuterol 0.083% neb soln 1 neb ih q6h:prn dyspnea - ondansetron 4 mg iv q8h:prn nausea order - albuterol inhaler 6 puff ih q4h:prn wheezing - potassium chloride 40 meq / 500 ml d5w iv - albuterol 0.083% neb soln 1 neb ih q6h:prn dyspnea - polyethylene glycol 17 g ng constipation - bisacodyl 10 mg pr hs:prn constipation - propranolol 20 mg po/ng daily - docusate sodium 100 mg po bid - fluoxetine 80 mg po/ng daily - senna 1 tab po/ng :prn constipation - heparin 5000 unit sc tid - ursodiol 300 mg po bid - trazodone 50 mg po/ng hs:prn for sleep - lactulose 30 ml po/ng tid discharge medications: 1. scopolamine base 1.5 mg patch 72 hr sig: three (3) patch 72 hr transdermal once (once): to thin secretions. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation: please place rectal suppository if constipated for more than 3 days. 3. morphine concentrate 20 mg/ml solution sig: 5-10 mg po q4h (every 4 hours) as needed for pain/discomfort: palliative care. disp:*500 mg* refills:*0* 4. lorazepam 1 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety: place under tongue. disp:*30 tablet(s)* refills:*0* 5. acetaminophen 650 mg suppository sig: one (1) suppository rectal q4h (every 4 hours) as needed for fever. discharge disposition: extended care facility: care and rehab discharge diagnosis: hypoxemic respiratory failure vre sepsis hiatal hernia cirrhosis nash mental retardation hyperlipidemia discharge condition: mental status: confused - always. level of consciousness: lethargic, intermittently arousable. activity status: bedbound. discharge instructions: you were initially transferred to the hospital for management for your hepatitis. after being transferred to the hospital we noted that your hepatitis was actually end stage liver disease called cirrhosis. you had a complicated hospitalization which included several intubations after you developed a lung infection after aspirating, you also had a severe infection called sepsis and you were in the intensive care unit for a prolonged time. after your breathing tube was removed you unfortunately still remained very sick with difficulty breathing. after talking with your family it was decided that you should be comfortable and you transferred to comfort measures only. followup instructions: discharge to hospice Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Hemodialysis Closed (percutaneous) [needle] biopsy of liver Venous catheterization for renal dialysis Percutaneous abdominal drainage Arterial catheterization Closed [endoscopic] biopsy of bronchus Infusion of drotrecogin alfa (activated) Laparoscopic repair of diaphragmatic hernia, abdominal approach Diagnoses: Anemia of other chronic disease Esophageal reflux Pure hypercholesterolemia Acute kidney failure with lesion of tubular necrosis Cirrhosis of liver without mention of alcohol Acute and subacute necrosis of liver Hepatorenal syndrome Acquired coagulation factor deficiency Severe sepsis Candidiasis of other urogenital sites 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 Cellulitis and abscess of upper arm and forearm Paralytic ileus Candidiasis of lung Other ascites Altered mental status Encounter for palliative care Hepatic encephalopathy Phlebitis and thrombophlebitis of superficial veins of upper extremities Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Other specified disorders of stomach and duodenum Streptococcal septicemia Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Leukocytosis, unspecified Unspecified intellectual disabilities Diaphragmatic hernia with obstruction Dysphagia, oropharyngeal phase Unspecified vascular insufficiency of intestine Dyskinesia of esophagus Infection with microorganisms with resistance to multiple drugs Autoimmune hepatitis |
allergies: no known allergies / adverse drug reactions attending: chief complaint: unresponsiveness major surgical or invasive procedure: intubation at outside hospital mechanical ventilation extubation history of present illness: 25 year old male without any known medical problems but with possible depression/anxiety/bipolar disease who was called out from the icu today after an extubation for violent and agitated behavior. he was involved in a violent altercation with his father two evenings ago, fueled a likely overdose of dextrmethorphan combined with alcohol. per report, he had nearly strangled his father to unconsciousness, who required 30 stitches and now filed a restraining order. the police arrived at the scene, and were unable to subdue the patient with multiple taser shocks (3-5 times). he remained uncooperative. he was eventually brought to lgh, though had apparently some respiratory distress en route. alcohol and marijuana were detected in the . he was so agitated that he apparently required propofol/vecuronium sedation and was intubated. he was transferred to thereafter. in the ed, initial vs 97.3 100 140/80 18 100% unknown vent settings. he was found to have an abrasion over his left hand which was irrigated, and received amp/sulbactam. he was then admitted to the micu for further management. in the micu, he continued unasyn overnight and was extubated the following day. he was continued on ciwa due to an elevated etoh level but he did not require additional benzos. a transition to po augmentin yesterday was short-lived, as he spiked fevers to 101 last evening, 100.4 this morning. he was seen by hand surgery, who splinted the hand and recommended continued iv unasyn. psychiatry and social work are both following. a warrant exists in for his arrest, and police will be providing a 1:1 sitter shortly. he has a long history of violent behavior, which prompted his "other than honorable discharge" from the marines several years ago. per his mother, he tends to get violent when under the influence of drugs. currently, he has a dry cough which has been present for about 24 hours. he denies shortness of breath. he denies malaise, fatigue, weakness, nausea, vomiting, dysuria, hematuria, loose stools. past medical history: - adhd, not on meds - possible depression/anxiety - two psychiatric hospitalizations at in from to and in from to6/11/10. one hospitalization at least for suicide attempt. - polysubstance abuse- etoh, marijuana, dextromethorphan - violent behavior social history: patient is unemployed since having a "other than honorable" discharge from the marines. he had been living with his parents recently. smokes 1ppd cigarettes for 5 years. denies alcohol or illicit drug use, though per family members, he has been abusing dextromethorphan and his admission tox screen positive for etoh and marijuana. family history: nc physical exam: admission exam: vs: 96.8 100 127/70 98% ac 550x20, 5, 0.4 gen: intubated, sedated heent: pupils 2->1mm cv: tachy s1+s2 pulm: ctab anteriorly abd: s/nt/nd +bs, -hsm ext: no c/c/e neuro: sedated. pupils as above. skin: 2 1 mm incision over left 4th finger consistent with tooth marks. discharge exam: vs: t96.5 (tm 98.4) bp118/78 p76 rr18 sat97ra general: no acute distress heent: mmm, op clear cards: tachy, normal s1 s2 no mrg pulm: clear to auscultation, no rhonchi or crackles appreciated abdomen: snt nd +bs ext: less edema of the left hand today. sensation intact, suspended in stocking and splint. pertinent results: admission labs: 06:10am urine hours-random creat-84 sodium-173 potassium-62 chloride-200 06:10am urine osmolal-738 06:10am urine color-straw appear-clear sp -1.025 06:10am urine -neg nitrite-neg protein-neg glucose-neg ketone-10 bilirubin-neg urobilngn-neg ph-5.5 leuk-neg 05:41am glucose-63* urea n-10 creat-0.7 sodium-138 potassium-4.0 chloride-110* total co2-20* anion gap-12 05:41am alt(sgpt)-32 ast(sgot)-30 ld(ldh)-235 ck(cpk)-251 alk phos-33* tot bili-0.3 05:41am albumin-3.5 calcium-7.4* phosphate-2.7 magnesium-1.7 05:41am wbc-11.4* rbc-4.05* hgb-13.1* hct-36.5* mcv-90 mch-32.4* mchc-36.0* rdw-13.5 05:41am plt count-145* 01:29am type-art rates-0/18 tidal vol-550 o2-100 po2-484* pco2-43 ph-7.32* total co2-23 base xs--3 aado2-212 req o2-42 -assist/con intubated-intubated 01:29am o2 sat-99 12:55am glucose-85 urea n-12 creat-0.9 sodium-136 potassium-4.3 chloride-104 total co2-23 anion gap-13 12:55am ck(cpk)-256 12:55am asa-neg ethanol-111* acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 12:55am urine hours-random 12:55am urine hours-random 12:55am urine bnzodzpn-pos barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 12:55am wbc-12.1* rbc-4.48* hgb-14.8 hct-40.7 mcv-91 mch-32.9* mchc-36.2* rdw-13.1 12:55am neuts-71.0* lymphs-23.2 monos-4.7 eos-0.4 basos-0.7 12:55am plt count-175 discharge labs: 06:35am wbc-9.2 rbc-4.49* hgb-14.4 hct-41.0 mcv-91 mch-32.0 mchc-35.1* rdw-13.7 plt ct-182 07:00am glucose-95 urean-7 creat-0.8 na-141 k-4.4 cl-105 hco3-27 angap-13 7:38 pm swab source: l hand ring finger fight bite wound. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): no growth. anaerobic culture (preliminary): no growth. culture x 2: ntgd urine culture negative ekg : sinus rhythm with borderline sinus tachycardia. prominent/modestly peaked t waves are non-specific and may be within normal limits. cannot exclude possible hyperkalemia. clinical correlation is suggested. no previous tracing available for comparison. cxr : the lungs are well expanded and show bibasilar atelectasis. the cardiac silhouette is top normal. the mediastinal silhouette, hilar contours and pleural surfaces are normal. an et tube terminates 4.8 cm above the carina appropriately. an ng tube terminates in the stomach. impression: bibasilar atelectasis was much more pronounced on ct torso two hours earlier. left hand, 3 views : no specific localizing history is available. allowing for this, no fracture or dislocation is detected about the left hand. no focal lytic or sclerotic lesion is identified. there is soft tissue swelling along the dorsum of the hand. no radiopaque foreign body or subcutaneous emphysema is detected. brief hospital course: mr. is a 25 year old male with a nonspecific history of depression/anxiety/violence, polysubstance abuse, who was involved in a violent altercation requiring significant sedation and eventual intubation at an outside institution, who was transferred to for further management of mechanical respiration and a left hand infected bite wound. active problems: 1. mechanical ventilation: he was intubated at an osh for agitation. cxr was clear without evidence of gas exchange impairment. patient extubated without difficulty. sw and psych evaluated the patient while in the icu, with recommenadtion for prn haldol, ativan, and benadryl for further agitation. 2. agitation/violence: social work and psychiatry teams were immediately consulted for further management of his agitation. his mother revealed a dextromethorphan overdose pattern which causes euphoria and agitation, and the patient later confirmed this fact. psych initially recommended benadryl/haldol/ativan for sedation, though was calm upon extubation and required no further chemical sedation. he did not physically or verbally abuse staff members. psychiatry followed him throughout the hospitalization. per psych attending discharge recommendations: patient's history is suggestive of antisocial personality disorder, although there are some inconsistencies in the reported historical data (compare information from c info patient later reported to dr. , so it is difficult to say c certainy how accurate this diagnosis is. i don't appreciate persuasive evidence for a major mood or anxiety disorder, although patient does have some situational anxiety. at present, there is no psychiatric contraindication to patient's return to the legal system. based on current data, i do not see an indication for a placement in a forensic psychiatric setting for acute risk; however, appreciating that risk assessment is dynamic, depending on the specific charges that patient is facing (e.g., level of severity, which we do not know at this time), his risk for impulsive self-harm might escalate in proportion to subjective sense of desperation & anxiety that is independent of a major mental illness. patient is able to voice a clear understanding regarding his immediate future plans and an apparent acceptance of the situation. we rev'd how to access care within the justice system. 3. left hand bite wound: he sustained a left 4th mcp fight bite which subsequently became infected. he developed fevers to 102 in the icu with tachycardia. received fluids and intravenous unasyn. the hand surgery team was consulted and cleaned the wound and splinted it. swelling was intitially substantial, but improved with elevation in stockignette. he required no operative debridement. he continued 72 hours of intravenous unasyn and was discharged to complete 10 additional days of po augmentin. he will follow up with the hand team in one week, at which point he will likely have an extensor tendon repair, which was partially torn in the fight. will need daily dressing changes. elevation no longer necessary. tylenol and ibuprofen for pain. 4. electrical injury: patient received multiple electrical shocks from taser, putting him at risk for arrythmia, rhabdomyolysis, and burns. ck stable without evidence of rhabdomylolysis. 5. polysubstance abuse: patient with etoh level of 200 at osh with report of history of polysubstance abuse, particularly the dextromethorphan that triggered his acute agitation. hyperstimulation and disassociation likely in setting of dextromethorphan. pcp and ketamine labs were pending at the time of discharge. 6. legal: a warrant was issued for his arrest. discharged into police custody. labs pending at discharge: - ketamine and pcp cultures x2 transitional care issues: -follow up with hand surgery team in one week -outpatient psychiatric care medications on admission: none discharge medications: 1. amoxicillin-pot clavulanate 875-125 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 10 days. disp:*20 tablet(s)* refills:*0* discharge disposition: extended care discharge diagnosis: primary diagnosis: cellulitis left hand laceration discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital after being intubated. you were monitored in the intensive care unit, where you had your breathing tube removed. you were noted to have an injury to your hand, so you were seen by the hand surgeons. you were started on antibiotics to treat an infection of your hand. you did not need any surgery during this hospitalization, but you will need to follow up in hand clinic next week for an injury to one of your tendons. the following changes were made to your medications: #. start augmentin 875mg by mouth every 12 hours for 10 days followup instructions: you have been scheduled the following appointment with the hand doctors: department: orthopedics when: tuesday at 10:30 am with: hand clinic building: sc clinical ctr campus: east best parking: garage Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Dysthymic disorder Other, mixed, or unspecified drug abuse, continuous Cellulitis and abscess of hand, except fingers and thumb Open wound of finger(s), without mention of complication Assault by human bite Antisocial personality disorder |
allergies: sulfa (sulfonamide antibiotics) / epinephrine / levofloxacin / penicillins / benadryl attending: chief complaint: dyspnea major surgical or invasive procedure: bronchoscopy history of present illness: 75 yo w with recurrent/refractory multiple myeloma presenting with several days of increased shortness of breath and cough/chest congestion, transferred to the for management of hypoxia. . she was recently admitted to the bmt service from where she received a number of antimicrobials to treat fever, cough, and uri symptoms ultimately attributed to parainflenza virus iii. the patient initially tested positive for parainfluenza on and failed outpatient treatment with a z-pack. during this last admission she also received ivig and a video swallow study to evaluate chronic aspiration attributed to hiatal hernia. on she started cytoxan/velcade/decadron with d8 of velcade on . . according to the patient, she has not experienced any fevers, chills, or night sweats since discharge. she felt her symptoms had improved dramatically, but not entirely resolved. after receiving chemo her symptoms returned and are now worse than before. she endorses worsening sputum production, now pink and occasional episodes of frank blood. no sick contacts or significant outdoor exposures. her dyspnea worsens with laying flat and is associated with l-sided pleuritic chest pain. she denies pnd or le swelling, hx of blood clots, hematuria, or rash. . she contact her oncologist and was sent to the ed for evaluation of potential post-viral pna. her initial vs on presentation were: 98.8, 76, 136/86, 20, 88% on ra. she was placed on a nrb and her o2 sats rose to 98%. cxr revealed b/l pleural effusions and opacification of the bases. she received vancomycin and cefepime. they attempted to wean her supplemental o2 to 40% fio2 on venturi mask; however, her oxygen saturations again dropped to the 80s. vitals prior to transfer were 141/94, 20, 99% nrb. . on admission to the , she appeared uncomfortable and tachypneic. she was tired, but willing to converse. she answered appropriately and expressed a need for pain medication to control her "rib pain." . . review of sytems: (+) per hpi, + n/v/d attributed to recent chemotherapy (-) denies fever, chills, night sweats. denies headache, sinus tenderness. denied chest pain or palpitations. denied constipation or abdominal pain. no dysuria. denied arthralgias or myalgias or rash. past medical history: past medical history: - vitiligo starting in - diverticulosis- found in colonoscopy . last had colonoscopy 6 months ago in . - atrial fibrillation - history of thyroidectomy - for benign cyst - history of radiation to her tonsils - history of radiation to a left clavicle plasmacytoma after a pathological fracture. - history of mitral valve prolapse - allergies - since stem cell transplant - chronic back pain - s/p 9 compression fractures related to multiple myeloma - restless leg syndrome - 30 yrs - auto. stem cell bone marrow transplant - multiple myeloma diagnosed in . . past oncologic history: "she is most recently status post five cycles of bendamustine with her fifth cycle on . she was noted for increasing lower back and right hip pain and underwent an mri of the thoracic and lumbar spine on , which showed unchanged extensive myelomatous involvement of the thoracic vertebrae with no evidence of an epidural soft tissue mass. there were chronic deformities of t7 through t12 and myelomatous involvement of the lumbar spine, particularly the left anterior aspect of l4. ms. developed increasing numbness of her right lower leg from the anterior ankle and up the shin with some disruption of her balance and gait due to this numbness. she had no changes in bowel or bladder functioning. she was initiated on decadron 4 mg four times per day on , and began radiation therapy on to the lower back in hopes of improving her symptoms. her decadron has been decreased to 4 mg three times per day on , 4 mg twice per day as of , 4 mg once per day on , and 2 mg daily as of . radiation therapy completed on . she also received weekly velcade while she was undergoing radiation therapy in order to continue to give her some systemic therapy during her treatment. she received a dose on , and . she required periodic platelet transfusions during this time. social history: retired former administrator for gte. lives in . 4 children who live in the area. she is a widow, now has male partner , with whom she does not live. no tobacco history. occasional social drinking. family history: no known family history of myeloma or other blood disorders. grandmother: breast cancer. father: mi. physical exam: admission physical exam: vitals: 98.2, 114, 151/96, 16, 95% on 4l nc and high flow mask general: alert, oriented, tachypneic, in no acute distress heent: sclera anicteric, dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: diffuse rhonchi bilaterally cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops appreciated abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge physical exam: afvss gen: well appearing, nad heent: sclera anicteric, mmm, oropharynx clear, plasmacytoma noted on scalp lungs: ctab except for decreased bs in lllf heart: regular, no m/r, +s3 abd: soft, nt, nd, with bs, no hsm ext: no c/c/e, wwp pertinent results: admission labs -wbc-4.2 rbc-2.84* hgb-9.1* hct-27.8* mcv-98 mch-32.1* mchc-32.9 rdw-16.3* plt ct-24*# neuts-92.8* lymphs-2.5* monos-3.7 eos-0.2 baso-0.8 -wbc-1.6*# rbc-2.50* hgb-8.4* hct-23.6* mcv-94 mch-33.8* mchc-35.8* rdw-17.0* plt ct-39* neuts-91.1* lymphs-5.6* monos-2.9 eos-0.3 baso-0.1 -wbc-0.8* rbc-2.71* hgb-8.9* hct-26.1* mcv-96 mch-32.8* mchc-34.1 rdw-16.7* plt ct-36* neuts-88* bands-1 lymphs-7* monos-3 eos-0 baso-0 atyps-0 metas-1* myelos-0 . -pt-13.5* ptt-24.8 inr(pt)-1.2* -glucose-146* urean-25* creat-1.4* na-141 k-3.7 cl-105 hco3-24 angap-16 -alt-19 ast-33 ld(ldh)-357* ck(cpk)-31 alkphos-112* totbili-0.3 . -glucose-186* urean-27* creat-1.5* na-141 k-4.2 cl-104 hco3-24 angap-17 -glucose-153* urean-29* creat-1.6* na-140 k-4.0 cl-102 hco3-28 angap-14 . ck-mb-4 ctropnt-0.09* ck-mb-5 ctropnt-0.27* probnp-* igg-632* imaging final ct chest 1. multifocal consolidations throughout all lung lobes. while consolidations in the right and left lower lobes are more consistent with bacterial pneumonia, the other consolidations are concerning for fungal infection, specifically invasive aspergillosis. 2. small bilateral pleural effusions, increased since ct of . 3. prominent main pulmonary artery which may be seen with pulmonary hypertension. 4. large hiatal hernia. cxr impression: ap chest compared to and : pulmonary vascular congestion and mild pulmonary edema have improved since . large area of consolidation at the right lung base and a smaller one at the left lateral to the large hiatus hernia have worsened, consistent with progressive pneumonia. moderate-to-severe cardiomegaly is longstanding. small bilateral pleural effusions are presumed. no pneumothorax. right subclavian infusion port ends in the svc. mr head impression: no acute infarcts. small vessel disease. bony abnormalities in the skull and cervical vertebrae as well as the clivus indicative of multiple myeloma. no significant epidural disease is seen, although evaluation is limited without gadolinium administration. ct chest impression: improving bilateral bronchocentric ground-glass opacities, right pulmonary consolidation and bilateral pleural effusions, consistent with a responding multifocal consolidation, angioinvasive aspergillosis is considered a probable explanation for the appearance on the prior ct. cardiac mr impression: 1. moderately dilated left ventricle with global left ventricular systolic dysfunction. the lvef was mildly depressed at 45%. the effective forward lvef was moderately depressed at 35%. no cmr evidence of myocardial edema. 2. normal right ventricular cavity size and systolic function. the rvef was normal at 57%. 3. moderate mitral regurgitation. 4. the indexed diameters of the ascending and descending thoracic aorta were normal. the main pulmonary artery diameter index was normal. 5. mild right atrial enlargement. 6. a note is made of bilateral pleural effusions and a hiatal hernia. microbiology respiratory virus screen 4:00 pm rapid respiratory viral screen & culture source: nasopharyngeal swab. respiratory viral culture (pending): respiratory viral antigen screen (final ): negative for respiratory viral antigen. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. refer to respiratory viral culture for further information. mycolytic blood cx 7:06 pm blood culture ( myco/f lytic bottle) source: line-poc. blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. bal 10:15 am bronchoalveolar lavage bronchial lavage. vic will also r/o cmv. reported to and read back by at 1320. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~/ml commensal respiratory flora. legionella culture (final ): no legionella isolated. potassium hydroxide preparation (final ): no fungal elements seen. this is a low yield procedure based on our in-house studies. koh performed per . immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (final ): yeast. acid fast smear (final ): no acid fast bacilli seen on direct smear. no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): afb grown in culture; additional information to follow. viral culture: r/o cytomegalovirus (final ): test cancelled, patient credited. please refer to viral culture for result. viral culture (preliminary): no virus isolated. sputum cx 12:25 pm sputum source: induced. 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. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (final ): yeast. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): reported to and read back by dr., and , @ 15:30, . afb grown in culture; additional information to follow. sent to state lab for further identification . - per verbal report from state lab, probe of plated organism + legionella negative **final report ** cmv igg antibody (final ): positive for cmv igg antibody by eia. 35 au/ml. reference range: negative < 4 au/ml, positive >= 6 au/ml. cmv igm antibody (final ): negative for cmv igm antibody by eia. interpretation: infection at undetermined time. a positive igg result generally indicates past exposure. infection with cmv once contracted remains latent and may reactivate when immunity is compromised. if current infection is suspected, submit follow-up serum in weeks. greatly elevated serum protein with igg levels > mg/dl may cause interference with cmv igm results. all blood cxs no growth/pending. discharge labs complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:26 5.0 2.84* 9.2* 27.3* 96 32.3* 33.6 17.9* 23* differential neuts bands lymphs monos eos baso atyps metas myelos nrbc 05:26 85* 0 4* 11 0 0 0 0 0 renal & glucose glucose urean creat na k cl hco3 angap 05:26 901 29* 1.7* 141 4.2 107 23 15 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili 05:26 24 23 243 142* 0.5 free kappa/lambda light chains pending brief hospital course: 75 yo w with recurrent/refractory multiple myeloma, recent parainfluenza virus infection, presenting with increased dyspnea, transferred to for management of hypoxia . # dyspnea/hypoxia: likely multifactorial in etiology. patient has an element of volume overload from acute congestive heart failure, supported by bnp of 33k, bilateral pleural effusions, and improvement with initial bipap and iv lasix boluses. she also demonstrated multifocal opacities on ct chest, concerning for bacterial pna (and potentially invasive aspergillus). given her immunocompromised state she was immediately started on broad antimicrobials (vancomycin, cefepime, and azithromycin) and extensive studies for bacterial, viral, and fungal pathogens were sent. respiratory culture was positive for parainfluenza iii. sputum grew gram positive cocci from one induced culture that were further speciated to respiratory flora. a bronchoscopy was performed and revealed alveolar hemorrhage. per infection control, pt needs to stay on droplet precautions until parainfluenza negative. . after stabilization, she was called out to the bmt floor. she received ivig x1 for the paraflu, and we continued her abx for a 14 day course. she did well and her oxygenation improved to the point that her ambulatory saturation did not dip below 91. the patient then started to have afb + cultures (x 3), and id was consulted. she was empirically started on a brief course of linezolid, imipenem, and clarithromycin as she will likely require chemotherapy soon for her myeloma. however, the state lab probed her cx which was + for , and her regimen was changed to rifabutin, ethambutol, and clarithromycin. she will require a baseline eye exam as an outpatient, and she has close f/u with oncology and infectious disease. . # acute congestive heart failure: patient presented with dyspnea and hypoxia (as above). cxr revealed b/l pleural effusions. bnp was elevated at 33k. echocardiogram revealed ef of 30% with severe hypokinesis of the inferior wall and basal 2/3rds of the septum and anterior wall, which was new from her prior echo in . cardiac biomarkers did not support acute coronary syndrome. cardiology was consulted and recommended starting low dose beta-blocker and uptitrating as needed to provide rate control and augment cardiac output. initiation of ace-inhibitor was deferred until hemodynamic stability was assured. the etiology of her cardiomyopathy is unclear. amyloid was considered (spep negative, upep was +), as well as parainfluenza virus, velcade (very rare), or a missed ischemic cardiac event. . out of concern that the echo showed coronary distribution hypokinesis, a cardiac mr was done which was c/w chemo induced cardiomyopathy, not a coronary issue. the repeat study showed an ef of ~ 45%. the cmr also did not show any signs of amyloid involvement. a cardiology c/s was recalled to assist with cm management, and metop was uptitrated to 37.5 potid, and lisinopril was started and titrated to 5 mg po daily, which she tolerated well. on discharge, her metop was changed to long acting toprol xl 100 mg po daily. . # multiple myeloma: diagnosed in and s/p auto sct in . currently on c1d1 of cytoxan/velcade/decadron on . had increase of lytic lesions while on prior bendamustine. anc on admission was approaching neutropenia, so the patient was placed on neutropenic precautions. hematolog/oncology followed closely and provided daily recommendations. we transfused to maintain platlets >20 and hct >25. she was continued on her prophylactic acyclovir, inhaled pentamidine (last dose 3/17), and current dexamethasone. per onc recs, her pentamidine was held. her pain and other symptoms were controlled. given the need for chemotherapy soon, she was placed on tx for mac (see above). she has close f/u with oncology scheduled. . # word finding difficulty: pt endorsed word finding difficulty a few hours after bronchoscopy. given concern for possible pulmonary/systemic fungal infection, aspergillosis or even mucor, vs acute embolic event, she was sent for mri wo contrast. neurological exam was negative for any focal findings. preliminary read on mri was negative for acute infarct, notable for chronic small vessel disease, mild atrophy, and skull deformities in l frontal/parietal/clivus/cervical vertebrae c/w known multiple myeloma. a neuro c/s was called, and as the patient improved, the thought was that this was toxic/metabolic causes from acute infection. the word finding difficulty resolved over time, and she was set up for outpatient f/u appointment in neurology. . # chronic kidney injury: related to multiple myeloma. cr currently uptrending in the setting of diuresis. baseline 1.4-1.8. trended and was stble throughout stay. all medications were renally dosed. . # prolonged pt: likely secondary to nutritional deficiency and/or recent antibiotic use. she was given 1 dose of po vitamin k 5 mg for repletion and inr improved. . # paroxysmal atrial fibrillation: held asa 81 daily given low plts and monitored on telemetry. pt was tachycardic and not on nodal blocking as outpatient. last ekg shows st with frequent pacs. troponins peaked (othwer biomarkers flat), likely heart failure/demand in setting of cki. per cards, started low dose bb. metoprolol 12.5 tid was started with subsequent improvement in rate and uptitrated to 25mg tid per cards rec. they attribute cardiomyopathy to chemotherapy and anticipate improvement w time. as above, these medications were continued to be titrated to metop succinate 100 po daily as well as lisinopril 5 mg for afterload reduction . # hypothyroidism: continued outpatient levothyroxine 112mcg daily. . # hiatal hernia: continued ranitidine 150 mg daily (home dosage unknown), to restart home dose at discharge (25 mg effervescent tab). medications on admission: -cetirizine 10 mg tab 1 (one) tablet(s) by mouth once a day -emla 2.5 %-2.5 % topical cream apply to poc site prior to blood draw -caltrate 600+d plus minerals 600 mg-400 unit tab 1 tablet(s) by mouth once a day -nystatin 100,000 unit/ml oral susp 5 cc(s) by mouth four times a day swish and spit as needed -vitamin c 500 mg tab 1 tablet(s) by mouth once a day will hold during radiation treatment -triamcinolone acetonide 0.1 % topical cream apply to affected area twice per day do not use on face. -aspirin 81 mg chewable tab 1 tablet(s) by mouth once a day -acetaminophen 325 mg tab 1 to 2 tablet(s) by mouth every hours as needed -ativan 0.5 mg tab tablet(s) by mouth q4-6 as needed for nausea, insomnia -milk of magnesia 400 mg/5 ml oral susp suspension(s) by mouth as needed for constipation -furosemide 20 mg tab 0.5 (one half) tablet(s) by mouth once a day in the morning. presently on hold per patient -alprazolam 0.5 mg tab 2 tablet(s) by mouth one hour before procedure. take additional 0.5 mg tablet if needed. -dexamethasone 4 mg tab 0.5 (one half) tablet(s) by mouth once a day icd-9 code: 203.00 -prochlorperazine maleate 5 mg tab tablet(s) by mouth every eight (8) hours as needed for nausea -promethazine 12.5 mg tab tablet(s) by mouth q 8 hours as needed for nausuea -anti-itch 0.5 %-0.5 % lotion apply to affected areas three times a day as needed for itching -colace 100 mg cap 1 capsule(s)(s) by mouth twice a day as needed for constipation levothyroxine 112 mcg tab 1 tablet(s) by mouth once a day -nebupent 300 mg solution for inhalation 300 mg(s) inhaled every month for 6 months diluted in 6 ml sterile water administered via aerosol. please administer 2 puffs of albuterol prior to treatment as needed. -oxycontin 10 mg 12 hr tab 1 to 2 tablet(s) by mouth every eight (8) hours -oxycodone 5 mg cap 1 - 2 capsule(s) by mouth every four (4) hours as needed for breakthrough pain -b complex cap one capsule(s) by mouth daily -acyclovir 400 mg tab 1 tablet(s) by mouth two times a day -folic acid 1 mg tab 1 tablet(s) by mouth once a day -ranitidine 25 mg effervescent tab -ondansetron hcl 4 mg tab 1 to 2 tablet(s) by mouth every eight (8) hours as needed for nausea icd-9 code: 203.00 -cetirizine 10 mg tab 1 (one) tablet(s) by mouth once a day discharge medications: 1. rifabutin 150 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 2. ethambutol 400 mg tablet sig: two (2) tablet po days (mo,we,fr). disp:*24 tablet(s)* refills:*2* 3. clarithromycin 250 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. toprol xl 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* 6. caltrate 600 + d oral 7. nystatin 100,000 unit/ml suspension sig: five (5) cc po four times a day as needed for thrush. 8. vitamin c oral 9. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical twice a day as needed for rash. 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever, pain. 11. ativan 0.5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for nausea or anxiety. 12. milk of magnesia 400 mg/5 ml suspension oral 13. dexamethasone 2 mg tablet sig: one (1) tablet po daily (daily). 14. emla topical 15. alprazolam 0.5 mg tablet sig: two (2) tablet po asdir as needed for before procedure: take 1 hr before procedure. 16. prochlorperazine maleate 5 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea. 17. promethazine 12.5 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea. 18. sarna anti-itch topical 19. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 20. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 21. nebupent 300 mg recon soln inhalation 22. oxycodone 10 mg tablet extended release 12 hr sig: tablet extended release 12 hrs po every eight (8) hours. 23. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 24. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 25. acyclovir 400 mg tablet sig: one (1) tablet po daily (daily). 26. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 27. ranitidine hcl 25 mg tablet, effervescent sig: one (1) tablet, effervescent po once a day. 28. zofran 4 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea. 29. cetirizine 10 mg capsule sig: one (1) capsule po once a day. discharge disposition: home discharge diagnosis: primary diagnosis pneumonia secondary diagnoses mycobacterium avium intracellulare multiple myeloma parainfluenza 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 hospitalization. you were admitted to with shortness of breath and were in the icu because you needed to have assistance with your breathing. you were treated with antibiotics for 14 days for a bacterial pneumonia, and you were given ivig because you were para-influenza positive. finally, we found acid-fast bacilli in your sputum multiple times which required you to stay on precautions while here. infectious disease saw you while you were here and they felt you could be discharged with three drugs to treat mac before your next round of chemo. we also had our cardiologists see you who added on medicine to keep your heart healthy. we also had our neurologists see you because of some word-finding difficulty, and they would like to see you in clinic. please make the following changes to your medications - stop taking lasix - stop taking aspirin - decrease your acyclovir to 400 mg by mouth daily - start taking rifabutin 150 mg by mouth daily - start taking ethambutol 800 mg by mouth every mon, wed, fri - start taking clarithromycin 250 mg by mouth daily - start taking metoprolol succinate (toprol xl) 100 mg by mouth daily - start taking lisinopril 5 mg by mouth daily please follow up with you physicians as indicated below followup instructions: you will be contact by the /bmt department regarding an appointment on monday with . **you should also schedule an eye exam in the next week since you are on ethambutol ** otherwise, these are the appointments for your follow up: department: when: wednesday at 1:45 pm with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/bmt when: thursday at 1:30 pm with: , md building: sc clinical ctr campus: east best parking: garage department: neurology when: tuesday at 1:30 pm with: drs. & building: sc clinical ctr campus: east best parking: garage Procedure: Non-invasive mechanical ventilation Closed [endoscopic] biopsy of bronchus Diagnoses: Other chronic pain Abnormal coagulation profile Mitral valve disorders Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Candidiasis of mouth Chronic kidney disease, unspecified Diaphragmatic hernia without mention of obstruction or gangrene Peripheral stem cells replaced by transplant Acute respiratory failure Primary pulmonary hypertension Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Acute systolic heart failure Metabolic encephalopathy Drug induced neutropenia Backache, unspecified Bacterial pneumonia, unspecified Disseminated due to other mycobacteria Other secondary thrombocytopenia Secondary cardiomyopathy, unspecified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: tremulous major surgical or invasive procedure: none history of present illness: 54m with chronic alcohol use presenting with symptoms of withdrawal, his last drink was reported to be last night. patient drinks approximately 1.75l of etoh per day. he reports that he felt unable to walk today and had to sit down because his "legs were going to give out". had a fall 2 days ago w/ apparenty head trauma. apparently he had a similar problem last week and was admitted to for withdrawal. patient states that his withdrawal usually manifests as shakiness, no history of withdrawal seizures. the patient has dried blood on face, unclear when trauma, ct head demonstrates miniscule sdh. . patient's last drink was afternoon. . patient was admitted to the icu because the patient will need frequent monitoring. . in the ed inital vitals were, 98.6 112 161/101 18 98% ra. pt received head ct - negative on initial read (? small sdh on attending read). pt received ativan per ciwa scale, pt received 6mg po ativan (shaky). pt received po thiamine, mvi, folate. . on arrival to the icu, afebrile, 110, 160/86, 96%ra. patient tremulous, able to provide a reliable history. . review of systems: (+) per hpi: diarrhea, night sweats, 20lb weight loss in past 2 years, cough. (-) denies fever, chills. denies headache, sinus tenderness, rhinorrhea or congestion. denies shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: -etoh abuse -neuropathy lower extremities (past month) -hit head on curb 1 year ago --> residual l leg pain social history: has had alcohol abuse for many years. many rehabs, many withdrawals. pt does not smoke. pt does not use illicit drugs currently -- had used iv drugs in 70s. pt unemployed currently, used to be a wholesale representative. lives near symphony, alone. has a girlfriend. a son, daughter and one grandchild. divorced. family history: father alcoholic. died of lymphoma. mother died of multiple myeloma. brother with ms brother w/ morbid obesity, alcohol abuse. physical exam: admission physical exam: afebrile, 110, 160/86, 96%ra general: alert, oriented heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pe - tremulous, dried blood on face under l eye, tachycardic with small systolic ejection murmur, lungs cta bilaterally, abd sntnd, 5/5 strength x 4 extremities. mildly decreased sensation to soft touch in lower extremities, b/l. pertinent results: admission labs: 02:15pm blood wbc-5.9 rbc-3.80* hgb-13.8* hct-39.1* mcv-103* mch-36.4* mchc-35.3* rdw-13.3 plt ct-228 02:15pm blood neuts-81.1* lymphs-11.5* monos-5.7 eos-0.9 baso-0.8 06:30pm blood pt-9.7 ptt-30.8 inr(pt)-0.9 02:15pm blood glucose-88 urean-11 creat-0.7 na-141 k-4.7 cl-96 hco3-24 angap-26* 02:15pm blood alt-39 ast-61* alkphos-78 totbili-0.5 02:15pm blood lipase-67* 02:15pm blood albumin-4.6 calcium-9.6 phos-3.9 mg-1.5* 02:15pm blood asa-neg ethanol-30* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg imaging: impression: no acute intracranial process; mild left maxillary sinus disease. note on attending review: there is a small dense focus along the convexity in the right frontal/parietal regions likely representing a small acute subdural hemorrhage. a small venous tribuatry is noted adjacent and underneath. small amount of scalp soft tissue swelling is noted overlying. ( se 601b, im43; se 2, im 15) no obvious fracture noted. consider followup as clinically indicated. prominent ventricles, sulci and extra-axial csf spaces related to volume loss-correlate for risk factors. brief hospital course: 54 yo m with chronic alcohol use presenting with etoh withdrawal. . # alcohol withdrawal: last drink was less than 24 hours prior to arrival. very tremulous, requiring diazepam 10mg about every 2 hours for ciwa >10, fo total of 50mg in icu. received last 10mg dose valium on medical , and was started on 2 days of q6hr librium to complete as outpatient as a natural benzo taper for anxiety and mild tremors despite ciwa < 10. also received some ativan in the ed. received multivitamin, thiamine and folate. he met with social work who gave him list of day programs. he plans on attending program because of convenient location to his home, and his son's family. . # sdh: per radiology, very small frontal r sdh, likely from most recent fall. no symptoms and non-focal neurological exam. neurosurgery recommended repeat head ct. repeat was unchanged. . # amemia: macrocytosis (103), hct 39.1. likely chronic alcohol, marrow suppression, or b12. b12 level is normal, patient was given folic acid. . # neuropathy: pt w/ peripheral neuropathy, complaining of it for a few months. has worsened recently. pt w/ full strength in extremities, mildly decreased sensation. etiologies include etoh neuropathy, b12 deficiency, dmii. a1c = 5.0%, b12 level is pending. he was empirically started on 100mcg b12 for 1 month. . # weight loss: 10-20lb over last 6 months, coincides with heavy drinking. he will seek support for abstinence, and was referred to primary care for further evaluation and health maintenance issues. cxr was normal. . # he was set up with pcp f/u apptmt at for , and indicated he will keep appoitment. medications on admission: none discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*0* 5. chlordiazepoxide hcl 25 mg capsule sig: one (1) capsule po four times a day for 2 days. disp:*8 capsule(s)* refills:*0* 6. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: alcohol withdrawal alcohol dependency mild anemia - likely alcohol related peripheral neurophathy - likely alcohol related 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 alcohol withdrawal. you had a recent fall with abrasions to the face and knee. you indicated you have been driking 1-2liters vodka daily for past 6 months. you were admitted to icu for monitoring, and then to the medical . you had 2 head cts which showed a stable, small subdural hematoma which does not need follow-up (per neurosurgical evaluation). you are tolerating a full diet. you were seen by physical therapy and deemed safe for home, to continue using your cane. b12, tsh, and hgba1c were all normal. . you were started on metoprolol for high heart rate and high blood pressure. you tolerated this well. . you indicated you have not been eating well because of the heavy drinking, and that you have lost weight. a chest xray was normal. you indicated you did not wast to follow-up with your current primary care physician and have requested a referral to . i recommend you see your pcp weeks (new or old) for further evaluation of your overall health, including weight loss, age appropriate cancer screening and other preventive health measures. please take the medications as prescribed. vitamin b12 levels and evaluation for diabetes was normal. the neuropathy is likely from chronic alcohol use. please follow up with your primary care physician for further evaluation. followup instructions: department: when: tuesday at 1:45 pm with: , md building: sc clinical ctr campus: east best parking: garage **dr is your new physician at . she works closely with dr. , both will be involved in your care.** Procedure: Alcohol detoxification Diagnoses: Anemia of other chronic disease Unspecified essential hypertension Loss of weight Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection Unspecified hereditary and idiopathic peripheral neuropathy Tachycardia, unspecified Alcohol withdrawal Acute alcoholic intoxication in alcoholism, continuous Abrasion or friction burn of hip, thigh, leg, and ankle, without mention of infection Fall resulting in striking against other object |
allergies: nifedipine attending: chief complaint: nausea/vomiting major surgical or invasive procedure: intubation suboccipital craniectomy and r venticulostomy - ventriculostomy - vp shunt- trach and peg history of present illness: neurology at bedside for evaluation after code stroke activation within: 2 minutes time (and date) the patient was last known well: 12:30 on nih stroke scale score: 10 t-: --- yes time t-pa was given ------:------ (24h clock) -x- no reason t-pa was not given or considered: out of window i was present during the ct scanning and reviewed the images instantly within 20 minutes of their completion. nih stroke scale score was 0: 1a. level of consciousness: 0 1b. loc question: 0 1c. loc commands: 0 2. best gaze: 1 3. visual fields: 0 4. facial palsy: 2 5a. motor arm, left: 0 5b. motor arm, right: 0 6a. motor leg, left: 0 6b. motor leg, right: 2 7. limb ataxia: 0 8. sensory: 2 9. language: 0 10. dysarthria: 2 11. extinction and neglect: 0 hpi: mr. is a 42 yo portuguese-speaking man with h/o dm2, htn, hl who presents with l facial droop, r sided numbness, and slurred speech. history is somewhat limited due to language barrier and acute code stroke setting. the patient developed nausea/vomiting at 12:30 am today. over the next several hours, he worsened, developing difficulty with balance and right sided numbness and weakness. at 4:00pm, wife noticed l facial droop. patient was brought to hospital. nchct was interpreted as normal. neurology was consulted over the phone. nihss 8. received iv labetalol 20 mg total, zofran and asa 325 mg. he was transferred to without any thrombolysis (unclear if on-call stroke line thought he was out of window). in , patient had nihss 9. bp was elevated at 254/125. he was started on nicardipine drip for bp control. according to patient's wife, he has been stable to slightly improving over past few hours. he was quite restless because he is bothered by the absence of sensation on his right side. he has no pain or headache. no nausea. no diplopia in primary gaze, and no vertigo. on limited ros, no fever, cough, sob, chest pain. past medical history: dm2 htn hl social history: married, no tobacco. speaks portuguese. understands very limited english family history: h/o cad physical exam: admission exam physical exam: vitals: t: afeb p:100 r: 16 bp:215/135 sao2:96/ra general: awake, cooperative, 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 cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd extremities: no c/c/e bilaterally skin: no rashes or lesions noted. neurologic: -mental status: alert, oriented x 3. attentive and cooperative. language is fluent with intact naming and comprehension. speech was moderately dysarthric. able to follow both midline and appendicular commands. there was no evidence of apraxia or neglect. -cranial nerves: i: olfaction not tested. ii: r pupil 6mm, l pupil 4mm, both briskly reactive both direct and consensual responses. vff to confrontation with blink to threat. iii, iv, vi: in primary gaze, l eye deviated inward. complete l gaze palsy b/l. on r gaze there is horizontal nystagmus. vertical gaze and convergence intact. v: facial sensation intact to light touch. vii: upper and lower facial musculature weakness. viii: hearing intact to voice grossly. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii. xii: tongue protrudes in midline. -motor: normal bulk. decreased tone in right side. r pronator drift present. no adventitious movements, such as tremor, 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 r 5 5 5 5 5 5 5 3 4- 4- 4 4- -sensory: decreased light touch and pinch on right upper and lower extremities (now intact on face though previously right face numb). no extinction to dss. -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was flexor on left, extensor on right. -coordination: no intention tremor, no dysdiadochokinesia noted. no dysmetria on fnf bilaterally. -gait: deferred on transfer out of icu: spontaneously awake, follows commands, shows thumbs-up for yes and shakes pointer finger for no. pupils r 2.5->1.5, l 2->1.5. l gaze palsy, r eye abducens weakness (r beating nystagmus when looking r). no blink to threat. no corneals. l upper/lower face weakness. +gag. +cough. lue/lle 4+ to 5/5 strength. rue/rle hemiplegia but r fingers/wrist/elbow extending/flexing now and r quad contracts (almost antigravity). inconsistent with r side depending on exhaustion level. r toe up. discharge exam: spontaneously awake, follows commands, shows thumbs-up for yes and shakes pointer finger for no. pupils r 2.5->1.5, l 2->1.5. l gaze palsy, r eye abducens weakness (r beating nystagmus when looking r). l upper/lower face weakness. lue/lle 5/5 strength. rue/rle hemiplegia but r fingers/wrist/elbow extending/flexing now, can move r quad anti-gravity and dorsi/plantar flex foot with good strength. r toe upgoing. pertinent results: 07:15pm wbc-11.6* rbc-5.87 hgb-17.8 hct-52.3* mcv-89 mch-30.3 mchc-34.1 rdw-13.0 07:15pm plt count-278 07:15pm pt-9.8 ptt-26.9 inr(pt)-0.9 07:15pm urea n-16 07:26pm glucose-353* na+-141 k+-4.1 cl--100 tco2-23 08:30pm urine blood-tr nitrite-neg protein-100 glucose-1000 ketone-40 bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 08:30pm urine rbc-1 wbc-1 bacteria-none yeast-none epi-<1 08:30pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 10:58pm calcium-9.1 phosphate-3.4 magnesium-1.9 10:58pm ck-mb-3 10:58pm ck(cpk)-171 10:58pm glucose-313* urea n-14 creat-0.9 sodium-140 potassium-3.7 chloride-103 total co2-26 anion gap-15 3:41 pm bronchoalveolar lavage left lung. **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs and singly. respiratory culture (final ): 10,000-100,000 organisms/ml. commensal respiratory flora. staph aureus coag +. 10,000-100,000 organisms/ml.. sensitivities performed on culture # from . fungal culture (final ): no fungus isolated. 7:48 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). smear reviewed; results confirmed. respiratory culture (final ): sparse growth commensal respiratory flora. gardnerella vaginalis. moderate growth. 10:01 pm mini-bal bronchial lavage. **final report ** gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive rod(s). respiratory culture (final ): >100,000 organisms/ml. commensal respiratory flora. yeast. 10,000-100,000 organisms/ml.. 2:16 pm blood (toxo) source: venipuncture. **final report ** toxoplasma igg antibody (final ): positive for toxoplasma igg antibody by eia. 53 iu/ml. reference range: negative < 4 iu/ml, positive >= 8 iu/ml. toxoplasma igm antibody (final ): negative for toxoplasma igm antibody by eia. interpretation: infection at undetermined time. a positive igg result generally indicates past exposure. infection with toxoplasma once contracted remains latent and may reactivate when immunity is compromised. if current infection is suspected, submit follow-up serum in weeks. ecg normal sinus rhythm. q waves in leads iii and avf consistent with prior inferior myocardial infarction. no previous tracing available for comparison. cta head/neck impression: 1. unremarkable head ct without evidence of infarct or hemorrhage. mri is suggested if clinically warranted. 2. hypoplastic right vertebral and small left vertebral arteries, likely developmental. both vertebral arteries end as pica with reconstitution of the right vertebral artery from the right superior cerebellar. cxr impression: 1. unremarkable head ct without evidence of infarct or hemorrhage. mri is suggested if clinically warranted. 2. hypoplastic right vertebral and small left vertebral arteries, likely developmental. both vertebral arteries end as pica with reconstitution of the right vertebral artery from the right superior cerebellar. cxr as compared to the previous radiograph, there is no relevant change. minimal atelectasis at the right lung base. borderline size of the cardiac silhouette. no pneumonia, no pulmonary edema. the nasogastric tube is in constant position. mri/a brain findings: there is an acute infarct with hemorrhagic conversion identified in the left cerebellum in the region of posterior inferior and anterior inferior cerebellar arteries extending to the left side of the pons. there is mass effect on the fourth ventricle. there has been a craniectomy identified in the region for decompression. there is mild indentation of the lateral ventricles and there is presence of a right frontal approach ventricular drain with the tip in the region of left lateral ventricle. the temporal horns are mildly dilated indicating some degree of obstructive hydrocephalus. there is signal change within the anterior portion of corpus callosum related to the tract of the ventricular drain. the flow void of the distal left vertebral artery is not well visualized. on the mra of the head no abnormalities are seen in the anterior circulation. both vertebral arteries are not visualized beyond posterior arch of c1. subtle flow signal is identified in the distal basilar artery but flow signal is not seen in the proximal basal artery nor the distal vertebral arteries. there are fluid levels within the left maxillary sinus which could be related to intubation. impression: postoperative changes for decompression secondary to hemorrhagic left cerebellar infarct. there remains mass effect on the fourth ventricle and some dilatation of the lateral ventricle. a ventricular drain is in position. both vertebral arteries are not visualized distal to the posterior arch of c1 level. the proximal basal artery is not visualized as well. there abnormalities on the anterior circulation on mra. nchct impression: 1. known left cerebellar infarct with hemorrhage, with mass effect on the 4th ventricle and basal cisterns, stable in appearance since the earlier study of . 2. stable positioning of the ventricular drain, coursing through the frontal of the left lateral ventricle, terminating at its lateral margin. minimal interval increase in the ventricular size since ct study. nchct impression: 1. interval repositioning of the right external ventricular drain with tip now projecting anterior to the frontal of the right lateral ventricle adjacent to the falx, outside the ventricular system. 2. otherwise similar exam with left cerebellar infarct with hemorrhagic conversion, adjacent mass effect, and stable ventricular size. nchct impression: 1. interval repositioning of right frontal external ventricular drain, now terminating in the left putamen or internal capsule. ventricles have decreased in size since the prior exam. 2. left cerebellar infarction with stable posterior fossa mass effect and hypodensity extending into the pons. nchct impression: 1. significant interval decrease in size of left lateral ventricle is likely related to over shunting through the right frontal approach evd, as there is no associated sulcal effacement or new edema. correlate with catheter function and close f/u. assessment of the position of the tip of the catheter is difficult due to the significant decompression of the ventricle- it is either outside the ventricular margin or within. pl. review the images to decide on further management. 2. left cerebellar infarct with stable posterior fossa mass effect and suboccipital craniectomy. nchct impression: 1. right frontal approach evd terminates in the left lateral ventricle. left lateral ventricle has increased in size since the prior exam, with ventricles and sulci now similar in size and configuration to . 2. status post suboccipital craniectomy with unchanged posterior low-density fluid collection. left cerebellar infarction and pontine infarction are stable. slight improvement in effacement of fourth ventricle. r lower ext - doppler us: findings: -scale and doppler son of the right common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins were performed. there is normal compressibility, flow and augmentation. impression: no evidence of deep venous thrombosis in the right lower extremity. nchct impression: 1. repositioning of the evd with the tip in the third ventricle. 2. continued effacement of the fourth ventricle by mass effect in the left cerebellar hemisphere. status post suboccipital craniectomy. renal son: renal son: the right kidney measures 12.8 cm, and the left kidney measures 13.6 cm. there is no hydronephrosis, stones, or mass. bladder is collapsed with a foley in place. impression: normal renal son. tee: 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 or patent foramen ovale is seen by 2d, color doppler or saline contrast at rest x 4 injections (central line x 2; peripheral line x 2). there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch (clip ) and 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 valve abscess is seen. 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. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no valvular vegetation, intracardiac mass/thrombus seen. no evidence for an atrial septal defect or patent foramen ovale by color flow doppler or saline injection at rest. simple thoracic atheroma. brief hospital course: 42yo m with h/o dm2, htn who presented with l lower face weakness, dysarthria, r sided sensory loss and hemiparesis, nausea/emesis, found to have l vertebral and proximal basilar artery occlusion resulting in l cerebellar / l pontine infarct. . acute ischemic stroke, vertebrobasilar occlusion - the patient was found to have a clinical syndrome consistent with a brainstem stroke and was found on imaging to have stenosis of both vertebral arteries and the proximal basilar artery. he arrived at the hospital outside the window for intravenous tpa or intra-arterial therapies. he has two fetal pcas coming from his anterior circulation which would preclude him from being able to have a mechanical thrombectomy. he was started on a heparin infusion with goal ptt 60-80 to aid the dissolution of the thrombus. after hemorrhagic conversion was found on a repeat mri, this was switched to aspirin 81 mg daily. a tte was performed which was unrevealing for thrombus, wall motion abnormalities, or intracardiac shunt, but the suspicion for venous hypercoagulability causing paradoxical embolism remained high given the history of a brother of similar age with bilateral lower extremity dvts. hypercoagulability labs (except for genetic studies) were obtained and were normal. a tee was obtained that failed to show an intracardiac shunt and showed only aortic arch simple atheroma. the patient will have genetic hypercoagulability studies as an outpatient. . he was transferred to the stroke step-down unit on and remained stable. his exam has continued to improve, as he is more alert and following commands well. he has begun to use a passy-muir valve to speak and is tolerating this well. his right hemiparesis is also improving, and he is currently able to lift his r arm over his head, can extend his leg anti-gravity, and dorsi/plantarflex his foot. . increased intracranial pressure - on , he transiently developed worsening neurologic deficits including losing his corneal, cough and gag reflexes. a repeat nchct showed worsening infarction of the left cerebellum and compression of the fourth ventricle. he was taken to the or by neurosurgery for emergent decompression/occipital craniectomy and placement of a ventriculostomy. the ventriculostomy was revised/replaced twice for improved placement. due to mildly elevated icp and csf drainage, this was converted to a ventriculoperitoneal shunt on . he had no complications and no further signs of increased icp after the procedure. . pulmonary edema/volume overload - in the setting of receiving ivf, he became net positive in his fluid balance, tachypneic, and hypoxic. furosemide did not sufficiently improve his respiratory status. he was also noted to have worsening leukocytosis and extensive secretions concerning for infection. he subsequently was electively intubated to provide further respirator support. he was unable to wean from the ventilator and failed an extubation trial. an endotracheal tube was placed on . he succeeded in tolerating the trach mask for 36-48 hours on and was subsequently transferred to the stroke step-down unit. his secretions have improved with a scopolamine patch. he continues to have intermittent tachypnea of unclear etiology without desaturation or any compromise of his respiratory status. . pneumonia - he had recurrent fevers shortly after admission. cultures were obtained and revealed mssa in the sputum. he was treated with iv antibiotics for 10 days for this. he also had proprionobacterium acnes in the blood. later he again began having fevers and increased sputum production. he underwent bronchoscopy again on and was treated with vap protocol (cefepime, cipro, and vanc) from , during which time his fever curve and sputum improved. he had transient low grade fevers to 99.8 axillary on ; repeat infectious work-up including ua/ucx/blood cultures/cxr as well as leni's was negative. he subsequently remeained afebrile with no signs of infection. . diabetes - his hgba1c was 11.9, and his blood sugars were initially difficult to control. he was placed on an insulin gtt and then transferred to long acting insulin. blood sugars remained well-controlled on this regimen. . hyperlipidemia - initial ldl was 109. he was restarted on statin therapy and this improved to 59. he will continue on atorvastatin 20mg daily for his hyperlipidemia. . nutrition - he was maintained on tube feeds. due to the likelihood of an inability to swallow based on the area of his stroke, a gastrostomy was placed on . our speech/swallow team continue to follow for progress. his phos has been running a little high; please check a chem-10 in the next week to re-evaluate. . . transitional care issues: he will need intensive pt, ot, and speech therapy. please check chem-10 at least once in next week to re-evaluate his bun/creatinine and phos. hypercoagulability - prothrombin and factor v leiden gene mutation tests should be obtained as an outpatient. he has a follow-up appointment scheduled with dr. in our stroke clinic on . he also has an appointment to establish care with a new pcp . on . medications on admission: asa 81 atenolol 50 mg daily chlorthalidone 10 mg daily hctz 25 mg daily lisinopril 40 mg daily amlodipine 10 mg daily pravastatin 40 mg daily metformin 1000 mg daily discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 2. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 3. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 4. acetaminophen 650 mg/20.3 ml solution sig: six y (650) mg po q6h (every 6 hours) as needed for pain/fever. 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 6. amlodipine 5 mg tablet sig: four (4) tablet po daily (daily). 7. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 8. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 9. clonidine 0.1 mg tablet sig: three (3) tablet po tid (3 times a day). 10. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 11. erythromycin 5 mg/gram (0.5 %) ointment sig: see instructions ophthalmic qid (4 times a day): apply to both eyes qid. 12. labetalol 100 mg tablet sig: five (5) tablet po q6h (every 6 hours). 13. insulin glargine 100 unit/ml solution sig: thirty five (35) unit subcutaneous twice a day: 35u with breakfast and dinner. 14. insulin aspart 100 unit/ml solution sig: as instructed subcutaneous achs: give achs as per insulin sliding scale. 15. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 16. polyethylene glycol 3350 17 gram powder in packet sig: one (1) powder in packet po daily (daily) as needed for constipation. 17. white petrolatum-mineral oil 56.8-42.5 % ointment sig: one (1) appl ophthalmic qid (4 times a day): left eye. 18. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic qid (4 times a day). 19. scopolamine base 1.5 mg patch 72 hr sig: one (1) patch 72 hr transdermal q 3 days (): for increased secretions. discharge disposition: extended care facility: - discharge diagnosis: left cerebellar/pontine stroke occlusion of the left vertebral and basilar arteries hypertension hyperlipidemia diabetes type ii 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. , you were admitted to on due to nausea/vomiting, right sided weakness, and a left facial droop. you were found to have a stroke in the left side of your cerebellum as well as part of your brainstem. this stroke likely resulted from a clot in your vertebral artery in your neck. this may be related to your high blood pressure, high cholesterol, and diabetes. you had tests to look at your heart as well as to look for any disorders of blood clotting and these were normal. you had tracheostomy and gastrostomy tubes placed while in the intensive care unit. you will need intensive physical therapy to help regain your strength. you were started on some new medications to better control your blood pressure and cholesterol. we made the following changes to your medications: increased amlodipine to 20mg daily started clonidine 0.3mg 3 times a day and labetalol 500mg 4 times a day to help control your bloood pressure held atenolol 50mg daily and hctz 25mg daily continued lisinopril 40mg daily changed from pravastatin to atorvastatin 20mg daily to help control your cholesterol changed from metformin to lantus 35mg twice a day in addition to insulin sliding scale injections to better control your diabetes if you experience any of the below listed danger signs, please call your doctor or go to the nearest emergency department. it was a pleasure taking care of you during your hospital stay. followup instructions: you have the following appointment scheduled with a new primary care physician at : provider: , md phone: date/time: 2:15 you also have the following appointment scheduled with dr. in stroke clinic: provider: , md, phd: date/time: 3:00 md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnostic ultrasound of heart Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Ventricular shunt to abdominal cavity and organs Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Insertion or replacement of external ventricular drain [EVD] Diagnoses: Obstructive hydrocephalus Unspecified essential hypertension Acute kidney failure, unspecified Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction Intracerebral hemorrhage Compression of brain Other and unspecified hyperlipidemia Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Pulmonary congestion and hypostasis Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Ventilator associated pneumonia Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Occlusion and stenosis of basilar artery with cerebral infarction Other fluid overload Dysphagia, unspecified Conjunctivitis, unspecified Flaccid hemiplegia and hemiparesis affecting unspecified side |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: coffee ground emesis major surgical or invasive procedure: none history of present illness: mr. is an 81 yo russian speaking male with dementia, h/o cva previously on coumadin, left sided weakness, dysphyagia s/p gtube, htn, hyperlipidemia transferred from rehab with coffee ground emesis. reportedly has had several days of diarrhea and abdominal distention and then developed acute vomiting of coffee ground emesis on the day of admission. he also has history of constipation with recent reports of hypoactive bowel sounds and abdominal distention. . in the ed t95.3 bp 130/80 hr 90 97% 2l ra. during ems transport he was noted to have large amount of coffee ground emesis. on arrival in the ed he was given 3l ns, 16 gauge piv placed and he was given protonix 40mg iv and a protonix gtt was started. ng lavage of g tube reportedly with coffee grounds with streaks of red blood. gi fellow was notified and tentative plan for scope in the morning unless concern for acute bleeding. past medical history: h/o cva with left hemiparesis - previously on coumadin however d/c'd due to falls dysphagia s/p g tube vascular dementia parkinson's disease type 2 diabetes coronary artery disease stage iii chronic kidney disease left ankle decubitus ulcer hypertension hyperlipidemia gerd bph essential tremor herpes zoster constipation right lung calcified granuloma restless leg syndrome pruritis social history: lives at rehab facility family history: n/c physical exam: on admission: vs:bp 133/48 hr 77 rr 20 93% on 3l nc gen: sleeping quietly, awakens to voice, answers yes to russian interpreter on the phone but no other verbal communication, appears frightened heent: nc at cv: regualr rate and rhythm, 2/6 systolic murmur lungs: bibasilar crackles, right > left otherwise ctab no wheezing abd: distended, firm to palpation, gtube in place with coffee ground emesis on suction, hypoactive bowel sounds rectal: guaiac positive in ed ext: warm, no pedal edema, dp's palpable bilaterally neur: contracted, lying on right side, only verbalizes yes with the russian interpreter . on discharge: t99.1 hr65 - 92 bp109/46 - 182/107 rr 20 spo2: 97% gen: sleeping quietly, awakens to voice, heent: nc at cv: regualr rate and rhythm, 2/6 systolic murmur lungs: bibasilar crackles, right > left otherwise ctab no wheezing abd: abd; soft, nt/nd, g-tube in place, no coffee grounds in or around g-tube, nabs ext: warm, no pedal edema, dp's palpable bilaterally neur: contracted, lying on right side, only verbalizes yes with the russian interpreter pertinent results: ekg: nsr at 85 bpm, normal axis, rbbb, st segment depressions in v2-v6 compared with prior from . 02:10am blood wbc-9.3 rbc-3.84* hgb-12.0* hct-36.3* mcv-94 mch-31.3 mchc-33.2 rdw-13.8 plt ct-357 06:39am blood wbc-6.3 rbc-3.40* hgb-10.8* hct-32.4* mcv-95 mch-31.6 mchc-33.3 rdw-13.9 plt ct-299 12:28pm blood hct-31.0* 06:08pm blood hct-32.3* 12:56am blood hct-30.8* 03:45am blood wbc-5.6 rbc-3.22* hgb-10.5* hct-30.7* mcv-96 mch-32.5* mchc-34.1 rdw-14.2 plt ct-296 02:10am blood glucose-144* urean-47* creat-1.3* na-142 k-4.5 cl-103 hco3-26 angap-18 06:39am blood glucose-114* urean-46* creat-1.1 na-141 k-4.5 cl-109* hco3-26 angap-11 03:45am blood glucose-101 urean-29* creat-1.2 na-147* k-4.0 cl-114* hco3-24 angap-13 02:10am blood alt-6 ast-14 ck(cpk)-39 alkphos-45 totbili-0.4 06:39am blood ck(cpk)-34* 06:08pm blood ck(cpk)-32* 02:10am blood ck-mb-notdone ctropnt-0.01 06:39am blood ck-mb-notdone ctropnt-0.02* 06:08pm blood ck-mb-notdone ctropnt-0.03* 03:45am blood calcium-9.0 phos-2.5* mg-2.2 brief hospital course: pt was admitted with concern for gib given coffee ground material from g-tube. the patient was admitted to the icu for monitoring, but remained hemodynamically stable throught his hospital stay. initially, metoprolol, lisinopril and isosorbide were held, but metoprolol and lisinopril were restarted once the patient became slightly hypertensive. isosorbide should be restarted in days if his bp remains stable. his aspirin was also held and should be held for 7-10 days and can then be restarted on a baby aspirin (rather than 325mg). the patient was also placed on a pantoprozole drip and will need to be on the drip for 72 hrs, until the morning of per gasteroenterology consult. he can then be transitioned to a high dose ppi for a month. the patient did not receive an egd as it was determined that the patient would require intubation and as he is dnr/dni. the decision not to perform egd was discussed with the patient's niece. on admission, the patient's hct did come down from 36->32 with fluids, but then remained stable at 30-32. medications on admission: glargine 18 units qhs simvastatin 20mg qhs acetaminophen 975mg tid citalopram 40mg daily famotidine 20mg qpm hydrocortisone cream gabapentin 200mg zinc oxide topical metoprolol 25mg terazosin 4mg qhs lisinopril 2.5mg daily aspirin 325mg daily bisacodyl suppository prn cetirizine 5mg daily isosorbide dinitrate 10mg tid lactulose 15 ml tid discharge medications: 1. insulin glargine 100 unit/ml solution sig: eighteen (18) units subcutaneous at bedtime. 2. simvastatin 20 mg tablet sig: one (1) tablet po at bedtime. 3. acetaminophen 325 mg tablet sig: three (3) tablet po three times a day. 4. citalopram 40 mg tablet sig: one (1) tablet po once a day. 5. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 6. hydrocortisone 1 % cream sig: as directed topical as needed. 7. gabapentin 100 mg tablet sig: two (2) tablet po twice a day. 8. zinc oxide lotion sig: as directed topical as needed. 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day. 10. terazosin 2 mg capsule sig: two (2) capsule po at bedtime. 11. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. 12. bisacodyl 5 mg tablet sig: one (1) tablet po once a day as needed for constipation. 13. cetirizine 5 mg tablet sig: one (1) tablet po once a day. 14. lactulose 10 gram/15 ml solution sig: fifteen (15) ml po three times a day. 15. aspirin 325 mg tablet sig: one (1) tablet po once a day. 16. isosorbide mononitrate 10 mg tablet sig: one (1) tablet po three times a day. 17. pantoprazole 8 mg/hr iv infusion until discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnosis: 1. coffee-ground emesis discharge condition: afebrile, vital signs stable, hematocrit stable. discharge instructions: you were admitted to for bleeding in your g-tube, likely from your stomach. you were treated with iv medications, and your hematocrit dropped to the low 30s but remained stable. you did not require any blood transfusions. the gi specialists were consulted, who recommended medical management given the stable blood count. your medications and tube-feeds are being restarted now. the following changes are being made to your medications: . 1. change famotidine to omeprazole 40mg . 1. hold aspirin for 1 week before restarting. 2. hold isosorbide mononitrate for 1-2 days before restarting, as tolerated by blood pressure. . you should follow-up with your primary care physician. there is further bleeding, you should call your doctor. you should also call your doctor or return to the emergency room for: * fevers, chills * chest pain, shortness of breath * abdominal pain, bloody stools or black tarry stools followup instructions: primary care physician: , . provider: , : date/time: 11:20 Procedure: Enteral infusion of concentrated nutritional substances Injection or infusion of other therapeutic or prophylactic substance Gastric lavage Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Long-term (current) use of insulin Right bundle branch block Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Diarrhea Nonspecific abnormal findings in stool contents Hematemesis Dementia in conditions classified elsewhere without behavioral disturbance Surgical or other procedure not carried out because of contraindication Flatulence, eructation, and gas pain Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Gastrostomy status Vascular dementia, uncomplicated Cerebral atherosclerosis Dementia with lewy bodies Restless legs syndrome (RLS) Hypothermia Other late effects of cerebrovascular disease, dysphagia Essential and other specified forms of tremor |
allergies: codeine / sulfa (sulfonamides) / penicillins attending: chief complaint: hepatocellular ca major surgical or invasive procedure: right hepatecomy history of present illness: 77-year-old female who was recently diagnosed with a right lobe hepatocellular carcinoma. this was initially diagnosed during routine imaging follow-up for renal cell carcinoma of her right kidney which is now status post rfa. she has had prior imaging from dating back to that showed a liver lesion of 2.3 cm. most recently, a ct scan and pet scan both demonstrated enlargement of the liver lesion to greater than 9 cm. a biopsy demonstrated hepatocellular carcinoma. the kidney lesion has been noted to be stable. a ct scan of the chest demonstrated no evidence of pulmonary metastases. a triphasic ct scan demonstrated a large arterial and hyper-enhancing mass involving segments 5 and 6 of the liver consistent with a biopsy-proven hcc with no further concerning lesions being identified. preoperative liver function tests included ast 66, alkaline phosphatase 116, total bilirubin 0.4, albumin 4.7, cea 2.7, ca-125 9.3, ca19-9 6. she has undergone thorough preoperative evaluation of her cardiac and cerebrovascular vasculature and has been cleared for surgery. she has provided informed consent and is brought to the operating room for right hepatic lobectomy. past medical history: the patient has a history of coronary artery disease and had a heart attack in . peripheral vascular disease s/p r external iliac stent and angioplasty. hypertension, hyperlipidemia, depression, osteoarthritis, anemia, cataracts, 3 cm abdominal aortic aneurysm, vulvar cancer, r renal cell cancer s/p radiofrequency ablation. psurghx; r le angioplasty, bilateral cataract surgery, vulvar cancer resection and bilateral inguinal lymph node biopsy, hip replacement x2, right knee replacement, and appendectomy as a child. social history: she smokes one pack of cigarettes a day and has done so for 54 years. she denies alcohol or drug use. family history: mother died of sbo, father died of cerebral hemorrhage, sister died of leukemia, sister with bladder cancer, brother with prostate cancer physical exam: post-op exam: t 98.3 hr 71, bp 119/51, rr 18, spo2 98% gen: sedated, difficult to arouse, opens eyes to painful stimuli but not voice, intubated cardiac: rrr chest: ctab, upper airway sounds abd: decreased breath sounds, mildly distended, clean dressings, sanguinous drainage in jp gu: foley, urine concentrated ext: warm and well-perfused, decreased pedal pulses pertinent results: 11:52am blood wbc-3.1*# rbc-3.77* hgb-9.9* hct-30.1* mcv-80* mch-26.2* mchc-32.9 rdw-16.3* plt ct-120* 04:28am blood wbc-9.0# rbc-4.58 hgb-12.8 hct-37.2 mcv-81* mch-28.0 mchc-34.5 rdw-16.1* plt ct-92* 04:57am blood wbc-13.0* rbc-5.22 hgb-14.3 hct-43.5 mcv-83 mch-27.4 mchc-32.9 rdw-16.7* plt ct-76* 04:50am blood pt-17.3* inr(pt)-1.5* 04:50am blood glucose-54* urean-24* creat-0.8 na-133 k-4.1 cl-100 hco3-26 angap-11 intraoperative liver u/s: large right lobe liver mass which is lobulated in contour but appears to be solitary. pathology: pt1n0mx g2 greatest dimension: 11 cm. additional dimensions: 10 cm x 7 cm. liver u/s: no large fluid collections are seen. normal color flow and doppler waveforms were noted in the main hepatic artery, hepatic vein, and portal vein. the common duct measures 3 mm. mrcp: status post right hepatectomy. the liver demonstrates moderate dropout of signal intensity on out-of-phase imaging consistent with fatty infiltration. there is no evidence of other worrisome lesions. there is no evidence of intrahepatic or extrahepatic biliary dilatation. small amount of perihepatic fluid is noted, without evidence of organized fluid collection. the portal vein is patent. the hepatic artery is patent. ct abdomen/pelvis: 1. extensive perihepatic hematoma with mass effect upon the liver, portal vein and stomach. 2. small bilateral pleural effusions, right greater than left. liver u/s: 1. stable appearance of the resection bed hematoma (heterogeneous collection measuring 9.5 x 6.4 x 7.3 cm) as compared to the ct from . 2. normal flow in the main portal vein, left hepatic vein, and hepatic artery. liver bx: 1. severe hepatocellular and canalicular cholestasis, primarily involving zone 3 with prominent hepatocellular swelling. 2. mild lobular and focal portal neutrophilic infiltration with neutrophilic aggregates and infiltration of bile ducts. no bile duct proliferation is seen. 3. mild to focally moderate steatosis (not seen on previous resection). cxr: interval increase in bilateral right greater than left small pleural effusions with associated atelectasis without evidence of pneumonia. cxr: as compared to the previous radiograph from , there is improvement with decrease in extent of the right-sided pleural effusion. the clips, the drains projecting over the liver and the monitoring and support devices are in unchanged position. no newly appeared focal parenchymal opacity suggesting pneumonia. no evidence of pneumothorax. liver u/s: 1. resolving collection in the right hepatic surgical bed. 2. no biliary dilatation and appropriate vascular waveforms seen in the left lobe of the liver. 3. right pleural effusion. le u/s: no lower extremity deep venous thrombosis. brief hospital course: on , she underwent right hepatic lobectomy and cholecystectomy, with intraoperative ultrasound. surgeon was dr. . please refer to operative note for complete details. postop, patient was transferred intubated to the pacu due to episodes of apnea on cpap accompanied by respiratory acidosis, likely related to the earlier administration of intrathecal morphine. consequently, further opiate medication was limited. patient was successfully extubated and transferred to the floor. on was tolerating a regular diet and started on lasix for weight gain and edema. total bilirubin and alkaline phosphatase increased post-op: alk phos peaked at 614 on and t bili at 23.4 on before starting to decline. for this reason, an mrcp was obtained on that demonstrated no biliary obstruction. on wbc rose to 29.3 from 19.0 the day before. patient was afebrile; cultures were obtained and were negative. drain output had 10,000 wbcs but fluid culture was negative. she was empirically started on vancomycin, levofloxacin, and flagyl for the leukocytosis. sanguinous output was noted from jp. patient received 2u prbc on after a decline in hct to 24.4 as well as 2 u ffp for an inr of 2.7. a dobhoff was placed and tube feeds were started for poor oral intake. on l blood was noted from jp drain with a decline in hct to 28.9 from prior 32.8 and was taken to or for hematoma evacuation. hematoma was observed but no active bleeding was identified. please refer to dr. operative note from for further detail. two jp drains were placed. patient was kept in sicu following surgery for monitoring. she required albumin and a fluid bolus for hypotension/low uo, prbcs for hct 27.5, and 1 u plts for platelets of 66. she had an episode of delerium treated with seroquel. liver biopsy obtained intra-operatively demonstrated severe cholestasis. cultures obtained from the hematoma intra-op grew sparse coag neg staph aureus. on she was hemodynamically stable and was transferred to the floor, but still had confused mental status despite withholding of sedating medications. on 1 ffp, 1 plt, and vitamin k were given for an inr of 2.1, but there was no evidence of bleeding from the jp drains, which had decreased output. on dermatology was consulted for a worsening rash over her flanks and lower abdomen and suggested a drug reaction versus contact dermatitis. that afternoon, she was noted to have worsening mental status and complaint of shortness of breath for which albuterol nebs were given. chest xray demonstrated right greater than left pleural effusion but mild vascular congestion. she was maintaining her saturations at 96% on 2l nc and appeared more awake and responsive by the late afternoon. the morning of patient was transferred to the sicu for increased confusion and tachypnea with concern over airway protection. ammonia level was 51. patient was closely monitored in the icu and was maintaining her airway until 17:15, when she was found to be in respiratory arrest and was subsequently intubated. at this time patient went into cardiac arrest and acls was initiated with pressor drip. bleeding was noted from drains accompanied by abdominal distension, with drop in hct from 41 to 20, rise in inr from 1.6 to >3, and platelets of 33. massive transfusion protocol was initiated and patient underwent exploratory laparotomy at bedside by dr. , but bleeding was unable to be controlled and patient required cpr and external pacing. patient expired at 20:29 after discussion with daughter to withdraw care. for details, see death pronouncement note of . medications on admission: atenolol 50 mg daily omeprazole 20 mg isosorbide mononitrate 40 mg lovastatin 40 mg daily amitriptyline 125 qhs ferrous sulfate 325 mg discharge medications: n/a discharge disposition: expired discharge diagnosis: hepatocellular ca s/p resection intra-abdominal hematoma s/p evacuation delirium respiratory depression cardiac arrest hemorrhage/coagulopathy discharge condition: expired discharge instructions: n/a followup instructions: n/a md, Procedure: Insertion of intercostal catheter for drainage Enteral infusion of concentrated nutritional substances Closed (percutaneous) [needle] biopsy of liver Cholecystectomy Reopening of recent laparotomy site Reopening of recent laparotomy site Other conversion of cardiac rhythm Cardiopulmonary resuscitation, not otherwise specified Lobectomy of liver Diagnoses: Acidosis Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified pleural effusion Urinary tract infection, site not specified Unspecified essential hypertension Acute posthemorrhagic anemia Unspecified septicemia Severe sepsis Peripheral vascular disease, unspecified Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Cardiogenic shock Old myocardial infarction Dermatitis due to drugs and medicines taken internally Other ascites Malignant neoplasm of liver, primary Abdominal aneurysm without mention of rupture Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Obstruction of bile duct Other and unspecified coagulation defects Delirium due to conditions classified elsewhere Personal history of malignant neoplasm of other female genital organs Unspecified drug or medicinal substance causing adverse effects in therapeutic use Transfusion associated circulatory overload |
allergies: aspirin / penicillins attending: chief complaint: shortness of breath major surgical or invasive procedure: cardiac catheterization with drug eluting stent to left anterior descending artery and balloon angioplasty to diagonal artery history of present illness: 43 year female with h/o dmt2, osa, asthma, and dyslipidemia presents from osh for asa desensitization before pci. patient has had 6 month history of left chest pain/pressure that lasts for a couple of minutes and is a . it radiates to the right chest. associated with shortness of breath and recently some diaphoresis and nausea. she states she used to walk about 2 blocks before the cp starts, but it has been progressively getting worse as she must stop and rest quite a bit more with progressively shorter distances. she also states that this chest pain has begun to occur at rest. prior to 6 months, she has never had this episode before. she went to her pcp who then referred her to get a exercise tolerance test: she walked 6 minutes according to a standard . her isotope study showed lateral ischemia. she was then admitted yesterday to hospital for a cardiac cath performed today. () her cath revealed a proximal 80% long lesion, totally occluded cx, occluded diagnoal, mild rca disease. lvef reportedly 55%. since the patient has an asa allergy associated with rash/angioedema/and questionable wheezing (per patient), she was loaded with 600 mg of plavix, 50 mg of atenolol and transferred here for asa desensitization and further intervention. past medical history: past medical history: 1. cardiac risk factors: + diabetes (complicated by peripheral neuropathy, + dyslipidemia, -hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: none -pacing/icd: none 3. other past medical history: obesity asthma obstructive sleep apnea: recent sleep study shows indication for cpap, although not currently using anxiety/depression social history: social history -tobacco history: never -etoh: none -illicit drugs: none lives with family in family history: 2 aunts with "big heart", father died of cva, uncertain of age; sister has h/o tachycardia? physical exam: vs: t=97.6 bp=160/70 hr= 66rr=20 o2 sat= 97% 2lnc general: well nourished obese female in nad. oriented x3. mood, affect appropriate. heent: sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp of cm. hepatojugular reflux 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, obese, ntnd. no hsm or tenderness. extremities: no c/c/e. right femoral sheeth in place; ttp in bilateral calves skin: discoloration of ble pulses: right: carotid 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: 07:15am blood wbc-11.9* rbc-4.49 hgb-12.9 hct-37.7 mcv-84 mch-28.7 mchc-34.2 rdw-13.4 plt ct-288 07:15am blood glucose-189* urean-10 creat-0.5 na-138 k-4.4 cl-104 hco3-25 angap-13 07:15am blood ck(cpk)-66 09:55pm blood ck(cpk)-71 12:43pm blood alt-32 ast-20 alkphos-88 totbili-0.4 12:43pm blood ck-mb-3 ctropnt-<0.01 07:15am blood calcium-8.5 phos-3.6 mg-2.2 12:43pm blood hdl-37 chol/hd-5.3 ldlmeas-130* . echo: the left atrium is dilated. 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). 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) 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. impression: normal regional and global biventricular systolic function. no pathologic valvular abnormality seen. . cardiac catheterization : comments: 1- limited selective coronary angiography confirmed the presence of a long mid lad 80% stenosis with a totally and chronically occluded long diagonal branch (originates from the diseased lad segment). the lmca had mild plaquing and the lcx was chronically occluded in mid vessel with collaterals filling the om2. the rca was not engaged as it was found to be patent on earlier cath performed at osh. 2- limited resting hemodynamic assessment showed normal systemic arterial bp (130/70). 3- successful ptca of the chronically and totally occluded diagonal branch with 20% residual ostial stenosis, timi 3 flow and no dissection or distal emboli. 4- successful ptca and stenting of the mid lad with a 2.5x23 mm cypher des, postdilated to 2.75 mm. final angiography whosed no residual stenosis with timi 3 flow and no dissection or distal emboli. 5- sucecssful closure of the lcfa with a perclose proglide closure device. final diagnosis: 1. two vessel coronary artery disease. 2. sucecssful stenting of the mid lad with a cypher des. 3. successful poba of the diagonal branch. 4. sucecssful closure of the lcfa with a perclose proglide closure device. 5. dual antiplatelet therapy (asa and plavix) for a minimum of 12 months then asa indefinitely. . cxr: reason for examination: chest pain after breast surgery. the portable ap chest radiograph was reviewed with no prior studies available for comparison. the study was obtained in lordotic projection. the heart size is mildly enlarged, which might be exaggerated by the lordotic projection of the study. the lungs are essentially clear. there is no pleural effusion or pneumothorax. mediastinal position, contour and width are unremarkable. impression: no acute cardiopulmonary findings. brief hospital course: #acs/cad: pt admitted for aspirin desensitization. no signs of wheezes, rash or pruritis with aspirin dose. s/p cath with diffuse 3vd with des to mid lad and poba to diagonal. no further sob during hospital stay, pt was able to ambulate in halls without difficuty prior to discharge. ck's flat, no evidence of prior mi or wall motion abnormality on echo. started on clopodigrel, metoprolol, simvastatin and full dose asa. pt will need to take aspirin and clopodigrel every day for at least one year because of her drug eluting stent. #pump:no hx or symptoms of chf. cxr clear, ls without crackles and no peripheral edema. echo preserved ef. # right shoulder pain: unclear precipitant. developed after cardiac catheterization. no similar pain pta, no obvious trauma or strain. worse with movement and palpation at bicep area. right shoulder somewhat diffusely swollen and tender but and pain decreased prior to discharge. better with narcotics and ice. right shoulder films showed no fracture. ekg and ck's stable, not thought to be cardiac related. pt told to f/u with her pcp if right shoulder pain continues. # dyslipidemia: not on statin on admission, started on 80 mg simvastatin. see lipid panel above. pt will need lft's checked in 2 months and then at 6 months to assess for transaminitis. low fat diet discussed with pt. she will need reinforcement. #type 2 diabetes :glargine and humalog cont, metformin held because of contrast load. pt told to restart metformin on . no changes at d/c. #asthma: home medications of singulair and abluterol continued. no wheezes on exam or o2 requirement. no exacerbation with asa. # osa: per pt, is being worked up as outpt. cpap machine offered to pt but mask did not fit well and pt ref to use. medications on admission: singulair 10 mg daily flovent prn prventil nebulized with albuterol 2 puffs qid metformin 1000mg risperdal 1 mg qhs trazadone 50 mg qhs omeprazole 20 mg docusate 100 mg prn cialopram 40 mg daily gabapentin 400 mg novolog 10 units in am lantus 70 units qhs discharge medications: 1. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 2. insulin glargine 100 unit/ml solution sig: seventy (70) units subcutaneous once a day. 3. insulin lispro 100 unit/ml solution sig: ten (10) units subcutaneous once a day. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 6. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 7. gabapentin 400 mg capsule sig: one (1) capsule po daily (daily). 8. risperidone 0.5 mg tablet sig: two (2) tablet po hs (at bedtime). 9. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*11* 10. nitroglycerin 0.3 mg tablet, sublingual sig: 1-3 tablets tablet, sublinguals sublingual prn (as needed) as needed for chest pain: take 5 mintues apart. if still have chest pain after 3 tablets, call 911. disp:*1 bottle* refills:*1* 11. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 12. simvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 13. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 14. acetaminophen 500 mg tablet sig: two (2) tablet po four times a day as needed for pain, discomfort: for right shoulder pain. 15. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 16. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation. 17. trazodone 50 mg tablet sig: one (1) tablet po at bedtime. 18. metformin oral discharge disposition: home discharge diagnosis: coronary artery disease diabetes mellitus type 2 obstructive sleep apnea asthma depression/anxiety discharge condition: stable discharge instructions: you had a cardiac catheterization that showed blockages in multiple coronary arteries. a drug eluting stent that was placed in your left coronary artery and a balloon procedure was used to open a blockage in your diagonal artery. it is very important that you call your cardiologist, dr. , if you have any more chest pain or trouble breathing. you did not have a heart attack. you can now take aspirin safely but you need to take it every day for the rest of your life, don't miss . you also have to take clopodigrel (plavix) every day for one year. don't miss or stop taking plavix unless dr. tells you to. you may not drive for 48 hours. please let dr. know if you have any increased tenderness, bleeding, swelling or redness at your groin sites. no pools or baths for one week, you may shower. new medicines: 1. clopodigrel (plavix): a blood thinner to keep the stent in your heart open 2. aspirin: a blood thinner to keep the stent open 3. metoprolol: a beta blocker medicine to prevent a heart attack 4. lisinopril: an ace inhibitor medicine to lower your blood pressure 5. do not take your metformin until saturday 6. your omeprazole was changed to ranitidine 7. you were started on simvastatin for your cholesterol 8. you were given a prescription for nitroglycerin, to take if you had chest pain or trouble breathing again. please refer to the spanish information on how to take nitroglycerin. . please call dr. for any chest pain, trouble breathing, dizziness or fainting, dark or bloody stools or any other concerning symptopms. . please come in to the walk in clinic on monday with your discharge papers, your doctor is on an extended leave of absence but you can be seen by another provider . followup instructions: cardiology: , b. date/time: at 3:00pm at the office . primary care: , phone: date/time: please go to the walk in clinic tomorrow. Procedure: 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 two vessels Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Asthma, unspecified type, unspecified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Dysthymic disorder Other and unspecified hyperlipidemia Pain in joint, shoulder region Chronic total occlusion of coronary artery |
allergies: iodine attending: chief complaint: gib major surgical or invasive procedure: egd history of present illness: the patient is a 54y/o woman with a pmh of h. pylori and depression admitted with doe and anemia with hct of 19. the patient noted onset of doe 2 days prior to presentation, with worsening so that she was unable to ambulate without significant difficultly over the past 24 hours. she noted black stools 24 hours prior to presentation. denies previous recent history of bleeding. she underwent a routine screening colonoscopy in which demonstrated grade 1 internal hemorrhoids. she denies any other bleeding (urine, gums). she denies weight changes, fevers, chills, night sweats. she has nto had any bowel movements since admission. in the ed, initial vitals t 98.2, hr 80, bp 119/75, rr 16, o2 100% ra. on exam she was found to have dark, guaiac + stools. ng lavage negative. 2 18 guage piv were placed. she was transfused 1u prbc. on arrival to the micu, the patient is resting comfortably, in nad. denies current cp/sob. the gi performed an upper endoscopy on arrival to the micu which demonstrated a large polyp with no evidence of current bleeding. intervention was deferred overnight for planned excision and biopsy with eus. she was transfused 3 units prbc's with appropriate improvement in her hct and has been hemodynamically stable in the icu. 10 point review of systems otherwise negative except as noted above. past medical history: melanoma in-situ, lentigo maligna type - l cheeck depression h. pylori social history: the patient is married and has one teenage son. she runs the gift shop at . the patient denies tobacco, etoh, ivdu. denies over the counter herbal supplements. family history: nephew with deficiency physical exam: vs: t 97.3 hr 59 bp 102/69 rr 18 sat 99% ra gen: wll appearing woman in nad eye: extra-occular movements intact, pupils equal round, reactive to light, sclera anicteric, not injected, no exudates, conjunctiva pink ent: mucus membranes moist, no ulcerations or exudates neck: no thyromegally, jvd: flat cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops respiratory: clear to auscultation bilaterally, no wheezes, rales or rhonchi abd: soft, non tender, non distended, no heptosplenomegally, bowel sounds present extremities: no cyanosis, clubbing, edema, joint swelling neurological: alert and oriented x3, cn ii-xii intact, normal attention, sensation normal, asterixis absent, speech fluent, dtr's 2+ patellar, achilles, biceps, triceps, brachioradialis bilaterally, babinski down-going bilaterally integument: warm, moist, no rash or ulceration psychiatric: appropriate, pleasant, not anxious hematologic: no cervical or supraclavicular lad pertinent results: 05:57pm comments-green top 05:57pm hgb-7.8* calchct-23 05:50pm glucose-87 urea n-20 creat-0.8 sodium-141 potassium-3.7 chloride-108 total co2-25 anion gap-12 05:50pm wbc-5.5 rbc-2.22* hgb-6.8* hct-20.4* mcv-92 mch-30.8 mchc-33.4 rdw-14.0 05:50pm neuts-68.4 lymphs-24.4 monos-5.5 eos-1.4 basos-0.2 05:50pm plt count-211 05:50pm pt-11.3 ptt-21.8* inr(pt)-0.9 01:46pm glucose-95 01:46pm urea n-23* creat-0.8 sodium-141 potassium-4.4 chloride-109* total co2-29 anion gap-7* 01:46pm estgfr-using this 01:46pm alt(sgpt)-13 ast(sgot)-20 alk phos-57 tot bili-0.2 01:46pm wbc-3.9* rbc-2.13*# hgb-6.4*# hct-18.9*# mcv-92 mch-30.0 mchc-32.8 rdw-14.1 01:46pm neuts-64.6 lymphs-24.2 monos-8.8 eos-1.9 basos-0.5 01:46pm plt count-177 01:46pm pt-11.9 ptt-23.5 inr(pt)-1.0 01:46pm urine color-yellow appear-clear sp -1.019 01:46pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg egd : impression: polyp in the second part of the duodenum on wall opposite ampulla otherwise normal egd to third part of the duodenum recommendations: patient will require polypectomy of this polyp. we do not have the equipment to perform this as an emergency procedure. can have clear liquids. give protonix 40 mg twice daily. colonoscopy : impression: grade 1 internal hemorrhoids otherwise normal colonoscopy to cecum brief hospital course: this is a 54y/o woman with a h/o h. pylori and depression with acute blood loss anemia, gib, duodenal polyp. 1. acute blood loss anemia due to gi bleeding: she presented with blood loss anemia, secondary to slow gi bleed. she had an emergent egd which showed a duodenal polyp. she improved with transfusion of 3 units of blood with stable hematocrit. she will need to restart an supplement on discharge. . 2. duodenal polyp: underwent eus on for evaluation of polyp found on initial egd. eus showed 3 cm pedunculated polyp in the second part of the duodenum. the ampulla was identified and was separate from the mass. the ampulla appeared normal. on eus, this lesion appeared as a pedunculated polyp. no extension of the lesion beyond the submucosa was noted. the muscularis was clearly identified and was intact. she went for removal on . during that egd, egd on she was found to have angioectasia in the stomach (treated with thermal therapy), a polyp in the second part of the duodenum (treated with polypectomy, endoclip, and otherwise normal egd to third part of the duodenum. she was discharged home after the polypectomy, with advise to return in the event of pain, hematemesis, or worsening melena. she will have a cbc approximately 5 days post discharge, results to her pcp. . 3. depression: continuee wellbutrin and celexa. . outstanding tests: polyp, pathology pending medications on admission: on admission: bupropion hcl 200 mg tablet sr daily citalopram 20 mg tablet daily lorazepam 0.5 mg tablet one half to one tablet(s) by mouth @ hs no more than 3 nights per week ferrous sulfate 325 mg (65 mg ) tablet multivitamin tablet 1 tablet(s) by mouth daily (otc) on transfer: bupropion (sustained release) 200 mg po qam citalopram hydrobromide 20 mg po daily pantoprazole 40 mg iv q12h discharge medications: 1. bupropion hcl 100 mg tablet sustained release sig: two (2) tablet sustained release po qam (once a day (in the morning)). 2. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 3. (ferrous sulfate) 325 mg (65 mg ) tablet sig: one (1) tablet po once a day. 4. outpatient lab work cbc, . results to dr. phone . discharge disposition: home discharge diagnosis: upper gi bleed acute blood loss anemia duodenal polyp depression discharge condition: stable, hematocrit 31.5, no active bleeding, ambulating without shortness of breath discharge instructions: you were admitted with anemia, due to blood loss. the most likely cause was the polyp in your duodenum, which was slowly oozing. you improved with transfusions with a stable blood count throughout your stay after the transfusion. you had the polyp removed on the day before discharge. . no aspirin, or nsaids. you do not need to take protonix. . return to the ed if you get short of breath or dizzy. your stool will probably turn black from the , that is expected. . start eating solid food tonight. stay well hydrated in the next few days. followup instructions: call the gi department to make an appointment with in the next 2-3 weeks. the phone number is . they will give you the results of your polyp removal. . provider: , md phone: date/time: 3:00 (resident working with dr. . blood count check next week. Procedure: Other endoscopy of small intestine Other endoscopy of small intestine Endoscopic excision or destruction of lesion of duodenum Transfusion of packed cells Diagnostic ultrasound of digestive system Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Depressive disorder, not elsewhere classified Iron deficiency anemia, unspecified Hemorrhage of gastrointestinal tract, unspecified Dehydration Internal hemorrhoids without mention of complication Angiodysplasia of intestine (without mention of hemorrhage) Benign neoplasm of duodenum, jejunum, and ileum |
allergies: no known allergies / adverse drug reactions attending: chief complaint: unstable angina major surgical or invasive procedure: left & right heart catheterization, coronary angiogram insertion of intraaortic balloon urgent mitral valve repair (p2 triangular resection),ring annuloplasty(34mm physio ii annuloplasty ring, model number 5200,serial number )/ coronary artery bypass grafting times 3 lima-lad,svg-d1,svg-om1) history of present illness: this 45 year old white male began about one and a half months ago to notice chest discomfort "like indigestion", across the entire chest when exerting himself. he is avid walker and has noticed this discomfort when going up any type of incline and resolving with rest. he has not noticed this discomfort when walking on a level surface. it is easily reproducible. he underwent a stress echo which revealed mild lv enlargement with preserved lv function. the left atrium was moderately dilated. there was moderate mitral valve prolapse involving the posterior leaflet with severe mitral insuffiency and pulmonary vein flow reversal. mild tr and borderline aortic root dilation were seen. he exercised 6 minutes and developed chest pain at peak exercise along with lateral st depression. pvc's were noted. echo imaging showed anteroseptal ischemia. he was referred for cardiac catheterization to further evaluate. he was found to have coronary artery disease upon cardiac catheterization and referred to cardiac surgery. he continued to complain of chest pain on a nitro drip and morphine. he had an intraaortic balloon placed with stabilization and was taken the following day to the operating room for an urgent operation. enzymes were flat. past medical history: mitral prolapse/regurgitation mild hyperlipidemia, recently started on statin non sustained vt 13 years ago, on atenolol since hemorrhoids with occasional rectal bleeding bone spurs s/p surgery remote history of migraines social history: race:caucasian last dental exam: lives with:wife and three kids contact: (wife) # occupation:works at a bank as a temporary worker doing booking cigarettes: smoked no yes hx:occasional cigarette/cigar (none in 2 months) other tobacco use:denies etoh: 2 glasses of wine per day illicit drug use:denies family history: adopted. patient does not know his family history. physical exam: height:6'2" weight:228 lbs unable to assess patient due to emergent nature of case. no h&p in chart. pertinent results: 05:35am blood wbc-5.8 rbc-3.08* hgb-9.1* hct-27.0* mcv-88 mch-29.4 mchc-33.5 rdw-13.0 plt ct-138* 04:30am blood wbc-6.0 rbc-3.27* hgb-10.2* hct-28.9* mcv-88 mch-31.1 mchc-35.2* rdw-12.8 plt ct-133* 02:11am blood wbc-6.7 rbc-3.68* hgb-11.2* hct-32.0* mcv-87 mch-30.3 mchc-34.9 rdw-13.3 plt ct-148* 05:35am blood glucose-125* urean-14 creat-0.8 na-140 k-4.1 cl-107 hco3-27 angap-10 04:30am blood glucose-142* urean-10 creat-0.9 na-138 k-4.0 cl-105 hco3-25 angap-12 02:11am blood glucose-109* urean-9 creat-0.7 na-137 k-3.8 cl-110* hco3-23 angap-8 02:16pm blood urean-14 creat-1.0 na-138 k-4.1 cl-106 hco3-24 angap-12 tte results measurements normal range left ventricle - inferolateral thickness: 0.7 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *7.1 cm <= 5.6 cm left ventricle - systolic dimension: 3.9 cm left ventricle - fractional shortening: 0.45 >= 0.29 left ventricle - ejection fraction: 50% to 55% >= 55% left ventricle - stroke volume: 113 ml/beat left ventricle - cardiac output: 8.48 l/min left ventricle - cardiac index: 3.69 >= 2.0 l/min/m2 aorta - annulus: 2.7 cm <= 3.0 cm aorta - sinus level: *3.7 cm <= 3.6 cm aorta - sinotubular ridge: *3.2 cm <= 3.0 cm aorta - ascending: *3.6 cm <= 3.4 cm aorta - arch: 3.0 cm <= 3.0 cm aorta - descending thoracic: 2.4 cm <= 2.5 cm aortic valve - lvot vti: 25 aortic valve - lvot diam: 2.4 cm left atrium: dilated la. la not well visualized. no spontaneous echo contrast or thrombus in the body of the laa. right atrium/interatrial septum: no spontaneous echo contrast in the body of the ra or raa. no asd by 2d or color doppler. left ventricle: normal lv wall thickness. moderately dilated lv cavity. low normal lvef. right ventricle: normal rv systolic function. aorta: mildy dilated aortic root. mildly dilated ascending aorta. normal aortic arch diameter. no atheroma in descending aorta. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: moderately thickened mitral valve leaflets. moderate/severe mvp. partial mitral leaflet flail. moderate to severe (3+) mr. to the eccentric mr jet, its severity may be underestimated (coanda effect). tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: pulmonic valve not visualized. no ps. physiologic pr. pericardium: no pericardial effusion. conclusions pre-bypass: the left atrium is dilated. 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 or right atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is low normal (lvef 50-55%). the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the descending aorta appears free from atherosclerotic plaque with some limitation in the study due to the presence of an intraaortic balloon pump. the distal tip of the iabp appears end prior to the subclavian artery takeoff. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is moderate/severe posterior leaflet mitral valve prolapse. there is partial posterior (p2) mitral leaflet flail. moderate to severe (3+) mitral regurgitation is seen. due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (coanda effect). there is no pericardial effusion. postbypass: the patient is in sinus tachycardia on low dose epinephrine & moderate dose phenylephrine infusions. the biventricular function is maintained. there is a well seated annuloplasty ring in the mitral position. there is trace mr. there are peak and mean gradients of 11 & 5mmhg, respectively. the remaining valves are unchanged. the aorta appears intact, though the descending aorta has suboptimal imaging due to the presence of an iabp. the iabp continues to remain with the distal tip in appropriate position. 04:40am blood wbc-6.0 rbc-3.00* hgb-9.0* hct-26.3* mcv-88 mch-30.2 mchc-34.4 rdw-12.9 plt ct-217# 04:40am blood na-141 k-4.0 cl-105 brief hospital course: this is a 45-year-old male referred from dr. for consideration of coronary artery bypass grafting as well as mitral valve repair. the patient developed severe angina after his diagnostic cardiac cath which revealed moderate left main disease and high-grade lad and diagonal stenoses. the patient was not responsive to nitroglycerin and therefore was brought to the operating room and an intra-aortic balloon pump inserted. this abated his chest pain. a stat echo in the operating room showed severe mitral regurgitation. it was felt that the patient should proceed with mitral valve repair or replacement and coronary artery bypass grafting the next morning. the patient had a stable night and did not rule in for a myocardial infarction by serial enzyme analysis. on he was taken to the operating room and underwent mitral repair and coronary artery bypass grafting times 3. cardiopulmonary bypass time: 155 minutes cross-clamp time: 126 minutes. see operative note for full details. the operation went without complication and the patient was transferred to the cvicu in stable condition. he was initially hypoxic which improved with recruitment maneuvers. the intraaortic balloon pump was removed on the night of surgery and he remained hemodynamically stable off all vasoactive medications. he was started on precedex and extubated on his post operative night. on pod1 beta blockers were started and he was gently diuresed with lasix. chest tubes were removed per cardiac surgery protocol and follow up cxr showed no pneumothorax. he was transferred to the step down unit in stable condition. pacing wires were removed on pod3 per cardiac surgery protocol without difficulty. he was changed from percocet to ultram due to confusion and lethargy. he worked with physical therapy for strength and mobility. he was kept an extra day due to unsteadiness with ambulation. on pod 5 he was ambulating with assistance, tolerating a full oral diet and his incisions were healing well. it was felt that he was safe for discharge home with visiting nurse services. there was a tiny amount of serosanguinous drainage on the sternal dressing the morning of discharge, however, the sternum was stable, no further drainage could be expressed and he was afebrile with a normal white blood cell count. all follow up appointments were arranged. medications on admission: atenolol 50 mg tablet - 2 tablets by mouth daily atorvastatin 40 mg tablet - 2 tablets by mouth every evening aspirin 81 mg daily discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever or pain. 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 6. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: severe mitral regurgitation unstable angina with left main stenosis s/p insertion of intra aortic balloon s/p urgent mitral valve repair and coronary artery bypass grafts s/p left & right heart catheterization, coronary angiogram hyperlipidemia hemorrhoids discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with ultram incisions: sternal - healing well, no erythema or drainage leg right- healing well, no erythema or drainage. 1+ edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr () on at 1:45 pm cardiologist:dr. () at 1:30pm wound check at cardiac surgery office on / at 10:00am please call to schedule appointments with: 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 Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Implant of pulsation balloon Open heart valvuloplasty of mitral valve without replacement Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Tobacco use disorder Mitral valve disorders Congestive heart failure, unspecified Other opiates and related narcotics causing adverse effects in therapeutic use Other and unspecified hyperlipidemia Family history of ischemic heart disease Acute diastolic heart failure Internal hemorrhoids with other complication Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Other premature beats Reactive confusion |
allergies: vasotec attending: chief complaint: aortic stenosis major surgical or invasive procedure: aortic valve replacement (21 stjude porcine) history of present illness: 87 year old woman with hypertension presented to after awakening with chest discomfort on . she had had several months of progressive doe and fatigue. she lives alone and at baseline is self-sufficient. she had never had chest pain before. she denied any history of syncope. at lgh, she was found to have severe as and was transferred to on for avr. past medical history: aortic stenosis hypertension status post cholecystectomy 40yrs ago social history: lives alone(5 sons near by, one in ajoining unit) occupation:homemaker cigarettes: never etoh: less than 1 drink/week illicit drug use none family history: non-contributory physical exam: pulse: resp:14 o2 sat: 98% ra b/p right:134/78 left: height:61" weight:164 general:wdwn skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade _4/6 sem -> neck 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:m left:m pertinent results: wbc-5.0 rbc-3.53* hgb-10.4* hct-33.3* mcv-95 mch-29.5 mchc-31.2 rdw-14.8 plt ct-196 wbc-4.1 rbc-3.59* hgb-10.4* hct-33.6* mcv-94 mch-29.0 mchc-31.0 rdw-14.2 plt ct-151 glucose-183* urean-16 creat-0.7 na-139 k-4.5 cl-96 hco3-35 glucose-176* urean-18 creat-1.0 na-141 k-4.3 cl-104 hco3-26 alt-37 ast-55* ld(ldh)-233 alkphos-40 totbili-0.3 mg-1.9 mrsa screen (final ): no mrsa isolated. cxr: : there is cardiomegaly which is stable. there are bilateral pleural effusions, right side worse than left as well as a left retrocardiac opacity. no overt pulmonary edema or pneumothoraces are seen. the tip of the right ij cordis is in the superior svc. echo: pre-cpb: no thrombus is seen in the left atrial appendage. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. no thoracic aortic dissection is seen. the aortic valve is bicuspid with horizontal commissure. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. post-cpb: a bioprosthetic valve is seen in the aortic position. the valve appears well-seated with normally mobile leaflets. a tiny filamentous mass is seen in the lvot side of the aortic valve, possibly debris from debridement or a suture. there are no paravalvular leaks, there is no ai. the peak gradient across the aortic valve is 21mmhg, the mean gradient is 9mmhg with co of 3.5l/min. biventricular systolic function remain normal. other valvular function remain unchanged from pre-bypass. there is no evidence of aortic dissection. 05:40am blood wbc-5.4 rbc-3.33* hgb-9.5* hct-30.2* mcv-91 mch-28.6 mchc-31.5 rdw-14.3 plt ct-181 09:30am blood wbc-5.0 rbc-3.53* hgb-10.4* hct-33.3* mcv-95 mch-29.5 mchc-31.2 rdw-14.8 plt ct-196 05:40am blood glucose-117* urean-14 creat-0.7 na-138 k-4.4 cl-96 hco3-36* angap-10 09:30am blood glucose-183* urean-16 creat-0.7 na-139 k-4.5 cl-96 hco3-35* angap-13 brief hospital course: the patient was brought to the operating room on where the patient underwent aortic valve replacement with a 21-mm biocor tissue valve. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. the patient was gently diuresed toward the preoperative weight. she exhibited a high degree av block initially, which would show signs of recovery prior to discharge. ep was consulted and made recommendations. beta blockade was attempted, however this compromised her normal sinus rhythm. 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. she will not be discharged on a beta blocker, and nodal agents should not be initiated in the future. by the time of discharge on pod 8 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to rehab in good condition with appropriate follow up instructions. medications on admission: lisinopril 40mg daily, aldactone 25mg daily, nadolol 160mg daily discharge medications: 1. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 2. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain, fever. 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 7. furosemide 20 mg tablet sig: two (2) tablet po once a day for 5 days. 8. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po once a day for 5 days. 9. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for rash. 10. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five (5) ml po q6h (every 6 hours) as needed for cough. 11. cepacol sore throat 15-2.6 mg lozenge sig: one (1) mucous membrane four times a day as needed for sore throat. discharge disposition: extended care facility: nursing and rehab center discharge diagnosis: aortic stenosis hypertension status post cholecystectomy yrs ago discharge condition: alert and oriented x3 nonfocal ambulating, deconditioned sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage trace edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: surgeon dr. date/time: 1:15 in the a please call to schedule the following: cardiologist dr. 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 Open and other replacement of aortic valve with tissue graft Diagnoses: Unspecified essential hypertension Iron deficiency anemia secondary to blood loss (chronic) Aortic valve disorders Atrioventricular block, complete Congenital insufficiency of aortic valve Other nonspecific abnormal finding of lung field |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxic respiratory failure major surgical or invasive procedure: none history of present illness: mr. is a 77 y.o. male w/ h.o. diastolic dysfunction, a. fib/flutter s/p recent pvi, copd, asthma, ?ipf, htn, initially presented to w/ week h.o of lower extremity edema, shortness of breath. intubated for hypercapneic respiratory distress. transferred for further hypoxic work-up whether this is copd exacerbation, pna, chf exacerbation. . on review of pt's outside medical records it appears he was initially admitted to on w/ a 2 week h.o. progressive lower extremity edema, several days of sob. day prior to admission pt was seen by his pcp who prescribed steroid taper, azithromycin for possible copd exacerbation. upon assessment in the ed it appears his oxygen saturation was 52% on ra, hr 120, rr 32, bp 157/99. his labs at that time were significant for a leukocytosis of 22.0 (attributed to steroids). pt was given iv diuresis 100mg with poor urine output response. a cxr was obtained which showed extesnive alveolar edema. pt was given repetitive furosemide doses with little to no response in urine output, pt was noted to have increase creatinine, decreased urine output. his admission labs also showed +ck-mb, mbi, troponins but negative cks, am echo which was obtained 3 days later, however, showed normal lv function, rv dilatation, no mr, trivial tr. pul htn 37. . during the evening of pt was noted to become hypoxic to the 70% and was placed on a nrb where his o2 sat was ntoed to be 86-88%. he was titrated up to bipap with no reoslution in his hypoxia, he was noted to be more lethargic. abg showed ph of 7.17, po2 66, pco2 82-101, hco 30.6, pt was intubated. his initial abg showed co2 49, hco3 30.4, ph 7.40. sputum cx were sent which showed . he was also noted to be anemic in the low 20s on admission. surgery and gi were consulted and he underwent a ct scan of his abdomen to check for an rp bld given his recent pvi which was negative. stools were guaiac negative as were ng lavage. he was transfused 2 units with stable hcts. prior to him leaving he received cefepime, levofloxacin, iv solumedrol. a femoral line was placed for central access. he was influenza neg, sputum cx showed pmns, gpc chains, rare. gp bacili. . of note pt was admitted to last year with similar presentation, was initially diuresed for ?chf exacerbation and went into . eventually was diagnosed with influenza a. he has been noted to have ct changes in his chest suggesting ipf though he has not seen a pulmonologist. he was also admitted to in with new onset a. fib/flutter and underwent pulmonary vein isolation. he was discharged on coumadin as well as a course of steroids. per his wife he has been on a requirement of 5l n.c. over the past month or so. over the past week he has been noted to desaturate to mid 80s on 5l n.c. with movement. . review of systems: unable to obtain past medical history: 1. he has a chronic history of asthma and a possible copd/chronic obstructive lung disease. 2. possible pulmonary fibrosis that was diagnosed on a ct of the chest but per wife he never had any further evaluation of this fibrosis and never had any lung biopsies. 3. atrial flutter status post ablation on , and started on coumadin. 4. history of anemia that required blood transfusion around 1 year ago. no clear origin for the anemia. previous workup for retroperitoneal bleed. guaiacs were all negative. 5. hypertension. 6. steroid-induced hyperglycemia. 7. low vitamin b12. 8. diastolic congestive heart failure, chronic lower limb edema with an ef of 65%. 9. diverticulosis as noted above. 10. previous admissions for ards, chf, copd exacerbation, influenza a, a flutter. social history: social history: he lives at home. he is independent in his adl, iadls but over the last year he had a big decline in his functional status. he denies any drug abuse. no history of smoking. he has a history of alcohol intake three to four beers. family history: non-contributory physical exam: general: elderly caucasian male intubated laying down in bed heent: perrla, mmm. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: ctab, good air movement biaterally. abdomen: nabs. soft, nt, nd. no hsm groin: femoral central noted in rt groin with pulsatile wave form. extremities: 2+ edema noted b/l le to calf. skin: multiple ecchymoses noted. neuro: intubated, sedated. pertinent results: 02:30pm pt-32.4* ptt-33.6 inr(pt)-3.3* 02:30pm plt count-264 02:30pm wbc-16.7* rbc-2.72* hgb-8.0* hct-25.4* mcv-93 mch-29.4 mchc-31.5 rdw-15.7* 02:30pm albumin-3.2* calcium-8.0* phosphate-7.4* magnesium-2.6 02:30pm alt(sgpt)-19 ast(sgot)-34 ld(ldh)-592* alk phos-53 tot bili-0.4 02:30pm estgfr-using this 02:30pm glucose-149* urea n-80* creat-3.0* sodium-135 potassium-5.0 chloride-99 total co2-25 anion gap-16 02:40pm lactate-1.1 02:40pm type-art po2-147* pco2-79* ph-7.17* total co2-30 base xs--1 04:12pm ck-mb-11* mb indx-6.3* ctropnt-0.06* 04:12pm ck(cpk)-175 04:34pm type-art temp-35.6 rates-24/6 tidal vol-400 peep-7 o2-70 po2-74* pco2-73* ph-7.20* total co2-30 base xs--1 -assist/con intubated-intubated 04:55pm other body fluid wbc-0 rbc-0 polys-97* lymphs-1* monos-1* other-1* 05:25pm urine mucous-occ 05:25pm urine hyaline-6* 05:25pm urine rbc-70* wbc-8* bacteria-few yeast-none epi-0 05:25pm urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-sm 05:25pm urine color-yellow appear-hazy sp -1.010 05:25pm urine hours-random urea n-380 creat-63 sodium-25 11:35pm freeca-1.12 11:35pm glucose-117* k+-5.2 11:35pm type-art po2-83* pco2-76* ph-7.21* total co2-32* base xs-0 12:00am pt-21.5* ptt-31.5 inr(pt)-2.0* original cxr: ap single view of the chest has been obtained with patient in supine position. the patient is intubated, the ett is seen to terminate in the trachea some 3 cm above the level of the carina. heart size is difficult to determine because of obscuring pulmonary abnormalities. there exist extensive bilateral pulmonary parenchymal densities occupying practically all lung fields in this single view examination. there exist undoubtedly some coinciding perivascular haze with blurred-out vascular contours. the pleural spaces on the other hand are grossly free and in particular the lateral pleural sinuses are not blunted. there is no pneumothorax identified, nor is there any chest wall emphysema. impression: not having any clinical history available, conclusive diagnosis cannot be established. findings as presented here are compatible with acute left-sided heart failure and extensive pulmonary edema or ards. severe pulmonary edema related to left-sided heart failure is a likelihood. differential diagnosis must rely on clinical presentation. comparison with possibly available previous examinations is essential tte: the left atrium is elongated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the estimated cardiac index is normal (>=2.5l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). doppler parameters are most consistent with grade ii (moderate) left ventricular diastolic dysfunction. the right ventricular cavity is mildly dilated with normal free wall contractility. 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. there is mild functional mitral stenosis (mean gradient 3 mmhg) due to mitral annular calcification. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. impression: mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mild right ventricular dilation. diastolic dysfunction. moderate pulmonary hypertension. brief hospital course: ##. hypoxic respiratory failure: pt has had underlying hypoxia of unknown etiology over the past month with a requirement of 5l o2 particularly during activity. pt noted to be hypoxic at outside hospital eventually requiring intubation. etiology of hypoxic respiratory failure includes possible infection, cardiogenic pulmonary edema, copd, ipf exacerbation. tte was repeated and was significant for moderate diastolic dysfunction and pulmonary hypertension. bronchoscopy and bal was done, bacterial, viral, fungal and pcp were negative. revealed bloody sputum and friable airway. patient was initiated on empiric high dose steroids, broad spectrum antibiotics and nebulizers. vent settings were maintained for ards-like picture, given high plateua pressures suggesting very poor compliance. given and worsening electrolytes, patient was also started on cvvh and diuresed aggressively. patient continued to be acidotic and with no improvement in weaning off vent. he was made cmo on (see below). . ##. : on admission pt noted to have a creatinine of 1.8 which trended up to 3.0 in the setting of diuresis. etiology was likely contrast induced. cr continued to trend up, with worsening hyperkalemia, elevated calcium-phos product and evidence of volume overload. patient was started on cvvh for dialysis and fluid removal. . ##. femoral line: placed at osh prior to transfer. appears to be placed in artery as opposed to vein given blood gas draw from line and wave form when transduced. pt has elevated inr of 3.3. line was pulled after patient was given ffp. pt was checked for femoral bruit, hematoma, and distal pulses q6 hours after line pulled. . ##. a. flutter: pt recently underwent pvi for new onset a. flutter, currently in sinus rhythm. inr was noted to be supratherapeutic, coumadin was held and pt given ffp. continued on diltiazem. . ##. hl: continued on home regimen of simvastatin . : 16:00 pt??????s family verbalizing decision to make pt comfort care. crrt stopped and pt switched from fentanyl and versed drip to morphine drip. pt appearing very comfortable. pt??????s ett remained in placed and pt remaining on vent titrated down to rm air by resp therapist. morphine drip titrated to comfort. at 17:22 pt pulseless. cyanotic. dr. pronounced pt at 5:27pm. pt??????s wife requesting autopsy. emotional support provided to family. post mortem care provided. all lines left in for autopsy. medications on admission: medications on transfer: propofol gtt furosemide 60mg albuterol/ipratropium inh esomeprazole 40mg iv qday asa 81mg daily clonidine 0.1mg simvastatin 20mg qhs levothyroxine 37.5mcg daily methylprednisolone 80mg q8hrs flunisolide 1 puff diltiazem 180mg daily monteluekast 10mg daily colace vancomycin 1gm cefepime 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 Venous catheterization, not elsewhere classified Hemodialysis Venous catheterization for renal dialysis Closed [endoscopic] biopsy of bronchus Diagnoses: Acidosis Hyperpotassemia Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Atrial fibrillation Other chronic pulmonary heart diseases Atrial flutter Other B-complex deficiencies Acute respiratory failure Disorders of phosphorus metabolism Postinflammatory pulmonary fibrosis Long-term (current) use of anticoagulants Chronic obstructive asthma with (acute) exacerbation Diverticulosis of colon (without mention of hemorrhage) Chronic diastolic heart failure Other drugs and medicinal substances causing adverse effects in therapeutic use |
allergies: aspirin / ibuprofen attending: chief complaint: asa desensitization major surgical or invasive procedure: cardiac catheterization () intubation () history of present illness: the pt is a 73-yo man w/ severe copd and recently-diagnosed cardiomyopathy with ef 30% who presented to osh on with complaints of increasing sob, doe, orthopnea, pnd, chest tightness, and wheezing. he denied any chest pain, palpitations, lightheadedness, syncope, lower extremity edema, fevers, chills, cough, or sputum production. he was treated as an acute on chronic chf exacerbation with diuresis as well as a copd exacerbation with steroids and nebulizers. he was seen by cardiology and pulmonology consults, and repeat tte showed an lvef of 20-25% with global lv hypokinesis and chamber dilatation, and the possibility of an apical thrombus could not be ruled out. he was started on weight-based heparin gtt and transferred to the cardiac cath lab for catheterization. catheterization here showed diffuse 20-30% stenosis with mid-vessel 80% stenosis of the lad and mild luminal irregularities with mid-vessel 60% eccentric stenosis of the lcx. given his asa allergy, he is admitted to the ccu for asa desensitization and investigation of viability of the anteroapical wall in anticipation of probable pci of the lad lesion. . on arrival to the ccu: vs - temp 97.6f, bp 125/93, hr 94, r 22, sao2 97% 2l nc. he complains of mild left groin pain at the catheterization site. . ros: he acknowledges a prior history of tia but denies any history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. all of the other review of systems were negative. . past medical history: - severe copd / bronchial asthma - cardiomyopathy w/ ef 30-35%, cause unknown - suspected tia - h/o recent pneumonia - lbbb on ecg - nephrolithiasis - s/p cataract surgery - s/p hernia repair social history: lives with his wife, fairly independent until symptomatic w/ sob. -tobacco history: x15-20years, quit smoking: -etoh: quit in . -illicit drugs: none. family history: mother had a stroke, father had cad. no early cad. physical exam: vs: t = 97.6 f, bp = 125/93, hr = 94, rr = 22, o2 sat = 97% 2l nc general: wa middle-aged man in nad. oriented x3. mood, affect appropriate. heent: nc/at. sclera anicteric. perrl/eomi. conjunctiva pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 10cm. no lad or thyromegaly. cardiac: pmi located in 5th intercostal space, non-displaced. rrr w/ freq apcs and pvcs. normal s1, s2. + hsm at apex. no r/g, thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp mildly labored, tachypneic, no accessory muscle use. +bibasilar crackles and scattered wheezes, prolonged expiratory phase. abdomen: +bs, soft/nt/nd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: wwp, 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: 08:26pm blood wbc-8.2 rbc-4.02* hgb-11.8* hct-35.0* mcv-87 mch-29.4 mchc-33.8 rdw-15.0 plt ct-293 08:26pm blood neuts-84.6* lymphs-9.4* monos-5.9 eos-0.1 baso-0 08:26pm blood pt-12.7 ptt-25.9 inr(pt)-1.1 08:26pm blood glucose-106* urean-26* creat-0.9 na-141 k-4.7 cl-103 hco3-31 angap-12 05:31am blood ld(ldh)-333* 05:31am blood ctropnt-0.08* 08:26pm blood calcium-9.2 phos-4.5 mg-2.3 . . ecg (): sinus rhythm with atrial premature beats and possible first beat being a ventricular premature beat. left bundle-branch block. no previous tracing available for comparison. . cardiac cath (): 1. selective coronary angiography of this left dominant system revealed one vessel coronary artery disease. the lmca had no angiographically apparent disease. the lad had diffuse 20-30% lesions throughout with a mid vessel 80% stenosis. the lcx had mild luminal irregularities with a mid vessel 60% eccentric stenosis. the rca was small and nondominant without any angiographically apparent stenosis. 2. resting hemodynamics revealed elevated right sided filling pressures with an rvedp of 17 mmhg. there was moderate pulmonary hypertension with a pulmonary artery pressure of 47/21 mmhg. there were moderately elevated left sided filling pressures with a pcwp mean of 24 mmhg. there was normal central aortic pressures of 126/77 mmhg. the cardiac index was normal at 2.9 l/min/m2. 3. left vetriculography was deferred. final diagnosis: 1. one vessel coronary artery disease. 2. moderate pulmonary hypertension. 3. moderate diastolic dysfunction. 4. elevated rvedp . cxr (): 1. hazy opacity in the lingula and left lower lobe, concerning for early pneumonia versus asymmetric edema. 2. cardiomegaly. mild vascular congestion with interstitial edema. 3. right retrocardiac density, atelectasis versus pneumonia. pa and lateral views are recommended for better assessment of this area. . tte (): the left atrium is normal in size. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis (lvef = %). 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) are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: dilated left ventricular cavity with severe global hypokinesis. preserved right ventricular cavity size and systolic function. moderate mitral regurgitation. mild pulmonary hypertension. . ct abdomen/pelvis (): 1. there is no evidence of a retroperitoneal hematoma. 2. marked asymmetric enlargement of the proximal right thigh musculature, consistent with the patient's history of a known hematoma. 3. small left greater than right pleural effusions with associated compressive atelectasis of the posterior lung bases. 4. cholelithiasis. 5. extensive colonic diverticulosis without evidence of diverticulitis. . femoral vascular u/s (): findings: there is no evidence of pseudoaneurysm or a-v fistula, as questioned. there is a large right groin/thigh hematoma as seen on ct, measuring at least 13.0 cm in greatest dimension. impression: no evidence of pseudoaneurysm of avf. large right groin/thigh hematoma. . brief hospital course: the patient is a 73-year-old man with severe copd and recently-diagnosed cardiomyopathy with ef 30%, who presented to an osh on with symptoms of acute on chronic systolic heart failure, transferred to for cardiac catheterization to assess for ischemic cardiomyopathy, which showed lad disease. he was admitted to the ccu for aspirin desensitization with plan for repeat cardiac catheterization and pci. . #. aspirin desensitization - the patient was admitted to the ccu overnight for aspirin desensitization. he completed the protocol overnight, but approximately 1 hour after completion he suffered from acute-onset of severe respiratory distress with chest tightness and wheezing, consistent with anaphylaxis. he was treated with steroids, h1- and h2-blockers, as well as treatments directed at his copd, chf, and anxiety, with no improvement, so he was intubated for respiratory failure. he was extubated later that day with significant improvement. he was seen by the allergy consult service, who felt that this was consistent with anaphylaxis, and recommended repeat desensitization after a couple weeks if needed. he is stable for discharge. . #. acute on chronic systolic chf - the patient was recently diagnosed with a cardiomyopathy of unknown etiology, and was being treated for acute on chronic systolic heart failure prior to transfer. on transfer, he was still mildly fluid overloaded, so diuresis was continued with lasix and spironolactone. repeat tte here revealed ef 15% with global lv dysfunction and no wall-motion-abnormalities to suggest ischemic cardiomyopathy. he is being discharged on lasix and spironolactone, as well as a beta-blocker and an ace-inhibitor. . #. coronary artery disease - the patient underwent cardiac catheterization that showed a left-dominant system, an lad with diffuse 20-30% lesions throughout and mid-vessel 80% stenosis, and a lcx with mild luminal irregularities and mid-vessel eccentric 60% stenosis. he was admitted for the aspirin desensitization protocol as above, but given his anaphylaxis he is not being discharged on aspirin. it was also suggested that he would need a viability study to assess for antero-apical myocardial viability in preparation for a potential pci of his mid-lad lesion, but his tte showed no wall-motion-abnormalities to suggest ischemia as the reason for his cardiomyopathy, so there was felt to be no indication for viability study at this time. he is being discharged home on plavix, beta-blocker, and lisinopril. . # ? apical thrombus - the patient was transferred to for evaluation for apical thrombus as the tte done at osh was unable to properly assess the apex. he was transferred on an iv heparin gtt, but tte here showed no evidence of apical thrombus, so this was discontinued. he is being discharged off of anticoagulation. . # copd - the patient has a history of severe copd, with mild wheezes on exam on admission. this was significantly worsened after his intubation for anaphylaxis as above, so he was treated with iv solu-medrol and then quickly transitioned to prednisone for a rapid taper. he was otherwise continued on advair, spiriva, and nebulizers as needed, and showed significant improvement by discharge. medications on admission: home medications: - plavix 75mg po daily - nexium 40mg po daily - lisinopril 10mg po daily - toprol xl 37.5mg po daily - salmeterol 50mcg 1puff inh - spironolactone 25mg po daily - tiotropium 18mcg 1puff inh daily - docusate 100mg po daily . . transfer medications: - plavix 75mg po daily - lisinopril 10mg po daily - advair diskus 250/50 1puff inh - guaifenesin syrup 200mg qid prn - sl ntg prn - tylenol prn - nexium 40mg po daily - solu-medrol 60mg iv daily - tiotropium 18mcg 1puff inh daily - spironolactone 25mg po daily - toprol xl 37.5mg po daily - lasix 20mg iv bid - xopenex nebs prn discharge medications: 1. plavix 75 mg tablet sig: one (1) tablet po once a day. 2. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 3. lisinopril 10 mg tablet sig: one (1) tablet po once a day. 4. toprol xl 25 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po once a day. disp:*90 tablet sustained release 24 hr(s)* refills:*2* 5. advair diskus 250-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. disp:*1 diskus* refills:*2* 6. spironolactone 25 mg tablet sig: one (1) tablet po once a day. 7. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) puff inhalation once a day. 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 9. lasix 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 10. digoxin 125 mcg tablet sig: () one-half tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation every 4-6 hours. disp:*1 inhaler* refills:*2* discharge disposition: home discharge diagnosis: 1. aspirin allergy: anaphylaxis 2. non-ischemic cardiomyopathy (ef 15%) 3. coronary artery disease 4. severe copd 5. atrial fibrillation discharge condition: afebrile, vital signs stable. discharge instructions: you were admitted to for cardiac catheterization, and you were found to have a blockage in one of the arteries of your heart. since you are allergic to aspirin, you were admitted to the ccu for aspirin desensitization. at the end of the desensitization you had an anaphylactic reaction that required intubation. you were extubated quickly and have done well since. you do have an exacerbation of your copd (chronic lung disease) and are being treated for it with steroids. you will need to continue to take your medications as prescribed below. you also have atrial fibrillation but were not treated with blood thinners because you were not on this medication at home. you should discuss starting blood thinners (coumadin) with your cardiologist at home. you should follow-up with your primary care doctor and your cardiologist within 1 week. weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet you should call your doctor or return to the emergency room for any concerning symptoms, including: - chest pain, shortness of breath, wheezing, palpitations - allergic reaction - leg swelling, feeling faint - fevers or chills - any other concerning symptoms. followup instructions: you should follow-up with your cardiologist at home within 1 week. you should follow-up wiht your pcp (dr. within weeks. you should discuss blood thinners with your cardiologist for your atrial fibrillation. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of endotracheal tube Immunization for allergy Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Atrial fibrillation Chronic obstructive asthma with (acute) exacerbation Acute on chronic systolic heart failure Other drugs and medicinal substances causing adverse effects in therapeutic use Salicylates causing adverse effects in therapeutic use Other drug allergy |
allergies: aspirin / ibuprofen attending: chief complaint: chest pain major surgical or invasive procedure: - coronary artery bypass grafting x3 with left internal mammary artery grafted to the left anterior descending, reverse saphenous vein graft to the posterior descending artery and the marginal branch. history of present illness: 74 yo m with known 2vcad who presents to clinic for evaluation for possible surgical revascularization. pt was admitted to hospital on with increasing sob and chest pain. he was treated for chf as well as copd flare. he was then transferred to for asa desensitization and cardiac cath. pt developed anaphylactic reaction shortly after desensitization procedure complete and required short intubation for respiratory failure. cath during that admission showed small, nondominant right coronary artery with 80% lad lesion and 60% lesion in the circumflex. of note, his chest discomfort has improved dramatically with the initiation of imdur. past medical history: - severe copd / bronchial asthma - cardiomyopathy w/ ef 30-35%, cause unknown - suspected tia - h/o recent pneumonia - lbbb on ecg - nephrolithiasis - s/p cataract surgery - s/p hernia repair - chronic systolic heart failure social history: lives with his wife, fairly independent until symptomatic w/ sob. -tobacco history: x15-20years, quit smoking: -etoh: quit in . -illicit drugs: none. family history: mother had a stroke, father had cad. no early cad. physical exam: physical exam: vs: t 97 hr:100 resp:20 o2 sat:96% ra b/p right: 137/60 left: 134/56 ht 64" wt 59.6k general: elderly gentleman in no acute distress skin: dry intact - well healed abd incision, mesh palpable from prior hernia operation heent: perrla eomi anicteric, mmm, op benign neck: supple full rom no lymphadenopathy chest: diffuse inspiratory and exp wheezing heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema: none varicosities: none neuro: grossly intact, a&ox3, mae, follows commands pulses: femoral right: 2+ left: 2+ dp right: decreased left: decreased pt : decreased left: decreased radial right: 2+ left: 2+ carotid bruit right: none appreciated left: none appreciated ++ femoral bruits noted bilaterally pertinent results: echo pre-bypass: no mass/thrombus is seen in the left atrium or 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 is mildly dilated. overall left ventricular systolic function is severely depressed (lvef= 20 %). right ventricular chamber size is normal. with borderline normal free wall function. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. torn mitral chordae are present. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. post-bypass: the patient is av-paced and receiving 0.02 mcg/kg/min of epinephrine post-cpb. the lv - ef is approximately 30%. there is mild mitral regurgitation. all other findings are consistent with pre-bypass findings. the aorta is intact post-decannulation. all findings communicated to . 06:45am blood wbc-9.8 rbc-3.87* hgb-11.3* hct-35.0* mcv-90 mch-29.2 mchc-32.3 rdw-14.6 plt ct-294 06:45am blood pt-14.4* inr(pt)-1.2* 06:45am blood glucose-119* urean-19 creat-0.8 na-139 k-3.9 cl-99 hco3-28 angap-16 brief hospital course: mr. was admitted to the on for surgical management of his coronary artery disease. he was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. within the next 24 hours, he awoke neurologically intact and was extubated. hew as then transferred to the step down unit on postoperative day one. he was gently diuresed towards his preoperative weight. he was started on an ace-i due to a low ejection fraction. the physical therapy service was consulted for assistance with his postoperative strength and mobility. chest tubes and pacing wires were removed per cardiac surgery protocol. his narcotics were discontinued due to visual hallucinations and he was using ultram sparingly for pain control. his visual haalucinations abated. he benefited from vigorous pulmonary therapy. he has an allergy to asa and therefore was not started on it. he is being anticoagulated with plavix and coumadin for a history of dvt. first inr draw to be done mon with results to be called to dr. at or faxed to for further instructions for coumadin dosing. goal inr for history of dvt. he was deemed safe for discharge home with services on pod#5. medications on admission: plavix 75 mg daily spiriva 18 mcg daily lisinopril 10 mg daily advair 500/50 ipuff prn albuterol inh ii puffs daily prn xopenex neb 1.25mg spironolactone 25 mg daily lasix 40mg daily digoxin 0.125mcg tablet daily simvastatin 40mg daily warfarin daily metoprolol daily imdur 30 daily discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). disp:*30 cap(s)* refills:*2* 4. carvedilol 6.25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). disp:*60 disk with device(s)* refills:*2* 6. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 7. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. advair diskus 500-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. disp:*30 * refills:*2* 9. lasix 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 10. coumadin 5 mg tablet sig: one (1) tablet po once a day: dosing per the office of dr. . . disp:*30 tablet(s)* refills:*2* 11. outpatient lab work inr to be drawn on with results sent to the offie of dr. . fax number ( discharge disposition: home with service facility: vna discharge diagnosis: cad s/p cabgx3 aspirin allergy severe copd, lifelong asthma coronary artery disease, ischemic cardiomyopathy hypertension dyslipidemia history of tia - no residual deficit history of dvt/significant groin hematoma(post-cath) - right lower extremity, on coumadin left bundle branch block nephrolithiasis nasal polyposis recurrent sinusitis discharge condition: good discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. in the event that you have drainage from your sternal wound, please contact the at (. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. gently pat the wound dry. please shower daily. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5) no lifting greater then 10 pounds for 10 weeks from date of surgery. 6) no driving for 1 month or while taking narcotics for pain. 7) first inr/potassium blood draw with results to be faxed to or called to with instructions for coumadin dosing to be given-goal inr 7) call with any questions or concerns. followup instructions: please follow-up with dr. in 1 month. ( please follow-up with dr. in weeks ( please follow-up with dr. in 2 weeks. please call all providers for appointments. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Other and unspecified angina pectoris Other left bundle branch block Chronic systolic heart failure Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Chronic obstructive asthma, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: weakness major surgical or invasive procedure: cvl placement history of present illness: the patient is a 60 year old female with a history of ms who presents with complaints of weakness. patient has significant debilitation from her ms, with the use of a wheel chair at baseline. she is followed by dr. of neurology at , but hasn't been seen by her in over 3 years. 6 weeks prior, the patient developed shingles. since that time, she has felt continued malaise and fatigue. she denies any weight loss, weight gain, fevers, chills, cough, chest pain, or shortness of breath. in the few days prior to presentation, the patient felt a dramatic increase in her fatigue, such that she couldn't transfer from bed to chair. she also felt confused, not recognizing her own kitchen. she denies any headahes, blurred vision, or worsening motor/sensory deficit. she was told by her care taker that her urine may be smelly. she called dr. , who recommended evaluation in our ed. of note, she has not noted any blood in her stools, and last scope was 2 years prior. in the ed, initial vs were: t 97.9 p 76 bp 85/50 r 19 o2 sat 99% on 2l nc. the patieng triggered on arrival for hypotention, although all remainin bp in ed was > 100 systolic over a 4.5hr time perior, and sbp on time of transfer was 145/71. with complaints of generalized weakness and foul smelling urine, the patient was given vanc/ceftaz/levo with concern of urosepsis. she was given 3l of ns. the patient was then found to be grossly guaic positive w/ reports of dark stool. she had a negative ng lavage. a fast u/s was optained and was negative. she was given 40mg iv protonix, had a cvl placed for access, and was admitted to the micu for further manegment. past medical history: secondary progressive ms rectal discomfort hypothyroidism social history: patient is divorced and lives alone, with the assistance of a care taker. ex-husband active in routine. son would be hcp. does not smoke or drink family history: no family history of colon cancer or colonic polyps. physical exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs on admission: 07:50pm urine color-yellow appear-clear sp -1.017 07:50pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-lg urobilngn-neg ph-6.5 leuk-neg 05:33pm lactate-1.4 05:21pm glucose-122* urea n-45* creat-1.5* sodium-142 potassium-4.3 chloride-104 total co2-28 anion gap-14 05:21pm alt(sgpt)-21 ast(sgot)-26 ck(cpk)-135 alk phos-101 tot bili-0.3 05:21pm lipase-31 05:21pm ctropnt-0.03* 05:21pm ck-mb-6 05:21pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 05:21pm wbc-10.7 rbc-3.27* hgb-10.3* hct-30.5* mcv-93 mch-31.7 mchc-33.9 rdw-13.5 05:21pm neuts-83.5* lymphs-12.1* monos-3.6 eos-0.5 basos-0.2 05:21pm plt count-277 05:21pm pt-11.9 ptt-24.4 inr(pt)-1.0 labs during admission: 04:14am blood ck-mb-5 ctropnt-0.01 04:29pm blood ck-mb-4 ctropnt-<0.01 01:10am blood ck-mb-4 ctropnt-<0.01 05:21pm blood alt-21 ast-26 ck(cpk)-135 alkphos-101 totbili-0.3 04:14am blood ck(cpk)-204* 04:29pm blood ck(cpk)-140 01:10am blood ck(cpk)-123 05:21pm blood ctropnt-0.03* 02:39am blood freeca-1.20 02:13am blood free t4-1.2 04:20am blood tsh-0.18* 04:20am blood caltibc-280 ferritn-72 trf-215 10:00am blood hapto-173 7:50 pm urine site: catheter **final report ** enterococcus sp.. >100,000 organisms/ml.. viridans streptococci. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- =>16 r vancomycin------------ <=1 s labs on discharge: 06:10am blood wbc-7.4 rbc-3.36* hgb-10.6* hct-30.8* mcv-92 mch-31.6 mchc-34.4 rdw-14.5 plt ct-379 06:10am blood glucose-84 urean-8 creat-0.6 na-144 k-4.3 cl-111* hco3-24 angap-13 06:10am blood calcium-9.3 phos-3.6 mg-1.9 studies: ct abd : 1. inflammatory wall thickening in 12 cm loop of proximal transverse colon. differential diagnosis includes inflammatory, infectious, or ischemic. no focal abscess or fluid collection. although there are scattered colonic diverticula this does not appear to be the source of this problem. 2. multiple liver cysts. . cxr : overall findings are suggestive of mild/early chf. prominence of the left paratracheal stripe in the configuration of aortic arch suggests unfolding. if a dissection is suspected clinically, ct of the chest is warranted. . cxr : since , right internal jugular catheter was removed. lungs are clear. the cardiomediastinal silhouette and hilar contours are normal. there is no pleural effusion. brief hospital course: # : her was likely due to a combination of urosepsis and tizanidine induced . there was initial concern for gi bleed given strongly guaiac positive bm in ed. however, pt with no further evidence of gi bleed and her lactate was normal. she was treated broadly for infection with vanc/zosyn given in setting of t>98 (considered fever in ms patients) and leukocytosis. urine cultures grew out >100,000 pan-sensitive enterococcus; also with 10,000-100,000 strep viridans, and her antibiotics were narrowed to ampicillin. she was also started on on midodrine due to concern for autonomic dysfunction with ms. and midodrine was discontinued. her blood cx and c diff were all negative. she was transferred to the medical floor and had episodes of to the high 70s and low 80s which were responsive to fluid. it was discovered to be tizanidine (in combination with baclofen) induced and her tizanidine was decreased in dose from 8mg and tapered down to 2mg. she was told not to take tizanidine within 2 hours of your baclofen or within one hour of lisinopril. outpatient antihypertensives were held and then lisinopril was later restarted at a decreased dose of 5mg daily. her hctz was not restarted prior to discharge. her amitriptyline dose was decreased as well to prevent . # gi bleed: per report, the patient had a bm in ed that was dark and strongly guaiac positive. that with the combination of was concerning for significant bleed. hct on presentation was 30. she reported a prior cscope 2 years prior w/o abnormalities. she had a negative ng lavage. in the icu her sbp dropped to the 80s and she was transfused 1 unit. hemolysis labs were negative. she was started on levophed. an a-line was placed. she was continued on iv ppi . gi was consulted and felt there was no need for emergent scope. her hct remained stable for the rest of the admission with no further bloody stools. she did have a with proximal transverse colon thickening that was thought to more consistent with ischemic rather than infectious or inflammatory processs. initial hematochezia may have been secondary to mild bowel ischemia from in a pt with low reserve. she should have an outpatient colonoscopy. . # weakness/confusion: given her complicated neurologic history, her complaints of muscle weakness and confusion were likely due to both her ms, uti, and transient . her tsh was low but her t4 was normall. provigil was held and her outpatient neurologist was contact and agreed. she should follow up with neurology as an outpatient. # ms: patient was continued on baclofen, amitriptilene, copaxone, keppra, and tizanidine (at a decreased dose as detailed above). she was transiently on midodrine as detailed above. # renal failure: she initially presented with arf which was likely hypovolemic in the setting of , uti, and ?gi. her creatinine with transfusion and fluids. # anion gap acidosis: she had a normal lactate with no evidence of uremia. her anion gap acidosis was likely secondary to ketosis in setting of npo status. this improved with iv fluids and diet restarted. # hypothyroidism: tsh was low but t4 was normal. she was continued on synthroid. # hyperlipidemia: continued zocor. # prophylaxis: continued on home famotidine and heparin sc. # code: full code medications on admission: baclofen 20mg qid simvastatin 20mg daily hctz 50mg daily famotidine 20mg levothyroxine 25 mcg daily lisinopril 10mg daily provigil 100mg tizanidine 8mg tid colace 100mg id amitriptyline 10mg qhs arginine 500mg daily mvi daily asa 81mg daily copaxone 20mg daily keppra 500mg discharge medications: 1. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 2. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 6. glatiramer 20 mg kit sig: twenty (20) mg injection kit subcutaneous daily (). 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 8. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 9. amitriptyline 10 mg tablet sig: 0.5 tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 10. baclofen 10 mg tablet sig: two (2) tablet po qid (4 times a day). 11. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for skin rash/fungal infection. disp:*1 bottle* refills:*0* 12. tizanidine 2 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 13. lisinopril 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 14. provigil 100 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home with service facility: vna discharge diagnosis: primary diagnosis: urinary tract infection with question of resulting likely secondary to drug effect of combination of tizanidine and baclofen . secondary diagnosis: secondary progressive ms rectal discomfort hypothyroidism discharge condition: stable. normotensive. discharge instructions: you were admitted with a urinary tract infection and decreased blood pressure. in the intensive care unit you required pressors to maintain your blood pressure. on the normal medical floor your blood pressure dropped several times and it responded to iv fluids. we think your blood pressure dropped due to a combination of tizanidine and baclofen. we spaced out these medications and we decreased your dose of tizanidine. you should not take tizanidine within 2 hours of your baclofen. please do not take your lisinopril within 1 hour of your tizanidine. you were treated for a urinary track infection and you have completed your course of treatment. you also had a decreased hematocrit and we do not know whether you had a bleed in your gi tract but we do know that your hematocrit is stable now. you should have a colonoscopy as an outpatient. please talk to your primary care doctor about arranging this. . the following medications were started: -miconazole powder for your rash . the following medications were stopped: -hydrochlorothiazide is being temporarily stopped to ensure you do not become hypotensive. please discuss with your primary care doctor when to restart this. . the following medications were changed in dose: -lisinopril was decreased to 5mg po daily to ensure you do not become hypotensive. please discuss with your primary care doctor when to restart this. -amirtiptyline was decreased to 5mg po daily to ensure you do not become hypotensive. -tizanidine was decreased to 2mg po tid -aspirin was decreased to 81mg po daily . please return to the hospital if you develop fatigue, dizziness, lighteheadedness, pain with urination, blood in your urine, diarrhea, blood in your stool, chest pain, shortness of breath, or any new concerning symptom. followup instructions: appointment #1 md: dr specialty: primary care date and time: at 12pm location: , phone number: . appointment #2 md: dr specialty: neurology location: clinical center phone number: scheduler will call you with appointment. please call the above number if you do not hear by next tuesday. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Acidosis Other iatrogenic hypotension Urinary tract infection, site not specified Acute kidney failure, unspecified Unspecified acquired hypothyroidism Other and unspecified hyperlipidemia Other constipation Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Hemorrhage of gastrointestinal tract, unspecified Multiple sclerosis Other accident caused by striking against or being struck accidentally by objects or persons Contusion of lower leg Skeletal muscle relaxants causing adverse effects in therapeutic use |
allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p cardiac arrest major surgical or invasive procedure: central venous catheter placement cardiopulmonary resuscitation endotracheal intubation history of present illness: 86 yo m with history of metastatic prostate cancer with bilateral nephrostomy tube and recent diagnosis of malignancy in chest, initially presenting with altered mentatl status, who had an asystolic cardiac arrest in the ed, and is now transferred to micu post-arrest. . the patient was diagnosed with a uti 2 days ago, and was started on antibiotics (unclear what antibiotic). he took 2 doses of the antibiotic and presented this a.m. with confusion. he was following commands, but more confused that his baseline, which is a+ox3. , in the ed, the patient was taken for ct head and cxr, and was noted to be non-responsive after the imaging studies. he was found to be in asystole, and received 2 minutes of cpr. during the resuscitation, he was given atropine 1 mg, epinephrine 1 mg, and amiodarone 300 mg. he was subsequently intubated, receiving etomidate and succinylcholine peri-intubation. he was started on peripheral dopamine, switched to levophed. a central line was placed ed prior to transfer to the micu. the cxr that was done pre-arrest showed bilateral plerual effusions and interstitial edema. a bedside echo showed no rv strain. fast scan negative. only exam finding before code was mild abdominal pain. vital signs on transfer pulse 59 bp 137/51 rr 18 100%/ra. . in micu, the patient was initially non-responsive, with only corneal reflexes present. subsequently, he withdrew to pain in all extremities. past medical history: - metastatic prostate adenocarcinoma to bone with local extension to bladder and rectum also complicated by bilateral hydronephrosis s/p nephrostomy tubes. he has been treated with casodex, lupron, and most recently, ketoconazole. he has declined chemotherapy. - recently diagnosed extensive intrathoracic malignancy - coronary artery disease - atrial fibrillation (previously on coumadin) - hyperlipidemia - hypertension - type 2 diabetes - pleural effusion s/p right thoracenteses x 2 in the past month social history: mr. has 8 children who live nearby and are involved in his care. previously worked at as a transporter. reports no smoking, etoh, or illicits. he is a jehovah's witness and notes that his faith plays a central role in his life. family history: his mother 'may' have had diabetes. physical exam: vitals: t 98.2: bp 164/57: p 79: r 11: sat: 100% o2: general: intubated, not on sedation. non-responsive. heent: sclera anicteric, mmm neck: supple, jvp not elevated lungs: clear ventillated breath sounds bilaterally. cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: bilateral nephrostomy tubes in place ext: warm, well perfused, 1+ bilateral le edema neuro: non-responsive to sternal rub or painful stimuli. pupils 3 mm and non-reactive. corneal reflex present bilaterally. does not move any extremity initially. subsequently withdrew to pain. pertinent results: admission labs: 01:30pm blood wbc-11.4* rbc-2.84* hgb-6.6* hct-20.3* mcv-72* mch-23.3* mchc-32.6 rdw-17.8* plt ct-232 01:30pm blood neuts-83* bands-0 lymphs-8* monos-6 eos-0 baso-0 atyps-0 metas-3* myelos-0 01:30pm blood pt-13.7* ptt-30.7 inr(pt)-1.2* 01:30pm blood glucose-163* urean-42* creat-1.7* na-125* k-5.7* cl-88* hco3-25 angap-18 01:30pm blood alt-12 ast-28 alkphos-214* totbili-0.3 01:30pm blood lipase-27 11:44pm blood ck-mb-5 ctropnt-0.11* 01:30pm blood albumin-2.9* calcium-9.0 phos-4.1 mg-2.2 . ct head w/o contrast : 1. no acute intracranial process. 2. opacification of the left mastoid air cells . clinical correlation is recommended to assess for mastoiditis. . cxr (portable ap) : 1. worsening bilateral pleural effusions. increased opacity at the lung bases bilaterally may be a combination of pleural effusions and atelectasis. however, underlying pneumonia cannot be excluded. 2. bilateral hilar lymphadenopathy. stable right paratracheal mass. 3. mild pulmonary edema. brief hospital course: 86 yo m with metastatic prostate cancer and recent diagnosis of extensive intrathoracic malignancy, initially presenting with altered mental status, who had asystolic cardiac arrest in the emergency department. the pt arrived to the micu intubated and on blood pressure support. however given his extensive comorbidity combined with grave prognosis and failure to respond to supportive measures, it was ultimately decided by the family to focus on comfort measures and the patient was terminally extubated and died on . please see below for further details by problem. # goals of care: per recent omr notes, the patient elected a hospice approach and was dnr/dni. however, per family request, this was reversed in the ed and the patient was resuscitated and intubated. after discuss with family, patient was made full code but cpr not indicated. family meeting on demonstrated that they were not ready to withdraw life support and were hoping for a miracle. on , the family expressed some desires to not escalate care. on family meeting, it was decided to withdraw care and focus on comfort. # s/p asystolic cardiac arrest: his initial rhythm was asystole in the er with underlying etiology unclear. patient's fast exam was negative in the er and blood cultures on admission were positive which suggests septic shock as possible cause of asystole. he was not cooled, and mri the following day did not show any signs of anoxic brain injury. however, the eeg showed epileptiform activity and keppra was started. he had another episode on when on pressure support on the vent and turning where is hr decreased, he desatted and his bps dropped. he responded to atropine, and levophed was restarted. family meeting established the cpr was not indicated. neurology used eeg, clinical exam, and somatosensory evoked potentials to monitor the patient's neurologic status. the ssep were present which did not change the overall poor neurologic status as he was not improving. . # hypotension: vital signs were normal on initial presentation but he became hypotensive requiring levophed for blood pressure support s/p arrest. his hypotension could be related to cardiac stunning in setting of recent arrest but was more likely related to underlying sepsis. echo was orderd in the icu which showed focal regional left ventricular systolic dysfunction c/w cad. aneurysmal interatrial septum. moderate pulmonary hypertension with at least moderate tricuspid regurgitation and mildly dilated right ventricle. very small pericardial effusion. the patient continued to require norepinephrine for blood pressure support. with acute renal failure and poor urine output, and hypervolemia on exam, the patient was transitioned to low dose dopamine gtt with lasix boluses on , which improved his blood pressures and his creatinine 1.8 --> 1.7 with good urine output (100cc/hr x2-3 hours with each bolus). lasix gtt was started however his cr rose and this was discontinued. # respiratory failure: he was intubated in the er and has been ventilating well on the ventilator. he did have a near arrest on cpap and required reinitiation of full vent support. the patient was gradually transitioned back from assist control to psv with thoughts that intermittent tachypnea due to central process and some discomfort that responded to fentanyl 25mcg boluses. he was unable to be weaned from the vent and ultimately terminally extubated. # altered mental status: initially likely toxic-metabolic process in setting of medical illness/uti. ct head was non-focal, and mri after arrest without signs of hypoxic brain injury. his underlying toxic-metabolic encephalopathy is likely contributing as well. neurology followed and recommended continuing eeg with somatosensory potential evaluation from and respectively. . # urinary tract infection: u/a consistent with infection. he was broadly covered with vanc/zosyn, and urine culture was sent. urostomy tubes bilaterally continued to put out purulent fluid although right urostomy tube output was persistently ~half that of left urostomy tube. both tubes gradually had decreased output . # bacteremia: grew strep viridans from bcx. the patient was also cdiff negative. . # extensive intrathoracic malignancy: invades mediastinum and encases svc, brachiocephalic, jugular, esophagus, and all major airways. mechanical complications of this malignancy could underlie arrest, although echo in ed does not support this, and hypoxemia seems more likely given rapid return of spontaneous circulation. if patient improved, would have considered ct chest. . # metastatic prostate cancer: currently not on any treatment. . medications on admission: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation: hold for loose stools. disp:*60 tablet(s)* refills:*0* 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. disp:*30 suppository(s)* refills:*0* 6. oxycodone 5 mg tablet sig: 0.5-1 tablet po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 7. ferrous gluconate 325 mg (37.5 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. folic acid 1 mg tablet sig: five (5) tablet po daily (daily). disp:*200 tablet(s)* refills:*2* 9. cyanocobalamin (vitamin b-12) 100 mcg tablet sig: 0.5 tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 10. home oxygen home oxygen 2-3l nasal cannula continuous discharge medications: n/a discharge disposition: expired discharge diagnosis: n/a discharge condition: deceased discharge instructions: n/a followup instructions: n/a md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Urinary tract infection, site not specified Toxic encephalopathy Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Acute respiratory failure Cardiac arrest Cachexia Malignant neoplasm of prostate Long-term (current) use of anticoagulants Pressure ulcer, lower back Malignant neoplasm of other parts of bronchus or lung Altered mental status Encounter for palliative care Do not resuscitate status Pulmonary congestion and hypostasis Hydronephrosis Secondary malignant neoplasm of bone and bone marrow Anemia in neoplastic disease Pressure ulcer, stage II Other artificial opening of urinary tract status |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: weakness major surgical or invasive procedure: picc line placement dc cardioversion history of present illness: mr. is a 68 yo gentleman with hx cabg, mi x2, of stage iv heart failure, multiple admissions for chf exacerbation who was transferred for further management of his heart failure. pt states that most recently he has been in rehab and has been doing well with increased exercise tolerance, until approximately a week ago when he felt weak all over and slowly fell to the ground, no loc. since that time, pt states that he has been feeling progressively weak. while he denies worsening sob, nursing noted labored breathing and low bps to the 80s systolic for the last two days. pt also denies cp, palpitations or worsening le edema. he requested transfer to for further management of his heart failure. his most recent hospitalization was in for sob. at that time, pressures were in the 80s/90s and pt was satting 89-95% on ra. he was treated with diuresis and ciprofloxacin for a uti. at that time, pt was offered hospice but refused. he was transferred to rehab facility on discharge on review of systems, s/he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. s/he denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, recent syncope or presyncope. pt does state that he had one episode of syncope over , but none since. also states that he has trouble lying flat but cannot articulate why. past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, -hypertension 2. cardiac history: 1. ischemic cmp, with an ef of 25%. s/p mi at age 37 and 52. s/p cabg in with lima to lad, svg to d1, svg to om, and svg to pda. s/p stent placement to the rca graft in 08/00. 2. s/p biv. icd implant in for primary prevention of scd, in the setting of cad, low ef, and inducible vt on eps. also had prolonged hv and bifascicular block (rbbb/lahb). 3. paroxysmal atrial fibrillation, s/p av node ablation , now pacemaker dependent. at this time, he was taken off of quinidine, started on dofetilide which was subsequently dc'd as the pt reverted into a-fib, and the pt was dc'd on an increased dose of coreg. . 3. other past medical history: - diabetes mellitus type 2, on insulin - osteoarthritis - pulmonary fibrosis? - asthma - seasonal allergies - stage ii ckd - htn - dyslipidemia - hx of multiple mis, most recent episode , anginal equivalent is back pain . pshx: cholecystectomy (), turp, "benign tumor excision" social history: he is married, and lives with his wife but has been in rehab for the past month. he is retired, former businessman. he is a former smoker and quit in . he denies alcohol or illicit drug use. family history: father with mi at 51, mother with mi age 84, sister with mi age 76, brother with mi age 79. physical exam: vs: t=96.0 bp=90/66 hr=79 rr=24 o2 sat=100% 3l general: chronically ill appear 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 jvd to the earlobe 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. crackles bilaterally in bases approx 1/3 up the lung fields. abdomen: soft, ntnd, +bs. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: 1+ le edema to the knees. cool ues. 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: on admission: 06:49pm blood wbc-7.2 rbc-3.97* hgb-9.2*# hct-31.9*# mcv-80* mch-23.3* mchc-29.0* rdw-18.8* plt ct-145* 06:49pm blood pt-29.9* ptt-50.4* inr(pt)-3.0* 06:49pm blood glucose-155* urean-54* creat-1.7* na-131* k-4.0 cl-86* hco3-39* angap-10 06:49pm blood calcium-9.1 phos-3.8 mg-2.3 iron-19* . on discharge: 05:34am blood wbc-11.7* rbc-4.44* hgb-10.8* hct-34.3* mcv-77* mch-24.3* mchc-31.4 rdw-19.9* plt ct-168 05:34am blood wbc-11.7* rbc-4.44* hgb-10.8* hct-34.3* mcv-77* mch-24.3* mchc-31.4 rdw-19.9* plt ct-168 05:34am blood pt-31.6* ptt-45.2* inr(pt)-3.2* 08:30pm blood neuts-81.6* lymphs-10.8* monos-6.0 eos-1.0 baso-0.7 08:30pm blood hypochr-2+ anisocy-2+ poiklo-2+ macrocy-normal microcy-3+ polychr-occasional spheroc-occasional ovalocy-1+ pencil-occasional tear dr 05:34am blood glucose-151* urean-45* creat-1.8* na-129* k-3.5 cl-85* hco3-32 angap-16 05:34am blood calcium-9.0 phos-3.9 mg-2.5 . while inpatient: + wbcs and blood in urine, urine cx with ampicillin sensitive enterococci tsh 13 t4 5.3 tibc 441 ferritin 54 trf 339 . ekg: ventricular paced rhythm with ventricular couplets. atrial mechanism is uncertain. since the previous tracing of atrial activity/question pacing is more difficult to assess. . cxr: mild cardiomegaly is stable. left transvenous pacemaker leads terminating in standard position in the right atrium, right ventricle and through the coronary sinus. there is haziness of the perihilar regions minimally increased from prior study consistent with chronic chf. there is no strong evidence of pneumonia. there is no pneumothorax. there is no large pleural effusion. sternal wires are aligned. . tte: the left atrium is markedly dilated. the right atrium is moderately dilated. there is mild (non-obstructive) focal hypertrophy of the basal septum. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis (lvef = 15-20%). the estimated cardiac index is depressed (<2.0l/min/m2). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the right ventricular cavity is markedly dilated with severe global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. 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. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. . impression: severely dilated and hypokinetic right and left ventricles with moderate to severe mitral and tricupsid regurgitation and mild pulmonary artery systolic hypertension. the inferior and inferior septum are severely hypokinetic akinetic with the other segments being moderately hypokinetic. . compared with the prior study (images reviewed) of , the function of the lateral wall is probably worse on the current study. the degrees of mitral and tricuspid regurgitation have increased. the estimated pulmonary artery systolic pressures are slightly lower but are probably underestimated given the severity of tricuspid regurgitation. . cxr chronic chf. the patient with biventricular pacing, but no significant interval change since next preceding portable chest examination of . . cxr the pacemaker leads terminate in right atrium and right ventricle, unchanged in appearance. cardiomediastinal silhouette is unchanged including severe cardiomegaly involving mostly the left ventricle. the left ventricular pacer is unchanged as well. the patient is in mild vascular engorgement as well as there is no change in bibasal interstitial abnormalities. note is made that the lung apices were not included in the field of view. the broken third sternal wire is unchanged as well. repeated radiograph is highly recommended including the lung apices for precise evaluation of the abnormalities. brief hospital course: mr. is a 68 yo gentleman with hx cabg, mi x2, of stage iv heart failure, multiple admissions for chf exacerbation (ef 20%) who was transferred for further management of his heart failure. resp status initally improved since admission with diuresis, however required icu transfer for hypotension and respiratory distress concerning for pulmonary edema. he was made dnr/dni while in the icu, transferred back to the floor in stable condition with request for no further escalation of care, medical management only. . # pump: most recent echo showed lvef of 15-20%. mr was treated with aggressive diuresis with a lasix gtt and metolazone while on the floor. also received acetazolamide for treatment of elevated bicarb in the setting of aggressive diuresis. on transfer to the icu, mr was below dry wt of 204 lbs however continued to have evidence of volume overload on exam with elevated jvp, crackles, le edema. pt required transfer to the icu as he was unable to maintain pressures while on aggressive diuresis. he was treated with milrinone and lasix gtt while in the ccu with phenylephrine for pressure support. he was diuresed several liters of fluid and approached euvolemia. phenylephrine and milrinone were weaned off, and the pt was switched to po diuretic regimen of torsemide 40mg po daily and aldactone 25mg po daily. pt should have daily lytes checked and adequate repletion with potassium. bb and acei were held in the setting of hypotension and end of life care. . # coronaries: known 3 v disease based on cardiac cath, however patent lima and smg grafts, low concern for acs at this time. the patient is on asa and plavix. bb, acei and statin held for hypotension and end of life care. if patient's pressures increase and his blood pressure tolerates, a low dose bb and/or acei would be indicated. . # rhythm: hx afib, previously on 2.5 mg/day of warfarin. pt was cardioverted on previous admission in and started on warfarin at that time. on arrival, afib was not clearly identified on ecg, but evident on echo. he was loaded on amiodarone and cardioverted in attempt to restore atrial kick and improve forward flow. digoxin was held to high levels, and metoprolol was held to hypotension. the patient was rate controlled on amiodarone - he will be discharged on a taper: 200mg po bid x2 weeks (through ), 200mg po daily thereafter. inr was supratherapeutic, up to 4.6. warfarin has been discontinued as the patient had supratherapeutic inr on low dose of warfarin, and the risks outweigh the benefits, as the patient is in the end stage of his heart disease. . # hypotension: pt runs in the 80s-90s systolic at baseline, likely due to poor systolic function. while in the hospital he was asymptomatic until day 6 of his admission when pressures dropped to <80. at this time he had increasing difficulty with attention, some sob, no cp, was transferred to the icu given need for aggressive diuresis given his worsening respiratory status and volume overload. he was started on phenylephrine for pressure support and weaned off. he maintained sbp >100 after diuresis. . # hypoxia: improved with diuresis, but new cough developed on the day of transfer to the icu possibly due to aspiration event. pt also with ? underlying lung disease (copd, pulm fibrosis) which may be contributing. the patient was not febrile in the ccu and maintained sats in mid-90s on 2lnc. . # ckd: pt with history of stage ii ckd, creatinine trended up to 2.1 with lasix, but improved to 1.9 prior to discharge. . # anemia: no evidence of active bleed, however significantly decreased from baseline. iron studies suggest iron deficiency anemia, pt started on iron supplementation. haptoglobin wnl, guaiac negative. crit stable for several days now. . # leukocytosis: concerning for infection in the setting of amp sensitive enterococci in urine and worsening pulmononary exam. pt was treated with ampicillin for uti. blood cxs were drawn and are ntd. leukocytosis improved, pt remained afebrile. . # metabolic alkaloisis: appears to be chronic, most likely due to contraction alkalosis in the setting of aggressive diuresis. also likely a component of respiratory acidosis from co2 retention in the setting of ?copd/pulmonary fibrosis. . # hypothyroidism: tsh elevated but levothyroxine recently increased as an outpatient. pt was continued on levothyroxine, will hold on dose adjustment for now given recent increase. thyroid function tests should be repeated as an outpatient. . # gerd: continue on ranitidine . # diabetes: stable on levemir as an outpatient. sugars stable on glargine and iss. . # depressed mood: pt was seen by sw and palliative care. pt is aware that this is end-stage of his disease. . # seasonal allergies: continued on fexofenadine, montelukast . # constipation: bm uptitrated while on the floor. regimen decreased in ccu as the patient had 2 episodes of bowel incontinence. rectal tone was intact and there were no other neurologic deficits. . # goals of care: the patient was seen by social work and palliative care during this hospitalization. it was decided that he would be maintained on the current medical therapy with minor changes if they would be helpful in the short-term. he understands that this is the end-stage of his heart disease. there is to be no escalation of care beyond the medications/treatments outlined in this discharge summary aside from minor changes if they would be helpful in the short-term. while in the icu, decision was made not to re-hospitalize. the patient is dnr/dni. if he decompensates on these medications, he should be transferred to hospice for end of life care. medications on admission: -albuterol 0.083% neb soln -ipratropium bromide neb -artificial tears -levothyroxine sodium 75 mcg po/ng daily -aspirin 325 mg po/ng daily -metoprolol xl 25 mg q day -atorvastatin 40 mg po/ng daily -montelukast sodium 10 mg po daily -clopidogrel 75 mg po/ng daily -mupirocin cream 2% 1 appl tp -nitroglycerin sl 0.4 mg sl prn cp -digoxin 0.125 mg po/ng daily -potassium chloride 20 meq po tid -docusate sodium 200 mg po hs -ranitidine 150 mg po/ng daily -fexofenadine 60 mg po bid -senna 2 tab po/ng hs -furosemide 160 mg po/ng daily -gabapentin 100 mg po/ng tid -sodium chloride nasal -tamsulosin 0.4 mg po hs -tramadol (ultram) 50 mg po -levemir 26 units at dinnertime discharge medications: 1. torsemide 20 mg tablet sig: two (2) tablet po once a day. 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. amiodarone 200 mg tablet sig: one (1) tablet po twice a day: please take 200 mg twice a day through , then take one tab once a day. disp:*30 tablet(s)* refills:*0* 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob, wheezing. 6. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob, wheezing. 7. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). 8. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 10. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 11. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). 12. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 13. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 14. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed) as needed for dryness. 15. sodium chloride 0.65 % aerosol, spray sig: sprays nasal (2 times a day) as needed for dry mucosa. 16. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 17. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day). 18. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 19. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 20. outpatient lab work please check daily lytes and replete until a stable repletion regimen is determined. 21. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 22. levemir 100 unit/ml solution sig: twenty six (26) units subcutaneous at dinnertime. 23. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 24. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily). 25. morphine concentrate 20 mg/ml solution sig: five (5) mg po q4 hrs as needed for sob/cp: hold for oversedation, rr<12; 5mg should equal 0.25 ml. 26. ampicillin 500 mg capsule sig: one (1) capsule po every eight (8) hours for 7 days. discharge disposition: extended care facility: life care of discharge diagnosis: primary: acute on chronic decompensated congestive heart failure atrial fibrillation microcytic anemia secondary: coronary artery disease chronic kidney disease discharge condition: activity status:out of bed with assistance to chair or wheelchair mental status:confused - sometimes level of consciousness:alert and interactive discharge instructions: you were admitted to the hospital with fluid overload from worsening of your heart failure. several liters of fluid were removed with intravenous lasix. . you also had an abnormal heart rhythm called atrial fibrillation. your heart was converted back into a normal rhythm. you are on medications to help control your heart rate and prevent it from going back into the abnormal rhythm. . we made several changes to your medication regimen. we changed the doses of your diuretic medications and stopped some of your nonessential medications including your metoprolol, warfarin, atorvostatin and digoxin. followup instructions: please follow-up with your primary care physician after discharge from rehab. Procedure: Venous catheterization, not elsewhere classified Atrial cardioversion Diagnoses: Other iatrogenic hypotension Esophageal reflux Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Aortocoronary bypass status Depressive disorder, not elsewhere classified Other specified forms of chronic ischemic heart disease Constipation, unspecified Other and unspecified hyperlipidemia Long-term (current) use of insulin Old myocardial infarction Postinflammatory pulmonary fibrosis Iron deficiency anemia, unspecified Hypoxemia Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Acute on chronic systolic heart failure Mixed acid-base balance disorder Chronic kidney disease, Stage II (mild) Pain in limb Other specified cardiac device in situ |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: spinal avm major surgical or invasive procedure: :angiogram, partial embolization of spinal avm history of present illness: 50m with elective admission for embolization of spinal avm past medical history: htn / non-compliant with outpt regime, le weakness social history: resides at home with wife +tobacco use family history: non-contributory physical exam: on discharge: aox3, strength full except le's with exception of df left 3-/5, right df 4-/5. rectal tone sl. diminished pertinent results: labs on admission: 08:00am blood wbc-5.1 rbc-5.36 hgb-14.9 hct-41.8 mcv-78* mch-27.8 mchc-35.7* rdw-13.3 plt ct-216 08:00am blood pt-13.0 inr(pt)-1.1 05:30pm blood glucose-105 urean-10 creat-0.7 na-143 k-3.1* cl-111* hco3-25 angap-10 05:30pm blood ck(cpk)-72 05:30pm blood albumin-3.5 calcium-8.7 phos-3.3 mg-1.9 uricacd-5.6 , m 50 radiology report cardiac perfusion persantine study date of cardiac perfusion persantine clip # reason: 50yr old needs cardiac clearance for or. final report radiopharmaceutical data: 3.1 mci tl-201 thallous chloride (); 19.7 mci tc-m tetrofosmin stress (); history: 50 year-old male with history of niddm and htn with abnormal ecg prior to surgery. summary from the exercise lab: dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min. imaging method: resting perfusion images were obtained with thallium. tracer was injected approximately 30 minutes prior to obtaining the resting images. following resting images and two minutes following intravenous dipyridamole, approximately three times the resting dose of tc-m tetrofosmin was administered intravenously. stress images were obtained approximately 30 minutes following tracer injection. imaging protocol: gated spect. this study was interpreted using the 17-segment myocardial perfusion model. interpretation: left ventricular cavity size is normal. rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. gated images reveal normal wall motion. the calculated left ventricular ejection fraction (lvef) is 51%. there is no prior for comparison. impression: normal myocardial perfusion study. lvef is 51%. , m.d. , m.d. approved: mon 5:17 pm , m 50 cardiology report stress study date of exercise results resting data ekg: sinus, lae, lvh with st-t abnls, prwp heart rate: 71 blood pressure: 146/108 protocol / stage time speed elevation heart blood rpp (min) (mph) (%) rate pressure 1 0.142mg/ kg/min 80 122/86 9760 total exercise time: 4 % max hrt rate achieved: 47 symptoms: atypical st depression: none interpretation: this 50 yo niddm man with a h/o hypertension was referred to the lab for the evaluation of an abnormal ekg prior to surgery. the patient was infused with 0.142 mg/kg/min of iv dipyridamole over 4 minutes. early post-infusion, the patient reported a nonprogressive central "chest heaviness" which resolved quickly with administration of 125 mg iv aminophylline. no significant st segment changes were noted during the infusion or in recovery. the rhythm was sinus with no ectopy. systolic and diastolic hypertension noted at rest (146/108mmhg) with an appropriate hemodynamic response to the infusion. impression: questionable persantine-induced symptoms with no significant st segment changes. atypical symptoms. nuclear report sent separately. signed: , , echocardiography report , tte (complete) done at 9:53:13 am final referring physician information , j. - division of neurosurger , status: inpatient dob: age (years): 50 m hgt (in): 68 bp (mm hg): 130/90 wgt (lb): 200 hr (bpm): 70 bsa (m2): 2.05 m2 indication: abnormal ecg. hypertension. preoperative assessment. left ventricular function. icd-9 codes: 402.90, 427.89 test information date/time: at 09:53 interpret md: , md test type: tte (complete) son: doppler: full doppler and color doppler test location: west echo lab contrast: none tech quality: adequate tape #: 2008w058-0:20 machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: 3.2 cm <= 4.0 cm left atrium - four chamber length: 4.2 cm <= 5.2 cm left atrium - peak pulm vein s: 0.8 m/s left atrium - peak pulm vein d: 0.4 m/s left atrium - peak pulm vein a: 0.2 m/s < 0.4 m/s right atrium - four chamber length: 4.3 cm <= 5.0 cm left ventricle - septal wall thickness: *1.5 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.3 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 3.7 cm <= 5.6 cm left ventricle - systolic dimension: 2.5 cm left ventricle - fractional shortening: 0.32 >= 0.29 left ventricle - ejection fraction: >= 60% >= 55% left ventricle - stroke volume: 103 ml/beat left ventricle - cardiac output: 7.21 l/min left ventricle - cardiac index: 3.52 >= 2.0 l/min/m2 left ventricle - lateral peak e': *0.07 m/s > 0.08 m/s left ventricle - septal peak e': *0.05 m/s > 0.08 m/s left ventricle - ratio e/e': 8 < 15 aorta - sinus level: *3.9 cm <= 3.6 cm aorta - arch: *3.6 cm <= 3.0 cm aortic valve - peak velocity: 1.0 m/sec <= 2.0 m/sec aortic valve - lvot vti: 18 aortic valve - lvot diam: 2.7 cm mitral valve - e wave: 0.5 m/sec mitral valve - a wave: 0.6 m/sec mitral valve - e/a ratio: 0.83 mitral valve - e wave deceleration time: *303 ms 140-250 ms findings left atrium: normal la and ra cavity sizes. right atrium/interatrial septum: normal ivc diameter (<2.1cm) with 35-50% decrease during respiration (estimated ra pressure (0-10mmhg). prominent eustachian valve (normal variant). left ventricle: mild symmetric lvh with normal cavity size and regional/global systolic function (lvef>55%). estimated cardiac index is normal (>=2.5l/min/m2). tdi e/e' < 8, suggesting normal pcwp (<12mmhg). no resting or valsalva inducible lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: mildly dilated aortic sinus. mildly dilated aortic arch. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: normal mitral valve leaflets with trivial mr. no mvp. tricuspid valve: normal tricuspid valve leaflets with trivial tr. indeterminate pa systolic pressure. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: no pericardial effusion. conclusions the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 0-10mmhg. there is mild-moderate symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the estimated cardiac index is normal (>=2.5l/min/m2). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). there is no left ventricular outflow obstruction at rest or with valsalva. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic arch 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 no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: mild-moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. dilated thoracic aorta. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. electronically signed by , md, interpreting physician 11:45 , m 50 radiology report spinal art study date of 2:39 pm , sched spinal art clip # reason: spinal embolization of dural avm., avm seen on angiogram tod contrast: optiray medical condition: dural spinal avm, left lower extremity weakness reason for this examination: spinal embolization of dural avm. avm seen on angiogram today - plan embo today as well preliminary report preliminary reports are not available for viewing. dr. dr. preliminaryapproved: mon 1:02 pm imaging lab brief hospital course: patient was electively admitted on for embolization of spinal avm. post-operatively, in the pacu; he developed t-wave inversion in the setting of hypertension. cardiology was consulted and made recommendations to start lisinopril, hctz, norvasc. his cardiac work-up/ekg was negative for acute mi. persantine stress test and echo were done for cardiac clearance - he was deemed safe for d/c home per cards on medications previously recommended. he agrees with this plan and is to see his pcp . dr will call pt tomorrow with a formal neurosurgical plan for the spinal avm. medications on admission: hydralizine, hctz discharge medications: 1. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*0* 2. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 3. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: spinal avm discharge condition: neurologically stable discharge instructions: angiogram with embolization and/or stent placement medications: ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort. 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 call to schedule follow-up with dr. on in the office. he will call you - if you don't hear from his office by 3pm - call them at the above number. you must also arrange for follow up with your pcp / cardiology at in the building call for the managment of your htn within the next 2 weeks. Procedure: Arteriography of other specified sites Diagnoses: Tobacco use disorder Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Malignant essential hypertension Spinal vessel anomaly Procedure not carried out for other reasons |
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