Health Record Face Sheet
Record Number: 79-50-77
Age: 36
Gender: Female
Length of Stay: 5 Days
Service Type: Inpatient
Discharge Status: To Home
Diagnosis/Procedure: Insulin reaction
Renal failure
Diabetes Mellitus, Type II, long term insulin
dependence
Permanent catheter right internal jugular
Removal peritoneal dialysis catheter
DISCHARGE SUMMARY
PATIENT: RAINEY INPATIENT
RECORD NUMBER: 79-50-77
ADMITTED: 12-19-XX
DISCHARGED: 12-24-XX
PHYSICIAN: DR. ALEX, M.D.
DISCHARGE DIAGNOSES:
1. Insulin reaction.
2. Renal failure.
3. Diabetes mellitus, Type II.
OPERATIONS/ PROCEDURES:
1. Permanent catheter right internal jugular.
2. Removal of peritoneal dialysis catheter.
DISCHARGE MEDICATIONS:
1. Ceftin 250 mg bid.
2. Reglan.
3. Prilosec.
4. Iron.
5. Procardia.
HISTORY: This patient is a 36-year-old woman who was admitted
because of insulin reaction, nausea, and vomiting. She has renal
failure. The plan was to admit her for placement of a permanent
access catheter for dialysis and she had an insulin reaction with a
blood sugar of 17 Dextrostrip prior to the admission. She was given
Glucagon in the unit. An IV was started in the emergency room. She
was given D5 and water. She had been experiencing nausea and had
not eaten as well as probably was necessary as an outpatient.
LABORATORY DATA: EKG showed T-wave inversion inferiorly and ST
segment depression, stable and on specific. Urine culture and blood
culture at the time of this dictation reveals no growth. SMAC
showed a creatinine of 7.0, BUN 34, glucose 208, uric acid 5.9,
alk. phos. 283, SGOT 238, LDH 294, total protein 4.7, albumin 1.4
grams, sodium 130, potassium 3.5, chloride 95 millimoles per liter,
cholesterol 111, the rest of the SMAC was normal. Hemoglobin on
admission had been 10.8, hematocrit 32.5, white count 4.1K with a
normal differential. Platelets were adequate. The hematocrit was
17.8 the day before discharge. She was given one unit of packed red
blood cells. Chest x-ray showed significant improvement on 12-21 of
the pleural effusion she had had on previous films.
HOSPITAL COURSE: The patient was admitted to the hospital with an
insulin reaction and given intravenous glucose as above after she
had had an insulin reaction in the field and glucagon had been
given. She received Prilosec and Reglan intravenously initially and
then the Reglan was changed to oral. I gave it 2 hours before the
meal. This seemed to enable her to eat and retain food. She had a
slight fever. Cultures of the urine and blood were obtained but no
growth was present so far. She had been on Cipro as an outpatient.
I did not think any catheters were infected nor was there any
evidence of peritonitis from the peritoneal dialysis. The
peritoneal dialysis catheter had been removed during this hospital
stay and another catheter placed in the right upper chest. I
treated her empirically with Fortaz after obtaining cultures. The
morning of Dec 24th, she was very anxious to go home for
Christmas. I told her that I recommended she stay in the hospital
to take the intravenous antibiotics and continue to monitor things
as we had had such a difficult time controlling the blood sugar
ranging from nearly 900 one day to below 50 the next. She, however,
was well oriented, understood the situation, and definitely wanted
to leave the hospital for Christmas with her family.
DISPOSTION: She was discharged on 12/24. She would take her usual
medications at home except would d/c the Cipro and take Ceftin 250
mg bid. She would continue Reglan, Prilosec, Iron and Procardia.
Dialysis would be again on Thursday and then again on Saturday.
Follow up in about one week in the office.
DR. ALEX, M.D.
Electronically authenticated by Dr. Alex, M.D., 12-26-xx
5568
HISTORY AND PHYSICAL
PATIENT: RAINEY INPATIENT
RECORD NUMBER: 79-50-77
ADMITTED: 12-19-XX
DISCHARGED: 12-24-XX
PHYSICIAN: DR. ALEX, M.D.
CHIEF COMPLAINT: Severe renal failure secondary to very brittle
diabetes mellitus, Type II, with long-term treatment with
insulin.
HISTORY OF PRESENT ILLNESS: Severe renal failure secondary to very
Type II diabetes mellitus, long-term treatment with insulin. This
patient with renal failure was previously on peritoneal dialysis.
She is not tolerating peritoneal dialysis due to very low total
protein and albumin. This patient needs a more permanent
hemodialysis access. We will place a temporary subclavian or
temporary jugular catheter. The patient is being admitted to the
hospital at this time for placement of dialysis catheter via one of
the internal jugular sites.
DRUG ALLERGIES: None known.
PERSONAL MEDICAL HISTORY: Otherwise unremarkable. Most recently,
she had a severe episode of hypoglycemia. The patient subsequently
went home and was admitted to the hospital the morning surgery was
to be accomplished having been found by her mother cold and with a
very low blood sugar. She was brought to the emergency room and
taken straight to the floor where she responded.
FAMILY HISTORY: Paternal grandmother with diabetes mellitus.
REVIEW OF SYSTEMS: Otherwise unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 87.5. Blood pressure of 153/86, pulse
of 85, respirations 16.
GENERAL: The patient felt cold.
HEENT/NECK: Otherwise unremarkable.
LUNGS: Clear to auscultation and percussion.
CARDIOVASCULAR: Regular sinus rhythm.
ABDOMEN: Benign.
EXTREMITIES: Unremarkable.
IMPRESSION: Severe renal failure secondary to very brittle diabetes
mellitus, Type II, long-term dependence on insulin.
RECOMMENDATIONS: Placement of perm-cath through one of the internal
jugular sites.
DR. ALEX, M.D.
Electronically authenticated by Dr. Alex, M.D., 12-26-xx
5568
OPERATIVE REPORT
PATIENT: RAINEY INPATIENT
RECORD NUMBER: 79-50-77
SURGERY DATE: 12-19-XX
DISCHARGED: 12-24-XX
PHYSICIAN: DR. ALEX, M.D.
PREOPERATIVE DIAGNOSIS: Chronic renal failure in a very brittle
diabetic, unable to tolerate peritoneal dialysis because of loss of
protein and albumin.
POSTOPERATIVE DIAGNOSIS: Chronic renal failure in a very brittle
diabetic, unable to tolerate peritoneal dialysis because of loss of
protein and albumin.
OPERATIVE PROCEDURE: Cut down placement of permanent catheter right
internal jugular and removal of peritoneal dialysis catheter.
ANESTHESIA: General endotracheal.
DESCRIPTION: The patient was taken to the operating room having
been put to sleep, endotracheal tube in place. She had Betadine
prep of the entire neck, jaw, and upper thorax down to the nipples.
She also had prep of the left lower quadrant around the permanent
catheter. She had a sterile drape in both areas. Attention was
turned towards placing the permanent catheter. Initially, a
transverse incision was made in the skin line, distal third of the
neck on the right, transverse fashion and carried down through
platysma muscle. Hemostasis was obtained with a Bovie. Flaps were
developed inferiorly and superiorly, sufficient to allow
muscle-splitting incision through anterior body sternocleidomastoid
muscle. The dissection was carried straight down. Deep fascia of
the neck was encountered and there was marked scarring in this
location. The patient had a previous temporary dialysis catheter
long term on this side. The carotid artery was palpated and
adjacent to the artery just laterally. The lateral border of the
scarred, whitish colored wall of the internal jugular vein was
identified. With gradual dissection over the top of this, we were
able to isolate the jugular vein from the carotid artery, taking
care not to injure the vagus nerve. The vein was dissected free
from a distance of approximately 2 cm, vascular tape was passed
without difficulty. Dissection was prolonged because of the dense
tissue in this region. We were able to get around this without
entering the vessel. A #4-0 Prolene vascular purse string was then
placed in Trendelenburg position. Ends were placed inferiorly on
the purse string so that it could be tied directly down on the
vein. The catheter was then inserted after what was felt to be the
appropriate length was selected. Incision was then made so a #36
French catheter could be inserted through skin tunnel located below
the clavicle on the right side and brought through a portion of the
muscle to allow for adequate bend without kinking. Once this was
accomplished, the internal jugular was lifted anteriorly with the
Bakke pickups and a #15 blade was used to make an opening in the
vein.
The vein, as indicated, was scarred and sclerosed, however, an
opening was made sufficient to allow placement of the catheter
without difficulty. In the process, approximately 25 cc of blood
was lost. The purse string was then tied down. There was a small
leak on the superior aspect and stick tie of #4-0 Vascular Prolene
was then sewed to secure this. X-ray was obtained and catheter was
seen in the part of the superior vena cava, and it was pulled out
approximately 2 cm so that the pledget regressed still just inside
the skin. This was accomplished and wound was irrigated. A #2-0
Vicryl was used to approximate the deep fascial layer of the neck
and platysma muscles also approximated with #2-0 Vicryl. A #4-0
Vicryl was used subcuticular and Steri-Strips were used on the
skin. The wound was dressed and tegaderm was placed over the
catheter where it came out of the skin. Attention was then turned
towards the peritoneal dialysis catheter. Dressings were removed
off of this location and cut so we could get down to where the
catheter had been inserted just above the iliac crest on the left.
The incision for insertion was well above where the catheter went.
It was a good 6 cm above where the catheter failed to go. A ¼ -inch
incision was made directly over where we thought the catheter was
inserted on the lateral border of the rectus muscle. Hemostasis was
obtained with a Bovie after incision was made in the skin. With
blunt dissection, we were able to go down and identify the
catheter, go through the abdominal wall musculature. This was
identified just lateral to the edge of the rectus. The catheter was
then grasped. It was cut in this location and the pledget was
placed near the skin, was removed after making a 1½ cm incision
along the tract of the catheter down to its junction with the
peritoneum. This was identified. The catheter was pulled back after
it was removed and there adherent omentum on the catheter in this
location. This was transected after being clamped with a small
clamp, the end of the omentum tied off with #2-0 silk, and the
omentum was tucked back into the abdominal cavity. The edges of the
peritoneum and fascia, which were hypertrophied, were grasped with
clamps and three #3-0 stick ties of #0 Vicryl were used to close
this opening in the peritoneum.
The wound was irrigated and the fascial layer anteriorly was then
used to approximate the subcuticular layer and #4-0 Prolene used to
run and close skin. Accu-Chek prior to coming back to the ICU
approximately 30 minutes before case was over was 230. The patient
had no complications during surgery. She was sent to the recovery
room with stable vital signs.
DR. ALEX, M.D.
List Principal Diagnosis
List secondary diagnosis
List Principal Procedure
List secondary procedures
Principal diagnosis is insulin reaction
Secondary diagnosis are :-
Renal failure.
Diabetes mellitus, Type II.
Principal procedure is Permanent catheter right internal jugular.
Secondary Procedure is Removal of peritoneal dialysis catheter.
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