ChanBeDu/relevant_section_length · Datasets at Hugging Face

19,267

117,996

30448

Discharge summary

report

Admission Date: [**2188-2-22**] Discharge Date: [**2188-2-24**] Date of Birth: [**2107-8-19**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1711**] Chief Complaint: PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 72378**] . Chief Complaint: Transferred from OSH for NSTEMI/CHF Major Surgical or Invasive Procedure: None History of Present Illness: This is an 80-year-old female patient with history of COPD and presumed CAD and CHF who presented to [**Location (un) 16843**] ED the day prior to trasnfer to [**Hospital1 18**] with chief complaint of SOB. CXR was consistent with CHF and BNP was 727. The patient was intubated for hypoxia to 80% on room air. The patient was given solumedrol and lasix in the ED and sent to the ICU. In the ICU, the patient was diuresed with lasix and placed on NTG gtt. Her cardiac enzymes was initially flat but subsequent enzymes returned elevated with CK 1796 and trop I 34. Echocardiogram showed EF approximately 30% without previous baseline. She received plavix 300 mg and Lovenox (last dose at 10 am the day of transfer). She also received Lopressor 2 mg IV and was placed on insulin gtt 4 Units/hour with her last FSBS of 147. She has an elevated creatine at 1.6 and her WBC is now 18.6. She is in a sinus rhythm and EKG shows ST depressions in the inferoanterior leads. . Today, cardiac cath revealed severe 3-vessel disease not suitable for PCI (80% LMCA, RCA 80% ostial, long mid disease to 80%, Lcx with 80%, LAD small vessel with moderate disease at D1). PA 55/38/45, mean PWCP 36, CI 2.26, CO 3.92, LV 110/40. CT surgery was consulted and reviewed the cath but declined surgery secondary to poor target site. The patient was noted to have severe PVD including aortoiliac disease, and IABP was not able to be placed for CHF. Swan ganz was placed to monitor hemodynamics. . Currently, patient is sedated and intubated, therefore unable to answer any questions regarding current symptoms or review of systems. Past Medical History: COPD CAD not previously diagnosed CHF not previously diagnosed HTN Hyperlipidemia GERD Anxiety DM II Social History: Per OSH report, she lives alone and is independent. She has 5 children. Past smoking history but none currently. There is no history of alcohol abuse. Family History: Unknown. Physical Exam: VS - 98.5, 94/51, 88, 14, 95% on AC 0.4/600/14/5 Gen: Sedated, intubated. HEENT: NCAT. PERRL. Neck: Lying flat, difficult to assess JVP. CV: Difficult to auscultate heart sounds due to coarse breath sounds and diffuse wheezes. Chest: Mechanically ventilated, diffuse coarse breath sounds and wheezes. Abd: Soft, ND, decreased BS. Ext: Cool extremities, trace edema bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 1+ DP dopplerable PT dopplerable Left: Carotid 1+ DP dopplerable PT dopplerable Pertinent Results: [**2188-2-22**] 12:30PM BLOOD WBC-17.7* RBC-3.55* Hgb-10.4* Hct-31.8* MCV-89 MCH-29.4 MCHC-32.9 RDW-16.3* Plt Ct-282 [**2188-2-24**] 04:42AM BLOOD WBC-12.0* RBC-2.93* Hgb-8.8* Hct-25.8* MCV-88 MCH-29.9 MCHC-34.1 RDW-16.3* Plt Ct-233 [**2188-2-22**] 12:30PM BLOOD Neuts-94.8* Bands-0 Lymphs-3.5* Monos-1.4* Eos-0.2 Baso-0.1 [**2188-2-24**] 04:42AM BLOOD PT-12.3 PTT-86.6* INR(PT)-1.1 [**2188-2-24**] 04:42AM BLOOD Glucose-132* UreaN-62* Creat-2.4* Na-139 K-3.9 Cl-104 HCO3-23 AnGap-16 [**2188-2-22**] 12:30PM BLOOD Glucose-168* UreaN-35* Creat-1.8* Na-138 K-4.7 Cl-104 HCO3-24 AnGap-15 [**2188-2-23**] 04:35AM BLOOD CK(CPK)-1446* [**2188-2-22**] 07:59PM BLOOD ALT-60* AST-187* CK(CPK)-[**2191**]* AlkPhos-97 TotBili-0.6 [**2188-2-22**] 12:30PM BLOOD ALT-59* AST-182* AlkPhos-95 TotBili-0.5 [**2188-2-22**] 07:59PM BLOOD CK-MB-131* MB Indx-6.5* cTropnT-4.58* [**2188-2-23**] 04:35AM BLOOD CK-MB-90* MB Indx-6.2* cTropnT-4.11* [**2188-2-22**] 12:30PM BLOOD Albumin-3.4 [**2188-2-24**] 04:42AM BLOOD Calcium-7.7* Phos-5.7* Mg-2.5 [**2188-2-22**] 07:59PM BLOOD calTIBC-231* VitB12-222* Folate-4.6 Ferritn-141 TRF-178* [**2188-2-22**] 12:30PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE [**2188-2-24**] 04:50AM BLOOD Type-ART Rates-12/ PEEP-5 FiO2-40 pO2-90 pCO2-40 pH-7.40 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2188-2-23**] 11:51AM BLOOD Type-MIX Temp-36.6 [**2188-2-23**] 05:15AM BLOOD Type-ART Rates-14/ Tidal V-600 PEEP-5 FiO2-40 pO2-73* pCO2-36 pH-7.44 calTCO2-25 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2188-2-22**] 05:41PM BLOOD Type-ART Rates-/14 Tidal V-600 PEEP-5 FiO2-100 pO2-408* pCO2-37 pH-7.42 calTCO2-25 Base XS-0 AADO2-266 REQ O2-51 -ASSIST/CON Intubat-INTUBATED Vent-CONTROLLED . [**2-22**] Cath COMMENTS: 1. Selective coronary angiography in this right dominant system revealed severe three vessel coronary artery disease. The LMCA was a short diffusely disease vessel with an 80% stenosis. The LAD was a small vessel with moderate disease throughout. The LCx was a small vessel with diffuse disease to 80% in the mid vessel. The RCA had an 80% ostial stenosis and diffuse disease to 80% in the mid vessel. 2. Limited hemodynamics demonstrated pulmonary arterial hypertension with a pulmonary artery pressure of 56/36 mmHg. The left ventricular end diastolic pressure was 36 mmHg. Central aortic pressure was 107/60 mmHg. There was no gradient across the aortic or mitral valve. Cardiac index was perserved at 2.5 l/min/m2. Right ventricular and right atrial pressures were not obtained. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. . [**2-22**] ECHO GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Suboptimal image quality - ventilator. Emergency study performed by the cardiology fellow on call. Conclusions: The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses and cavity size are normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed with global hypokinesis and akinesis of the distal LV and apex. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . [**2-24**] CXR Endotracheal tube and nasogastric tube are in standard position. Cardiac silhouette is mildly enlarged but stable in size. Vascular engorgement and perihilar haziness are present consistent with mild CHF. Within the right upper lobe, a new focal opacity has developed with associated slight elevation of the minor fissure. This is most likely due to an area of atelectasis but aspiration should also be considered in the appropriate clinical setting. Bibasilar retrocardiac opacities are likely due to atelectasis, and there are probable small pleural effusions. Brief Hospital Course: 80 year-old female with CAD, CHF, [**Hospital 2182**] transferred from OSH for NSTEMI and CHF causing respiratory failure. The patient was transferred intubated and on a ventilator. Cardiac catheterization revealed severe 3-vessel disease. The patient's anatomy was not suitable for PCI and cardiac surgery declined due to poor targets. Echocardiogram revealed ischemic cardiomyopathy with worsened ejection fraction of [**9-27**]%. The patient was not a candidate for IABP due to severe PVD involving the aortoiliac system. The patient's family was made aware of her poor prognosis. The patient was initially managed in the CCU with lasix gtt despite worsening creatinine. The patient did not improve after 24 hours and blood pressure was tenuous. The [**Hospital 228**] health care proxy and family were made aware of the poor prognosis. After discussion with the family, the goals of care were changed to comfort. The patient expired [**2188-2-24**] at 13:15. Medications on Admission: Lasix 80 iv BID ASA 325mg qday Protonix 40mg iv qam metoprolol 2mg iv q6H Lovenox 70mg sc q12h Regular insulin gtt Plavix 300mg qday Solumedrol 125mg q12h Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "403.90", "285.9", "410.71", "250.00", "496", "530.81", "425.4", "585.9", "428.0", "272.4", "443.9", "518.81", "414.01", "785.51", "416.8", "300.00" ]

icd9cm

[ [ [] ] ]

[ "37.21", "96.71", "88.56" ]

icd9pcs

[ [ [] ] ]

8371, 8380

7165, 8138

445, 451

8431, 8440

2986, 5553

8492, 8498

2400, 2410

8343, 8348

8401, 8410

8164, 8320

5570, 7142

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2425, 2967

370, 407

479, 2090

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179,888

20691+20692+57197

Discharge summary

report+report+addendum

Admission Date: [**2183-5-13**] Discharge Date:[**2183-6-2**] Date of Birth: [**2128-10-4**] Sex: M Service: MED DATE OF DISCHARGE IS PENDING AT THE TIME OF THIS DICTATION. SERVICE: MICU Green CHIEF COMPLAINT: Dyspnea / wheezing. HISTORY OF PRESENT ILLNESS: The patient is a 54 year old male with a history of chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, question idiopathic pulmonary fibrosis and severe tracheobronchial malacia, status post stents to the distal trachea and right main stem bronchus in [**2183-3-20**]. He developed the sudden onset of dyspnea and wheezing two days prior to admission. The patient initially presented to [**Hospital 28159**] Hospital where he was found to be respiratory distress with significant bronchospasm, tachycardia and tachypnea. A chest x-ray showed the stents to be in place and did not show any evidence of pneumonia. Cardiac enzymes were negative per report. The patient was transferred to [**Hospital1 190**] on BiPAP and with around the clock nebulizers. An arterial blood gas prior to transfer was 7.42, 43, 97, on BiPAP. Per report, the patient was anasarcic with significant lower extremity edema. No workup for pulmonary embolus was undertaken. The patient was intubated prior to transfer on a propofol drip. On arrival, the patient was intubated and sedated. Additional history obtained through his wife was significant for marked improvement in his respiratory status status post stent placement. Prior to the stent being placed, the patient was dyspneic with minor exertion including getting dressed. After stent placement, he was able to ambulate and climb stairs without significant dyspnea. PAST MEDICAL HISTORY: 1. Status post appendectomy. 1. Status post tonsillectomy. 1. Status post septoplasty. 1. History of hand tremor. 1. Obstructive sleep apnea on home BiPAP. 1. Hypercholesterolemia. 1. Hypertension. 1. Gastroesophageal reflux disease. 1. Tracheobronchomalacia. 1. Asthma / chronic obstructive pulmonary disease. 1. Steroid induced diabetes mellitus. 1. Question idiopathic pulmonary fibrosis. 1. Anxiety. 1. Question coronary artery disease. SOCIAL HISTORY: The patient lives with his wife and is a retired plumber. He is a former smoker and quit 12 years ago. The family denies any alcohol history or any drug abuse. FAMILY HISTORY: Significant for a father who had "black lung" and was on home oxygen. MEDICATIONS: Medications upon transfer were: 1. Albuterol / Atrovent nebulizers. 2. Solu-Medrol 80 mg intravenously q eight hours. 3. Prevacid 30 mg q day. 4. Singulair 10 mg q day. 5. Zoloft 50 mg q day. 6. Lipitor 10 mg q day. 7. Levofloxacin 500 mg q day. 8. Glyburide 20 mg q day. 9. Lasix 20 mg q day. 10. Tussionex 5 cc three times a day. 11. Flonase. 12. Morphine sulfate. 13. Nitroglycerine paste. 14. Humalog sliding scale. 15. Lovenox 30 mg subcutaneously twice a day. 16. Ativan. 17. Advair, one puff twice a day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On admission, temperature 97.0 F.; blood pressure 143/84; respiratory rate 14; saturation of 100 percent on AC with a tidal volume of 700 and rate of 14, PEEP of 5 and FIO2 of 1.0. On these settings he was put on tidal volumes of 600. In general he was an ill appearing overweight male in no acute distress, sedated and intubated. HEENT examination: Pupils equal, round and reactive to light. Mucous membranes moist. Cardiac examination: Regular rate and rhythm with no murmurs, rubs or gallops. Normal S1 and S2. Pulmonary examination: Clear to auscultation bilaterally posteriorly. Abdomen was soft, distended, with normoactive bowel sounds, nontender to palpation. Extremities with two plus bilateral lower extremity edema up to the knee. Neurological examination: Unable to assess secondary to sedation. LABORATORY DATA: From the outside hospital, CBC revealed a white blood cell count of 10.2 with a hematocrit of 43 and platelet count of 293. Chem-7 revealed a sodium of 137, potassium of 4.0, chloride was 95; bicarbonate 29, BUN 15, creatinine 0.13 and serum glucose was 220. Calcium was 9.0 and magnesium was 1.8. CK was 230 with an MB fraction of 12.1 and troponin T of 0.0. EKG showed normal sinus rhythm at 92 with a normal axis and normal intervals. There were no ST changes, T wave inversions or Q waves. Chest x-ray showed increased right atrial contour with a dilated pulmonary artery, right greater than left. ET tube was well placed. There was no evidence of congestive heart failure or pneumonia. HOSPITAL COURSE BY PROBLEM: 1. RESPIRATORY DISTRESS: The patient underwent bronchoscopy with BAL on the morning following admission. Copious secretions were suctioned including an obstructing plug at the left main stem bronchus. Initially, it was felt that mucous plugging was the cause of the patient's respiratory decline, however, the patient continued to have a high FIO2 requirement despite aggressive suctioning. The patient was continued on Levofloxacin which was begun at an outside hospital for possible tracheobronchitis. His initial BAL was negative for any organisms. He was also treated for a chronic obstructive pulmonary disease exacerbation with intravenous steroids, MDIs and high dose guaifenesin. The patient was initially on pressure control ventilation and was eventually able to be weaned to pressure support. With weaning of his sedation, he was able to tolerate a spontaneous breathing trial and on [**2183-5-24**], he was successfully extubated. Of note, he did continue to have significant wheezing peri extubation. Discussions will be forthcoming with the Interventional Pulmonary Team as well as with Thoracic Surgery regarding possible tracheal reconstruction, however, at this time, he will continue to have the stents in place. 1. HYPERTENSION: The patient had no prior history of high blood pressure, however, he was noted to have elevated blood pressures during his Intensive Care Unit course. An echocardiogram was obtained, however, due to the patient's body habitus, poor windows were obtained. Nevertheless, there was no evidence of systolic dysfunction. He was started on hydrochlorothiazide and Captopril for control of his blood pressure with good response. 1. DIABETES MELLITUS: The patient had elevated blood sugars throughout his Intensive Care Unit course which was felt to be in part due to high dose steroids. For the initial portion of his admission, he was maintained on an insulin drip. On [**2183-5-24**], he was transitioned to Lantus and a Regular insulin sliding scale. 1. GASTROESOPHAGEAL REFLUX DISEASE: The patient was maintained on a twice a day proton pump inhibitor. 1. TACHYCARDIA / CHEST PAIN: Per report, the patient had complaint of chest pain prior to his transfer to [**Hospital1 55251**]. Of note, he did have an outpatient stress test prior to this admission which showed an equivocal reversible wall motion abnormality. He was ruled out for myocardial infarction on presentation with negative cardiac enzymes times three. An EKG was checked and it did not show any evidence of ischemia. As stated above, he was started on anti-hypertensives and echocardiogram was obtained. 1. FLUID, ELECTROLYTES AND NUTRITION: The patient was on tube feeds while he was intubated. He tolerated these well. 1. SEDATION: The patient was initially very agitated and dyssynchronous with the ventilator. He required high doses of propofol and Versed to achieve adequate sedation. He was eventually weaned off of both with the addition of scheduled Haldol. At the time of this dictation, he is off both Propofol and Haldol and receiving scheduled doses of Haldol and Ativan. The remainder of this dictation will be completed by the next house officer to assume the patient's care. That portion of the dictation will include his discharge diagnoses, medications and discharge plan. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 55252**] Dictated By:[**Doctor Last Name 6328**] MEDQUIST36 D: [**2183-5-24**] 21:44:09 T: [**2183-5-24**] 23:02:34 Job#: [**Job Number **] Admission Date: [**2183-5-13**] Discharge Date: [**2183-5-28**] Date of Birth: [**2128-10-4**] Sex: M Service: MED ADDENDUM: In brief, the patient, as above, with significant medical history of tracheobronchomalacia, asthma, presented to outside hospital with increased dyspnea and transferred to [**Hospital1 18**] for bronchoscopy, intubated. Bronch revealed mucous plug which was aspirated. MICU course uncomplicated. Extubated on [**2183-5-24**] and called out to general medicine floor on [**2183-5-26**]. On general medicine floor, the patient continued with scheduled nebulizers. Reinitiated BIPAP at 10/20 q hs. The patient continued to show improvement with saturations at 97 percent on 3 liters. The patient to be continued on prednisone 30 mg po qd until further assessment by outpatient pulmonologist. Per interventional pulmonology, CT surgery deferment of tracheoplasty at this time. Will allow patient to recover from 12-day ICU stay with intense physical and respiratory therapy. The patient transitioned back onto oral hyperglycemics, as well as Lantus and regular insulin sliding scale for steroid-related type 2 diabetes. HYPERTENSION: Patient maintained on hydrochlorothiazide and ACE inhibitor with adequate control. BLOOD PRESSURE: Tachycardia felt to be secondary to steroids and scheduled albuterol. A TE as done in the MICU was without evidence of pulmonary hypertension. AGITATION: Upon extubation, the patient noted to be acutely delirious, felt to be concomitant steroid psychosis with ICU delirium. Continued on scheduled Ativan 1 mg tid and Haldol 1 mg tid. On the floor the patient was weaned off Haldol. Continued on Ativan 1 mg po tid without sequelae. The patient to continue physical therapy secondary to ICU deconditioning. DISCHARGE FOLLOW-UP: The patient to follow-up with outpatient pulmonologist in 1 week to assess pulmonary status and to further titrate prednisone. Will also follow-up with interventional pulmonology regarding possible future CT surgery intervention tracheoplasty. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg po qd. 2. Prednisone 30 mg po qd. 3. Senokot 1 tablet po bid prn. 4. Ipratropium nebulizer 2 puffs q 4-6 prn. 5. Ativan 1 mg po tid. 6. Ipratropium MDI 2 puffs q 4-6 prn. 7. Ativan 1 mg po tid. 8. Ipratropium MDI 2 puffs q 4-6 prn. 9. Regular insulin sliding scale with 14 U Lantus q hs. 10.Glyburide 10 mg po qd. 11.Hydrochlorothiazide 25 mg po qd. 12.Subcutaneous heparin 5,000 U subcu tid. 13.Haloperidol 1 mg po tid prn agitation. 14.Colace 100 mg po bid. 15.Captopril 12.5 mg po tid. 16.Albuterol nebulizer 1 neb q 4-6 prn dyspnea. 17.Tylenol 650 po q 4-6 prn. Final active medication list pending and will be on of discharge sheet at time of discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 26164**] Dictated By:[**Last Name (NamePattern1) 46270**] MEDQUIST36 D: [**2183-5-27**] 15:08:41 T: [**2183-5-27**] 15:39:25 Job#: [**Job Number 55253**] Name: [**Known lastname **], [**Known firstname 5204**] D Unit No: [**Numeric Identifier 10373**] Admission Date: [**2183-5-13**] Discharge Date: [**2183-6-2**] Date of Birth: [**2128-10-4**] Sex: M Service: MED Due to bed unavailability, the patient was unable to be discharged on Friday, [**2183-5-30**]. Patient stayed over the weekend, did well except for one episode of hyperglycemia of 400. Found to be in the setting of poor adherence to diabetic diet as well as prednisone therapy. Patient's blood sugars had consistently been running in the 175-200 range, increased patient's p.m. Glargine dose to Glargine 12 units subQ q.h.s. as well as regular insulin-sliding scale q.4 scale. Patient's following blood sugars were 150-200 at the time of discharge. The patient also had one episode of tachypnea and shortness of breath and Interventional Pulmonary evaluation was undertaken given prior mucus plugging of stent. Patient received an Atrovent nebulizer with rapid resolution of symptoms felt to be not attributable to mucus plugging, but likely patient's underlying reactive airway disease. Patient is to continue on prednisone nebulizer therapy, Humibid, as well as chest PT. At time of discharge, the patient will require aggressive Physical Therapy, Occupational Therapy, and Pulmonary Rehab prior to any consideration for future tracheoplasty. Patient is discharged to [**Hospital6 10374**] on [**2183-6-2**] on baseline O2 of 3 liters nasal cannula. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 10375**] Dictated By:[**Last Name (NamePattern1) 7164**] MEDQUIST36 D: [**2183-6-2**] 11:00:57 T: [**2183-6-2**] 11:21:26 Job#: [**Job Number 10376**]

[ "250.00", "112.0", "493.22", "518.81", "519.1", "530.81", "515", "996.59" ]

icd9cm

[ [ [] ] ]

[ "93.90", "33.24", "38.91", "38.93", "96.72", "96.05", "96.6" ]

icd9pcs

[ [ [] ] ]

2392, 3069

10468, 13202

3092, 4629

235, 256

4657, 10445

285, 1717

1739, 2195

2212, 2375

518

185,375

44021

Discharge summary

report

Admission Date: [**2111-7-6**] Discharge Date: [**2111-7-14**] Date of Birth: [**2062-9-18**] Sex: M Service: MEDICINE Allergies: Clindamycin / Ace Inhibitors / Valsartan Attending:[**First Name3 (LF) 1936**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: 48 y/o M with hx of HTN, DM, ESRD on HD, HIV (CD4 count [**5-19**] 346, undetectable VL), and hx of PE on coumadin since [**2098**]. Presented to ED on [**7-6**] with hematemesis. He was feeling well and then became nauseated after his lunch, initially vomitting brown vomit with food particles and then had about 1 cup of bright red and dark red blood. He then felt well, but again after dinner had similar episode with about 1 more cup of bright and dark blood. At that time he presented to the emergency room. He denied abdominal pain, diarrhea, melena, BRBPR. He has not had anything like this before. He denies light headedness, chest pain, shortness of breath. He is on ASA 325 mg and coumdain for hx of PE. He has not had NSAIDs or etoh recently. . In the ED, his vitals were 98, 74, 103/60, 24, 96% RA. his Hct 38.4 and INR was 1.7. His stools were guiac negative and he refused an NG lavage while there. . Overnight, he was admitted to [**Hospital Ward Name 121**] 10. His vitals remained stable throughout the night with Tm 99.1, BP 100/50 to 128/76, HR 64 to 74 and 96% on RA. Serial Hcts were 38.4 to 36.1 to 35.3 to 34.3 (last checked at 445 AM today). He was taken to the endoscopy suite and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear was noted in the distal esophagus. One clipped was placed and he was noted to have some bleeding. Two subsequent clips were placed and bleeding had stopped. He was transferred to the MICU for further monitoring. . On the floor, he is sedated and cannot answer questions. One 18 g IV was placed in addition to his 22 g PIV. . Review of sytems: per report, unable to obtain due to sedation (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Type 1 diabetes - HIV: dx'd [**2096**]; (CD4 count [**5-19**] 346, undetectable VL) - ESRD on HD MWF, attempted on PD on transplant list (clinical study for HIV/solid organ transplant) - PE, on Coumadin, diagnosed [**6-16**] - Malignant Hypertension - hx Serratia bacteremia (presumed AV graft) tx 6 wks meropenem - Hx schistosomiasis - Restless leg syndrome - Peripheral neuropathy on gabapentin - S/p cholecystectomy - s/p R nephrectomy in [**2092**] secondary renal nephrolithiasis Social History: quit smoking for [**1-13**] yrs, used to smoke for 25 yrs with 0.5ppd, occ drinking, denies illicit drug use, lives with family. Moved from [**Country 4812**] in [**2091**]. Lives with wife in [**Location (un) 538**]. Family History: Noncontributory Physical Exam: General: snoring, sedated, no acute distress, pupils small approx 2 mm, reactive 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, HD catheter in L subclavian, unused [**Location (un) 2286**] fistula in L arm Pertinent Results: [**2111-7-6**] 11:28AM BLOOD WBC-3.9* RBC-3.73* Hgb-12.2* Hct-38.4* MCV-103* MCH-32.8* MCHC-31.9 RDW-14.4 Plt Ct-254 [**2111-7-7**] 04:45AM BLOOD WBC-4.8 RBC-3.35* Hgb-11.5* Hct-34.3* MCV-102* MCH-34.2* MCHC-33.5 RDW-14.9 Plt Ct-267 [**2111-7-13**] 05:40AM BLOOD WBC-4.7 RBC-3.35* Hgb-10.7* Hct-34.7* MCV-103* MCH-32.0 MCHC-30.9* RDW-13.8 Plt Ct-273 [**2111-7-14**] 03:59AM BLOOD WBC-5.9 RBC-3.35* Hgb-11.1* Hct-34.7* MCV-104* MCH-33.0* MCHC-31.9 RDW-13.9 Plt Ct-239 [**2111-7-6**] 11:35AM BLOOD PT-18.7* PTT-32.9 INR(PT)-1.7* [**2111-7-7**] 04:45AM BLOOD PT-19.5* INR(PT)-1.8* [**2111-7-14**] 03:55PM BLOOD PT-26.2* PTT-101.2* INR(PT)-2.5* [**2111-7-6**] 11:28AM BLOOD Glucose-90 UreaN-38* Creat-7.7*# Na-130* K-9.6* Cl-94* HCO3-23 AnGap-23* [**2111-7-13**] 05:40AM BLOOD Glucose-85 UreaN-51* Creat-12.4*# Na-135 K-5.0 Cl-92* HCO3-26 AnGap-22* [**2111-7-14**] 03:59AM BLOOD Glucose-73 UreaN-31* Creat-8.1*# Na-137 K-4.9 Cl-95* HCO3-29 AnGap-18 [**2111-7-6**] 11:28AM BLOOD ALT-13 AST-52* LD(LDH)-892* AlkPhos-103 [**2111-7-7**] 04:45AM BLOOD Calcium-10.7* Phos-9.3*# Mg-2.4 [**2111-7-14**] 03:59AM BLOOD Calcium-10.4* Phos-5.7* Mg-2.3 UNILAT UP EXT VEINS US Clip # [**Clip Number (Radiology) 94531**] Reason: r/o Veinous clot on Right Arm. Please do at bedside if possi [**Hospital 93**] MEDICAL CONDITION: 48 year old man with ESRD on HD, HIV, Gi Bleed and new Forearm swelling REASON FOR THIS EXAMINATION: r/o Veinous clot on Right Arm. Please do at bedside if possible Provisional Findings Impression: MKjd FRI [**2111-7-10**] 5:15 PM Right internal jugular vein thrombus. CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 94532**] Reason: ? Bleed. [**Hospital 93**] MEDICAL CONDITION: 48 yo M with h/o malignant HTN, IDDM, HIV (CD4 count [**5-19**] 346, undetectable VL), ESRD on HD (MWF, on on transplant list) and PE on coumadin (from [**2108**], INR 2.2). Pt with severe bilateral temporal HA, reports that it is worst ever. No nauea, no visual changes. REASON FOR THIS EXAMINATION: ? Bleed. CONTRAINDICATIONS FOR IV CONTRAST: ESRD Wet Read: JKSd WED [**2111-7-8**] 8:44 PM No acute intracranial process. Final Report INDICATION: 48-year-old male with history of malignant hypertension, IDDM, HIV, and end-stage renal disease on hemodialysis. Patient now with severe bilateral temporal headaches and reports that is the worst ever. COMPARISON: Multiple head CTs, most recent of [**2109-12-29**]. TECHNIQUE: Axially acquired images were obtained through the head without contrast. FINDINGS: There is no evidence of acute intracranial hemorrhage, large areas of edema, mass, or mass effect. There is no evidence of an acute large vascular territory infarct. There is normal preservation of [**Doctor Last Name 352**]-white matter differentiation. Prominence of the ventricles has remained stable since the previous study of [**2109-12-29**]. There is calcification of the tentorium and the falx. Visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial process. Findings were discussed with Dr. [**Last Name (STitle) **] [**Name (STitle) **] at the time of review on [**2111-7-8**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**] Approved: [**Doctor First Name **] [**2111-7-9**] 7:51 AM Brief Hospital Course: 48 y/o M with hx of DM, HTN, ESRD on HD, HIV and hx of PE on anticoagulation presents to ED after hematemesis. Found to have deep [**Doctor First Name 329**] [**Doctor Last Name **] tear. . # Hematemesis/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear: He underwent EGD was found to have deep [**Doctor First Name 329**] [**Doctor Last Name **] tear and which was clipped. He had mild rebleeding post-procedure but remained stable. He continued IV BID PPI and had 2 PIVs for access. Hct were stable post procedure and throughout admision. Coumadin was held while in the ICU, but re-started on [**7-12**]. . # Mild R hand swelling: Pt developed mild R hand swelling on [**7-9**]. A RUE U/S was done and he was found to have a RIJ thrombus. The thrombus distended from the right internal jugular vein from its mid portion to the level of the subclavian. He has a RIJ HD catheter so the possibility of this being the cause was entertained. IR was consulted to see if replacement of the catheter was a viable option but they reccomemended treating medically and follwing up. . # HTN: patient currently normotensive, has hx of malignant hypertension. On nifedipine and toprol at home. Home meds were held in setting of bleed and being NPO, but were re-started after patient was stable. . # ESRD: patient on MWF [**Month/Year (2) 2286**], had shortened session the day of admission in light of his presenting symptoms. Electrolytes stable. He was hyperkalemic post procedure, but had no EKG changes and HD was done on his normal schedule. . # DM: given half doses of insulin while NPO then when eating returned to [**Location 213**] sliding scale. . # HIV: pt with nondetectable VL and CD4 349. HARRT held while NPO, then resumed. . # Hx of PE: last PE in [**2108**], has been anticoagulated since then. In setting of GI bleed, held anticoagulation, but restarted after he was stable. Medications on Admission: Lamivudine 10 ml daily; take after [**Year (4 digits) **] on HD days Fexofenadine 60 mg once to twice daily Tenofovir Disoproxil Fumarate 300 mg qweek on Saturdays Sensipar 90 mg daily Regular insulin per sliding scale Insulin NPH 10u qam and 7u qpm Raltegravir 400 mg [**Hospital1 **] Intelence 200 mg [**Hospital1 **] Aspirin 325 mg qday Metoclopramide 10 mg TID Clotrimazole 10 mg prn Nifedical XL 60 mg [**Hospital1 **] Colace 50 qHS Coumadin 4mg qdaily Neurontin 200 mg TID Toprol XL 100 mg [**Hospital1 **] Discharge Medications: 1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 2. Lamivudine 10 mg/mL Solution Sig: One Hundred (100) mg PO DAILY (Daily). 3. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 8. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia for 10 days. Disp:*20 Tablet(s)* Refills:*0* 9. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*60 Tablet(s)* Refills:*0* 10. Pantoprazole 40 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* 11. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 12. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: One (1) Subcutaneous twice a day: Please take 10 units in the AM, 7 in the PM. 13. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection three times a day: Per sliding scale. 14. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain for 10 doses. Disp:*15 Tablet(s)* Refills:*0* 16. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Per INR. Discharge Disposition: Home Discharge Diagnosis: - [**Doctor First Name **]-[**Doctor Last Name **] Tear of Esophagus - Right Internal Jugular Thrombus - Type 1 diabetes - HIV: dx'd [**2096**]; (CD4 count [**5-19**] 346, undetectable VL) - ESRD on HD MWF, attempted on PD on transplant list (clinical study for HIV/solid organ transplant) - PE, on Coumadin, diagnosed [**6-16**] - Malignant Hypertension - hx Serratia bacteremia (presumed AV graft) tx 6 wks meropenem - Hx schistosomiasis - Restless leg syndrome - Peripheral neuropathy on gabapentin - S/p cholecystectomy - s/p R nephrectomy in [**2092**] secondary renal nephrolithiasis Discharge Condition: afebrile, tolerating regular diet, stable Discharge Instructions: You were admitted with bloody vomit. It was discovered that there was a large tear in your esophagus. This was managed with clips and you never bled again. Afterward you developed a terrible headache but a CT scan showed no bleeding in your brain. Last, we discovered a clot in your neck vein around your [**Year (4 digits) 2286**] port. With regard to this clot, our plan will be for you to follow up with Dr. [**Last Name (STitle) 1366**] and determine whether it is appropriate for you to change the site of your catheter. You INR (coumadin number) is 2.5 today and is within the range we want you to be. Given the tear in the esophagus, you do have a risks of bleeding on coumadin, but have a risk of clots while not taking coumadin. We discussed this and you were interested in restarting coumadin. . Return to the hospital if you have any bleeding with vomiting, any black or tarry stools, high fevers, facial swelling or any symptoms that concern you. . . NEW medications Sevelamer - this medication will help with your phosphate levels that are high because of your kidney disease Reglan - you have taken this medication before, use it three times daily to help with your nausea. Pantoprazole - this helps reduce stomach acid Ambien - you have taken this before; take 5-10 mg each night as needed for sleep. Never take more than prescribed. Cinicalcet - Please take this medication before bedtime. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4026**]. You can reach him at [**Telephone/Fax (1) 250**]. Please see him in [**12-12**] weeks. Please call the GI offices at ([**Telephone/Fax (1) 2233**] and make an [**Telephone/Fax (1) 648**] with any gastroenterologist within the next [**12-12**] weeks. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2111-7-21**] 8:20 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Date/Time:[**2111-7-21**] 10:00 Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2111-7-21**] 4:00

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48018

Discharge summary

report

Admission Date: [**2131-10-11**] Discharge Date: [**2131-10-25**] Date of Birth: [**2051-2-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Found Down Major Surgical or Invasive Procedure: None History of Present Illness: 80 year-old F with HTN, hyperlipidemia, spinal stenosis, mild renal insufficiency who had EMS called after she did not make an appearance for days. Patient is incoherent thus most of the history is obtained from previous records. [**Name (NI) **] sister in law ([**Name (NI) **] [**Name (NI) 3748**] [**Telephone/Fax (1) 101284**]) can be contact[**Name (NI) **] in the morning for confirmation of her information. Sister in law reported having contact last week and the patient appeared normal without any concerns. . Patient was not seen by her neighbors "for days" as they noted her mail was piling up and subsequently they called EMS to address their concern. EMS found an elder female that responded to her name, but was disoriented. She was found down on her right side on the floor, incontinent of stool and urine. Although she couldn't give purposeful answer, she was able to voluntarily move her extremitites. Patient was also noted to have multiple old lacerations on her knees and elbows. . EMS placed a cerical spine collar and she was brought to [**Hospital1 18**] ED. In ED patient received 30 mg of Kayexcalate; 1 amp D50, 10 units of insulin; She also received 150 mEq bicarb in 1L of NS. . ROS has to be defered as patient is not able to give history. Past Medical History: -hypertension -spinal stenosis -GERD -hyperlipidemia -chronic renal insufficiency, baseline creatinine 1.5-1.9 -cataracts s/p surgery -right total knee replacement -rheumatoid arthritis -cervical laminectomy in [**2117**] Social History: Lives alone at home. No history of tobacco abuse. She occasionally drinks alcohol. She is a retired transcriptionist. Family History: Mother died of alcohol-related disease. Father died of pneumonia. Physical Exam: Vitals: 96.3 149/73 (140-150) HR 120 (110-120) RR 14 Sats 98% General: patient minimally responsive to name and noxiuos stimuli, NAD, deep respirations HEENT: NC/AT, no scleral icterus noted, 4 mm -> 3 mm reactive pupils, grossly clear OP, dry MM Neck: Cervical collar in place, no tenderness elicited Lungs: CTAB/l without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, hypoactive bowel sounds, no organomegaly, patient with tenderness and guarding over RUQ Back: no spinal tenderness, deformities appreciated. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: multiple abrasions over body, most notable large echomosis over the R lower ribs . Neurologic Exam per Neuro consult team: -mental status: Lying in bed with eyes open, mumbling incoherently. Inattentive. She will state her name, but does not answer any other of the examiner's questions. Does not follow commands. Her speech is mostly unintelligible. -cranial nerves: PERRL 3 to 2mm. Funduscopic exam was technically limited as the pt repeatedly forcefully closed her eyes on attempt to visualize fundus, but not overt papilledema. EOMI (observed when she spontaneously looked around the room, she would not track however). Left eye deviated slightly to the left. Corneal reflex and nasal tickle present bilaterally. No overt facial asymmetry. -motor: Mild wasting of intrinsic muscles of the hands. Tone increased in lower extremities. Withdraws to noxious stimuli in all four extremities briskly, except the right arm. She was seen to move all extremities spontaneously and purposefully, however (e.g. attempting to pull out IV and remove nasal canula and cervical collar). Some instances of myoclonus noted. -sensory: Grimaces to noxious stimuli in all four extremities, except in right arm. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 3 1 R 2 2 2 3 1 Plantar response was extensor bilaterally. Pertinent Results: [**2131-10-11**] 11:46PM URINE HOURS-RANDOM UREA N-498 CREAT-7 SODIUM-26 [**2131-10-11**] 11:46PM URINE OSMOLAL-360 [**2131-10-11**] 11:46PM URINE EOS-NEGATIVE [**2131-10-11**] 08:43PM TYPE-ART O2 FLOW-2 PO2-206* PCO2-41 PH-7.33* TOTAL CO2-23 BASE XS--4 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2131-10-11**] 06:00PM GLUCOSE-127* UREA N-157* CREAT-7.8*# SODIUM-140 POTASSIUM-6.6* CHLORIDE-107 TOTAL CO2-9* ANION GAP-31* [**2131-10-11**] 06:00PM ALT(SGPT)-46* AST(SGOT)-50* LD(LDH)-337* CK(CPK)-1042* ALK PHOS-89 AMYLASE-28 TOT BILI-0.4 [**2131-10-11**] 06:00PM CK-MB-20* MB INDX-1.9 [**2131-10-11**] 06:00PM cTropnT-0.11* [**2131-10-11**] 06:00PM TSH-0.94 [**2131-10-11**] 06:00PM WBC-11.1* RBC-4.47 HGB-12.9 HCT-38.8 MCV-87 MCH-28.9 MCHC-33.3 RDW-14.8 [**2131-10-11**] 06:00PM PT-14.9* PTT-25.7 INR(PT)-1.3* . CT Head: IMPRESSION: 1. Large extra-axial right posterior fossa mass with small calcifications suggestive of a meningioma. There is significant mass effect on the right cerebellar hemisphere and fourth ventricle, but no hydrocephalus is seen. 2. Tiny focus of hyperdensity along the lateral left frontal lobe, which is likely artifactual. . MRI Head: IMPRESSION: Limited examination due to patient motion artifact. The patient's right cerebellopontine angle meningioma has dramatically increased in size and now has considerable mass effect upon the underlying cerebellum and brain stem. There is displacement and compression of the fourth ventricle, however, there is no evidence of hydrocephalus with no change in the configuration of the lateral ventricles from [**2125-11-22**]. . MR C/s [**10-16**]: 1. Ligamentous injury cannot be ruled out in the setting of limited examination due to severe motion artifact. 2. Severe spinal canal narrowing at the levels of C2-3 and C3-4 as described above. Increased T2 signal in the spinal cord at the same level, that could be due to chronic stenosis changes, however contusion of the spinal cord cannot be ruled out in the setting of trauma. 3. Spinal cord atrophy at the level of C4-5. Syrinx at the level of C4 and C4-5 disc. 4. Posterior fossa mass, previously characterized as meningioma. . CT head [**10-16**]: IMPRESSION: Large right cerebellopontine angle meningioma with mass effect upon the fourth ventricle and brainstem. The lateral ventricles are slightly more prominent than on the prior examination, which could be a sign of early hydrocephalus. . CXR ([**10-17**]): Compared with [**2131-10-11**], an NGT is now present with its tip near the lower edge of the image in the proximal stomach, with the proximal sidehole marker below the GE junction. The heart, lungs, and mediastinum are unremarkable. . TTE: 1. The left atrium is mildly dilated. 2.There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**11-27**]+) mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. Brief Hospital Course: 80 y.o. F with HTN, CRI, GERD, brought to [**Hospital1 18**] after having found down for presumable several days. Patient found to be in acute renal failure, rhabdomyolysis, and profound encephalopathy with newly discovered 3x4 cm meningioma. . In the MICU, her electrolytes improved to a creatinine of 5.8 and a K of 4.3. Her sodium rose slowly to 151 but she could not receive free water due to increased ICP. She had an MRI confirming the large mass (see report below). Her mental status slowly improved to the point where she could answer questions intermittently. An NGT was unable to be placed [**12-28**] coiling in mouth. She was begun on decadron (10 mg IV x1 then 4IV q6h) per neurology recs. EEG was done that was consistent with diffuse encephalopathy. MRI C-spine was also recommended by neuro (C-spine unable to be cleared clinically) but was inconclusive to clear her c-spine. Her bicarb gtt was changed to NS per renal recs, and was then changed just to PPN as she was felt to be euvolemic and did not require more fluid resuscitation. She was called out to the floor on [**10-13**]. She was never unstable from a hemodynamic or respiratory standpoint. . On the night of [**2047-10-15**] she triggered for hypotension (sbp in the 80's). She responded to IVF after 500 cc bolus of LR (250 cc times two) with pressure coming up to 102 systolic. There was concern for early sepsis since [**2-27**] blood cultures were positive for GPC and had MSSA in urine. She was transferred to the MICU for further management. In the MICU she was volume resuscitated with LR and then with D5 1/2NS. She did not require pressors and recovered her BP on her own. She was started on Ceftazidime and Nafcillin. Per ID vancomycin was added prior to speciation/sensitivities to cover possible MRSA. Ceftaz was then discontinued. The patient had a NG tube placed and was noted to have blood returning from it. Her hct was serially monitored and remained stable. On the evening prior to transfer the patient's next of [**Doctor First Name **] was contact[**Name (NI) **] to discuss the patient's poor prognosis and goals of care. The decision was made to make her DNR/DNI. She was transferred to the floor when BP was stable. . While on the genral medicine floor she continued to have waxing and [**Doctor Last Name 688**] mental status, intermittently answering questions but overall no major improvement was made in her hospitalization. A family meeting was held with her brother, [**Name (NI) **] [**Name (NI) 3748**] and his wife [**Name (NI) **], with the medical team and palliative care services. At that meeting they were informed of her hospital course and overall poor prognosis and decided that the plan of care most concordant with her wishes would be to provide comfort measures only, stopping invasive interventions such as IV medications, antibiotics, feeding tubes, hemodialysis (should it have become necessary), endoscopic evaluation, vital signs and lab draws. . 1. ARF - Baseline Cr 1.3. Not oliguric. Acute renal failure was most likely due to rhabdomyolysis with elevated CK in the setting of prolonged hypoperfusion versus progressive ATN. Creatinine continued to trend down during this hospital course though no where near baseline, urine lytes [**10-21**] and renal US most consistent with intrinsic renal disease. Renal service was consulted during this admission, suspect ischemic ATN. She continues to make urine though minimal (35cc/hr). No need for HD at this point, given goals of care. . 2. HYPOTENSION: Patient became hypotensive on floor and was transferred back to MICU for IVF resuscitation. Responded to rehydration and did not require pressors. Likely [**12-28**] sepsis given MSSA bacteremia. Now resolved. She was on nafcillin for MSSA bacteremia and MSSA in urine which have cleared. Surviellance cultures have been negative. Nafcillin was discontinued with family approval after goals of care changed to CMO status. . 3 BACTEREMIA: ID followed throughout the admission. Blood cultures from [**10-15**] grew MSSA in [**2-27**] bottles. Urine culture from [**10-14**] also with MSSA. Surveillance blood cultures negative. TTE showed no evidence of endocarditis. Antibiotics discontinued as above after CMO status determined. . 4 GIB: Patient was noted to have both blood per rectum and blood return from NGT. Serial hct were followed in the MICU and remained stable. NGT blood could be [**12-28**] trauma vs gastritis in setting of steroids vs PUD vs AVM. Last colonoscopy in [**2127**] showed diverticula and hemorrhoids as well as polyp.Patient was noted to have both blood per rectum and blood return from NGT. She continued to have guaiac BRBPR and coffee grounds from NGT; however, given goals of care, the team stopped monitoring hct. In line with CMO status, the family did not want aggressive GI work up given goals of care. Morphine and ativan used to keep patient comfortable. Hyosciamine to manage secretions. . 5 ENCEPHALOPATHY - Most likely initial event was due to brain tumor causing syncope/seizure, and then she was down for quite some time causing renal failure which led to altered mental status. The patient had worsening MS [**First Name (Titles) 151**] [**Last Name (Titles) **] findings on [**10-16**] by neuro's neurologic exam. Stat CT showed slight increase in size of ventricle and neurosurg was contact[**Name (NI) **]. [**10-16**] [**Name2 (NI) **] report CT essentially unchanged/no hypdrocephalis and urgent VP shunt not indicated. Given matabolic derangements (ARF) and no evidence of hydrocephalus, there was no plan for VP shunt. Her mental status continues to wax and wane. . 6 Posterior fossa mass - 3.9x3.2cm right posterior fossa mass. Neurology and Neurosurgery were both consulted in the ED and felt there was no acute issues including impending danger of herniation even with significant mass effect on the right cerebellar hemisphere and fourth ventricle. There was no hydrocephalus seen. MRI confirmed larger mass, likely meningioma, with minimal edema. Neurosurgery does not feel that surgery is indicated at this time, but recommended placing patient on decadron, which was done. She was manintained on steroids IV to control edema until goals of care were changed to comfort measures. . 7 THROMBOCYTOPENIA: Patient's platelets have decreased significantly since admission. Were previously normal in the 200s and have trended down over last few days. Found to be 19 yesterday and Heme consult was obtained. Differential includes HIT, ITP, TTP/HUS, DIC, medication induced, ? related to cranial mass. HIT AB negative and unlikely DIC given normal coags, normal FDP and fibrinogen elevated. patient is on adequate steroid dose for ITP which also makes this less likely. Patient does have renal failure, MS changes and thrombocytopenia making TTP concerning, however no evidence of hemolysis on recent labs and no schistocytes. Heme thinks likely medication induced. Could be [**12-28**] nafcillin, however initial platelet drop occurred before first nafcillin dose. Could also be vancomycin so will hold this. Platelets increased after stopping vancomycin. . 8 TRAUMA- patient appeared to be s/p fall onto a sharp/pointed object on the right side. Unable to obtain further history of the incident. Given this finding she was maintained in C-collar as could not be cleared until goals of care changed to comfort when collar was removed, CXR did not show any rib fractures. Abraision wounds on extensor surfaces should be dressed as follows: cleanse all ulcers with commercial wound cleanser, pat dry, for elbows and knee apply wound gel to ulcer bases, cover with allevyn foam, change q3days. . 9 C-SPINE NARROWING: MRI showed narrowing at C2-C3 and C3-4 and Increased T2 signal in the spinal cord at the same level, that could be due to chronic stenosis changes, however contusion of the spinal cord cannot be ruled out in the setting of trauma. Placed back in c-collar for stabilization, which was removed once goals of care changed to comfort measures only. . 10 HYPERNATREMIA: This evolved during her hospital course thought to be secondary to free water restriction inate to mental status changes and resolved following IVF hydration with D5 1/2NS. Will continue to follow. . 11 HYPERTENSION - patient was hypertensive on arrival in the unit, which may be due to mass effect seen on CT. Neuro recommends maintaining SBP<160, antihypertensive medications were held to allow autoregulation and her blood pressure actually became of hypotensive as described above. . 12 CHF - EF previously 45%, however recent TTE showed normal EF. currently no signs of volume overload. She did not have any active issues with regard to her CHF. . 13 Hyperlipidemia - her statin was held out of concern for rhabdomyolisis with her fall and not restarted. Medications on Admission: Nifedipine 90mg PO daily Aldactone 50mg PO BID Anucort 25mg prn Captopril 50mg PO TID Ecotrin 325mg PO daily Lipitor 10mg PO daily Omeprazole 20mg PO daily Vioxx 25mg PO daily Zanaflex 2mg PO daily Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-27**] Drops Ophthalmic PRN (as needed). 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q4H (every 4 hours) as needed for oral secretions. 5. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-10 MG PO Q1-2H () as needed for discomforrt, shortness of breath, aggitation. 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for aggitation, shortness of breath: Please give as sublingual tablets. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1) Meningioma 2) Acute renal failure 3) Bacteremia 4) UTI 5) Gastrointestinal Bleed 6) Thrombocytopenia 7) Hypernatremia 8) Mental status changes Discharge Condition: Stable Discharge Instructions: Please continue all medications as prescribed to achieve maximal comfort. Followup Instructions: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

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icd9cm

[ [ [] ] ]

[ "96.08" ]

icd9pcs

[ [ [] ] ]

17384, 17450

7535, 16381

328, 334

17640, 17649

4090, 4943

17771, 17908

2033, 2101

16630, 17361

17471, 17619

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2116, 2840

277, 290

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4952, 7512

2855, 3068

1656, 1880

1896, 2017

7,709

151,800

45263

Discharge summary

report

Admission Date: [**2168-6-29**] Discharge Date: [**2168-8-2**] Date of Birth: [**2089-4-28**] Sex: F Service: MEDICINE Allergies: Plaquenil / Daypro / Atenolol Attending:[**First Name3 (LF) 689**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization [**2168-7-5**]. Left-sided thoracentesis [**2168-7-7**]. VATS and pericardial window [**2168-7-18**] History of Present Illness: 79 year-old long-standing smoker with atrial fibrillation on Coumadin, CHF (EF 40%) presumed non-ischemic, and HTN who presents with shortness of breath and pedal edema. She reports the onset of left side chest pain about 3 weeks ago, located under her lower rib cage, [**8-15**], pleuritic, intermittent, non radiating. She endorses associated nausea and dry heaves x 2-3 days. Nausea subsided, but intermittent pain continued. Approximately 2 weeks prior to admission, she also noted progressive shortness of breath. She reports feeling fatigued and SOB after walking for only 10 minutes, which was much less than her baseline. She may have noted onset DOE about a month prior to admission, but not significant until about 2 weeks ago. She also reports new bilateral ankle swelling. Denies orthopnea, PND, or SOB at rest. Symptoms of DOE became progressively worse, until patient could not wash her dishes w/o feeling SOB. Of note, recently taken off digoxin in the last month (caused blurry vision). Today she went to PCP for evaluation who referred her to the ED for further evaluation. ROS remarkable for occasional chills at night, no fevers. + dry, non-productive cough x 2 weeks. No sick contacts/recent travel. + 13 lb weight loss over last year. Denies melena/BRBPR. Reports 100% medication compliance and no dietary indiscretion. In ER, CXR done revealing mild CHF, with possible L pleural effusion. She was given ASA 325mg, levofloxacin, and lasix 20 mg IV x 1. Past Medical History: 1. Non-ischemic cardiomyopathy, last echo with EF 40% in 10/[**2167**]. Small ASD. Previously negative MIBI in [**2164**]. 2. Hypertension 3. Atrial fibrillation on Coumadin 4. Hypercholesterolemia, previously on statin 5. Occipital migraines. 6. Seronegative rheumatoid arthritis 7. History of gout 8. Colonic polyp, benign pathology. Last colonoscopy [**2168**]. 9. Nephrolithiasis 10. Osteoporosis 11. Spinal stenosis Social History: She is married and lives with her husband. [**Name (NI) **]-standing smoker, still smoking. No alcohol. Family History: Mother with diabetes. Physical Exam: Physical examination per admission note: VS: T: 96.7; HR: 115; BP: 130/73; RR: 18; O2: 97% RA GEN: Elderly female, lying in bed, NAD HEENT: PERRL bilat, EOMI bilat, anicteric, MMM, OP clear NECK: JVP @ 9-10cm CV: Irreg/irreg, tachy, normal s1s2, [**3-14**] HSM apex, no S3/S4 CHEST: + Bibasilar crackles (L>R), decreased BS @ L base, dullness to percussion at L base. no wheezes. no egophony. ABD: NABS, soft, NT, ND, no masses EXT: + Pedal edema bilat (L>R). +left calf tenderness. +bilateral ulnar deviation NEURO: CN 2-12 intact bilat, sensory/motor exam intact bilat Pertinent Results: Relevant laboratory data on admission: CBC: [**2168-6-29**] 07:10PM WBC-5.5 RBC-3.52* HGB-11.7* HCT-36.0 PLT COUNT-312# [**2168-6-29**] 07:10PM NEUTS-71.7* LYMPHS-23.1 MONOS-2.9 EOS-1.6 BASOS-0.6 Chem 7: [**2168-6-29**] GLUCOSE-126* UREA N-33* CREAT-1.3* SODIUM-136 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17 Cardiac Enzymes: [**2168-6-29**] 07:10PM BLOOD CK(CPK)-114 [**2168-6-29**] 07:10PM BLOOD CK-MB-4 cTropnT-<0.01 proBNP-[**Numeric Identifier **]* [**2168-6-30**] 06:10AM BLOOD CK(CPK)-49 [**2168-6-30**] 06:10AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2168-6-30**] 01:35AM BLOOD CK(CPK)-62 [**2168-6-30**] 01:35AM BLOOD CK-MB-NotDone cTropnT-<0.01 Pleural fluid [**2168-7-7**]: [**2168-7-7**] 04:35PM PLEURAL TotProt-4.3 Glucose-116 LD(LDH)-222 Albumin-2.4 [**2168-7-7**] 06:00AM BLOOD LD(LDH)-239 [**2168-7-7**] 06:00AM BLOOD PROTEIN 5.8 EKG on admission: Atrial fibrillation with rate 99, old LBBB. Relevant imaging data: [**2168-6-29**] LLE U/S: No evidence of DVT in the left lower extremity. [**2168-6-29**] CXR (portable): 1. New retrocardiac opacity could represent atelectasis or possibly early pneumonia. 2. Severe cardiomegaly with possible small bilateral pleural effusions. [**2168-6-30**] CXR PA/LAT: Cardiomegaly with associated left greater than right effusions. These findings are nonspecific with differential considerations in addition to CHF including pericarditis, pleural information, hypoalbuminemia, or pulmonary embolism. [**2168-6-30**] ECHO: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. RA moderately dilated. Small secundum ASD. LV wall thicknesses and size normal. Severe LV systolic dysfunction, EF 30-35%. Resting regional WMAs include HK of the anterior septum and anterior wall along with AK to DK of the mid to distal anterior septum and anterior wall. RV chamber size and free wall motion are normal. No AS. Mild AR. [**3-11**]+ MR. [**First Name (Titles) **] [**Last Name (Titles) **] systolic hypertensioin. Moderate sized pericardial effusion, circumferential, but layers mainly posteriorly. No echocardiographic signs of tamponade. [**2168-7-5**] Cardiac cath: LMCA normal. 40% mid LAD stenosis. No flow limiting disease. PCWP 20mm Hg. [**2168-7-6**] CXR PA/LAT: Stable cardiac silhouette. Small to moderate left-sided effusion, unchanged, ? loculated posteriorly. Likely LLL atelectasis, unchaged. [**2168-7-6**] ECHO: Overall LV systolic function is moderately depressed. RV systolic function appears depressed. There is a moderate sized pericardial effusion. The effusion appears circumferential, however, there is minimal fluid anterior to the RV. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. [**2168-7-7**] CT TORSO: 1. Moderate pericardial effusion. 2. Moderate bilateral pleural effusions. 3. Cardiomegaly. 4. Hypodense lesion in the left kidney upper pole is larger and does not measure simple fluid density. Followup ultrasound is recommended for further evaluation. 5. Multiple bilateral simple renal cysts. CXR [**7-21**]: Unchanged tiny left apical pneumothorax after removal of chest tube. Persistent moderate cardiomegaly with near complete resolution of pulmonary edema. Improving bibasilar atelectasis with small right pleural effusion. . Cytology: Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. . Bx results: Pleura, biopsy (A): A. Pleura with chronic inflammation, fibrosis and focal mesothelial cell hyperplasia. B. Unremarkable skeletal muscle. 2. Pericardium, biopsy (B): Pericardium with chronic inflammation, fibrosis and mesothelial cell hyperplasia with reactive atypia. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7018**] red stain is pending on specimen 2. Once reviewed, an addendum will be issued . [**7-28**]: CXR: The heart size is markedly enlarged but unchanged. The aorta is calcified with no evidence of focal dilatation. The tip of the left chest tube is projecting over the posterior superior pleural space. There is no pneumothorax. The subcutaneous emphysema is unchanged. There is marked decrease in bilateral pleural effusion, especially on the right. The lungs are unremarkable. Brief Hospital Course: Overview: 79 year-old female long-standing smoker, with HTN, atrial fibrillation, non-ischemic cardiomyopathy, and RA on MTX, admitted with DOE, found to have large exudative L pleural effusion, moderate echo-dense pericardial effusion, and renal lesion concerning for renal cell carcinoma, transferred to the ICU with hypotension initially poorly responsive to IVF on the floor. She spent some time in the ICU and then transitioned to the floor after which time she underwent VATS and pericardial window. Drainage into chest tube increased, patient underwent pleurodesis and then spent a night in the ICU for respiratory depression secondary to narcotics overuse. Following the ICU stay, her chest tube continued to have increased drainage and she was in decompensated CHF. She was diuresed with improvement in chest tube output and the drain was removed. She was transitioned back onto coumadin and was stable for d/c home. . 1.) Hypotension: Differential initially included tamponade given her known pericardial effusion, elevated JVP, pericardial friction rub, however her pulsus was < 10 and a bedside echo demonstrates a stable effusion. Additionally, her recent low grade temps, leukocytosis, and warm extremities were worrisome for an infectious/septic etiology. Possible sources would include an infected effusion (fluid culture from thoracentesis is without growth, however could have introduced bacteria during tap), and nosocomial infections such as MRSA and C. Diff. UA was contaminated. Cardiogenic etiology also possible, given h/o mixed CHF. Lastly, over-medication may have been contributing, as she had aggressive up-titration of her Toprol XL to 200 mg daily over the last couple of days (was on only 25 mg at home), with concurrent decline in her renal function which could have mildly affected clearance of the drug. Volume resuscitation was given, with pt receiving approximately 3L of NS over her initially 24hours. All BP meds held initially, then SA metoprolol was restarted at low dose and up titrated. Received one dose of empiric antibiotics to cover MRSA (vancomycin) and gram negative aerobes (levofloxacin), but this was stopped. BP and UO improved over the first 24h with IV hydration. Cultures remained negative. Patient continued to improve over hospital course and was tollerating BP meds at lower doses. This issue became more complicated at the end of the hospital course when patient was being diuresed for decompensated CHF and her BP was in the 90 to 100s range. Her HR was in the 100-110s at this time, but she could not tolerate her BP meds. After adequatly diuresed, she was re-started on her meds. These need to be up-titrated as an outpatient. By the time of discharge her heart rate stabilized in the upper 80s with the sytolic blood pressure in low 100s. . 2.) Bilateral pleural effusions/pericardial effusion: Workup included thoracentesis with exudate based on total protein and LDH criteria (normal cultures, negative cytology), a negative PPD, and positive RF and [**Doctor First Name **], with ESR 47 consistent with RA. There was concern that the effusions could be malignant (cytology only 50% sensitive with one specimen) given the suspicious renal lesion however MRI and ultrasound of L kidney do not show malignancy, only cyctic structures. She did develop significant pericardial effusion as well that became more complicated on echo reports as time progressed. Consulted Thoracic surgery who did a VATS/pleural/pericardial window and bx on [**7-18**]. Chest tube left in place and managed per their recs. Per Rheum, started empiric trial of prednisone to see if all related to RA and medication responsive. Patient was started on Prednisone and slowly tapered down, this did not seem to impact her course. The cultures from the VATS did not grow any organisms and the bx and cytology was negative for malignancy. Chest tube output was excessive and continued for many days. Pleurodesis was attempted on [**7-26**], and following this patient went to ICU for respiratory depression [**3-10**] narcotics use. She was gently diuresed for decompensated CHF x3 days, chest tube drainage decreased and was able to be pulled. After this, she was transitioned back onto her coumadin from the heparin gtt followed by several days on lovenox to complete the transition as an outpatient. . 3.) Atrial fibrillation: Initially her beta-blockers were held while she was hypotensive, but later restarted and titrated up as BP allowed. Held her outpt coumadin in case of VATS or renal bx, maintained on hep gtt and not Lovenox given ARF. EP consult was obtained as it was difficult to rate control her while diuresing for CHF. She was unable to tolerate large doses of BB as EP suggested. Prior to d/c transitioned back to coumadin. D/C cardioversion was considered. However following the gradual diuresis her blood pressure tolerated increasing doses of beta-blockers and her heart rate stabilized in the mid 80's prior to discharge. She was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-of-Hearts monitor so that she could continue to be monitored for her tachycardia. She will be seen in follow-up in the EP cardiology clinic. . 4.) Anemia: Concern initially for hemorrhagic conversion of pericardial effusion in setting of anticoagulation with lovenox, however echo with stable effusion. Patient has baseline iron deficiency and chronic inflammation associated anemia. Unclear etiology of acute change, though at least in part related to hydration. Folate and vitamin B12, as well as TSH, were normal. Stools were guaiac negative, negative colonoscopy in [**2168**]. Continued iron supplements. Hct remained stable >30 for the later half of hospital course. . 5.) ARF: Creatinine appears to be around 0.9 to 1.1 at baseline, rose to 1.4 with decrease in urine output in setting of hypotension. Her urine output had declined to less than 30 cc over a 3 hour period which was attributed to a pre-renal state secondary to her hypotension. Once she became euvolemic and her blood pressure recovered her renal function returned toward her baseline. Her renal function was not impaired following the gradual diuresis to treat her heart failure. . 6.) Hypotonic hyponatremia: Volume status difficult to assess as patient has peripheral edema and markedly elevated JVP (right heart failure), while hypotensive with poor forward flow. Likely multifactorial from hypovolemia, HCTZ. This slowly responded to fluid restriction and was in low 130s prior to discharge. She was stabilized in this regard to the point where she could be restarted on her home dose of HCTZ. . 7.) Rheumatoid arthritis: Effusions could be RA related serositis (see above discussion). Rheumatology followed. She was started on Prednisone ant this was tapered to Pred 20mg until [**8-2**], then pan to change to Pred 10mg for one week. The effusions were likely a combination of RA and CHF. MTX was re-started on [**7-29**], dosed q Friday. She will continue taking Bactrim will on steroids for PCP [**Name Initial (PRE) 1102**]. Patient should follow w/Rheum at outpatient. . 8.) Left renal mass on CT: This lesion was found incidentally on CT; it was concerning for malignancy, RCC or other, especially given h/o hematuria. MRI showed hemorrhagic cystic lesion in the upper pole of the left kidney. Ultrasound showed patent vessels and multiple cysts. Followup in one year is recommended to ensure expected stability. . 9.) CHF: Increased edema, increased output from drian s/p pleurodesis was likely related to CHF. EF known to be 25% this admission. Developed decompensated CHF [**Date range (1) 40196**]. Patient was gently diuresed over 3 days. [**7-30**], output from drain improved, pulmonary exam improved, neck veins improved, Leg edema showed mild improvement. The patient's discharge heart failure regimen consisted of a beta-blocker, diuretic, and coumadin for atrial fibrillation. Her home ACEi dose was stopped in the hospital secondary to low blood pressure and acute renal failure both of which resolved by discharge. The ACEi should be restarted as an outpatient as limited by hypotension. . 10.) Hypothyroid: As part of the evaluation for persistent effusions, her thyroid function was evaluated. She was found to be hypothyroid with TSH 9.2. She was started on thyroid replacement. This will be a new medication for her and should be follow up as an outpatient. . 11.) Proph: PPI and heparin SC . 12.) Code Status: the patient remained Full Code during her hospitalization. . 13.) Dispo: home Medications on Admission: Tylenol prn Allopurinol 300 mg daily Citracal 1500-200 PO BID Citalopram 10 mg PO QHS Folic acid 1 mg PO QD Fosamax 70 mg daily Hydrochlorothiazide 25 mg PO QD Lisinopril 20 mg PO QD Toprol 25 mg PO QD Methotrexate 5mg qweek on Friday Prilosec 40 mg daily Coumadin 5 mg PO QD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily): Do not use if you are smoking. Disp:*7 Patch 24HR(s)* Refills:*2* 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days: Take while on the prednisone. Disp:*7 Tablet(s)* Refills:*0* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg Subcutaneous Q12H (every 12 hours) for 4 days: Use until blood work demonstrates the coumadin is at the right level. Disp:*8 syringes* Refills:*0* 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 15. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Methotrexate 2.5 mg Tablet Sig: Four (4) Tablet PO 1X/WEEK (FR). Disp:*48 Tablet(s)* Refills:*2* 17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): This dose may need to be changed, talk to Dr. [**Last Name (STitle) 1683**]. Disp:*30 Tablet(s)* Refills:*2* 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 19. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Bilateral exudative pleural effusions Pericardial effusion Non-ischemic cardiomyopathy Mild acute renal failure, resolved Rheumatoid arthritis Probable renal cell carcinoma Discharge Condition: Patient discharged home in stable condition. Ambulating. Taking good POs Discharge Instructions: Please note that we have made some changes to your medications. Please take all medications as prescribed. Please return to the hospital or call your PCP if you develop chest pain, worsening shortness of breath, increasing leg swelling, dizziness or lightheadedness, or if you have a new fever. Please note that we have made some changes to your medications. Please take all medications as prescribed. Talk to Dr. [**Last Name (STitle) 1683**] about re-starting some of your old medications as on outpatient. You will need to take the Lovenox injections until your bloodwork shows that your coumadin is at the right level. VNA should check your blood on Thursday. You will need [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor. Follow the instructions. This will be reviewed and if there is a problem with your heart rate, the cardiology department will contact you sooner. You will send the results once a day at varrying times for 2 weeks so we can keep track of your heart rates. We are tapering your Prednisone to see if this will help with the fluid around your heart and lungs, which could be related to your rheumatoid arthritis. Please arrange a follow-up appointment with Dr. [**Last Name (STitle) **] within 2 weeks. Please return to the hospital or call your PCP if you develop chest pain, worsening shortness of breath, increasing leg swelling, dizziness or lightheadedness, or if you have a new fever. Followup Instructions: 1. Please call your primary care physician and schedule an appointment to be seen within 2 weeks to discuss your hospital admission. 2. Please also call Dr. [**Last Name (STitle) **] and schedule an appointment to be seen within 2 weeks to discuss your Prednisone course. Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD Phone:[**Telephone/Fax (1) 2309**] Date/Time:[**2168-8-15**] 11:15 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2168-8-18**] 1:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2168-11-23**] 11:30

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icd9cm

[ [ [] ] ]

[ "37.24", "34.92", "99.21", "34.91", "37.23", "88.56", "34.24" ]

icd9pcs

[ [ [] ] ]

18709, 18784

7410, 16026

308, 435

19001, 19076

3153, 3178

20582, 21328

2522, 2545

16352, 18686

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3494, 4017

249, 270

463, 1941

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69,433

122,170

47714

Discharge summary

report

Admission Date: [**2139-7-8**] Discharge Date: [**2139-7-15**] Date of Birth: [**2054-4-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1943**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Upper and lower endoscopy [**2139-7-14**] History of Present Illness: 85 yof with hisory of DM2, Afib on Coumadin, HTN, HL, CKD with baseline 2.8-3.5, hx of Anemia with baseline HCT 25, ?hx of LGIB who presents from home with weakness. Patient reports weakness x 6 weeks along with dark stools. She contact[**Name (NI) **] her [**Name (NI) **] endocrinologist today who then referred her to the ED. In the ED, initial vs were: T 98.4, P 96, BP 115/35, R 16 O2 sat. 100%. Hct found to be 13.0, INR 1.8. Patient was given 1uPRBC, vitamin K 10 mg IV. Rectal exam revealed maroon stool, guaiac +. NGL negative. GI was consulted, and recommended transfusing to keep Hct > 25-28%, and to consider colonoscopy and possible EGD later in the week. On the floor, the patient's vitals are 97.7, 103 (afib), 119/49, 13, 100% room air. She endorses chronic generalized weakness over past six weeks, but denies any acute worsening. Denies lightheadedness, dizziness, dyspnea, chest pain, or palpitations. Denies fevers, chills, sweats, weight changes, or change in bowel or bladder habits. Review of sytems: (+) Per HPI. Also endorses chronic knee pain from osteoarthritis. (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, nausea, vomiting, or abdominal pain. No dysuria. Past Medical History: - Type 2 Diabetes Mellitus - Atrial Fibrillation on Coumadin - Hypertension - Hyperlipidemia - Pulmonary arterial hypertension - Chronic kidney disease - Anemia - Hyperparathyroidism s/p parathyroidectomy [**6-21**] - Pelvic fracture lateral compression type I and a left proximal humerus fracture [**10-21**] - s/p Hysterectomy Social History: Denies tobacco or illicit drug use. Occasional EtOH use. Lives with sister, walks on her own Family History: Her mother had hypertension, died at 89. Her father had lung cancer, died at 74. Denies colon cancer, colon polyps in family. Physical Exam: Vitals: 97.7, 103 (afib), 119/49, 13, 100% room air General: Alert, oriented, [**Last Name (un) 664**], appropriate, no acute distress HEENT: +conjunctival pallor. Sclera anicteric, MMM, OP clear. No tonsillar exudate Neck: supple, no appreciable JVD or LAD Lungs: CTAB, no wheezes, rales, rhonchi. Good inspiratory effort CV: Irregularly irregular, 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, symmetric 2+ radial/DP/PT pulses, no clubbing, cyanosis or edema. No joint effusions. Pertinent Results: [**2139-7-8**]: WBC 6.6, HCT 13, PLT 324, MCV 101 Na 138, K 4.8, Cl 104, Bicarb 21, BUN 116, Cr 5.1, Gluc 107 Ca [**39**].3, Mg 2.2, P 4.6 PT 19.5, PTT 29.1, INR 1.8 [**2139-7-14**] WBC-7.2 Hct-32.3* MCV-91 Plt Ct-143* [**2139-7-15**] Hct-32.6* Glu-85 UreaN-38* Cr-2.5* Na-137 K-4.2 Cl-104 HCO3-21* EKG: Afib @ 95 bpm, normal axis, normal interval, TWI II, III, AVF, new ST depressions V4-V6 CXR [**2139-7-8**]: No acute cardiopulmonary abnormality. No definite evidence of free air beneath the diaphragms, given semi-upright study. EGD [**2139-7-14**]: Normal mucosa in the esophagus A few small fundic gland polyps in the stomach Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum COLONOSCOPY [**2139-7-14**]: Diverticulosis of the sigmoid colon, descending colon and transverse colon Several AVMs were noted in the cecum, with some of them actively oozing. Bicap was applied over the bleeding AVMs and hemostasis achieved. Internal hemorrhoids Otherwise normal colonoscopy to cecum Brief Hospital Course: Ms. [**Known lastname **] is an 85 year-old lady with DM2, Afib on Coumadin, HTN, HL, CKD(baseline Cr 2.8-3.5) anemia (baseline HCT 25) and prior lower gastrointestinal bleeds who presented from home with weakness and was found to be profoundly anemic in the ED, with HCT of 13. The patient was admitted to the ICU for active GIB. She was given 7 units PRBC and HCT stabilized in the 30's. She was subsequently transferred to the floor. Her HCT was stable in the 30's over the weekend while she waited for EGD/Colonoscopy. EGD/Colonoscopy revealed active oozing of blood from AVMs in the colon. HCT remained stable for 24 hours after the procedure and the patient was discharged home with services. PROBLEM LIST: 1. LOWER GI BLEED [**3-17**] bleeding AVMs in colon: Ms. [**Known lastname **] presented with weakness, maroon stools and HCT 13, which was concerning for GI Bleed. Given her prior colonoscopy reports, she has known polyps and diverticuli. The most likely source of her LGIB was diverticular bleed and also on the differential are arteriovenous malformations. Per report from GI fellow and ED resident, she had guiac positive maroon stools with fresh clot on presentation. She required a total of 7unts of PRBC over 48 hours given tachycardia and continued maroon stools. Her tachycardia resolved and her hct stabalized out. In the ICU she continued to have some bloody bowel movements but was otherwise stabe and so transferred to the medical floor. Endoscopies were performed and found bleeding AVMs. It is recommended that the patient undergo capsule enteroscopy to evaluate for AVMs in the small intestine. Anticoagulation for Afib will be deferred to PCP. [**Name10 (NameIs) **] that the patient stay off of anticoagulation for at least several weeks to allow areas of bleed to heal. 2. ATRIAL FIBRILLATION ON COUMADIN/EKG CHANGES: Pt's INR was 1.8 on admission and she received Vit K 10mg IV x 1 and 2u FFP. Her INR was 1.3 on 2nd hospital day and coumadin was held. Her baseline ECG had some ST depressions which were more pronounced in the setting of tachycardia and GI bleed. Her cardiac enzymes were negative and a repeat ECG did not show any dynamic changes. The patient had episodes of RVR that were controlled with her home dose of propranolol. Anticoagulation has been discontinued because of the recent severity of GIB. Pt to discuss with PCP regarding safety of restarting anticoagulation. 3. [**Name (NI) **] Pt was normoglycemic on admission labs. Humalog dose was decreased while in-house. Blood sugars were not too elevated on reduced dosing, so patient discharged on reduced dose. PCP to increase dose as needed for optimal control. 4. ACUTE ON CHRONIC RENAL INSUFFICIENCY: Baseline creatinine appears to be ~3.0. Was 5.1 on admission labs. Perfusion-related renal injury given significant anemia seems most likely. Pt's creatinine was closely monitored and improved with volume resuscitation. The Cr reached a nadir of 2.3. 5. HYPERTENSION: pt has hx hypertension but was hypotensive (relative to her baseline) in the ICU, likely in the setting of volume depletion from blood loss. BP was closely monitored and improved with volume resuscitation. Home anti-hypertensive regimen including diovan, nifedipine, furosemide and hydralazine was held in ICU. Pt was restarted on hydralazine, propranolol, and half dose of valsartan by the end of hospitalization. Nifedipine and Furosemide were held during the entire hospitalization and may be restarted by PCP as indicated. Medications on Admission: Digoxin 125 mcg PO DAILY Cholecalciferol 50,000u qweek Folic Acid 1mg PO DAILY Furosemide 80mg PO DAILY Hydralazine 50mg PO TID Lispro Protam & Lispro (75-25) Suspension 25U qAM, 40U qPM Nifedipine 90mg PO DAILY Pantoprazole 40mg PO BID Warfarin 2.5mg PO DAILY Diovan 320mg PO DAILY Simvastatin 40mg PO qHS Propanolol 80mg PO DAILY Calcium Carbonate 600 PO BID Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Subcutaneous : 25 units each morning and 40 units each evening. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Propranolol 80 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 9. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Previous dose was 320mg daily. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PRIMARY DIAGNOSES: - Lower gastrointestinal bleeding, from arteriovenous malformations - Anemia, severe, from acute blood loss and chronic kidney disease SECONDARY DIAGNOSES: - Type 2 diabetes mellitus - Atrial fibrillation - Hypertension - Hyperlipidemia - Pulmonary arterial hypertension - Chronic kidney disease 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 presented to the [**Hospital1 69**] with a lower gastrointestinal bleed and a critically low hematocrit of 13. You were admitted to the ICU for close monitoring. You received a total transfusion with 7 units of packed red blood cells. Your hematocrit stabilized in the low 30's. Upper and lower endoscopies were performed on [**2139-7-14**]. Active bleeding was seen in the colon from what is called an AVM (arteriovenous malformation) and were stopped. You should follow up with a gastroenterologist for follow up. AVMs may also be present in the small intestine, so you may discuss with your primary care physician or GI doctor regarding the utility of a capsule enteroscopy in assessing for AVMs in the small intestine. MEDICATION CHANGES (Do not restart STOPPED medications until discussing them with your primary care physician): 1. REDUCED DOSE: Insulin 75/25: take 10 units in the morning and 15 units in the evening (previously 25 units in the morning and 40 units in the evening) 2. REDUCED DOSE: Valsartan (Diovan) 160mg daily (previously 320mg daily) 3. STOPPED: Furosemide (Lasix) 80mg daily 4. STOPPED: Nifedipine 90mg daily 5. STOPPED: Warfarin (Coumadin) 2.5mg daily Followup Instructions: APPOINTMENT #1: Department: [**Hospital3 249**] When: TUESDAY [**2139-7-21**] at 1:10 PM With: [**Company 191**] POST [**Hospital 894**] CLINIC with Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] Phone: [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. APPOINTMENT #2: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2139-7-28**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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Discharge summary

report

Admission Date: [**2157-3-12**] Discharge Date: [**2157-4-8**] Date of Birth: [**2077-6-3**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**Doctor First Name 5188**] Chief Complaint: left thigh cellulitis, leukocytosis, thrombocytopenia, anemia, duodenal perforation Major Surgical or Invasive Procedure: [**2157-3-21**]- 1. Exploratory laparotomy. 2. Extended right colectomy and ileostomy. [**2157-3-22**]- Exploratory laparotomy, drainage of abscess in the lesser sac. [**2157-3-31**]- 1. Transthoracic ultrasound. 2. Tube thoracostomy (14-French pigtail) left side. PICC Line Placement Left thigh skin biopsy History of Present Illness: The patient is a 79-year-old male with past medical history significant for HTN, hypercholesterolemia, coronary artery disease, atrial fibrillation, premature atrial tachycardia, CHF, anxiety/depression and prior squamous cell cancer of the anus (s/p resection, chemotherapy and radiation -[**2151**])who presents now as a transfer from [**Hospital6 17032**] with CBC and differential concerning for acute leukemia. The patient went to PCP earlier this week with main complaint of left thigh cellulitis. The patient was sent to ED after CBC labs were markedly abnormal. ED labs on [**2157-3-11**] showed a marked leukocytosis to 45.7, platelet count of 15, Hct 26.8, Hgb 9, MCV 93.7. Manual differential showed 34% blasts, 5% promyelocytes, 12% myelocytes, 14% metamyelocytes, 14% bands, 14% neutrophils, 1% lymphocytes, 5% monocytes, 2% eosinophils, 7% nucleated RBCs. . At OSH a hematology/oncology consult was called and team felt his presentation was that of possible CML with blast crisis given increased blasts on differential. He was given 1 Unit of irradiated platelets and platelets rose from 15 to 26. He also received Hydrea 500mg x 2 doses. No blood transfusions. He was started on allopurinol 100mg Po tid. DIC panel showed INR 1.5, fibrinogen 347.8, d-dimer 1422. He had no fever spikes throughout his brief course at OSH and blood cultures were negative to date at transfer time. . In terms of his left thigh sores, Mr. [**Known lastname 68754**] explains that he went to his PCP [**Name Initial (PRE) **] 3 days ago complaining of left thigh "painful boils and redness" that had developed slowly over about 1.5 weeks. He was placed on PO Keflex for a few days. Then at ED, infectious disease team was consulted at OSH and placed him on IV Vancomycin and IV Ancef which he has been getting for last day leading up to his transfer. . Oncologic history is significant for prior squamous cell cancer of the anus that was resected and treated with 5-FU and mitomycin with radiation. His treatment ended on [**2151-12-2**]. Staging T2NOMO. Per OSH records, the patient had been in [**4-/2156**] for a routine visit with his cardiologist and labs at that time (for comparison) showed WBC 4.5 with 62% neutrophils, 1% bands, 11% atypical lymph cells, 17% monocytes, and platelets of 149. Also of note, he explains having been exposed to multiple chemicals and fumes while he worked in autobody business for many years. . Upon arrival to [**Hospital1 18**] BMT Unit his vitals were: temp 98F, BP 116/80, HR 83, RR 20, O2 Sat 94% RA. He appeared to be in no apparent distress. He complained of some diarrhea he had been having x 4 days since starting antibiotics. . Past Medical History: -Squamous Cell CA of anus ([**2150**], s/p chemotherapy and surgical resection) -Hypertension -Hypercholestrolemia -CHF -Atrial Fibrillation (cardioversions x 2) -taken off Coumadin last month for GI Bleed concerns -Premature Atrial Tachycardia -Colonic Polyps - s/p polypectomy [**3-/2156**] -Anxiety -Depression Social History: The patient is married and lives on [**Location (un) **] with his wife and daughter. [**Name (NI) **] is a retired autobody worker. Of significance, he reports exposure to multiple fumes and paint chemicals over the years while he worked in auto industry. He smoked 1PPD x 20years and quit 35 years ago. He used to drink 24 beers/week but stopped drinking 10 years ago. No history of IVDU/ illicits. Patient states he was exposed to multiple fumes and chemicals while working in autobody business for many years. . Family History: Patient states his mother died of CVA at 89yo, father died of MI at 69yo. He had an aunt who had cancer and died in 50s when he was young but he is uncertain of additional details and type of maliganncy. Patient denies any other known blood conditions or malignancies in family. Physical Exam: VS: temp 98F, BP 116/80, HR 83, RR 20, O2 Sat 94% RA. GENERAL: No acute distress. Oriented to person, place and time, affect appropriate. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Tongue erythematous/bright pink, no patchy thrush noted. NECK: Supple with JVP of 7cm. No cervical LAD LN: No head/neck lymphadenopathy, no groin/axillary/supraclavicular nodes noted CARDIAC: PMI nondisplaced. Irregular rhythm, S1/S2 appreciated, [**3-11**] holosystolic murmur at apex, no rubs/gallops. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Respirations were unlabored, no accessory muscle use. CTA bilaterally. No crackles, wheezes or rhonchi. ABDOMEN: large vertical 11" midline well healed scar, soft, NTND. No HSM or tenderness. Obese. Unable to palpate spleen but limited due to habitus. EXTREMITIES: 1+ bilateral pedal edema, 2+ pedal pulses bilaterally SKIN: Left thigh with outlined erythema of approximately 4x4x5" area and large central 2cm boil with pus at edges, no bleeding, no palpable masses but area edematous with scattered satellite boils and furuncles. No rashes. Stasis dermatitis at lower extremities. No petechiae. NEURO: CNs [**3-17**] grossly intact, no focal sensory or motor deficits, gait assessment deferred . At Discharge: Pertinent Results: [**2157-3-12**] 05:10PM GLUCOSE-99 UREA N-23* CREAT-1.1 SODIUM-134 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-13 [**2157-3-12**] 05:10PM estGFR-Using this [**2157-3-12**] 05:10PM ALT(SGPT)-13 AST(SGOT)-35 LD(LDH)-459* ALK PHOS-69 TOT BILI-0.8 [**2157-3-12**] 05:10PM ALBUMIN-2.9* CALCIUM-6.9* PHOSPHATE-2.8 MAGNESIUM-2.1 URIC ACID-10.0* IRON-152 [**2157-3-12**] 05:10PM calTIBC-186* FERRITIN-418* TRF-143* [**2157-3-12**] 05:10PM TSH-6.8* [**2157-3-12**] 05:10PM WBC-40.1* RBC-2.86* HGB-8.9* HCT-26.7* MCV-93 MCH-31.2 MCHC-33.4 RDW-18.0* [**2157-3-12**] 05:10PM NEUTS-18* BANDS-14* LYMPHS-8* MONOS-10 EOS-1 BASOS-0 ATYPS-0 METAS-7* MYELOS-5* PROMYELO-1* NUC RBCS-5* OTHER-36* [**2157-3-12**] 05:10PM I-HOS-AVAILABLE [**2157-3-12**] 05:10PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-OCCASIONAL STIPPLED-OCCASIONAL [**2157-3-12**] 05:10PM PLT SMR-VERY LOW PLT COUNT-29* [**2157-3-12**] 05:10PM PT-15.2* PTT-33.2 INR(PT)-1.3* [**2157-3-12**] 05:10PM FIBRINOGE-234 Brief Hospital Course: In summary, the patient is a 79-year-old male with PMH significant for HTN, CHF, hyperlipidemia, atrial fibrillation, prior squamous cell cancer of anus (s/p resection, chemotherapy and radiation in [**2151**]) and 1 week history of left thigh cellulitis who presented with atypical WBCs, thrombocytopenia and anemia concerning for acute leukemia. . Upon arrival to [**Hospital1 18**] BMT Unit his vitals were: temp 98F, BP 116/80, HR 83, RR 20, O2 Sat 94% RA. He appeared to be in no apparent distress. He complained of some diarrhea he had been having x 4 days since starting antibiotics. The patient's stool was positive for C. difficile toxin, and he was started on PO vanco and flagyl. . On the morning of [**3-21**] the patient developed some "burning" sensations at his epigastric region which were initially thought to be heartburn. He was given Maalox which offered limited relief. Upright and supine plain abdominal films were ordered STAT and revealed evidence of free air. A surgery consult was called and he had a CT of the abdomen ordered. Physical exam worsened and he had diffuse lower abdominal tenderness, decreased bowel sounds, and some rebound tenderness as well. CT showed new free intra-abdominal air and fluid surrounding the ascending colon concerning for perforation. He was given platelets, blood transfusions, an NG tube was placed and he was sent emergently to the operating room. . In the OR where he was noted to have a dusky bowel, but no obvious leak from the colon. The fluid in the abdomen did not contain stool, nor was it frankly bilious. The patient received extended R colectomy, mid-transverse Hartmann's and end-ileostomy. In the OR, the patient was hypotensive requiring 7 liters of IVFs, 2 units of platelets, and 2 units of pRBCs. He was started on levophed prior to transfer to the ICU. Of note, post operatively, radiology called regarding the scan with a concern for apparent extravasation of oral contrast at the junction of the 2nd and 3rd portions of the duodenum, suspicious for focal perforation. . On arrival to the ICU, the patient was intubated. He was sedated, not following any commands or responding to voice. He was also tachycardic to the 130s-150s on arrival. Antibiotics changed to meropenem, IV and PR vanc (c. diff), flagyl, fluconazole. . Repeat CT with oral contrast ([**2157-3-22**]) showed increased extraluminal contrast, and the patient returned to the OR for suspected duodenal perforation. The duodenal perforation was identified, and 3 drains were placed for wide drainage of a lesser sac abscess. . The patient returned to the ICU, still requiring pressure support. . The patient's course did improve over the next week or two. He was eventually extubated and weaned off of pressors. He had bilateral thoracentesis for effusions. He was cont on TPN and antibiotics. Unfortunately, the HemeOnc service believed that his leukemia was so severe that his life expectancy at best was on the order of weeks. The family decided to make him DNR/DNI and wanted to take him home with hospice. While waiting for this to be set up he was transferred to the floor. He began to deteriorate on [**2157-4-8**] and was made CMO. He later passed away that night at 809pm. #AML: Patient presented to OSH with WBC 45.7, Hct 26.8, platelets 15 and 34% blasts on differential. Given his longstanding fatigue complaints his presentation may be that of MDS with transformation to AML. Patient had received XRT and alkylating chemotherapy in [**2151**] for his squamous cell cancer of anus which places him at increased risk as well. Bone marrow biopsy was done which confirmed AML diagnosis. Subsequent skin biopsy of his left thigh lesion showed evidence of leukemia cutis in conjunction with a MRSA cellulitis. He was given Hydrea on the night of admission and this was continued through his hospital course up until XXXXX. Different chemotherapies were discussed and ultimately given his multiple co-morbidities, particularly his cardiac issues, he opted for Dacogen therapy. He was consented for treatment and he underwent a 5 day chemotherapy cycle from [**3-16**] until [**2157-3-20**] which he tolerated well. He required several platelet transfusions for his persistent thrombocytopenia. IVFs were continued and he was placed on allopurinol. Lysis labs and DIC labs were predominantly unremarkable with occasional elevations in XXX XXXX. - . #Left thigh cellulitis: Left thigh erythema, tenderness and large carbuncles. Smaller satellite surrounding boils noted over cellulitic inflamed area of about 5x4x4" over his left thigh/hip. Blood cultures were negative at time of transfer and he had been afebrile during his hospital course. After admission he was continued on IV Vancomycin. IV Cefipime was discontinued once he had a swab that confirmed MRSA in his wound and he was placed on MRSA precautions. Ultrasound of left thigh was neggative for any abscesses. Wound dressings were changed daily and a wound care consult was called to help with proper care. A dermatology consult was called due to question of leukemia cutis as there were multiple edematous and hardened inflammed areas adjacent to the MRSA lesions. He had a punch biopsy done which confirmed leukemia cutis. Hydrea therapy was therefore extended after completion of his Dacogen chemotherapy. . #Diarrhea: This was felt to be secondary to his recent antibiotics. He had a positive C.difficile stool study after admission and he was placed on Flagyl and PO Vancomycin was added. Frequency of diarrhea improved throughout his hospital course. . #Abdominal Pain: On the morning of [**3-21**] the patient developed some "burning" sensations at his epigastric region which were initially thought to be heartburn. He was given Maalox which offered limited relief. Upright and supine plain abdominal films were ordered STAT and revealed evidence of free air. A surgery consult was called and he had a CT of abdomen ordered. Physical exam worsened and he had diffuse lower abdominal tenderness, decreased bowel sounds, and some rebound tenderness as well. He was given platelets, blood transfusions, an NG tube was placed and he was sent emergently to the operating room. CT of his abdomen showed air and fluid around area of the ascending colon indicating perforation. He underwent XXXXXXXX and was transferred to the [**Hospital Unit Name 153**] post-operatively. . #Atrial Fibrillation : Known history of atrial fibrillation. Irregularly irregular rhythm on exam. Patient no longer on anticoagulation due to concerns over falls and bloody stools/GI bleed history when on Vioxx. He was continued on his usual Toprol and Verapamil for rate control, and initially he was place on Flecainide for rhythm control. However, after decision was made to start him on chemotherapy and AML confirmed a cardiology consult was called to review best approach to medical management of his atrial fibrillation with minimal drug interactions. Flecainide was discontinued and he was maintained solely on Toprol and Verapamil which proved to be good rate control up until [**2157-3-21**] when he was experiencing abdominal pains. At that time he went into rapid atrial fibrillation with rates in the 130s. Due to the urgency of his acute abdomen he was taken to the O.R. emergently with the surgical service. To control his rate he was given XXXXXX by surgical team and continued on telemetry monitoring. He had been taken off of his Coumadin about a month prior to his admission due to GI bleed history and possible fall risks. More recently, given his thrombocytopenias anticoagulation had been avoided. . #CAD: Per OSH records the patient had a cardiac catheterization in [**2154**] which showed LAD 40% occluded, 40% LMI, 50% RCA occlusion. Patient has no stents, no ACS history, no prior interventions. Denies any chest pains/angina. --holding statin for chemotherapy --holding all aspirin/anticaogulation given his thrombocytopenia --cardiac healthy diet . #HTN: Currently normotensive. --continue ot monitor while on IVFs --will continue Toprol and Lasix, no additional coverage needed . #CHF : Patient limited historian but OSH notes indicate prior LVEF 60% in [**2154**], he may have some diastolic dysfunction given his history of hypertension. Euvolemic on exam. Repeat TTE showed preserved LVEF >55% and moderate to severe mitral regurgitation. He was continued on daily Lasix and his BB. . #Anxiety/Depression : Stable mood and affect. --continue usual home Fluoxetine dose . . #Fluids, Electrolytes and Nutrition: Will replete electrolytes as needed, continuous IVFs at 100cc/hr, cardiac/low sodium diet. . #Access: PIV's . #Prophylaxis: No DVT prophylaxis needed with thrombocytopenia. . Medications on Admission: HOME MEDICATIONS: -Fluoxetine 40mg daily -Lipitor 10mg daily -Verapamil SR 120mg daily -Flecanide 25mg daily -Lasix 20mg [**Hospital1 **] -Toprol 12.5mg daily -KCL -Keflex qid -Centrum Silver MVI once daily -Nystatin Swish and Swallow x 1 week for thrush (day [**7-10**] at time of admission to OSH) . MEDICATIONS ON TRANSFER: Nystatin Swish and Swallow tid Ancef 2g IV q8hrs Vancomycin 1.5g IV q12hrs Ca Carbonate 500mg PO bid Flagyl 500mg PO tid Allopurinol 100mg Po tid Fluoxetine 40mg PO daily Lipitor 10mg PO daily Verapamil SR 120mg PO daily Flecainide 25mg PO tid Toprol 12.5mg PO daily Centrum Silver MVI daily Zantac 150mg PO daily Discharge Medications: Discharge Disposition: Expired Discharge Diagnosis: Primary: Duodenal perforation with abscess formation C. Diff colitis Bilateral pleural effusions Abdominal fluid collection post-op fluid overload requiring diuresis post-op hypotension requiring pressor support in ICU post-op infection/sepsis treated with IV antibiotics post-op AFIB/RVR . Secondary: -Squamous Cell CA of anus ([**2150**], s/p chemotherapy and surgical resection) -Hypercholestrolemia -CHF -Atrial Fibrillation (cardioversions x 2) -taken off Coumadin last month for GI Bleed concerns, on flecanide -Colonic Polyps - s/p polypectomy at [**Hospital1 1774**] summer, [**2156**] -appendectomy as child -R. ankle fracture iwth metal pinning many years ago -R. shoulder rotator cuff repair -Surgery for peptic ulcer disease thought related to NSAIDS -medical tx for H.pylori -Anxiety -Depression -MRSA-Left thigh cellulitis Discharge Condition: Stable Sips of fluid for comfort Pain well controlled with Comfort Medications Discharge Instructions: Per Hospice Agency Protocol. Comfort Measures. Followup Instructions: Not applicable. 1. Dr. [**Last Name (STitle) 5182**] [**Telephone/Fax (1) 5189**] (General Surgery) 2. Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 68755**](Oncology) [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]

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icd9cm

[ [ [] ] ]

[ "34.09", "99.25", "34.91", "86.11", "99.15", "96.72", "54.91", "45.73", "33.24", "54.12", "41.31", "38.93", "46.21", "96.04" ]

icd9pcs

[ [ [] ] ]

16430, 16439

6988, 15714

354, 664

17320, 17401

5904, 6965

17496, 17780

4254, 4535

16407, 16407

16460, 17299

15740, 15740

17425, 17473

4550, 5869

15758, 16042

5885, 5885

231, 316

692, 3367

16067, 16383

3389, 3705

3721, 4238

50,079

179,224

42048

Discharge summary

report

Admission Date: [**2188-12-5**] Discharge Date: [**2188-12-18**] Date of Birth: [**2124-9-28**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / moxifloxacin / metronidazole / cefazolin / Iodine / morphine / piperacillin / trimethoprim / Avelox Attending:[**First Name3 (LF) 5790**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2188-12-5**] Tracheoplasty with mesh right mainstem bronchus and bronchus intermedius, bronchoplasty with mesh left mainstem bronchus, bronchoplasty with mesh, bronchoscopy with bronchoalveolar lavage. History of Present Illness: Mrs. [**Known lastname 91270**] is a 64F with tracheomalacia s/p tracheal y-stent with subsequent stent removal [**2188-10-27**] for chronic infections. She has done well since her stent removal but continues to have a persistent cough and breathlessness with speaking. She presents now for right thoracotomy and tracheoplasty and bronchoplasty. Past Medical History: tracheomalacia s/p tracheal y-stent on [**2188-3-27**] s/p PFO closure [**2183**], [**Hospital1 3278**] Factor V Leiden deficiency with h/o DVT and CVA migraine fibrmyalgia asthma COPD, bronchiectasis glaucoma c-diff ([**2178**]) PSH: hemicolectomy (diverticulitis) nissen ([**2177**]) with chronic complications including gastroparesis and bilateral lower extremity neuropathy cholecystectomy appendectomy Social History: Retired social worker. Lives in [**Location 20291**] with husband. Alcoholism, quit 27 years ago. Tobacco use, quit [**2175**]. Family History: Father (d) depression, COPD Mother alcoholism Physical Exam: Temp 97.8, BP 107/68, HR 74, O2 sat 97% on RA General: Standing in exam room in no apparent distress. Cardiac: S1, S2, no r/m/g appreciated. Resp: RLL late expiratory crackles otherwise clear GI: Abdomen round. Skin: Warm, dry, no cyanosis. Neuro: A&O x3. Speech fluent and appropriate. Pertinent Results: [**2188-12-5**] 06:50PM WBC-14.4*# RBC-4.47 HGB-14.1 HCT-44.0 MCV-98 MCH-31.4 MCHC-32.0 RDW-14.4 [**2188-12-5**] 06:50PM PLT COUNT-272 [**2188-12-5**] 06:50PM PT-12.4 PTT-22.9 INR(PT)-1.0 [**2188-12-5**] 06:50PM CALCIUM-8.0* PHOSPHATE-2.4* MAGNESIUM-2.0 [**2188-12-5**] 06:50PM GLUCOSE-314* UREA N-23* CREAT-0.7 SODIUM-137 POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-13 [**2188-12-8**] CXR : 1. No pneumothorax visualized in the right apex. 2. Stable appearance to the chest with low lung volumes bilaterally and right hemidiaphragm elevation. Stable post-surgical changes to the right posterior rib. 3. Dilated esophagus due to esophagus dysmotility. [**2188-12-11**] Ba swallow : Dilated proximal esophagus with narrowing distally at the site of the prior Nissen. This likely reflects worsening stenosis in the Nissen fundoplication. [**2188-12-15**] EGD : The esophagus appeared tortuous and dilated with solid food retained within. The lower esophagael sphincter was open without pathological narrowing - the scope easily passed through. These findings are suggestive of an esophagael motility disorder rather than a mechanical obstruction. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mrs. [**Last Name (STitle) **] was admitted to the hospital and taken to the Operating Room where she underwent a right thoracotomy with tracheoplasty and bronchoplasty (see formal Op note for further details). She tolerated the procedure well and returned to the SICU in stable condition. She was extubated and placed on a non rebreather with adequate saturations. Her pain was controlled via an epidural catheter with Bupivacaine and a Dilaudid PCA. She maintained stable hemodynamics and stayed in the SICU for 48 hours for pulmonary toilet. Her chest tube was removed on [**2188-12-7**] and her post pull film showed a small right pneumothorax and low lung volumes. Following transfer to the Surgical floor she continued to make slow progress. She was maintained on bronchodilators, Chest PT and used her incentive spirometer though not always effectively. Her right thoracotomy incision was healing well without erythema or drainage. She complained of some dysphagia and was evaluated by the speech and swallow therapist who felt that all of her symptoms were related to her pre op GERD as opposed to a swallowing problem. She was placed on her pre op motility agents and PPI but continued to complain of epigastric pain and nausea with all foods/liquids. A barium swallow was done which revealed a dilated proximal esophagus with some narrowing distally, possibly at the site of her prior Nissen. She then underwent an EGD and the scope passed easily without obstruction. The esophagus showed evidence of reflux. In the interim she was placed on TPN to help maintain her caloric needs. After no new pathology was identified a diet was reinstituted and she was able to take small frequent meals. The psychiatric service was also consulted as she appeared depressed, discouraged and difficult to engage in her care. They felt that her symptoms were magnified by her anxiety and recommended continuing Ativan and increasing her Gabapentin. As her oral intake improved though modestly, her TPN was discontinued on [**2188-12-17**]. Her blood sugars were in good control and she was encouraged to eat upright at all times, take small frequent portions of soft, mushy foods and avoid bread. Due to her history of Factor 5 Leiden deficiency the hematologist recommended that she be maintained on 4 weeks of anticoagulation post op. She is on Lovenox which should continue through [**2189-1-2**] and she is able to administer it to herself. After a lengthy stay she was discharged on 11/1011 to home with VNA services including Physical Therapy and she will follow up in the Thoracic Clinic in 2 weeks. Medications on Admission: ASA', Celebrex 400', Celexa 60', Flexeril 10 QHS Advair 500/50", folate', SSI, loratadine 10', motilin 10 qachs, MVI, omeprazole 40'', simvastatin 20', Spiriva 18', mucinex 1200", metformin 500", Fioricet 20-325 prn headache, Zantac 300 qhs Discharge Medications: 1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to right shoulder. Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2* 4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day) as needed for glaucoma. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours). 6. meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO once a day. 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. citalopram 20 mg Tablet Sig: Three (3) Tablet PO once a day. 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a day. 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 12. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 14. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Flexeril 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Cosopt 2-0.5 % Drops Sig: One (1) drop Ophthalmic twice a day: Both eyes. 17. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 18. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily): thru [**2189-1-2**]. Disp:*16 mg* Refills:*0* 19. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 20. nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*100 Capsule(s)* Refills:*2* 21. ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* 22. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. Disp:*60 Tablet(s)* Refills:*2* 23. other medication Domperidome 1 tab QID before meals and at bedtime Discharge Disposition: Home With Service Facility: [**Location (un) **] VNA Discharge Diagnosis: Tracheobronchomalacia GERD 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 surgery to repair your trachea and main airway so that your breathing will be a bit easier. The operation was done through an incision in the right chest which is healing. * Your appetite has been poor due to your reflux but the endoscopy showed that everything is widely patent which is reassuring. * Make sure that you remain upright for an hour after meals. Elevate your head, neck and chest when in bed with a wedge pillow or place the headboard on blocks to help prevent reflux. * Stick with soft foods and things that appeal to you while you get your appetite back. * Use your incentive spirometer and continue to cough and deep breath to exercise your lungs and keep from developing pneumonia. * Take adequate pain medication so that you'll be comfortable with minimal incisional pain. These drugs can be constipating so take a stool softener or gentle laxative to stay regular. * Due to your history of blood clots, the hematologist recommended that you stay on a blood thinner for 4 weeks post op which goes through [**2189-1-2**]. * If you develop any increased work of breathing, chest pain, leg swelling or any other symptoms that concern you, please call your doctor or return to the Emergency Room. Followup Instructions: Call Dr. [**Last Name (STitle) 9035**] for a follow up appointment in [**3-13**] weeks to review your medications. Call Dr. [**Last Name (STitle) 19688**] for a follow up appointment in [**2-10**] weeks. Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2189-1-6**] at 2:30 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You will need a chest xray prior to your appointment so please report to Radiology on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical Center 30 minutes before your appointment. Completed by:[**2188-12-18**]

[ "V12.51", "309.0", "719.41", "519.19", "289.81", "511.9", "729.89", "250.00", "536.3", "530.5", "725", "365.9", "787.20", "493.20", "494.0", "438.89", "729.1", "346.90" ]

icd9cm

[ [ [] ] ]

[ "99.15", "33.24", "45.13", "31.79", "33.48", "98.02" ]

icd9pcs

[ [ [] ] ]

8360, 8415

3227, 5847

435, 642

8486, 8486

1987, 3204

9954, 10670

1614, 1662

6141, 8337

8436, 8465

5874, 6118

8669, 9931

1677, 1968

376, 397

670, 1020

8501, 8645

1042, 1452

1468, 1598

14,019

188,498

10931+56195

Discharge summary

report+addendum

Admission Date: [**2167-8-10**] Discharge Date: [**2167-9-10**] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 35516**] is a 51-year-old gentleman who was the unrestrained driver in a high speed motor vehicle collision. The patient reportedly went through the windshield where he sustained severe head and face trauma. The patient was initially evaluated and stabilized at [**Hospital6 3105**] and then he was transferred to the [**Hospital1 69**] via [**Location (un) **]. The patient was intubated at [**Hospital3 **] and intubation was complicated by the fact that he had severe facial trauma including facial fractures and nasal fractures and a partial avulsion of his nose. PHYSICAL EXAMINATION: The patient upon arrival to the [**Hospital1 1444**] was intubated, sedated and paralyzed. At that time blood pressure was 127/77, pulse 105 with respiratory rate of 16, he was 100% on the ventilator with a temperature of 98.6. HEENT: Patient had a left depressed skull fracture, he had bilateral periorbital edema and ecchymosis, he had a laceration of his lower lip with multiple broken teeth and avulsion of his nose which was actively bleeding from the nose and mouth. The maxilla was stable. The neck, the C collar was in place. Chest, he had no bony deformities. He had bilateral breath sounds that were equal and symmetrical. Cardiovascular, the patient had a normal S1 and S2, but was tachycardic. The abdomen was soft and there was no evidence of trauma to the abdomen. The patient had blood at the urethral meatus. There was a Foley in place at the time. The patient's pelvis was stable. On rectal exam, there was decreased rectal tone, normal prostate. Extremities were warm. The patient had strong distal pulses. There was no bony deformities. There were several superficial lacerations over his lower extremity. HOSPITAL COURSE: The patient was then taken to imaging where he underwent full trauma series. The patient also had CT scan of the head which was significant for left orbit fracture and lateral wall and nasal ridge fracture. The patient was taken to the surgical Intensive Care Unit where he remained intubated and stable. The patient's surgical Intensive Care Unit stay was complicated by failure to wean from the vent initially. The patient's prolonged SICU stay resulted in sepsis and later MRSA bacteremia. The source of his bacteremia was thought to be pneumonia. The infectious disease service followed along with the surgical Intensive Care Unit service and ultimately the patient received a full course of antibiotics and his symptoms resolved. This allowed him to be extubated. Of note, the patient did require a tracheostomy because of long term ventilation. The patient was continued on Vancomycin which he will be on until [**2167-9-30**] as per the infectious disease service at the [**Hospital1 1444**]. The patient also had persistent hematuria throughout his hospital stay. This was thought to be secondary to a false passageway. The genitourinary issues were managed by urology and he had an indwelling catheter in place until [**2167-9-9**]. The patient was transferred from the surgical Intensive Care Unit to the floor where he was stable. He was able to tolerate a pureed diet along with nectar thick liquids. His pain control was adequate. The patient underwent a CT scan of his orbit on [**2167-9-9**] to evaluate his need for surgery. He was offered surgery by the plastic surgical service. The patient continued to do well and was stable throughout his entire course on the surgical floor. He was discharged to rehabilitation on [**2167-9-10**] in stable condition. At that time his medications included Lopressor 25 mg po bid, Heparin 5000 units subcutaneously [**Hospital1 **], Detrol 1 mg po bid and Percocet 1-2 tablets po q 4-6 hours prn, Vancomycin 1.2 gm IV q 18. The Vancomycin will be continued through [**9-30**] at which time it should be discontinued. The patient will follow-up in the trauma clinic in two weeks. He will be seen by the urology clinic in two weeks and he will also follow-up with the plastic surgery clinic in two weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Doctor First Name 31859**] MEDQUIST36 D: [**2167-9-10**] 10:59 T: [**2167-9-10**] 11:17 JOB#: [**Job Number 35517**] Name: [**Known lastname 6332**], [**Known firstname **] Unit No: [**Numeric Identifier 6333**] Admission Date: [**2167-8-10**] Discharge Date: [**2167-9-10**] Date of Birth: [**2115-12-8**] Sex: M Service: ADDENDUM: Mr. [**Known lastname **] was offered surgery for his facial fractures by the plastic surgery team. After considering this option with his family, the patient decided not to undergo surgery for his facial fractures, which would only have been for cosmetic enhancement. Also of note, the patient had his catheter removed and was passing blood and clots at the time of discharge. This is to be expected for the next several weeks, as he had an injury to his prostate. As long as the patient does not go into urinary retention, there is no need for concern. Of course, if the patient does go into urinary retention, he will need to have a catheter placed and be seen by the urology service. [**First Name4 (NamePattern1) 168**] [**Last Name (NamePattern1) 1030**], MD [**MD Number(1) 1031**] Dictated By:[**Name8 (MD) 6334**] MEDQUIST36 D: [**2167-9-10**] 11:17 T: [**2167-9-10**] 11:38 JOB#: [**Job Number 6335**]

[ "E823.1", "518.5", "801.22", "802.0", "873.43", "996.31", "802.6", "038.10", "571.0" ]

icd9cm

[ [ [] ] ]

[ "21.86", "96.6", "96.72", "31.1", "08.81", "96.04", "27.51", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

1956, 5720

795, 1938

155, 772

28,752

125,981

11006

Discharge summary

report

Admission Date: [**2104-8-13**] Discharge Date: [**2104-9-15**] Date of Birth: [**2024-12-26**] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 1267**] Chief Complaint: right 4th web space ulceration with cellulitis Major Surgical or Invasive Procedure: angiogram of abdomial and pelvic +-vessels with rtight leg runoff viaRt. CFA [**2104-8-15**] cardiac cath left heart wityh 2 vessel disease severe aortic valve stenosis [**2104-8-18**] History of Present Illness: 79y/o male with known arterial vascular disease, type 2 diabetes insulindependant s/p left belowknee [**Doctor Last Name **] to At bpg for left toe ulcer [**6-6**] s/p left [**Doctor Last Name **] -pedal bpg for claudication [**5-6**] which failed. Presents with rt toe ulceration and cellulitis for one week.Ha an ulceration previously at same site which resolved with antibiotics. Patient has been on augmentin for one week without improvment.Denies fevr,chills, blood finger glucose changes, claudication or rest pain.Patient is limited in his ambulation secondary to ulceration. Admitted for vascular evaluation, Iv antibiotics and bed rest. Past Medical History: history of PVD s/p left bkpop-at with left cephalic vein [**6-6**],s/p left fem-pedal [**5-6**] failed DM2 with neuropathy and retinopathy CHF,systollic ostoarthritis-back l/s spine AF with embolic CVa,anticoaulated catracts s/p repair bilaterally inguinal hernia s/p repair retinopathy s/p OD laser Social History: retired married lives with spouse habits: Family History: unknown Physical Exam: Admission: 96.4-45-16 B/P 110/70 O2 sat 95% room air Gen: alert oriented x3 in no acute distress HEENT: OS with catract and deviated toward nose, No JVD,carotids palpable 1+ with transmitted heart mumur Lungs: diminished left base, no adventitious sounds Heart: RRR 3/6 SEM at base to apex to carotids ABd: bengin, no bruits PV: rt. 4th toe edematous, eruthematous with web space ulceration between 4th/5th toe with excudate. no gangrene Pulses: radial pulse 2+ bilaterally, femorals 2+ bilaterally rt. [**Doctor Last Name **] 1+ and dopperable pedal pulseson right. left poop aabsent with absent DP and dopperable Pt pulses. Neuro: Ox3, nofocal Discharge VS 97.5 100AF 156/70 24 100% 50%Trach collar Gen: NAD Neuro: Alert, follows commands. LUE weakness Pulm: Course throughout, trach in place CV: irreg-irreg, sternum stable, incision CDI Abdm: soft NT, +BS. PEG in place Ext: Warm, palpable pulses. [**1-8**]+ edema Pertinent Results: Cardiology Report ECHO Study Date of [**2104-8-14**] PATIENT/TEST INFORMATION: Indication: Murmur. Height: (in) 70 Weight (lb): 200 BSA (m2): 2.09 m2 BP (mm Hg): 116/70 HR (bpm): 74 Status: Inpatient Date/Time: [**2104-8-14**] at 12:08 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W038-0:16 Test Location: West Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *6.3 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *7.0 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.6 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.5 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.8 cm Left Ventricle - Fractional Shortening: 0.31 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aorta - Ascending: *3.9 cm (nl <= 3.4 cm) Aorta - Arch: 2.7 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: *4.7 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 88 mm Hg Aortic Valve - Mean Gradient: 53 mm Hg Aortic Valve - LVOT Peak Vel: 0.[**Age over 90 **] m/sec Aortic Valve - LVOT Diam: 2.3 cm Aortic Valve - Valve Area: *0.7 cm2 (nl >= 3.0 cm2) Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - E Wave Deceleration Time: 188 msec TR Gradient (+ RA = PASP): *33 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial septum. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal aortic arch diameter. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions: The left atrium is markedly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 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. There are three severely thickened/deformed aortic valve leaflets. There is severe aortic valve stenosis (area 0.7 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic stenosis. Symmetric LVH with preserved global and regionaln biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Mildly dilated thoracic aorta. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD on [**2104-8-14**] 13:37. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. RADIOLOGY Final Report CHEST PORT. LINE PLACEMENT [**2104-9-9**] 11:41 AM CHEST PORT. LINE PLACEMENT Reason: s/p line placement [**Hospital 93**] MEDICAL CONDITION: 79 year old man s/p AVR CABGx2 on Trach mask now tachypenic REASON FOR THIS EXAMINATION: s/p line placement HISTORY: Line placement. SUPINE PORTABLE CHEST RADIOGRAPH Comparison is made to [**9-4**] and [**9-9**] examinations. FINDINGS: There has been interval placement of a right subclavian central venous catheter with its tip terminating within the right atrium. There is no evidence of pneumothorax. Bibasilar atelectasis is slightly improved with more layering of the effusions on this supine radiograph. Amount of alveolar and interstitial edema may be slightly improved in the interval. Positioning of tracheostomy tube and left-sided central venous catheter along with left lower lobe/retrocardiac opacity is not significantly changed. IMPRESSION: 1. Tip of new right central venous catheter terminating within the right atrium. 2. Slight improvement in bibasilar atelectasis. Persistent layering pleural effusions. Perhaps mild increase to alveolar and interstitial edema (difficult to tell given change technique). Discussed with PA [**Doctor Last Name **] on date of exam at 1:30 p.m. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**] Approved: TUE [**2104-9-9**] 4:29 PM [**2104-8-13**] 12:40PM GLUCOSE-74 UREA N-27* CREAT-1.5* SODIUM-140 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [**2104-8-13**] 12:40PM %HbA1c-8.0* [**2104-8-13**] 12:40PM WBC-12.5* RBC-4.32* HGB-13.5* HCT-39.2* MCV-91 MCH-31.2 MCHC-34.4 RDW-14.3 [**2104-8-13**] 12:40PM PLT COUNT-197 [**2104-8-13**] 12:40PM PT-22.0* PTT-34.5 INR(PT)-2.2* COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2104-9-15**] 12:56AM 15.0* 3.12* 9.7* 28.7* 92 31.2 34.0 15.1 279 [**2104-9-15**] 12:56AM 18.7* 32.7 1.8* [**2104-9-15**] 12:56AM 155* 29* 1.1 141 4.2 106 30 9 Brief Hospital Course: [**2104-8-13**] admitted. wound c/s obtained began on Vanco/cirpo and flagyl.c/s gram negative staph a. no anerobes. foot xray negative for osteo. duplex of left graft was obtianed which showed an occluded graft. Echo was obtained to determine the presence or absence of aortic valvular disease secondary to heart mumur which showed EF 55% and severe aotic stensis with valvular area of 0.7cm2. Cardiology was consulted and on [**2104-8-15**] diagnositic angiogram via rt. femoral artery was done.The abdominal aorta was tortous with patent iliac system bilaterally. Patent SFa,PFA and CFa with disease popliteal artery system vessel disease with severe AS. CT [**Doctor First Name **] was consulted and on [**8-21**] the pt. underwent AVR(23mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] tissue valve)/CABGx2(LIMA->LAD, SVG->OM. He tolerated the procedure and was transferred to the CSRU in stable condition. Post op the patient was hypotensive and had a low cardiac output. He remained on Milrinone and Neo. He had intermittent AF and was on Amio. His creat. increased and renal was consulted. He was followed by [**Last Name (un) **] as well. He was unable to move his L arm and was evaluated by neurology who felt he had reexpression of an old CVA. He had negative head CTs and eventually became more alert. He eventually weaned off his pressors. On [**8-26**] he was found to be HIT+ and was treated with Argatroban and coumadin. He was unable to wean from the vent and underwent trach and PEG on [**9-2**]. He gradually improved and became more alert. He was discharged to rehab in stable condition on [**2104-9-15**]. Medications on Admission: Coumadin 2.5 alt w/ 5 Zocor 20' Metformin 500" Lisinopril 2.5' Dig .25' Lasix 40' Atenolol 25' NPH 24U [**Hospital1 **] RISS Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 160 mg/5 mL Solution Sig: [**10-25**] PO Q6hrs/PRN as needed. 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Warfarin 1 mg Tablet Sig: target INR 1.5-2.0 Tablets PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous once a day. 10. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day. 11. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 13. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Discharge Diagnosis: Aortic stenosis PVD L nonhealing toe ulcer CHF OA chronic af s/p embolic CVA CAD Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months Shower daily, let water flow over wounds, pat dry with a towel. Do not use powders, lotions, or creams on wounds. Call our office for sternal drainage, fever >101.5. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 35663**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2104-9-15**]

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icd9cm

[ [ [] ] ]

[ "37.23", "31.1", "38.93", "39.61", "88.47", "88.56", "96.04", "43.11", "36.15", "36.11", "96.72", "88.72", "35.21" ]

icd9pcs

[ [ [] ] ]

11632, 11647

8719, 10393

329, 515

11772, 11779

2557, 2610

12108, 12282

1589, 1598

10568, 11609

6649, 6709

11668, 11751

10419, 10545

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2636, 6370

1613, 2538

243, 291

6738, 8696

543, 1191

6402, 6612

1213, 1514

1530, 1573

59,505

157,168

51186

Discharge summary

report

Admission Date: [**2120-1-23**] Discharge Date: [**2120-2-1**] Date of Birth: [**2035-9-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 38616**] Chief Complaint: dyspnea, lower extremity edema Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: The patient is a 84 yo man with a past medical history of HTN, HL and recent diagnosis of lymphoplasmacytic lymphoma s/p four weekly doses of Rituxan in [**7-/2119**] with repeat bone marrow in [**Month (only) 205**] which revealed improvement in his disease burden who p/w dyspnea. The patient was last seen in his usual state of health 9 days ago by the patient's nephew [**Name (NI) 382**]. Today, the nephew picked up the patient for a routine visit with Dr. [**Last Name (STitle) 3759**], his Oncologist where it was noted that the patient was having increased dyspnea on exertion and new bilateral ankle swelling. At the visit, the patient was noted to be mildly hypoxic to the mid 90s and abnormal lung sounds. A CXR was obtained which showed a new moderate right pleural effusion. Per report, an EKG was unremarkable from clinic. The patient was admitted for further workup of this new pleural effusion and bilateral ankle swelling. . Currently, the patient feels well. He states his breathing has been bothering him for the past "couple weeks." He denies orthopnea, PND, fevers, chills, cough. States the leg swelling has been ongoing for about the same amount of time. . Of note, did have mechanical fall in early [**Month (only) 359**] that caused a non-operative subdural hemorrhage and a left wrist fracture which is currently splinted. Past Medical History: PAST ONCOLOGIC HISTORY: Patient and his nephew report several years of low grade pancytopenia and progressive fatigue. In the last year fatigue has reached the point that the patient has difficulty with some activities of daily living such a shoveling snow and ambulating outside of his house. Patient also reports a recent weight loss but denies fevers, chills or night sweats. Given the progression of symptoms and counts a bone marrow biopsy was performed which demonstrated a monoclonal B cell population consistent with a lymphoplasmacytic lymphoma. Patient started on Rituximab - Rituximab 4 weekly doses [**2119-7-7**] PAST MEDICAL HISTORY: - HTN - HL - dementia, patient reports trouble with memory - BPH - anemia - BPH - GERD - Back pain - Peripheral neuropathy - Inguinal hernia - Ventral hernia - Venous stasis PSgHx: - Cholecystectomy - Excision of scalp skin cancer Social History: Single. Never married. No children. Nephew ([**Known firstname **]) lives with him. this nephew has severe psychiatric illness and patient reports he cares for him. Denies tob, etoh, drugs. Family History: Brother died of pulmonary embolism Physical Exam: ON ADMISSION: VS: 96.2 146/72 71 24 95%RA; pain 0/10 GEN: No apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, decreased breath sounds in LLL; crackles bilaterally particularly towards the bases GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present, pt with 2+ pitting edema and erythema of the lower extremities up to the level of the mid-calf NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [**6-15**] motor function globally DERM: no lesions appreciated . AT DISCHARGE: AF Tm 98.2 127-154/60-70s 60s 18 95% RA GENERAL: NAD, very comfortable sitting in bed. SKIN: warm and well perfused, only trace lower extremity edema HEENT: MMM, nontender supple neck, no LAD, 6cm JVD CARDIAC: RRR, +S1, S2, no m/r/g LUNG: crackles at bases but minimal, much improved ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, +splenomegaly felt ~5cm below costal margin M/S: moving all extremities well, only tr pitting edema much improved from prior NEURO: CN II-XII intact, 5/5 strength upper/lower ext, grossly normal sensation Pertinent Results: LABS ON ADMISSION: [**2120-1-23**] 12:55PM cTropnT-<0.01 [**2120-1-23**] 12:55PM ALBUMIN-4.4 [**2120-1-23**] 12:55PM CRYO-NO CRYOGLO [**2120-1-23**] 12:55PM SERUM VIS-1.4 [**2120-1-23**] 11:40AM UREA N-13 CREAT-1.1 SODIUM-144 POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-30 ANION GAP-12 [**2120-1-23**] 11:40AM estGFR-Using this [**2120-1-23**] 11:40AM ALT(SGPT)-7 AST(SGOT)-11 LD(LDH)-250 ALK PHOS-85 TOT BILI-0.8 [**2120-1-23**] 11:40AM TOT PROT-6.0* CALCIUM-9.1 PHOSPHATE-3.1 [**2120-1-23**] 11:40AM FERRITIN-19* [**2120-1-23**] 11:40AM PEP-HYPOGAMMAG IgG-293* IgA-18* IgM-91 IFE-SEVERAL TR [**2120-1-23**] 11:40AM WBC-2.8* RBC-3.58* HGB-10.4* HCT-31.9* MCV-89 MCH-29.1 MCHC-32.6 RDW-13.7 [**2120-1-23**] 11:40AM NEUTS-72.9* LYMPHS-23.1 MONOS-3.0 EOS-0.5 BASOS-0.5 [**2120-1-23**] 11:40AM PLT COUNT-91* . [**2120-1-29**] TTE: IMPRESSION: There is a circumferential pericardial effusion which is relatively small. There is probably tamponade/near-tamponade physiology. Reduced LVEF with inferolateral and probable septal hypokinesis. Comparison to echo of [**2120-1-24**], the right ventricle appears smaller and there is probable tamponade physiology. The patient is more tachycardic and in atrial fibrillation. Wall motion abnormalities could not be compared as the current study was limited. . [**2120-1-30**] TTE: IMPRESSION: Moderate-sized pericardial effusion without evidense of tamponade physiology. Compared with the prior study (images reviewed) of [**2120-1-29**], the patient is no longer tachycardic. Short of a very brief diastolic RV "dip", there are now no clear signs of impaired ventricular fillling. . [**2120-1-30**] pCXR: FINDINGS: One portable AP upright view of the chest. Moderate right pleural effusion is new. Moderate left pleural effusion is unchanged. Bibasilar opacities likely represent atelectasis. Pulmonary edema has increased. Heart size may be slightly increased which may represent slight increasing pericardial effusion. No evidence of pneumonia. IMPRESSION: 1. New right moderate pleural effusion. Left moderate pleural effusion is unchanged. 2. Heart size slightly bigger which may indicate a slight increase in pericardial effusion. If clinically indicated, can correlate with echocardiogram. 3. Increased pulmonary edema. The study and the report were reviewed by the staff radiologist. . [**2120-1-26**] CT torso: CHEST: Unenhanced images of the chest demonstrate atherosclerotic calcifications within the normal-caliber aorta. There is no intramural hematoma. On contrast-enhanced images, there is no evidence of pulmonary embolus or aortic dissection. The moderate pericardial effusion has minimally increased in size. Left greater than right moderate pleural effusions have also increased in size. There is adjacent compressive atelectasis on the left. Patchy areas of consolidation at the right base are new. The airways are patent to the subsegmental levels. In addition to patchy right basilar opacities, there are scattered ground-glass opacities in the left and right upper lobe, lower lobes and middle lobe, mostly dependent posteriorly. The heart is at the upper limits of normal in size. Coronary artery calcifications which are moderate to severe are noted. There is also atherosclerotic calcification throughout the thoracic aorta. ABDOMEN: There is periportal edema. The hepatic and portal veins are patent as is the splenic vein. The spleen has increased in size when compared to prior PET-CT, now measuring 17.0 cm in AP dimension (previously 15.9 cm). In addition, there are multiple peripheral hypodense regions (3B:95, 3B:108, 3B:112) which may relate to splenic infarctions. The pancreas and right adrenal gland are within normal limits. The left adrenal gland is difficult to visualize. A small gastric diverticulum is noted (3B:88-92). The kidneys demonstrate symmetric uptake and excretion of contrast. There is no hydronephrosis. Bilateral simple cysts are redemonstrated. Retroperitoneal lymph nodes measuring 9 mm are unchanged. There is no mesenteric lymphadenopathy, free fluid or free air. Bowel loops are unremarkable. PELVIS: The Foley catheter is within the bladder. There is no evidence of extravasation. Tubular areas of enhancement (2B:159) likely relate to corpora cavernosal enhancement. The prostate gland enhances eterogeneously and is slightly enlarged. There is trace ascites within the abdomen and extending within a right inguinal and left inguinal hernia. There is a loop of sigmoid colon within the left inguinal hernia without evidence of obstruction. Scattered diverticula are present throughout the colon. OSSEOUS STRUCTURES: There is a hemangioma in L4 vertebral body. Facet arthropathy is present in the lower lumbar spine. There are no destructive osseous lesions. Anterior osteophytes are present throughout the thoracic spine. . IMPRESSION: 1. Interval increase in size of moderate pericardial effusion, and left greater than right pleural effusions which measure simple fluid in Hounsfield units. 2. Scattered patchy consolidation at the right base and bilateral ground-glass opacities in dependent location raises possibility of aspiration with pneumonia not excluded. 3. Splenomegaly, measuring 20.4 cm in craniocaudal dimension. There are new peripheral hypodense lesions which may relate to interval infarcts. 4. No pulmonary embolus. 5. Bilateral inguinal hernias with the right containing ascites and the left containing a non-obstructed loop of sigmoid colon. 6. Foley catheter within the bladder with no evidence of contrast extravasation. . HOSPITAL COURSE: [**2120-1-26**] 01:00PM BLOOD WBC-2.8* RBC-3.18* Hgb-9.0* Hct-28.9* MCV-91 MCH-28.3 MCHC-31.1 RDW-14.0 Plt Ct-84* [**2120-1-28**] 02:50PM BLOOD WBC-3.5* RBC-3.04* Hgb-8.7* Hct-26.5* MCV-87 MCH-28.6 MCHC-32.8 RDW-14.4 Plt Ct-15* [**2120-2-1**] 08:15AM BLOOD WBC-3.8* RBC-3.45* Hgb-9.7* Hct-31.2* MCV-90 MCH-28.0 MCHC-31.0 RDW-14.3 Plt Ct-88* [**2120-1-26**] 05:46AM BLOOD Glucose-143* UreaN-11 Creat-1.1 Na-144 K-3.4 Cl-104 HCO3-35* AnGap-8 [**2120-1-28**] 02:50PM BLOOD Glucose-153* UreaN-21* Creat-1.5* Na-138 K-3.3 Cl-94* HCO3-36* AnGap-11 [**2120-2-1**] 08:15AM BLOOD Glucose-175* UreaN-23* Creat-1.0 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 [**2120-1-31**] 07:45AM BLOOD ALT-14 AST-18 LD(LDH)-226 AlkPhos-79 TotBili-0.4 [**2120-1-23**] 12:55PM BLOOD Cryoglb-NO CRYOGLO [**2120-1-23**] 11:40AM BLOOD PEP-HYPOGAMMAG IgG-293* IgA-18* IgM-91 IFE-SEVERAL TR Brief Hospital Course: 84 yo man h/o HTN, HL, lymphoplasmacytic lymphoma s/p four weekly doses of Rituxan presented with new onset dyspnea and lower extremity edema found to have pleural effusion s/p drainage, found to have pericardial effusion with tamponade physiology, repeat TTE in CCU w/o tamponade physiology, now transfered back to floor. #. Pericardial effusion: He was noted to have a pericardial effusion on echo. There was initially some concern for tamponade given that his BP had decreased from 150s systolic to the 100s. A repeat TTE was obtained on HD6 ([**2120-1-29**]) which showed increased concern for tamponade physiology, however the effusion was too small for a pericardiocentesis. He was transferred to the CCU for closer monitoring and remained hemodynamically stable with a pulsus paradoxus <10 mmHg. A repeat TTE was obtained on HD7 which showed no tamponade physiology. No pericardiocentesis performed as was too high risk. BP remained stable in CCU and when transferred back to floor. PT to follow up with cardiology in 1 wk. . #. Right pleural effusion: Unilateral pleural effusion on exam and CXR. Differential most likely malignant vs CHF. CXR otherwise clear, and he had no signs/symptoms of pneumonia (no fever, cough, leukocytosis). ECG with no evidence of ischemia or right heart strain. IP was consulted. Therapeutic/diagnostic thoracentesis performed on [**2120-1-25**] with 1450 cc out. Fluid returned showing transudate, although flow cytometry of the fluid showed a minute population of lymphocytes c/w his known lymphoma. It was unclear if this was simply contamination of the pleural fluid by traumatic tap vs. lymphoma is the primary etiology of the effusion. Cx's negative to date. LENIs negative. Pt was diuresed aggressively and sent home without lasix. Resp status improved on discharge - able to ambulate without increased dyspnea. . #. Atrial fibrillation: Prior to CCU transfer, he was noted to be in new AF with HR in the 150s. HR improved with IV metoprolol and he was given PO metoprolol for rate control. This was thought [**3-15**] overdiuresis with high right sided pressures and pericardial effusion. He spontaneously converted back to sinus rhythm less than 24 hours after he went into Afib. He did not receive and electrical or chemical cardioversion. Pt was sent home on metoprolol with cardiology follow up in 1 week. The primary oncology team felt that although his CHADS score was 3 he was not a candidate for anticoagulation with warfarin given recent history of intracerebral hemorrhage and would not be a good candidate for aspirin given his low platelets in the setting of chemotherapy with likely continued chemotherapy in the near future. . #. Lower extremity edema: Bilateral and developed over last week PTA along with dyspnea on exertion. It was felt that the right leg was slighly larger and more erythematous than the left, R LENI performed and was negative for DVT. He did have elevated JVP concerning for CHF. Albumin normal and UA showed no protein, suggesting that hepatic or renal source was less likely than cardiac etiology. Echo showed pericardial effusion as well. It was felt that pleural effusions were most likely due to lymphomatous spread vs cardiogenic source (impaired cardiac function in setting of pericardial effusion). Resolved on discharge; pt with only trace lower extremity edema and no erythema present. . #. Lymphoplasmacytic lymphoma: His disease appeared to be controlled after 4 cycles of rituxan in [**Month (only) 116**], but on admission there was concern that pleural and pericardial effusions could be related to underlying disease. He was noted to have new splenomegaly, and mild leukopenia. Out of concern for progression of disease (most likely pericardial/pleural effusions reflecting this, and evidence of lymphoma cells on pleural fluid analysis), rituxan was started [**2120-1-28**]. He became flushed 15 minutes into administration, and then with cool towels began rigoring. He was given solumedrol and he tolerated the rest of the effusion without problems. [**Name (NI) **] was to continue with bendamustine, but pt became hypotensive and was transferred to the CCU out of concern for progressive pericardial effusion. Will continue with bendamustine as an outpatient. . #. Thrombocytopenia: Stable. PLTs initially trended down with administration of rituxan, with a nadir at 15 on the 3rd day after rituxan administration. He was administered 1u PLTS on transfer to the CCU in case of possible pericardiocentesis. Counts stabilized. PLTS on day of discharge at 88 trending up. . #. Trauamatic self-DC of foley: On 2nd day of hospitalization pt sundowned and become agitated/confused (see below). HD#3 in AM pt self-DCd foley. There was significant amount of blood, enough to saturate a 2 small towels. Clot eventually formed. 3 way foley was inserted and pt was continuously irrigated for >24 hours, eventually no clots were passing and foley was DCd. Pt was urinating on his own without incontinence at the time of discharge. . #. Delirium: Pt became confused and aggitated most nights during hospitalization. This was managed with trazodone and prn haldol. The last 2 nights of hospitalization he was calm and oriented without signs of aggression/confusion. Delirium resolved on discharge. . #. Hypertension, benign: Stable. Home lisinopril was changed to captopril as captopril has shorter half-life and in the setting of tamponade physiology there was concern of inducing futher hypotension. . #PT WAS MAINTAINED AS FULL CODE THROUGHOUT THE COURSE OF THIS HOSPITALIZATION. TRANSITIONAL ISSUES: Pt has follow up with cardiology, heme/onc, and PCP. [**Name10 (NameIs) **] attempted to obtain an EEG during this admission per outpatient provider request but was unable to be done. This should be performed as an outpatient. Will need follow up with Neurology as outpatient as well. - f/u immunophenotyping of Pleural fluid - f/u Acid fast culture of Pleural fluid - f/u with primary oncologist for bendamustine treatment . Pt expected to be at rehab for less than 30 days. Medications on Admission: FLUOXETINE - 40 mg Capsule - 1 Capsule(s) by mouth once a day for depression LEVETIRACETAM - 500 mg Tablet - 1 Tablet(s) by mouth twice a day for preventing seizures LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day gerd OXYBUTYNIN CHLORIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day nocturia Medications - OTC CARBAMIDE PEROXIDE - 6.5 % Drops - 5 DROPS in each ear twice a day For four days DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth twice a day as needed for constipation FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 10. captopril 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for insomnia. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living Discharge Diagnosis: PRIMARY: pericardial effusion pleural effusion SECONDARY: lymphoplasmocytic lymphoma paroxysmal atrial fibrillation hypertension hyperlipidemia trouble with memory benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent, but should be using a walker whenever possible to steady gait. Discharge Instructions: It was a pleasure taking care of you during your recent hospitalization. You came in with shortness of breath and lower leg swelling. We found that you had some fluid in your lungs and around your heart. We drained the fluid from your lungs but felt it was too dangerous to drain the fluid around your heart. Your heart experienced a lot of stress because it was surrounded by fluid and was not able to pump adequately. Because of that, you developed an abnormal heart rhythm called atrial fibrillation. You went to the cardiac intensive care unit for close monitoring, and your heart recovered when we gave you IV fluids. We repeated an echocardiogram and your heart function was improved. Also, your heart went back to it's normal rhythm. We feel the most likely explanation is that the lymphoma is causing the fluid around the heart. Regarding your lymphoma, we treated you with rituximab while you were in the hospital. You had a fever and chills as a reaction, but we were eventually able to finish the whole dose of medication without problems. Your platelets dropped very low which is to be expected with chemotherapy. We gave you a platelet transfusion to raise that number. You came back to the floor from the intensive care unit and did very well. Your breathing was much improved and you did not require oxygen. While you were here, we put in a foley catheter to drain your bladder because you were not making very much urine. The foley catheter was accidentally pulled out while you were moving around in the morning and caused a significant amount of bleeding. We used another catheter to irrigate the bladder and this healed without problems. We made the following CHANGES to your medications: STARTED metoprolol CHANGED your lisinopril to captopril (DO NOT TAKE LISINOPRIL ANYMORE. DO TAKE CAPTOPRIL). STARTED albuterol nebulizer IF NEEDED for trouble breathing or wheezing STARTED senna for constipation Followup Instructions: Department: HEMATOLOGY/BMT When: WEDNESDAY [**2120-2-7**] at 1:30 PM With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2120-2-9**] at 1:40 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 18**] [**Location (un) 2352**] When: FRIDAY [**2120-2-16**] at 8:10 AM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**]

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icd9cm

[ [ [] ] ]

[ "34.91", "99.25" ]

icd9pcs

[ [ [] ] ]

18606, 18747

10712, 16290

335, 350

18985, 18985

4248, 4253

21144, 22212

2859, 2895

17520, 18583

18768, 18964

16815, 17497

9835, 10689

19199, 20879

2910, 2910

3659, 4229

16311, 16789

20908, 21121

265, 297

378, 1731

4267, 9818

19000, 19175

2402, 2635

2651, 2843

8,102

143,169

48847

Discharge summary

report

Admission Date: [**2130-8-10**] Discharge Date: [**2130-8-18**] Date of Birth: [**2051-12-18**] Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Lasix Attending:[**First Name3 (LF) 1835**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Stereotactic brain biopsy History of Present Illness: 78M who presented to OSH with 2 weeks of "shaking" and confusion (reported by family). He has known lymphoma (diagnosed [**2-26**] by liver biopsy) s/p chemo as well as 3mm right lung nodule found [**4-28**] which has been followed and not grown in size. Pt had head CT at OSH showing left frontal mass with enhancing rim, central necrotic area, surrounding edema with minimal shift. Transferred to [**Hospital1 18**] at pt/family request. Past Medical History: * large B cell lymphoma involving liver/spleen/inguinal, started R-CHOP [**4-4**] * CABG [**2126-11-24**] ([**Hospital1 2025**]) Social History: Smoked 1-2 packs for 50 years and quit 3 years ago. Does not drink alcohol. Lives at home with wife and helps take care of 5 grandchildren ages [**1-29**] daily. Physical Exam: PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. HEENT: Pupils ERRLA EOMs full Neck: Supple. Extrem: Warm and well-perfused. No C/C/E. Diffuse erythematous rash with dry scaling skin throughout body Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place. date-> "[**8-13**], do not know year" Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-28**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal rapid alternating movements Pertinent Results: [**2130-8-10**] 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2130-8-10**] 07:02PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 MRI [**2129-8-10**]: there is a 4.9-cm bilobed mass in the left frontal lobe anteriorly. The mass appears to be centrally necrotic. It has irregular enhancing rim. There is surrounding FLAIR hyperintense edema and there is depression of the body and frontal [**Doctor Last Name 534**] of the left lateral ventricle without significant rightward shift of midline structures. There is some effacement of the left frontal sulci. There are other areas of patchy FLAIR hyperintensity in the cerebral white matter, but no underlying enhancing lesion is seen elsewhere. There is prominence of the ventricles and sulci. Posterior to the dens, there is low signal intensity material extending superiorly, along the posterior margin of the clivus, indenting the cervicomedullary junction without edema in the medulla or spinal cord. The appearance of this low signal intensity material and the thick adjacent dural enhancement suggests a heavily calcified meningioma. The lesion is of increased density on the CT that was obtained as a part of the PET scan on [**2130-3-15**]. It does not appear to have significantly changed in size. IMPRESSION: 1. There is an approximately 5-cm left frontal mass with some mass effect on the left frontal [**Doctor Last Name 534**]. It could be related to the patient's lymphoma or could be another malignancy such as a glioblastoma. 2. There is an anterior extra-axial mass associated with the dens and clivus with thick adjacent dural enhancement almost certainly a meningioma. There is a mild compression of the cervicomedullary junction. Brief Hospital Course: Pt was admitted to [**Hospital1 18**] oncology service from transfer from outside hospital. He was evaluated for his altered mental status and brain lesion. On [**8-11**] he went to the OR where under local anesthesia he underwent a stereotactic brain biopsy which preliminarily shows a glioma. He was transferred to the PACU and then had CT of brain which showed a good post op appearance. He was transferred to the floor. Activity and diet were advanced. He was seen by PT and OT and felt to need a rehab stay. His incision remained clean and dry. Medications on Admission: protonix,albuterol,toprol XL, zocor, [**Doctor First Name 130**], kenalog cream, sarna, atarax Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 4 days. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 17. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): 2mg tid for until [**8-20**] then wean to 2mg [**Hospital1 **]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Brain mass - glioma Discharge Condition: Neurologically stable Discharge Instructions: Keep incision dry. Sutures should be removed 10 days post op. Followup Instructions: Follow up in brain tumor clinic Dr. [**Last Name (STitle) 27037**] [**2130-9-18**] [**Hospital Ward Name 23**] [**Location (un) **] @ 2pm Please arrive on [**Hospital Ward Name 23**] 4 at 12:20 for an MRI Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2130-9-12**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2038**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2130-9-12**] 11:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**0-0-**] Date/Time:[**2130-9-12**] 1:00 Completed by:[**2130-8-18**]

[ "V10.79", "E944.4", "V45.81", "428.0", "276.51", "414.00", "496", "693.0", "403.91", "427.31", "518.89", "191.1" ]

icd9cm

[ [ [] ] ]

[ "01.59", "93.59" ]

icd9pcs

[ [ [] ] ]

6532, 6611

4281, 4835

317, 345

6675, 6699

2453, 4258

6810, 7433

4981, 6509

6632, 6654

4861, 4958

6723, 6787

1181, 1377

255, 279

373, 817

1642, 2434

1392, 1626

839, 969

985, 1151

23,353

171,087

12881

Discharge summary

report

Admission Date: [**2192-4-24**] Discharge Date: [**2192-5-3**] Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is an 83 year old female who has had some bilateral neck pain with a question of arthritis and increasing fatigue in the past year as well as shortness of breath with exertion. Her recent neck pain prompted a work up which included an echocardiogram. This showed an ascending aorta that was dilated to 5.3 cm. At the time of her initial evaluation on [**2191-8-18**], she had not yet had cardiac catheterization but her echo in [**2191-7-24**] showed a 5.3 cm ascending aorta with no dissection, no arch disease, mild AI, mild MR, no clot and normal LV function. She was seen again in the office for follow up after repeat scan, of note several months later than initially was expected. Her blood pressure at that time was, on the right, 132/74, and on the left 118/76. The CT scan from [**2192-3-23**] showed that her root was dilated to 6.8 cm x 6.2 cm and at the level of the carina, it was 4.9 cm x 5.5 cm, and then at the level of the descending aorta it was 4.5 cm x 3.7 cm. Also, the innominate takeoff was 4.0 cm and at the diaphragm, the aorta was 3.2 x 3.2 cm. In addition, there was a right apical 6 mm nodule noted. The patient was scheduled for aortic repair by Dr. [**Last Name (Prefixes) **] given the rapidly size of her ascending aortic aneurysm. PAST MEDICAL HISTORY: 1. Anxiety. 2. Legally blind with macular degeneration. 3. Osteoarthritis and degenerative joint disease. 4. Hypercholesterolemia. 5. Paroxysmal SVT with a question of a left anterior fascicular block. 6. AI. 7. Osteopenia. 8. Colon polyps. 9. She is also status post a left total knee replacement, bilateral vein strippings x2, abdominoplasty, bilateral cataract surgery, cystocele repair with total abdominal hysterectomy, and thoracic spine surgery for arachnoid cyst in [**2185**]. MEDICATIONS: Medications when she was originally seen in [**2191-7-24**] were as follows: 1. Digoxin 0.25 mg p.o. once a day. 2. Estrogen p.o. 3. Lorazepam 1 mg p.o. hs. p.r.n. 4. Amoxicillin p.r.n. for dental work. ALLERGIES: She had no known allergies. SOCIAL HISTORY: She is retired. Both of her parents lived into their 90s and died of old age. She lives alone with a son nearby. She never smoked and was a very rare social drinker and no use of recreational drugs. PHYSICAL EXAMINATION: On exam in the office, her heart rate was 72 and irregular with blood pressure 136/72. She came in for cardiac catheterization in late [**Month (only) 547**]. Preoperative labs were as follows: White count 11.7, hematocrit 38, platelet 275,000. INR 1.0. Sodium 139, K 4.1, chloride 97, bicarb 31, BUN 22, creatinine 1.2 with a blood sugar of 103. She denied any history of TIA, CVA, melena, or GI bleed. Her height was 5' 4", weighing 114 pounds. She had a small mole nevus noted in her left upper back. She was nonicteric with noninjected eyes. Her pupils were equally round and reactive to light and accommodation. She had decreased extraocular movements in her right eye. She had no JVD or bruits. She had prominent carotid pulsations. Her lungs were clear bilaterally. She occasionally had a question of missed beats with irregular heartbeat with S1, S2 tones present and a faint systolic ejection murmur. Her abdomen was firm with no hepatosplenomegaly, nondistended, slightly tender left lower quadrant without any CVA tenderness. She had bilateral lower extremity scars from her vein strippings. Her extremities were warm, well perfused with 1+ bilateral pedal edema. She also had venous stasis brawniness bilaterally in her lower legs. Her cranial nerves II through XII were intact with a grossly nonfocal neuro exam and moving all four extremities with good strength. Femoral pulses were 2+ bilaterally. Radial pulses 2+ bilaterally. DP and PT pulses 1+ bilaterally. STUDIES: Cardiac catheterization was performed which did not show any hemodynamically significant coronary disease. HO[**Last Name (STitle) **] COURSE: The patient was admitted on [**2192-4-24**] and underwent an ascending aortic and hemi-arch replacement with a 28 mm Gelweave graft, reimplantation of the innominate artery to the ascending aortic graft and an aortic all free suspension by Dr. [**Last Name (Prefixes) **]. She was transferred to the cardiothoracic ICU, a paced, in stable condition, on a propofol titrated drip. On postoperative day 1, her heart rate was 66 and sinus. Her blood pressure 116/70. She remained intubated with a white count of 20 and hematocrit of 30.5, platelet count 206, K 4.2, BUN 18, creatinine 1.0. Her Swan-Ganz and chest tubes were removed. She began Lasix diuresis and weaning for extubation began. She remained on a Nitroglycerin drip at 1.0 mcg/kg/min. She was a little bit slow to wean from the ventilator and was kept in the ICU. On postoperative day 2, it was noted she had a small left groin hematoma. Her creatinine remained stable. She continued to do very well. Her chest tubes were discontinued. On postoperative day 3, her exam was unremarkable with the exception of blood pressure of 91/31. She was saturating 96% on 4 liters nasal cannula after she was extubated. She remained on a Neo-Synephrine drip at 0.5 mg/kg/min. Beta blockade was started with Lopressor at 12.5 twice a day and aspirin therapy was also begun. Lopressor was almost immediately held given her low blood pressure as was her Lasix for that day. She was evaluated for her nutritional risks and was seen and evaluated by physical therapy to start her ambulation, increasing her activity level. Her mediastinal tubes had been removed the day before. Her pleural tube did remain in place on water seal. She was moving all extremities. She was alert and oriented. Her incisions were clean, dry, and intact. INR was 1.1. Creatinine remained stable. She was doing very well. Lasix was resumed. Lopressor was held on postoperative day 4, again for a blood pressure of 109/46, but she did remain in sinus rhythm. On postoperative day 5, her pleural tube was removed and her beta blockade was started again. Her blood pressure was 94/42. She was not transferred out to the floor until postoperative day 6. She had some incisional pain that she complained of on [**4-30**] for which Motrin was given. This was minimal at rest but increased significantly with coughing. Percocet was offered to the patient. Her appetite started to return. She had a bowel movement. She was voiding on her own in the bathroom with assist as well as ambulating with assist. She had one run of SVT with a heart rate in the 170s, blood pressure 80/50, 5 mg of I.V. Lopressor was given and 2 grams of magnesium were given. She then later had some PACs with sinus rhythm. She had some faint crackles at the base on [**5-1**], but continued to improve remarkably well. Given the SVT burst, a rehab screen was started. She had some diminished breath sounds at the bases with right greater than left. Her sternum was stable on postoperative day 7 and her pain control was better. Epicardial pacing wires had been removed. Incisions were clean, dry and intact. On postoperative day 8, she again had a rapid V-fib overnight. Her Digoxin was resumed and Coumadin was started. In the morning, she was in sinus rhythm and tachycardic at 110 with blood pressure of 91/62, respiratory rate of 20, and first dose of Coumadin was given that evening for atrial fibrillation occurrence and SVT. She was seen by and evaluated by cardiology who recommended continuing her Digoxin and Metoprolol, but there seemed to be no indication for anticoagulation at that time given her history of retinal bleed. They recommended if she became symptomatic in the future that we could consider an EP service evaluation as an outpatient with Dr. [**Last Name (STitle) **]. She was marginally symptomatic with this episode of SVT and the patient actually refused Coumadin given her history of retinal bleed in the past. It[**Last Name (STitle) 39608**]etermined the patient would be safe to go home with VNA services. On the day of discharge, postoperative day 9, her hematocrit was 30.3 with a K of 5.0. Her Digoxin was decreased to 0.125 p.o. once a day. She had diminished breath sounds at the bases and very fine rales half the way up bilaterally. Heart was regular rate and rhythm. Sternum was stable. She had positive bowel sounds with trace peripheral edema and the patient was cleared by physical therapy to go home with her family and was discharged with VNA services on [**2192-5-3**] in stable condition. The patient was instructed to follow up with Dr. [**Last Name (Prefixes) **] in the office in one month for a postoperative surgical visit and to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 39609**], for follow up appointment approximately 2-4 weeks post-discharge as well as seeing her cardiologist in approximately 2-4 weeks. DISCHARGE DIAGNOSES: 1. Status post ascending aorta and hemi-arch replacement with Gelweave graft and reimplantation of the innominate artery to the graft as well as aortic all free suspension. 2. Anxiety. 3. Macular degeneration, legally blind. 4. Osteoarthritis/degenerative joint disease. 5. Elevated cholesterol. 6. Paroxysmal supraventricular tachycardia with question of left anterior fascicular block. 7. Aortic insufficiency. 8. Osteopenia. 9. Colon polyp. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. once a day for 7 days. 2. Potassium chloride 20 mEq p.o. once a day for 7 days. 3. Colace 100 mg p.o. twice a day. 4. Enteric coated aspirin 81 mg p.o. once a day. 5. Percocet 5/325 one to two tablets p.o. p.r.n. q. 4-6 hours for pain. 6. Metoprolol 25 mg p.o. twice a day. 7. Digoxin 0.125 mg p.o. once a day. CONDITION ON DISCHARGE: The patient was discharged in stable condition on [**2192-5-3**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2192-6-7**] 16:30:14 T: [**2192-6-9**] 12:24:59 Job#: [**Job Number 39610**]

[ "396.3", "998.12", "427.89", "441.2", "V43.65", "369.4", "447.1", "458.29" ]

icd9cm

[ [ [] ] ]

[ "88.72", "35.39", "99.04", "38.45", "39.59", "39.61" ]

icd9pcs

[ [ [] ] ]

9081, 9536

9559, 9895

2447, 9060

1441, 2204

2221, 2424

9920, 10236

30,435

141,055

45177

Discharge summary

report

Admission Date: [**2141-2-26**] Discharge Date: [**2141-3-4**] Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Barium Sulfate / Prednisone / Collagen / IV Dye, Iodine Containing / Gantrisin Attending:[**First Name3 (LF) 14145**] Chief Complaint: chest pain, DOE Major Surgical or Invasive Procedure: cardiac cath History of Present Illness: [**Age over 90 **] yoF with hypertension, hyperlipidemia, prior admissions for pneumonia here with shortness of breath/DOE x1 week. Patient was in her usual state of health until 1 week ago when her BP was elevated. She went to see Dr. [**Last Name (STitle) **] who started her on hydralazine. Then, starting a few days ago, she began to notice centrally located chest pain as well as dyspnea with minimal exertion (walking from elevator to her apartment) which would normally not be a problem for her. Over the last 2 days her chest pain remained with her at rest and with exertion. She had been taking SL NTGs at home w/o significant change in her CP. She denied SOB at rest but had persistent dyspnea w/ minimal exertion. Today, as her symptoms persisted, she presented to the ED. In the ED, 97.4, 183/72, 83, 20, 100% NRB. On exam, chest pain reproducible and atypical. CXR was unremarkable. However, ECG with lateral ST depressions. Given NTGx1 with no effect. Aspirin given as well as morphine. ECG repeated w/ second set of CEs. ST depressions then diffuse w/ 2mm STD in precordial leads and some elevation in AVR. With ECG changes, patient received plavix 600mg, heparin gtt, and nitro gtt. She also received 1 dose of mucomyst w/ expectation of cath. CEs negative x2. She became chest pain free in the ED w/ nitro and heparin gtt. Upon arrival to the floor, she continues to be chest pain free. On review of systems, she denies any recent fever or chills. She does note some recent wheezing which she attributes to a [**Male First Name (un) 20181**] rug in her apartment. Denies any bowel or bladder symptoms. Past Medical History: # HTN # hyperlipidemia # h/o rheumatic fever # GERD # h/o pna requiring steroid taper # thyroid nodules s/p eval in nodule clinic, no FNA performed # urinary incontinence # arthritis Social History: Lives in independent living facility @ [**Street Address(2) **]. Widowed w/ one son. Denies tobacco and EtOH use. Family History: Family history is noncontributory. Physical Exam: VS: T: 98.5, BP: 131/46, HR: 67, RR: 20, O2: 94% on 2LNC Gen: Elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. Cannot appreciate JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2.II/VI <> sys murmur at LUSB and holosys murmur at apex. Chest: Bibasilar crackles, L>R. Diffuse end exp wheezes Abd: Soft, NTND. No HSM or tenderness. No organomegaly. Groin: 2+ femoral pulses. No bruits Ext: WWP. No c/c/e. 2+ DP pulses. Skin: No stasis dermatitis, ulcers, scars Pertinent Results: [**2141-2-26**] 4:15 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2141-2-28**]** URINE CULTURE (Final [**2141-2-28**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ECG [**2141-2-27**]: NSR @ 70. Nl axis and intervals. Inferior TW flattening w/ <[**Street Address(2) 4793**] depressions in II, aVF. 1 mm STD w/ TWI in V5-6. ECG [**2141-2-26**] 17:23: NSR@90. Nl axis and intervals. TWI in lateral leads c/w strain pattern of LVH. 1-2mm ST depressions in V4-6. [**Street Address(2) 13234**] depression in II. Compared to prior [**2139-5-6**], ST changes are new. CXR [**2141-2-26**]: The cardiomediastinal silhouette is stable. The left CPA is not included in this study. The upper lungs are clear. IMPRESSION: No evidence of CHF or acute cardiopulmonary process. CARDIAC CATH [**3-1**]: 1. Coronary angiography of this right dominant system revealed severe three vessel disease. The LMCA was normal. The LAD had 60-70% tubular diffuse disease. The LCX had 80% tubular diffuse disease. The RCA had 80% tubular diffuse disease. 2. Resting hemodynamics revealed elevated systemic arterial pressures during the case with an SBP of 139 mm Hg. 3. Left ventriculography was not performed. 4. After the diagnostic procedure, the patient complained of throat and eye itching. She subsequently developed facial erythema plethora with whole body pruritus and developed angioedema of the tongue and had difficulty speaking and breathing consistent with anaphylaxis. Arterial pressure rose to 220 mm Hg systolic. The patient was given benadryl, IV solumedrol, nitro gtt and IC nitro, albuterol nebulizers, pepcid, 100 mg IV lasix and epinephrine 0.3 mg SC x 1 with close respiratory monitoring. Anesthesia was present but intubation was not necessary and the patient was stabilized and transferred to the CCU for closer monitoring. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Anaphylaxis to IV contrast. [**2141-3-4**] 07:40AM BLOOD WBC-10.0 RBC-3.80* Hgb-11.6* Hct-33.5* MCV-88 MCH-30.6 MCHC-34.6 RDW-13.3 Plt Ct-465* [**2141-2-26**] 12:20PM BLOOD WBC-11.0 RBC-3.70* Hgb-11.1* Hct-32.6* MCV-88 MCH-30.1 MCHC-34.1 RDW-13.1 Plt Ct-447* [**2141-3-3**] 06:52AM BLOOD PT-11.9 PTT-24.6 INR(PT)-1.0 [**2141-3-4**] 07:40AM BLOOD Glucose-117* UreaN-48* Creat-1.4* Na-140 K-4.3 Cl-101 HCO3-29 AnGap-14 [**2141-3-3**] 06:52AM BLOOD Glucose-110* UreaN-41* Creat-1.2* Na-139 K-3.7 Cl-99 HCO3-30 AnGap-14 [**2141-3-2**] 03:34AM BLOOD Glucose-214* UreaN-30* Creat-1.4* Na-139 K-3.7 Cl-93* HCO3-30 AnGap-20 [**2141-3-1**] 10:00PM BLOOD Glucose-199* UreaN-29* Creat-1.3* Na-138 K-4.0 Cl-97 HCO3-29 AnGap-16 [**2141-3-1**] 06:05AM BLOOD Glucose-95 UreaN-27* Creat-1.2* Na-141 K-4.3 Cl-104 HCO3-28 AnGap-13 [**2141-2-28**] 08:10AM BLOOD Glucose-95 UreaN-21* Creat-1.0 Na-140 K-3.7 Cl-101 HCO3-26 AnGap-17 [**2141-2-27**] 06:40AM BLOOD Glucose-112* UreaN-26* Creat-1.0 Na-141 K-3.9 Cl-107 HCO3-24 AnGap-14 [**2141-2-26**] 12:20PM BLOOD Glucose-177* UreaN-38* Creat-1.4* Na-143 K-4.3 Cl-106 HCO3-22 AnGap-19 [**2141-2-27**] 06:40AM BLOOD LD(LDH)-175 CK(CPK)-36 TotBili-0.8 [**2141-3-2**] 03:34AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2141-2-27**] 06:40AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2141-2-27**] 01:07AM BLOOD CK-MB-NotDone [**2141-2-26**] 07:20PM BLOOD cTropnT-<0.01 [**2141-2-26**] 12:20PM BLOOD cTropnT-<0.01 [**2141-3-4**] 07:40AM BLOOD Mg-2.0 [**2141-3-3**] 06:52AM BLOOD Calcium-9.8 Phos-3.1# Mg-2.3 [**2141-2-27**] 06:40AM BLOOD Hapto-241* [**2141-3-1**] 03:59PM BLOOD Type-ART pO2-114* pCO2-55* pH-7.30* calTCO2-28 Base XS-0 [**2141-3-1**] 03:41PM BLOOD Glucose-165* Lactate-1.3 Na-138 K-4.2 Brief Hospital Course: CAD: The patient presented with unstable angina, she had ST depressions in her L anterior precordial leads which were 2mm depressions and seemed significant. She ruled out for MI. She was started on aspirin, plavix, statin, heparin, and a beta blocker. She underwent a cardiac cathterization which revealed severe calcified 3 vessel disease and no intervention was made. Decision was made for medical management. Started on Toprol 200mg daily, Losartan increased to 100mg daily. Norvasc 5mg daily continued, ASA 325mg daily, Plavix 75mg daily, Lipitor 80mg daily, hydralazine 25mg po tid. She should continue on these medications as an outpatient. URINARY TRACT INFECTION: pan sensitive Klebsiella UTI. Has had same organism multiple times in the past, simple UTI but given elderly and recurrance will treat for 7 days in total with ciprofloxacin. Day 1 of treatment was [**2-28**], last day should be [**3-6**]. ANAPHYLAXIS: The patient had an anaphylactic reaction to contrast dye during her cardiac cath. She began to have pruritis and tongue swelling initially and then shortness of breath as the cathters were pulled out. She was given sc epinephrine, solumedrol, pepcid, benadryl and responded well. She was never intubated and was not hypotensive. Symptoms resolved after 12 hours. CHRONIC RENAL INSUFFICIENCY: Cr. now stable between 1.2 and 1.4, baseline is 1.1. Acute on chronic renal insufficiency very likely related to contrast nephropathy. She did receive pre and post cath hydration in addition to mucomyst. Medications on Admission: Inderal 160 mg daily cozaar 50 mg daily aspirin 81 mg daily triamterene/hctz 37.5/25 mg QM/W/F detrol 2 mg daily pravastatin 80 mg daily norvasc 5 mg daily hydralazine 25 mg [**Hospital1 **] omeprazole 20 mg daily calcium vit D MVI Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days: last dose on [**3-6**] for total 7 day course. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 13. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] CENTER Discharge Diagnosis: Primary Diagnosis: Unstable Angina Urinary Tract Infection Hypertension Anaphylaxis to contrast dye Discharge Condition: Stable Discharge Instructions: You were admitted with chest pain. You were found to have severely narrowed coronary arteries with a decision to medically manage (treat with medications rather than a stent). You should continue to take your medications as prescribed. Please call your doctor or return to the emergency room if you have additional chest pain, shortness of breath or any other symptoms that concern you. Followup Instructions: Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 14149**] ([**Street Address(2) **] Cardiology) within 3 weeks of discharge from the hospital. Please follow up with your primary care physician [**Name9 (PRE) **],[**Name9 (PRE) 507**] [**Name9 (PRE) 508**] [**Telephone/Fax (1) 133**] within 2 weeks of your discharge from the skilled nursing facility.

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Discharge summary

report

Admission Date: [**2135-5-2**] Discharge Date: [**2135-5-30**] Date of Birth: [**2070-1-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Hypoxia, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 65 year old male with Non hodgkins lymphoma on HCD122 chemo protocol, prior mycobacterium xenopi and MRSA PNA, emphysema, HTN, s/p PEG placement, who was admitted to ED from oncology clinic appt with right shoulder/chest pain, mild hypoxia, hypotension, and tachycardia. . The patient had gone to oncology clinic for scheduled chemo (CD40 inhibitor study drug), when found to have new right-sided chest/shoulder pain, hypoxia to high 80s/low 90s on RA, tachycardia to 120s, and hypotension to 83/58. Patient describes 1 week h/o right sided pleuritic pain, fatigue, malaise, and decreased PO intake. Some increase in chronic cough Notes this pain is similar to symptoms of prior PNA. Also has slightly increased right arm swelling and reported G-tube with malodorous drainage. Denies fever, chills, diarrhea, wheezing, chest pain, palpitations. Has some increased urinary frequency without hematuria. He has had multiple hospitalizations in last year, the most recent being [**Date range (1) 55849**] for RSV infection - discharged on 10 days of levaquin for bacterial superinfection ppx. Since then he has been getting his chemo infusions, and had recently left rehab to live at sister's house, doing well until one week. . In the clinic, he was given heparin bolus 5000 units for concern of PE given increased lymphedema on right side and risk factors, and sent to ED. . In the ED, the patient's initial vitals were afebrile, tachy to 120s, BP 89/60, HR 24, 96% on 4L. CXR showed persistent right mid lung patchy opacity likely representing resolving pneumonia, with slightly enlarged right- sided pleural effusion. CTA showed no PE but showed increased R effusion and ground glass opacity likely persistent resolving infection, LLL opacity increased from prior. RUL US negative for DVT. CT abd/pelvis without contrast showed no acute process. Given IV vanc/cefepime, mucomyst prior to procedure, 2L NS. Labs significant for lactate 3.1, WBC 16.3 with 12 bands and 64N, Cr 2.4, LDH 262, uric acid 8.2. Patient's outpatient oncologist was made aware, pt was transferred to [**Hospital Unit Name 153**] for further care of her sepsis, hypoxia. On transfer, vitals were T98.9, HR120-150, 103/74, 24-28, 98% on 3L. . On arrival to the ICU, the patient's BP was 100-120s systolic. Patient still complaining of right sided pleuritic pain, otherwise with no other complaints. . Review of systems was otherwise negative. Past Medical History: - Follicular lymphoma with evidence of documented large cell transformation from lymph node bx done in [**1-3**]. Has been refractory to multiple chemotherapeutic regimens, currently enrolled on protocol DF#08-019 which is a Phase I/A/II multicenter open label study of HCD122 which is administered intravenously once weekly for 4 weeks -s/p 4 cycles of R-CVP -s/p 4 cycles of R-CHOP -s/p Zevalin in [**7-/2130**] -s/p Rituximab, fludarabine, and mitoxantrone in [**4-/2131**] -s/p 6 cycles bendamustine in [**2-/2132**] -s/p radiation therapy mesenteric mass in [**9-/2133**] -s/p radiation therapy to left pelvic lymphadenopathy causing ureteral obstruction) in [**1-/2134**] -s/p 1 course [**Hospital1 **] [**Date range (1) **]/[**2134**] . Other Medical History: 1) Mycobacterium xenopi infection since [**2132-12-26**]: Had received one year of Levofloxacin/Azithromycin therapy until [**3-/2134**] with good effect. Both were discontinued at that time but restarted in [**7-/2134**] as patient was having increased respiratory symptoms. Per ID, will need to continue for a total 6 month course (finish [**2135-2-16**]), after which he will be switched to azithromycin alone. s/p left VATS w wedge resections in [**2133**] for pulmonary nodules 2) C difficile colitis diagnosed during hospitalization in [**9-3**]. He was initially treated on PO metronidazole then converted to PO vancomycin on [**2134-9-22**]. 3) During last [**Hospital1 **] admission ([**Date range (1) 32408**]), he had a MRSA UTI, treated with a total of 2 weeks of Vancomycin and then Bactrim. 4) Admitted [**Date range (1) 55850**] for neutropenic fever and acute renal failure. ARF thought to be prerenal. No source identified for fever, treated empirically with cefepime. 5) Repeat admission for failure to thrive resulted in PEG tube placement on [**2135-1-5**]. 6) Emphysema with smoking history Social History: The patient has been living at sister's house, prior to this had been at Colony house for rehabilitation following multiple extended hospitalizations over the past several months. He is a retired mechanic. He was a heavy drinker for many years but quit about 20 years ago. Has extensive smoking history up to 2ppd x 50 years, just quit 12/[**2134**]. He has never been married. He has a daughter in [**Name (NI) 55851**]. Family History: Notable for heart problems in a sister. [**Name (NI) **] has two brothers who are older than him who are healthy. His father died young due to an old war injury. His mother died in her 90's. Physical Exam: On admission GENERAL: Elderly male with nasal cannula in place, not using accessory muscles, in NAD HEENT: Sclerae anicteric. Conjunctivae not pale. Moist mucous membranes. No thrush or oropharyngeal lesions. NECK: Supple. LYMPH NODES: Possible small right anterior cervical at base/supraclavicular node. Otherwise, no other cervical, supraclavicular, infraclavicular or inguinal lymphadenopathy noted. CHEST: Decreased at bases. Trace crackles at bases CARDIAC: RR, no MRG ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. G-tube with some crusting along side, but without redness or erythema or drainage. No suprapubic tenderness. BACK: Without CVA tenderness. EXTREMITIES: 1+ edema in his right hand, otherwise, no LE edema NEUROLOGIC: grossly nonfocal On discharge: GENERAL: Elderly male, NAD HEENT: Sclerae anicteric. Conjunctivae not pale. Moist mucous membranes. No thrush or oropharyngeal lesions. NECK: Supple. LYMPH NODES: Righa anterior cervical node, no other LAD. CHEST: Crackles and decreased breath sounds on left, clear on right CARDIAC: RR, no MRG ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. G-tube with some crusting along side, but without redness or erythema or drainage. No suprapubic tenderness. BACK: Without CVA tenderness. EXTREMITIES: 1+ edema in his right hand, wrapped in ace bandage. No LE edema NEUROLOGIC: grossly nonfocal Pertinent Results: [**2135-5-2**] 09:00AM GRAN CT-[**Numeric Identifier 55506**]* [**2135-5-2**] 09:00AM PLT SMR-NORMAL PLT COUNT-245 [**2135-5-2**] 09:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2135-5-2**] 09:00AM NEUTS-64 BANDS-12* LYMPHS-7* MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-3* PROMYELO-1* [**2135-5-2**] 09:00AM WBC-16.3* RBC-2.85* HGB-10.2* HCT-30.2* MCV-106* MCH-35.9* MCHC-33.9 RDW-18.4* [**2135-5-2**] 09:00AM TOT PROT-5.2* ALBUMIN-3.3* GLOBULIN-1.9* CALCIUM-9.1 PHOSPHATE-5.1* MAGNESIUM-1.7 URIC ACID-8.2* [**2135-5-2**] 09:00AM LIPASE-11 [**2135-5-2**] 09:00AM ALT(SGPT)-18 AST(SGOT)-22 LD(LDH)-262* ALK PHOS-95 AMYLASE-30 TOT BILI-0.3 DIR BILI-0.2 INDIR BIL-0.1 [**2135-5-2**] 09:00AM UREA N-57* CREAT-2.4* SODIUM-142 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-19* ANION GAP-24* [**2135-5-2**] 09:20AM PT-14.9* INR(PT)-1.3* [**2135-5-2**] 09:20AM D-DIMER-767* [**2135-5-2**] 10:25AM LACTATE-3.1* [**2135-5-2**] 03:22PM LACTATE-2.6* [**2135-5-2**] 03:22PM TYPE-ART PO2-86 PCO2-29* PH-7.42 TOTAL CO2-19* BASE XS--3 [**2135-5-2**] 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2135-5-2**] 03:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026 [**2135-5-2**] 03:50PM URINE OSMOLAL-345 [**2135-5-2**] 03:50PM URINE HOURS-RANDOM CREAT-43 SODIUM-25 [**2135-5-2**] 11:41PM CALCIUM-7.9* PHOSPHATE-5.8* MAGNESIUM-2.3 [**2135-5-2**] 11:41PM GLUCOSE-93 UREA N-49* CREAT-2.0* SODIUM-140 POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-18* ANION GAP-14 MICRO: RESPIRATORY CULTURE (Final [**2135-5-6**]): MODERATE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S LEGIONELLA CULTURE (Final [**2135-5-10**]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Final [**2135-5-17**]): YEAST. STOOL CULTURE CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2135-5-22**]): CLOSTRIDIUM DIFFICILE: FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). ------- IMAGING: CTA [**5-2**]: 1. No pulmonary embolus or acute aortic pathology. 2. Slightly increased right pleural effusion with associated atelectasis. 3. Persistent ground-glass airspace opacity in the right lower lobe likely represents resolving infectious process. 4. Increased nodular density adjacent to the left lower lobe suture line, which is a nonspecific finding and may represent inflammatory changes, although an infectious etiology cannot be excluded. 5. Resolution of left lower lobe mucoid impaction seen on prior study. 6. No change in axillary adenopathy. Mediastinal nodes are also stable, not pathologically enlarged CT Chest and Neck [**5-17**]: IMPRESSION: No relevant change as compared to the previous examination. Unchanged pre- existing right basal parenchymal opacities, with small ventral opacities that have newly occurred and most likely correspond to healing infection or atelectasis. No evidence of mediastinal or hilar lymphadenopathy. No pleural effusions. No recent pneumonia. No evidence of lymphoma in the abdomen. TTE [**5-19**]: 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. There is mild global left ventricular hypokinesis (LVEF = 50%). The right ventricular cavity is mildly dilated with depressed systolic function (more precise assessment is limited by poor acoustic windows). The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-28**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mildly dilated right ventricle with mild global biventricular systolic dysfunction. Mild to moderate mitral and tricuspid regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2135-4-29**], right ventricle is larger and biventricular systolic function is lower. Severity of mitral and tricuspid regurgitation. CT abdomen and pelvis [**5-21**]: 1. Loculated pleural effusion anteriorly is decreased in size although demonstrates enhancement and empyema can therefore not be excluded. 2. Unchanged appearance of infiltrative soft tissue mass involving the root of mesentery and retroperitoneum. Left pelvic side wall and right peri-psoas lymphadenopathy is also unchanged. 3. Stable mild intrahepatic ductal dilatation with no evidence for acute cholecystitis. 4. Unchanged bilateral renal cysts. CT Chest [**2135-5-27**]: IMPRESSION: Mild interval decrease in right pleural fluid. Otherwise, no relevant change in the appearance of the chest. Specifically, no evidence of new parenchymal infectious process DISCHARGE LABS: WBC: 13.4/9.2/28.1/347 CHEM 7: 136/4/96/25/29/1.3/97 Brief Hospital Course: 65 year old male with refractory Non hodgkins lymphoma on trial anti CD40 chemo protocol with a complicated medical history including COPD and M. xenopi infection as well as multiple recent pneumonias who presented with sepsis requiring brief ICU stay in the setting of a MRSA pneumonia. Treated with vancomycin and completed course. Developed C. diff and was treated with oral vancomycin starting [**2135-5-21**], total duration of treatment should be 2 weeks every 6 hours. Patient should then continue on prophylaxis of vancomycin 125mg po bid indefinitely. Patient was discharged in stable condition to rehab with oncology follow up. #. MRSA Pneumonia, sepsis: Given the patient's hypoxia and right-sided pleuritic chest pain upon presentation, a CTA was done which failed to find a PE. The patient completed a 14 day course of vancomycin during which his clinical status as well as his pleuritic chest pain improved dramatically. By the end of his treatment course he was able to ambulate on room air without desaturation. On [**5-21**], a CT abdomen was done to investigate diarrhea but ended up noting a loculated effusion at the lung base. Pulmonary was consulted and given than effusion was deceasing in size, no acute intervention was necessary as he was clinically improving. Recommend repeat chest CT in 2 weeks to trend size. # C.Diff: On [**5-20**] the patient began to complain of multiple loose stools with associated abdominal pain. Given his persistent bandemia and recent antibiotics, a C. diff culture was sent and returned positive. He was started on PO vanco for a total of 2 weeks, last dose should be the evening on [**2135-6-4**] and then should be continued [**Hospital1 **] indefinitely as above. Additionally, he was treated with IvIg on [**2135-5-29**] given persisently low IgG levels. #. Hypotension: The patient's home diltiazem was held given his initial hypotension. Once his clinical status improved however, he was persistently tachycardic and orthostatic. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was within normal limits as was TSH. Every attempt was made to maintain euvolemia without third spacing in the setting of hypoalbuminemia. He was started on [**Last Name (NamePattern4) 55852**] with slight improvement. A TTE was repeated and showed decreased LV and RV function. A cardiology consult was called and recommended uptitrating beta-blockage in the setting of a multi-factorial atrial and multi-focal atrial tachycardia from deconditioning, COPD, and progressive failure to thrive. #. Acute on chronic renal failure: Improved to stage 1 CKD with attainment of euvolemia. #. Non Hodgkins Lymphoma: Continued on prophylactic acyclovir and fluconazole as well as monthly pentamidine. He was also given a dose of IVIG. Per his primary oncologist, the CD40 study drug could not be obtained for the patient until 2 weeks after his completion of antibiotics (to end [**2135-6-4**]). While in the hospital, the patient noted a new, right-sided supraclavicular lymph node. This node was monitored and remained approximately 1.5 by 0.5 cm in size. CT head and neck were done without contrast to evaluate for progression of disease and did not show any obvious progression. Patient to have repeat echocardiogram and will follow up with his primary oncologist further treatment. # COPD: With long smoking history, currently without cigarettes for last 4 months. He was continued on home fluticasone and combivent and nebs prn. # Mycobacterium Xenopi: The patient was continued on Azithromycin q tuesday. # FTT, aspiration: Has been on going since [**11/2134**], head imaging and LP at that time were unrevealing. Unclear cause of aspiration, likely secondary to overall poor conditioning. The patient was maintained on tube feeds via his G-tube. He was evaluated by speech and swallow by bedside and video swallow at which time he was noted to be aspirating all types of foods and liquids. The patient was adament that he continue to be allowed occasional drinks PO. He was given swallowing exercises and continued to work with the speech therapy team on techniques to improve his swallowing and allow for eventual advancement of PO intake. His repeat video swallow on [**2135-5-26**] showed slight improvement but continued aspiration. He was kept NPO except for sips of tea as patient was insistent on drinking tea and unwilling to be entirely NPO. Has repeat out patient video swallow in several weeks. # Code: FULL Medications on Admission: Acyclovir 400mg [**Hospital1 **] Azithromycin 1,200mg Qweek Diltiazem 30mg QID Fluconazole 200mg daily Flagyl 500mg [**Hospital1 **] Fluticasone 110mcg, 2 puffs [**Hospital1 **] Hydrocodone acetaminophen 5/500, 1-2tabs Q6hr prn Combivent 18/103, 1-2 puffs Q6hr prn Lansoprazole 30mg daily Loperaminde 2mg QID prn Megestrol 400mg [**Hospital1 **] prn Mirtazapine 30mg QHS prn Compazine 10mg Q6hr prn Trazodone 50mg QHS prn Pentamadine Qmonth Tylenol prn Colace prn Senna prn Simethicone prn Multivitamins Discharge Medications: 1. Fluconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): per G-tube. 3. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 5. Acyclovir 200 mg/5 mL Suspension [**Last Name (STitle) **]: Four Hundred (400) mg PO every eight (8) hours. 6. Mirtazapine 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime): per g-tube. 7. Trazodone 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia: per g-tube. 8. Azithromycin 600 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO 1X/WEEK (TU) as needed for mycobacterium: Total is 1200mg per g-tube. 9. Fludrocortisone 0.1 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day): per g-tube. 11. Allopurinol 300 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily): per g-tube. 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Indwelling Port (e.g. Portacath), non-heparin dependent: Flush with 10 mL Normal Saline daily, PRN, and when de-accessing, per lumen. 13. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 14. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 15. Vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every 6 hours): Last dose evening of [**2135-6-4**]. 16. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Date Range **]: 15-30 MLs PO QID (4 times a day) as needed for gas. 17. Fluticasone 110 mcg/Actuation Aerosol [**Date Range **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 18. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 20. Erythromycin 5 mg/g Ointment [**Hospital1 **]: One (1) application Ophthalmic QID (4 times a day) for 6 days: apply to both eyes. Can decrease to [**Hospital1 **] if sx improve in 2 days. 21. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain, fever. 22. Ipratropium Bromide 0.02 % Solution [**Age over 90 **]: One (1) neb Inhalation Q8H (every 8 hours). 23. Saliva Substitution Combo No.2 Solution [**Age over 90 **]: Thirty (30) ML Mucous membrane TID (3 times a day). Discharge Disposition: Extended Care Facility: Colony House Nursing & Rehabilitation Center - [**Location (un) 32775**] Discharge Diagnosis: Primary: Methicillin Resisitant Staph Aureus Pneumonia Clostridium Difficile Diarrhea Failure To Thrive Secondary: Follicular lymphoma with evidence of documented large cell transformation from lymph node bx done in [**1-3**]. Has been refractory to multiple chemotherapeutic regimens, currently enrolled on protocol DF#08-019 which is a Phase I/A/II multicenter open label study of HCD122 which is administered intravenously once weekly for 4 weeks -s/p 4 cycles of R-CVP -s/p 4 cycles of R-CHOP -s/p Zevalin in [**7-/2130**] -s/p Rituximab, fludarabine, and mitoxantrone in [**4-/2131**] -s/p 6 cycles bendamustine in [**2-/2132**] -s/p radiation therapy mesenteric mass in [**9-/2133**] -s/p radiation therapy to left pelvic lymphadenopathy causing ureteral obstruction) in [**1-/2134**] -s/p 1 course [**Hospital1 **] [**Date range (1) **]/[**2134**] . Other Medical History: 1) Mycobacterium xenopi infection since [**2132-12-26**]: Had received one year of Levofloxacin/Azithromycin therapy until [**3-/2134**] with good effect. Both were discontinued at that time but restarted in [**7-/2134**] as patient was having increased respiratory symptoms. Per ID, will need to continue for a total 6 month course (finish [**2135-2-16**]), after which he will be switched to azithromycin alone. s/p left VATS w wedge resections in [**2133**] for pulmonary nodules 2) C difficile colitis diagnosed during hospitalization in [**9-3**]. He was initially treated on PO metronidazole then converted to PO vancomycin on [**2134-9-22**]. 3) During last [**Hospital1 **] admission ([**Date range (1) 32408**]), he had a MRSA UTI, treated with a total of 2 weeks of Vancomycin and then Bactrim. 4) Admitted [**Date range (1) 55850**] for neutropenic fever and acute renal failure. ARF thought to be prerenal. No source identified for fever, treated empirically with cefepime. 5) Repeat admission for failure to thrive resulted in PEG tube placement on [**2135-1-5**]. 6) Emphysema with smoking history 7) [**2135-3-13**] RSV infection - 10 day course of levofloxacin to prevent regrowth Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted to the hospital due to your difficult breathing and low blood pressure. You were found to have a MRSA pneumonia for which you were treated with 14 days of an IV antibiotic named vancomycin. [**Name2 (NI) **] completed that course with improvement in your breathing status but then developed worsening diarrhea and were found to have an infectious diarrhea called C.diff. You had treatment for this with the oral form of the same antibiotic (vancomycin). After you finish this treatment (which is vancomycin 4 times a day), you will need to continue this medication twice a day to ensure that the infection does not recur. You will need to be on it indefinitely. You blood pressure was also quite low and your heart rate was often fast for unclear reasons. You were started on a medication named [**Name (NI) 55852**] with improvement in your blood pressure. Additionally, you developed conjunctivitis (and eye infection) and were started on an anti-bacterial ointment four times a day. You should continue this until [**2135-6-2**]. Please be sure to keep all of your appointments as listed below. If you have any shortness of breath, fever, abdominal pain, chest pain, arm swelling, severe pain, headache, blurry vision or any other concerning symptom, please seek medical care immediately. It was a pleasure meeting you and participating in your care. Followup Instructions: ECHOCARDIOGRAM: Monday [**6-6**] 3pm, [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 5074**] [**Hospital1 18**]. [**Location (un) 436**] in Cardiology department. [**Telephone/Fax (1) 62**]. ONCOLOGY: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2135-6-15**] 12:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2135-6-15**] 12:30 VIDEO SWALLOW: Thursday [**6-9**] at 1pm. [**Hospital1 18**]. Clinical Center, [**Hospital Ward Name 517**], [**Location (un) 10043**] in Radiology Deparment.

[ "482.42", "507.0", "496", "584.9", "995.92", "031.0", "263.9", "V44.1", "V02.54", "287.5", "416.8", "008.45", "585.1", "799.02", "279.00", "783.7", "202.80", "424.0", "424.2", "403.90" ]

icd9cm

[ [ [] ] ]

[ "99.15", "99.10" ]

icd9pcs

[ [ [] ] ]

20320, 20419

12172, 16679

343, 349

22544, 22570

6777, 12079

23999, 24677

5155, 5347

17234, 20297

20440, 22523

16705, 17211

22594, 23976

12095, 12149

5362, 6136

6150, 6758

283, 305

377, 2794

2816, 4699

4715, 5139

12,938

179,057

2323

Discharge summary

report

Admission Date: [**2102-3-13**] Discharge Date: [**2102-3-16**] Date of Birth: [**2057-6-6**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Erythromycin Base / Floxin / Iodine; Iodine Containing / Gadolinium-Containing Agents / Amoxicillin / Latex Attending:[**First Name3 (LF) 1283**] Chief Complaint: IVC tumor Major Surgical or Invasive Procedure: Resection of IVC tumor, IVC graft repair of suprahepatic segment, T external illiac vein to IVC bypass History of Present Illness: 44 F who underwent a partial hysterectomy in 199 with completion in [**2095**] c/b PE, undergoing embolectomy. Since that time she had been followed for suspected chronic clot in IVC. MRI in [**Month (only) 1096**] suggested leimyomatosisThis tumor ran throughout the R internal illic vein, the IVC, up into the right atrium. Past Medical History: Invasive Leiomyotosis IVC tumor Saddle PE- s/p embolectomy asthma PUD hiatal hernia s/p repair '[**96**] colitis partial hysterectomy [**2094**](benign leiomyotosis) completion hysterectomy [**2095**] C-section '[**76**]&'[**78**] CCY '[**78**] Tubal ligation Appy '[**96**] sternal wire removal '[**01**] Social History: lives with mother and sister. [**Name (NI) 1403**] for [**Location (un) 5700**] ambulance Denies ETOH and tobacco Family History: noncontributory Physical Exam: On Admission: Afebrle, vitals witin nml range NAD CTAB RRR well healed sternal wound abdomen was non-tender no distended no edema Pertinent Results: [**2102-3-15**] 11:59PM BLOOD WBC-5.0 RBC-3.42* Hgb-10.1* Hct-29.3* MCV-86 MCH-29.5 MCHC-34.5 RDW-15.8* Plt Ct-157 [**2102-3-15**] 10:30PM BLOOD Hct-33.7* Plt Ct-185 [**2102-3-15**] 08:20PM BLOOD WBC-5.2 RBC-3.78* Hgb-11.2* Hct-31.4* MCV-83 MCH-29.7 MCHC-35.8* RDW-15.4 Plt Ct-187# [**2102-3-15**] 06:37PM BLOOD WBC-5.4 RBC-4.03*# Hgb-11.7* Hct-34.0*# MCV-85 MCH-29.1 MCHC-34.4 RDW-15.3 Plt Ct-71* [**2102-3-15**] 04:49PM BLOOD WBC-4.0 RBC-3.12*# Hgb-9.6*# Hct-27.1*# MCV-87 MCH-30.7 MCHC-35.4* RDW-14.8 Plt Ct-85* [**2102-3-15**] 11:19AM BLOOD WBC-3.7* RBC-4.46 Hgb-12.7 Hct-37.4 MCV-84 MCH-28.5 MCHC-33.9 RDW-13.9 Plt Ct-149* [**2102-3-13**] 01:00PM BLOOD WBC-4.8 RBC-4.72 Hgb-13.8 Hct-38.5 MCV-82 MCH-29.2 MCHC-35.8* RDW-13.8 Plt Ct-197 [**2102-3-15**] 11:59PM BLOOD Plt Ct-157 [**2102-3-15**] 11:59PM BLOOD PT-19.6* PTT-109.3* INR(PT)-1.9* [**2102-3-15**] 08:20PM BLOOD PT-19.8* PTT-83.2* INR(PT)-1.9* [**2102-3-15**] 06:37PM BLOOD PT-20.8* PTT-104.3* INR(PT)-2.0* [**2102-3-15**] 11:19AM BLOOD PT-15.6* PTT-119.0* INR(PT)-1.4* [**2102-3-14**] 04:24PM BLOOD PT-15.5* PTT-69.8* INR(PT)-1.4* [**2102-3-13**] 01:00PM BLOOD PT-14.9* PTT-26.2 INR(PT)-1.3* [**2102-3-15**] 08:20PM BLOOD Fibrino-245 [**2102-3-15**] 06:37PM BLOOD Fibrino-241 [**2102-3-15**] 11:19AM BLOOD Fibrino-317 [**2102-3-15**] 11:59PM BLOOD UreaN-11 Creat-1.1 Na-151* Cl-118* HCO3-19* [**2102-3-15**] 08:20PM BLOOD Glucose-126* UreaN-11 Creat-0.9 Na-148* K-3.4 Cl-114* HCO3-19* AnGap-18 [**2102-3-13**] 01:00PM BLOOD Glucose-86 UreaN-15 Creat-0.9 Na-141 K-3.6 Cl-106 HCO3-26 AnGap-13 [**2102-3-15**] 08:20PM BLOOD ALT-56* AST-98* LD(LDH)-464* AlkPhos-50 Amylase-28 TotBili-4.2* [**2102-3-13**] 01:00PM BLOOD ALT-28 AST-25 AlkPhos-63 Amylase-47 TotBili-2.1* [**2102-3-15**] 08:20PM BLOOD Lipase-31 [**2102-3-13**] 01:00PM BLOOD Lipase-39 [**2102-3-16**] 01:38AM BLOOD Type-ART PEEP-12 FiO2-100 pO2-37* pCO2-49* pH-7.25* calTCO2-23 Base XS--6 AADO2-636 REQ O2-100 Intubat-INTUBATED [**2102-3-16**] 01:04AM BLOOD Type-ART pO2-48* pCO2-48* pH-7.24* calTCO2-22 Base XS--6 [**2102-3-16**] 12:35AM BLOOD pO2-18* pCO2-68* pH-7.10* calTCO2-22 Base XS--11 [**2102-3-16**] 12:28AM BLOOD Type-ART pO2-41* pCO2-46* pH-7.18* calTCO2-18* Base XS--11 [**2102-3-16**] 12:04AM BLOOD Type-ART pO2-35* pCO2-52* pH-7.20* calTCO2-21 Base XS--8 [**2102-3-15**] 11:07PM BLOOD Type-ART pO2-251* pCO2-29* pH-7.45 calTCO2-21 Base XS--1 [**2102-3-15**] 11:07PM BLOOD Type-ART pO2-251* pCO2-29* pH-7.45 calTCO2-21 Base XS--1 [**2102-3-15**] 10:42PM BLOOD Type-ART pO2-47* pCO2-43 pH-7.19* calTCO2-17* Base XS--11 [**2102-3-15**] 09:18PM BLOOD Type-ART PEEP-12 pO2-61* pCO2-46* pH-7.24* calTCO2-21 Base XS--7 Intubat-INTUBATED [**2102-3-15**] 08:25PM BLOOD Type-ART pO2-82* pCO2-44 pH-7.29* calTCO2-22 Base XS--4 [**2102-3-15**] 07:52PM BLOOD Type-ART pO2-83* pCO2-46* pH-7.26* calTCO2-22 Base XS--6 [**2102-3-15**] 06:19PM BLOOD Type-ART pO2-153* pCO2-43 pH-7.31* calTCO2-23 Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [**2102-3-15**] 04:49PM BLOOD Type-ART pO2-121* pCO2-40 pH-7.32* calTCO2-22 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [**2102-3-15**] 04:07PM BLOOD Type-ART pO2-397* pCO2-39 pH-7.22* calTCO2-17* Base XS--11 [**2102-3-15**] 03:28PM BLOOD Type-ART pO2-420* pCO2-38 pH-7.37 calTCO2-23 Base XS--2 [**2102-3-15**] 03:05PM BLOOD Type-ART pO2-483* pCO2-33* pH-7.34* calTCO2-19* Base XS--6 [**2102-3-15**] 01:11PM BLOOD Type-ART pO2-742* pCO2-40 pH-7.32* calTCO2-22 Base XS--5 [**2102-3-16**] 01:38AM BLOOD Glucose-68* Lactate-13.1* [**2102-3-16**] 01:04AM BLOOD Lactate-11.5* [**2102-3-16**] 12:04AM BLOOD Glucose-97 Lactate-10.4* K-3.4* [**2102-3-15**] 10:42PM BLOOD Glucose-144* Lactate-10.1* K-4.3 [**2102-3-15**] 09:18PM BLOOD Glucose-118* Lactate-7.8* [**2102-3-15**] 08:25PM BLOOD Lactate-7.0* POST OP CXR: 1. Status post median sternotomy, placement of two right-sided chest tubes, two left-sided chest tubes, endotracheal tube and nasogastric tube. 2. Interval development of diffuse bilateral airspace opacities could represent pulmonary edema or massive aspiration. 3. Probable small residual left pneumothorax. Brief Hospital Course: She came in on [**2102-3-13**] preoperatively and was placed on a heparin drip and discussed her case with all of her physicians. She was seen preop by the cardiac, vascular, cardiology, and transplant team. She had all her questions answered and understood the risks and benefits of the procedure. On [**2102-3-15**] she underwent a resection of the IVC tumor, an IVC graft of the supraheptic segment of the IVC, and a right external illiac vein to IVC bypass. Intraop she received a total of 24,531 of IVF (5250 PRBC, 3686 FFP, 1032 plts, 2300 cell save, 263 cryo, [**Numeric Identifier 890**] crystalloid) and put out [**2035**] of urine. Her chest was closed and her abdomen was left open. Please refer to the respective operative notes for more details. She came out of the OR on epinephrine, milrinone, Neo-Synephrine, and vasopressin. She was paralyzed with cis-atracuronium since her abdomen was open. Her chest X-ray was suggestive of severe pulmonary edema. Her PaO2 was 80 on 100% O2. PEEP was increased and her tidal volumes were kept between 6-8 cc/kg. Her urine output was very low and she required higher doses of pressors. She was started on Nitric oxide without much benefit. She became increasingly harder to oxygenate and the decision was made to open her chest at the bed sites with the hope that her oygenation would improve. She was also increasingly acidotic and bicarb also was given. She also had her elevated INR corrected with 2 units of slowly infusing FFP. There was no sign of active bleeding. Her lungs looked very poorly compliant and were prominent. She was ventilated with an ambu-bag throughout the procedure. Post redo-sternotomy in the CSRU her PaO2 rose from 47 to 251. The retractor was kept in place since every time we attempted to remove it her pressures dropped. Her pressures remained around 110 with the retractor in. Two chest tubes were placed in the mediastium and lap pads and sterile towels followed by Ioban were used to cover the open wound. However, her pressure continued to drop and her oxygenation worsened as her next PaO2 came back at 35. Levophed was also started since her pressures dropped further. Her oxygenation remained poor and her blood pressure was becoming increasingly harder to keep up. Her family was at the bedside and decided on no further measures and she passed. Throughout the entire post op course the CSRU resident and the Cardiothoracic fellow were both at the bedside. The fellow was in discussion with the cardiac and ICU attendings and the vascular and transplant teams were also consulted with. Medications on Admission: Coumadin 5', Protonix 40', Vicodan prn, albuterol, ativan 2", Advair 500/50, lomotil prn, compazine prn, lasix 40-80/prn Discharge Disposition: Expired Discharge Diagnosis: IVC tumor Discharge Condition: expired Followup Instructions: none

[ "998.11", "238.1", "416.8", "238.8", "459.2", "V58.61", "453.2", "453.41", "493.90", "518.5" ]

icd9cm

[ [ [] ] ]

[ "34.03", "88.72", "99.05", "00.12", "39.61", "99.07", "99.06", "99.04", "00.17", "37.33", "38.47", "39.1" ]

icd9pcs

[ [ [] ] ]

8402, 8411

5624, 8230

397, 501

8464, 8473

1517, 5601

8496, 8503

1335, 1352

8432, 8443

8256, 8379

1367, 1367

348, 359

529, 858

1381, 1498

880, 1187

1203, 1319

16,868

107,126

16084+16085+56729

Discharge summary

report+report+addendum

Admission Date: [**2136-1-26**] Discharge Date: [**2136-1-30**] Date of Birth: Sex: Service: ACOVE HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 44755**] is a [**Age over 90 **] year-old woman with a history of hypertension, cellulitis and gastrointestinal bleed who presents from [**Location (un) **] Home via EMS with shortness of breath. In the Emergency Department she was found to be in atrial fibrillation and on chest x-ray had bilateral moderate pleural effusions. She was rate controlled with Diltiazem effectively and transferred to ACOVE unit for further medical management. Mrs. [**Known lastname 44755**] was in good health living independently with her sister until six to eight weeks prior to admission when she developed cough and decreased appetite. She was soon after hospitalized for a leg cellulitis. She was discharged to rehabilitation, but then readmitted for worsening cellulitis to [**Hospital1 336**] on [**1-11**], for which she was treated with Unasyn. On [**1-17**] she spiked a fever and a chest x-ray demonstrated pneumonia. Unasyn was at that point switched to Zosyn and Levofloxacin was added for concern of hospital acquired pneumonia. She was also given one dose of Linezolid for sputum growing VRE, although this was subsequently felt to be a contamination and Linezolid was discontinued. She was discharged to [**Hospital3 2558**] on [**2136-1-20**] and Levofloxacin and Zosyn, but it is unclear if she finished her course of Zosyn at [**Hospital3 2558**] or did not get this medication there. Again on the 23rd she developed shortness of breath and was found to be in respiratory distress and found to be in atrial fibrillation with rapid ventricular response. Chest x-ray demonstrated bilateral pleural effusions right greater then left and a left lower lobe consolidation. On Seven Felberg the patient was maintained on Levofloxacin for her pneumonia as well as Oxacillin for her bilateral lower extremity cellulitis. She had a right upper extremity ultrasound at the outside hospital that demonstrated superficial thrombophlebitis. This was repeated while on the floor here and was negative for deep venous thrombosis or superficial thrombophlebitis. On [**1-28**] te patient demonstrated worsening respiratory distress and was transferred to the Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Cellulitis. 3. Gastrointestinal bleed. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Lopressor 12.5 mg b.i.d., Levofloxacin 250 mg q day, Oxycodone 5 mg prn subQ heparin, colace, Trazodone and Albuterol and Atrovent. SOCIAL HISTORY: The patient previously lived independently with her sister. [**Name (NI) **] son is her health care proxy. His name is [**Name (NI) **]. His cell phone number is [**Telephone/Fax (1) 46004**], home phone [**Telephone/Fax (1) 46005**]. PHYSICAL EXAMINATION ON ADMISSION: Afebrile, vital signs are stable. Pulse tachycardic at 111. 96% on 4 liters. Heart is tachycardic and regular with systolic ejection murmur at the apex. Lungs are without crackles, but with decreased breath sounds at the bases. She has a grade two decubitus on her buttocks. Neurological cranial nerves II through XII are intact. Oriented to person and place. 4 out of 5 strength in the upper and lower extremities. LABORATORIES ON ADMISSION: White blood cell count 6.4, hematocrit 32.2, creatinine 0.7, INR 1.1, CK 33, troponin 0.5. Electrocardiogram demonstrates atrial fibrillation with a rate of 165. No ST or T wave changes and chest x-ray with bilateral effusions right greater then left. HOSPITAL COURSE: As noted above on the 25th the patient began to suffer from worsening respiratory distress. She had been evaluated and prepared for thoracentesis of her bilateral pleural effusions, which are felt most likely secondary to her congestive heart failure, although also possibilities include a peripneumonia effusion. Over the course of the day she went from oxygen saturations of the 90s on 4 liters to requirement of 100% nonrebreather with saturations dropping into the mid 80s. She was transferred to the Intensive Care Unit for likely intubation. Prior to this her code status had been DNR/DNI, but discussion with her son in the setting of a potentially reversible pneumonia, it was decided to change her code status to intubate if necessary, but still DNR. A chest x-ray on the floor demonstrated continued bilateral pleural effusions, stable congestive heart failure and worsening left lower lobe infiltrate. She was administered 40 mg of intravenous Lasix with urine output of 1200 cc. With respiratory therapy given some chest physical therapy, some increased cough, nebulizer treatment and with the diuresis of 1200 cc the patient began to saturate 100% on the 100% nonrebreather, but was still transferred to the Intensive Care Unit for more close monitoring. 1. Cardiac: The patient initially noted to be in atrial fibrillation with rapid ventricular response treated initially with 30 mg q.i.d. of Diltiazem. Echocardiogram demonstrated an EF of greater then 55% with mild symmetric left ventricular hypertrophy and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated. This was done on [**1-27**]. On the increased dose of Diltiazem the patient had a period of bradycardia into the 30s and Diltiazem was subsequently tapered to off. The patient remained with heart rates in the 50s to 60s with occasional drops to the 30s off of all cardiac medications. She is continuing to have paroxysmal atrial fibrillation, but remains in normal sinus rhythm for the majority of the time. Heparin GTT is being continued while the discussion of long term anticoagulation are ensuing. No further diuresis was initiated and it is unclear how much diuresis the patient received on the floor (secondary to computers being down during that time). The patient continues to have good urine output and to hold good blood pressures. 2. Pulmonary: A: Pneumonia, this is a hospital acquired versus aspiration pneumonia. The patient had a bedside swallow test on [**1-27**] for which she failed clear liquids. A video oropharyngeal swallow study was initiated on [**1-30**] and at that point she again failed clear fluids, but she can have thickened solids and nectar consistency liquids. She should not eat any meats. As of [**1-30**], we are continuing Pseudomonas coverage with day number three of Ceftazidine and MRSA coverage with day number three Vancomycin. We have been unable to receive a sputum sample as the patient is not coughing up anything of substance. We will also continue day number three of Flagyl for possibility of aspiration pneumonia. B: Also concern of pulmonary embolism given bilateral lower extremity cellulitis and a history of superficial thrombophlebitis in the past. Leni's were negative, but will perform CT angiogram today to rule out PE. This will help with decision on whether or not to anticoagulate this woman who may have a large fall risk. 2. Pleural effusion likely secondary to congestive heart failure in the setting of atrial fibrillation (which was in the setting of a pneumonia), right decubitus film initially without significant layers, but will repeat today. The patient may need thoracentesis to alleviate the large fluid burden on her lungs. 3. Cellulitis: Patient with bilateral lower extremity cellulitis and a grade two ulcer on her left lower extremity. Will continue dressing changes, have started zinc and vitamin C and is having good coverage of potential cellulitis pathogens with her current regimen of Vancomycin and Ceftazidime. 4. Neurological status: The patient remains agitated, but oriented times three. Have continued Risperdal, which was started on the floor and are giving Haldol prn. 5. Fluids, electrolytes and nutrition: Again the patient failed clear liquids, but will continue nectar substance liquids as well as pureed thickened solids. 6. Access: Single port PICC line placed on [**1-27**]. 7. Prophylaxis with intravenous heparin and Protonix. CODE STATUS: DNR. COMMUNICATION: With the son who is seeming overwhelm with the decision on what to do with his mother who has been functionally independent all of her life. Social work consulted to discuss with the patient and family. MEDICATIONS: Ceftazidine 1 gram intravenous q 12 hours, Flagyl 500 mg intravenous q 8 hours, Vancomycin 1 gram intravenous q 24 hours, Nystatin ointment q.i.d., zinc sulfate 220 mg po q day, ascorbic acid 500 mg po q day, Haloperidol 2.5 to 5 mg intravenous q 4 hours prn. Pantoprazole 40 mg po q 24 hours, Risperidone 0.5 mg po q day. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADF Dictated By:[**Last Name (NamePattern1) 43302**] MEDQUIST36 D: [**2136-1-30**] 12:00 T: [**2136-1-30**] 13:19 JOB#: [**Job Number 46006**] Admission Date: [**2136-1-26**] Discharge Date: [**2136-2-23**] Service: ACOVE HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 44755**] is a [**Age over 90 **]-year-old female who presented from [**Location (un) **] Home via EMS with shortness of breath. In the emergency room she was found to be in rapid atrial fibrillation. She was treated with diltiazem effectively. She has previously been healthy until the past 6-8 weeks when she developed a cough with decreasing appetite. She was hospitalized initially for a light cellulitis and was discharged to rehabilitation and then readmitted with pneumonia. She was last discharged on [**2136-1-24**] to [**Hospital3 2558**] on a course of levofloxacin. In general she has been in very good health all of her life and has only been ill in the last six weeks. Rule out symptoms: Positive pain in the back, positive shortness of breath, positive weakness and positive right arm pain. She denies chest pain, fever, chills, nausea, vomiting, abdominal pain, dysuria, headache, visual changes or constipation. PAST MEDICAL HISTORY: 1. Hypertension. 2. Cellulitis. 3. GI bleeds. MEDICATIONS ON ADMISSION: 1. Lopressor 12.5 twice a day. 2. Levofloxacin 250 once a day. 3. Oxycodone 5 mg p.r.n. 4. Subcutaneous heparin. 5. Colace. 6. Trazodone. 7. Albuterol. 8. Atrovent. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: Afebrile 96.9, blood pressure 120/70, pulse 111, at 96% on four liters. In general she was a weak, deconditioned woman in no apparent distress. Pupils were equal, round, and reactive to light, extraocular movements intact, sclerae anicteric. Neck was supple, no LID, no jugular venous distension. Heart was tachycardic and irregular. Lungs had negative crackles but decreased breath sounds at the bases. Abdomen was soft, nontender, nondistended with positive bowel sounds. She had grade II decubitus ulcers on the buttocks and right arm. She had positive bilateral edema with 2+ dorsalis pedis pulses. She was oriented to person and place. Cranial nerves two through 12 were intact. She had 4/5 strength in the upper and lower extremities. LABORATORY DATA: White count 6.4, hematocrit 32.2, platelet count 344. INR 1.1. Sodium 146, potassium 3.5, chloride 112, bicarbonate 25, BUN 21, creatinine 0.7, glucose 112, CK 33, troponin 0.5. EKG: Atrial fibrillation with a rate of 165. She had ST-T changes suggestive of acute coronary syndrome. Chest x-ray: Bilateral effusions, right greater than left. HOSPITAL COURSE: The patient was a [**Age over 90 **]-year-old female with no significant past medical history, previously well, admitted for rapid atrial fibrillation, bilateral pleural effusions and question of pneumonia. 2. Cardiovascular: The patient was found to be in rapid atrial fibrillation originally treated with p.o. diltiazem. The patient's respiratory status deteriorated during the stay and on [**2136-1-28**] the patient was transferred to the intensive care unit for treatment of pneumonia. In the intensive care unit the patient's atrial fibrillation became worse with rate to the 150s. The patient was started on a diltiazem drip. As the patient's respiratory status improved, the patient eventually left the intensive care unit on diltiazem 60 mg p.o. q.i.d. During that time the patient supposedly had episodes of bradycardia though nothing was documented. During her course on the floor the patient's rate control worsened to the patient where she was taking diltiazem 540 mg q.d. and Lopressor 12.5 mg b.i.d. needed to be added on, still with poor rate control. This poor rate control was in the setting of worsening aspiration pneumonia. Eventually the patient's rate was better controlled on Lopressor 25 t.i.d. and diltiazem 30 mg q.i.d. During this time the patient had frequent episodes of pauses and bradycardia. EP was consulted and they recommended pacemaker placement. The family was advised of this and to this point has declined pacemaker placement, the patient saying she wants no invasive procedures. The patient also had an echocardiogram done that showed a preserved ejection fraction. Likely the patient has diastolic dysfunction that is leading to congestive heart failure. The patient has bilateral pleural effusions from congestive heart failure. The patient was diuresed slowly during the stay with no real improvement to the pleural effusions. The patient had moderate rate control on diltiazem 30 q.i.d. and Lopressor 25 t.i.d., no pacemaker placement indicated at the time. 2. Pulmonary: The patient has likely aspiration pneumonia and continued to aspirate throughout the stay. Eventually the patient's aspiration pneumonia was treated with ceftazidime, Flagyl, vancomycin and azithromycin. It was determined that only ceftazidime and Flagyl were needed for treatment and the patient completed a 14-day course. The patient's respiratory status improved during this time, however the patient continues to aspirate and will continue to need some sort of treatment for aspiration pneumonia even though the patient was on aspiration precautions. We were not going to tap the pleural effusions because they were likely to reaccumulate in the setting of congestive heart failure and the patient's low albumin. During the stay the patient had frequent mucous pluggings, needed frequent chest physical therapy and deep suctioning. The patient's diuresis was slowed down in this setting because of the likelihood that the diuresis was leading to increased mucous plugging. 3. Infectious disease: The patient was admitted with both cellulitis and pneumonia. The cellulitis cleared up on intravenous oxacillin. Pneumonia was very difficult to clear. The patient ended up completing a 14-day course of ceftazidime and Flagyl but continued to aspirate and the risk of aspiration pneumonia remains very high and is the reason it is difficult to treat other processes. 4. Diet: The patient had a swallow study that showed that she was at very high risk for aspiration. The patient was given nectar-thickened food, was in the upright position at all times, kept her chin down while eating, swallowed and then put her chin up. Unfortunately the patient continued to aspirate even with all of these precautions. The patient was given Boost to increase nutritional status. The patient's albumin reached a low of 1.8 and then started to trend back up, currently 2.4. The patient is not a candidate for PEG tube to supplement diet, as that will not decrease aspiration risk, and the family does not want the patient to undergo PEG. Will continue aspiration precautions and will continue to suction and replete diet as necessary. 5. Prophylaxis: The patient throughout the stay was bed bound. The patient was treated with heparin subcutaneous. Physical therapy came by to help as needed, and the patient was on Protonix for GI prophylaxis. 6. Skin: The patient has stage II sacral decubiti. Wound care consultations were called multiple times and we appreciate their help. DuoDerm dressings were given and the patient had increased mobilization in bed with turning as much as possible. 7. Pain: The patient had frequent pain secondary to sacral decubiti. Originally she was treated with oxycodone 5 mg q. 4 hours. Pain regimen was switched to morphine 1 mg intravenous p.r.n. which also helps the patient's respiratory status. 8. Psychiatry: Near the end of her stay the patient reported being tired and not as interested in fighting the disease to physicians. Would likely recommend starting Ritalin and Zoloft and discontinuing Ritalin once the patient's mood improves from Zoloft's effectiveness, likely 2-3 weeks. 9. Fluids, electrolytes and nutrition: The patient was given fluid boluses as needed throughout the stay to keep up her urine output. The patient's electrolytes were repleted multiple times, especially in the setting of diuresis. The patient was slowly diuresed with Lasix 40 intravenous p.r.n. The goal of diuresis was to remove the pleural effusions, though that has been very difficult in the setting of the patient's poor nutrition and diastolic dysfunction. 10. Hematology: The patient originally was on Lovenox because of atrial fibrillation, though patient's clot risk was determined to be very low. At one point, cardioversion was considered and the patient was started on Coumadin for three days. The patient's INR increased very rapidly and the Coumadin was discontinued because electrocardioversion was unlikely to help as patient has fibrillation/flutter and when she broke it she went into MAT which is not a rhythm we can shock. The patient also received one unit of packed red blood cells during the stay. When her fluid volume was lowest that would stay in the intravascular space better in the setting of diuresis. The patient is on heparin subcutaneous for DVT prophylaxis. 11. Lines: The patient originally had a right PICC line but led to swelling in the right upper extremity, so a left PICC line was placed. There was concern that the patient had developed a right upper extremity DVT and her pulmonary status could be secondary to multiple chronic PEs. The patient could not have CTA because she had a PICC line in and no other access could be placed. The patient could not lie flat for an MRI and multiple upper extremity ultrasounds were negative for DVT. Therefore it is unlikely that the patient had multiple PEs leading to problem, likely pulmonary disease caused by pneumonia in the setting of rapid atrial fibrillation and diastolic dysfunction that is leading to pleural effusions, worsened by poor nutritional status. 12. Disposition: The patient originally came in full code but during the course of the stay and on discussion with family, the patient changed status to DNR/DNI as resuscitative efforts probably would not improve quality of life. The patient is interested in having a very good quality of life, has no interest in going to nursing home. If we cannot get her to a semi-independent lifestyle in [**Hospital3 **], the patient does not want care. As of now, the patient is refusing pacemaker and PEG placement, though this will be readdressed with family and team. DISCHARGE DIAGNOSES: 1. Pneumonia likely secondary to aspiration. 2. Cellulitis. 3. Rapid atrial fibrillation. CONDITION: Fair. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Name8 (MD) 23023**] MEDQUIST36 D: [**2136-2-23**] 09:40 T: [**2136-2-23**] 09:49 JOB#: [**Job Number 46007**] Name: [**Known lastname 8458**], [**Known firstname 1485**] Unit No: [**Numeric Identifier 8459**] Admission Date: Discharge Date: [**2136-2-26**] Date of Birth: Sex: F Service: Acove HOSPITAL COURSE: (From [**2136-2-24**] to [**2136-2-26**]) - The patient continually declined. The patient's respiratory effort became more and more labored and the patient was reluctant to go to the nursing home. The patient did not want any invasive treatments at that point. The patient was found to be in severe respiratory distress the evening of [**2136-2-26**]. The patient's son was [**Name (NI) 178**]. The family preferred to make the patient comfort measures only and Mrs. [**Known lastname **] passed away the evening of [**2136-2-26**]. [**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**] Dictated By:[**Name8 (MD) 4402**] MEDQUIST36 D: [**2136-5-23**] 15:58 T: [**2136-5-23**] 17:53 JOB#: [**Job Number 8460**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

19274, 19881

10155, 10382

19899, 20681

10405, 11526

9096, 10056

3412, 3667

10079, 10128

2684, 2944

4,159

175,133

48078

Discharge summary

report

Admission Date: [**2180-6-13**] Discharge Date: [**2180-6-19**] Date of Birth: [**2117-1-6**] Sex: M Service: OMED BMT SERVICE. AGE: 63. HISTORY OF THE PRESENT ILLNESS: The patient was admitted with the chief complaint of belly pain and rising white count. The patient was recently discharged from [**Hospital1 346**] on [**6-8**]. Please see discharge summary in the computer for details. This is a 63-year-old man with a history of AML diagnosed on [**1-/2180**] status post two cycles of idarubicin and ARA-c on [**2-22**] and [**3-21**]. He was discharged to rehabilitation on [**6-8**]. He had had a hospital course that was complicated by Staph abscesses requiring drainage and MRSA, positive blood culture, as well as small bilateral pleural effusion felt to represent foci infected with MRSA. On [**6-8**], it was noted that he line tip grew out coagulase negative Staphylococcus, MRSA, which was sensitive to Vancomycin. Starting at 5 AM on the [**6-12**], the patient noted abdominal pain described as a moderate negligible to mild right upper quadrant and right lower quadrant discomfort on rest, which became tender when palpated. At baseline he had frequent nausea and vomiting for the past few months, but he feels that he may have had more in the past few days. He also noticed new leg swelling that began three days ago, bilaterally. He also has ankle swelling. There was no diarrhea. Position does not change the pain. However, he also complained of mid sternal chest pain times two to three weeks and he complaints of shortness of breath and worsening pain while lying down that improved when he sits up and leans forward. There was no cough, no fever, no chills associated with this. The patient also complains of significantly decreased urine output over the past few days. He feels that has been taking a normal amount of PO intake. PAST MEDICAL HISTORY: 1. History was significant for acute myelogenous leukemia diagnosed in [**2180-1-8**], status post idarubicin and ARA-c treatment times two with consolidation chemotherapy on [**2180-5-1**]. 2. Hypertension. 3. Carotid stenosis. 4. History of alcohol abuse. 5. Acoustic neuroma. 6. Benign prostatic hypertrophy. MEDICATIONS ON ADMISSION: 1. Atenolol 25 mg p.o.q.d. 2. Zoloft 125 mg p.o.q.d. 3. Vancomycin 1 gram IV q.d., dose only for a trough level less than 20. The patient was to receive this dose through [**2180-8-14**]. 4. Flomax 0.4 mg p.o. q.d. 5. Multivitamin one p.o.q.d. 6. Reglan 10 mg p.o.q.i.d. 7. Oxycodone 5 mg to 10 mg p.o.q.4h to 6h p.r.n. for pain in the deltoid of his left calf. 8. Protonix 40 mg p.o.q.d. ALLERGIES: The patient is allergic to CEFTAZIDIME, which causes anaphylaxis. PHYSICAL EXAMINATION: Examination revealed the following: Temperature on admission was 98.7, pulse 72, blood pressure 110/70, pulsus paradoxus 16. GENERAL: The patient is elderly-appearing, mildly uncomfortable, no apparent distress. Pupils equally reactive to light. Extraocular muscles are intact. Oropharynx moist. There was no adenopathy. JVD was to the ankles. LUNGS: Clear to auscultation bilaterally. HEART: Heart revealed regular rate and rhythm, normal S1 and S2. Heart sounds were distant. There was a 2/6 systolic ejection murmur at the left lower sternal border. Abdomen was mildly distended, moderate tender in the right upper quadrant and the right lower quadrant. Bowel sounds were positive. There were no masses felt at the time. There was 2+ edema to the knees bilaterally. The patient had a left leg abscess and a right upper arm abscess, both packed. There was no erythema or exudate. LABORATORY DATA: Laboratory values on admission revealed the following: White count of 36.6, hematocrit 29.0, MCV 92. Differential on the white count was 67 neutrophils, 14 bands, 2 lymphs, 8 monos, 3 atypical cells, 4 metamyelocytes, and myelocytes. Coagulations studies revealed the following: 13.9, 25.5, and 1.3 with a platelet count of 63. SMA 7: 132, 3.8, 121, 17, 1.8, glucose of 121, albumin 2.6, globulin 8.9, calcium 8.9, phosphatase 3.3, magnesium 1.4, troponin less than .3, CK 29, ALT 167, AST 89, LDH 251, alkaline phosphatase 649, total bilirubin 0.4 and 0.2 direct, GTT 614. Urinalysis showed a large amount of blood, pH 6, leukocyte Estrace positive, no nitrites, 49 reds, 3 whites, no bacteria, less than 1 squamous epithelial cell. Urine sodium was 43, urine creatinine 95. Blood culture pending. Catheter tip was coagulase negative staphylococcus, sensitive to Vancomycin; multiple laboratory studies with MRSA. EKG: Sinus rhythm at 80 beats per minute, normal axis, diffuse flattening of the T waves especially in the lateral leads, Q wave in lead three and lateral ST flattening, now new compared to old EKG of [**2180-6-5**]. Chest CT, without contrast, showed a new large pericardial effusion. There was small bilateral pleural effusions, no the right being greater than the left. There was associated bibasilar compressive atelectasis. Mediastinal lymph nodes were again noted with a slight increase in size of the lymph nodes and in the paratracheal space, previous noted 6-mm and curly measuring 8 -mm and a short axis considered to be likely reactional given increase in size during the short interval. There was no significant axillary or hilar lymphadenopathy. Lung demonstrated bilateral parenchymal marginal opacities without cavitation, no changed compared with the prior examination and concerning foci for infection. CT of the abdomen showed no focal masses within the liver and no intrahepatic biliary ductal dictation. Gallbladder was not distended. Spleen, pancreas, jejunum, and kidneys were unchanged and unremarkable. There was a pigtail catheter, which was previously seen within the right psoas muscle, had been removed. There was a partial re-accumulation of the collection from the right psoas. This current measured 3.7 cm x 2.1 cm and could represent recurrence of the abscess. CT of the pelvis was unremarkable. Bone window show degenerative changes, but no suspicious lyticoblastic lesions seen. There was a focal area of fat straining within the left lower quadrant of uncertain source or significance. The patient, Mr. [**Known lastname **], upon admission, was then referred to the Cardiology Department because the large pericardial effusion, drained by pericardial centesis on [**6-14**] and 700 cc of hemorrhagic fluid was removed. Hematocrit was 6%, LDH 400, albumin 2.4, with improvement in the patient's blood pressure and symptoms in terms of pain and the blood pressure which had gone down to about systolic of 100 to 110. Pericardial fluid cytology was negative and cultures showed no growth. The patient was transferred to the Medical Intensive Care Unit following the pericardial centesis to permit additional drainage from the pericardium with additional 450 cc. The drain was discontinued on [**6-16**] after the drainage rate was down to 3 cc per hour. The patient had experienced transient atrial fibrillation on [**6-15**], but that spontaneously corrected. The patient remained in normal sinus rhythm. In addition, the patient was found as mentioned on CT to have an increased fluid collection in the right psoas muscle with accompanying leukemoid reaction with increased white cells. As the patient remained in the hospital, the white cell count increased from that noted on admission to, what would be found by the day of discharge, at 120 white cells; 50 cc of fluid was removed by interventional radiology. It was found that the psoas mass had gram-positive cocci in pairs and clusters. The patient's coverage for that was broadened to Levofloxacin and Flagyl. Pigtail catheterization was left in place protruding from the right posterior thorax. A pericardial window was not determined to be necessary at the time. The patient had transient hypotension with a systolic blood pressure in the 70s overnight, remaining symptomatic, responding to a 500 cc fluid bolus times one. The Atenolol was held. Because of the pericardial centesis and fluid drainage, it was expected that his white count would go down, however, it continued to rise and reached 109 white cells with many immature cells and blasts, seen on peripheral smear. Aspirate was attempted, however, no cells could be removed so that an iliac bone marrow biopsy and aspirate was done and evaluated under the microscope by Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. It was determined that the bone marrow was full of immature cells and blasts indicating that the patient had a relapsed AML. Given that the patient had relapsed AML and had been unable to clear his disseminated Methicillin-resistant Staphylococcus aureus infections in different parts of his body, it was determined that the patient, in discussion with him and the rest of his family, he would go home from the hospital with hospital care. So, the patient was discharged on [**2180-6-19**] to home-hospice care in stable condition. He was discharged on the following medications: DISCHARGE MEDICATIONS: 1. Fentanyl 25 mcg patch transdermally q 72 hours. 2. Linezolid 600 mg p.o.b.i.d. 3. Flomax 0.4 mg p.o.q.d. 4. Tylenol 650 mg p.o.q.4h. to 6h.p.r.n. 5. Zoloft 125 mg p.o.q.d. 6. Xanax 1 mg to 2 mg q.h.s.p.r.n. 7. Morphine sulfate elixir 10 mg to 20 mg p.o.q.4h.p.r.n. 8. Home hospice also included Lorazepam 0.5 to 2 mg q.4h.p.r.n. sublingual; Levsin 0.125 mg to 0.25 mg q.4h. to 6 h.P.r.n. sublingual and Morphine concentrate 5 mg to 20 mg q.1h. to 2h.p.r.n. sublingual. The patient was aware of his diagnosis and in favor of this treatment plan. The patient went home as a comfort measure only. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], M.D. [**MD Number(1) 10999**] Dictated By:[**Last Name (NamePattern1) 3033**] MEDQUIST36 D: [**2180-6-19**] 15:26 T: [**2180-6-19**] 15:29 JOB#: [**Job Number 101389**]

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icd9cm

[ [ [] ] ]

[ "37.21", "41.31", "37.0", "83.95" ]

icd9pcs

[ [ [] ] ]

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2260, 2738

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1915, 2234

65,516

166,782

50175

Discharge summary

report

Admission Date: [**2181-10-26**] Discharge Date: [**2181-10-30**] Date of Birth: [**2123-2-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: fevers, malaise, pleuritic chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 58F with a history of hypertension, prediabetes, hypothyroidism, and COPD who came to the ED with a chief complaint of fevers, malaise, and pleuritic chest pain for the past day. She reports that starting yesterday her chronic R posterior chest pain escalated in the context of generalized malaise. She developed a pleuritic component and fevers and chills. She had small hemoptysis (a spot of blood), and came to the ED for evaluation. On questioning, she reports a 40+ year smoking history of between [**11-26**] and 1 PPD. She has frequent colds that are difficult to recover from, and gets a bad respiratory infection each winter. She also has slowly progressive dyspnea with exertion, but no chest pain, palpitations, or sweats. She denies dysuria, rash, or HA other than her chronic HA. . In the ED her initial vital signs were T 103.4 BP 84/42 P 104 R 24 97% on NRB. A central line was placed, she was given tylenol, ibuprofen, vancomycin 1g, levofloxacin 750mg, metronidazole 500mg, osteltamivir 75mg, and started on norepinepherine. She was fluid resusitated with 4L NS. A chest xray showed a large RML infiltrate and abdominal CT was benign. Her vital signs improved and she was sent to the MICU on 0.30mcg/kg/min with VSS of T 97.4 BP 95/34 P 88 R 17 98% on 2L NC. . On the floor she complains of ongoing pleuritic chest pain on the R posterior chest. She denies dysnuria but is uncomfortable. . Review of systems: (+) Per HPI (-) Denies recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: - HTN on amlodipine 10mg daily and valsartan 160mg daily - Hypothyroidism on thyroid replacement therapy - Pre-diabetes not on hypoglycemics - COPD based on history, no PFTs in system Social History: - Lives with son and granddaughter - [**Name (NI) 1139**]: Smoked for the past 40 years up to 1 PPD, not [**1-24**] cigarette's daily - EtOH: Former heavy drinker, now in remission for many years - Illicits: former cocaine smoker, denies IVDU Family History: - Multiple family members with DM and CAD Physical Exam: GEN: Middle aged woman, uncomfortable, breathing comfortably HEENT: Dry MM, no OP lesions, adentulous, neck is supple, no cervical, suprclavicular, or axillary LAD CV: RR, distant, no MRG PULM: Diffuse dry crackles, prolonged expiration, denser crackles at lower [**11-24**] of the R lung with some dullness to percussion ABD: R CTA tenderness, BS+, abdomen NTND, no masses or HSM LIMBS: Clubbing is present, no tremors or asterixis NEURO: Reflexes 2+ of the biceps and patellar tendons, toes down bilaterally, grossly non-focal Pertinent Results: [**2181-10-26**] 135 99 19 ------------ 98 4.1 23 1.3 . estGFR: 42/51 (click for details) CK: 211 MB: 1 Ca: 10.0 Mg: 1.7 P: 2.4 ALT: 19 AP: 81 Tbili: 0.5 Alb: 4.3 AST: LDH: Dbili: TProt: 7.6 [**Doctor First Name **]: Lip: 17 . .......13.2 15.5 ------- 13.2 .......39.0 N:86.0 L:9.2 M:4.3 E:0.3 Bas:0.3 . PT: 15.2 PTT: 31.7 INR: 1.3 . Na:138 K:3.9 Glu:95 Lactate:1.3 Hgb:14.1 CalcHCT:42 . . [**10-27**] CXR: There is no significant change in the widespread parenchymal opacities which potentially might represent a combination of pulmonary edema with infection. Right upper lobe consolidation is unchanged. Overall, the lung volumes are lower than on the prior study. . [**10-26**] CT abdomen/pelvis: 1. Right upper lobe consolidation, partially imaged, consistent with pneumonia. Please refer to chest x-ray obtained earlier for further characterization. 2. Small right pleural effusion. 3. No evidence of bowel obstruction. 4. Right adnexal cystic lesion, slightly increased in size. Further evaluation with non-urgent pelvic ultrasound is recommended, given presumed postmenopausal state. . [**10-26**] CXR: Right mid lung zone consolidation worrisome for pneumonia. Follow-up chest radiograph after completion of treatment is recommended to ensure resolution. Brief Hospital Course: 58F with HTN, hypothyroidism, and likely COPD admitted with fever, hypotension, and infiltrates on CXR concerning for PNA and sepsis. UA is also concerning for a UTI. Stablized on pressors with improved oxygenation. . # Sepsis: Most likely source pneumonia vs. urosepsis. BCx were negative to date, UCx contaminated but UA positive for UTI. DFA for influenza negative. Patient initially maintained on Norepinephrine for goal MAP > 65 and CVP > 10. Patient stabilized, weaned off pressors. She remained hemodynamically stable and afebrile. . # Hypotension: Likely relate to sepsis. [**Last Name (un) **] stim test abnormal, placed on Prednisone (stress dose). Repeat [**Last Name (un) 104**] stim was normal x 2. She was discharged on steroid taper over 12 days. . # Pneumonia: CXR shows evidence of R mid lung pneumonia, differential included typical vs atypical CAP, including mycoplasma and Legionella, and influenza. DFA for influenza negative. Urine Legionella antigen negative. Patient empirically started on Ceftriaxone for CAP and UTI, Azithromycin for atypical coverage, and Osteltamivir for flu. Respiratory status improved, patient given Lasix with improvement of respiratory status. Patient will complete 10 day course of antibiotics with cefpodoxime and azithromycin at home. Patient should have CT chest with contrast to elucidate question of malignancy, once stable. . # positive UA: UA consistent with UTI with elevated WBC, LE, and nitrates, urine cx contaminated. Treated with Ceftriaxone 1g IV daily for PNA and transitioned to cefpodoxime at discharge. Patient had no symptoms of UTI, no infection unlikely. . # Hypertension: On amlodipine 10mg daily and valsartan 160mg daily at home. Antihypertensives held in the context of sepsis. BPs remained borderline low for this patient (100/70 range) and antihypertensives should be held at home until seen by PCP and BP improved. Unclear why this patient is not on ASA PPx, and should be discussed with PCP. . # Hypothyroidism: Medically managed. Thyroid studies nl. Home Levothyroxine [Levoxyl] 75 mcg daily. . # COPD: Exam finding of clubbing, hyperinflated chest, and prolonged expiration consistent with chronic SOB and obstruction. History of recurrent URIs also consistent with chronic bronchitis. Recommend outpatient PFTs. Will follow up in pulm clinic. Patient treated with nebs and discharged on steroid taper. . #. chronic pain/neuropathy: Patient had hand tingling and chronic back and knee pain. She was started on low dose gabapentin with good effect and should be titrated as necessary as outpatient. She was continued on home regimen tramadol and percocet. #. Medications on Admission: - Amlodipine [Norvasc] 10 mg daily - Atorvastatin [Lipitor] 10 mg daily - Levothyroxine [Levoxyl] 75 mcg daily - Potassium Chloride [K-Tab] 20 mEq daily - Tramadol [Ultram] 50 mg every 8 hours as needed for pain - Valsartan [Diovan] 160 mg daily Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 2. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* 3. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: Take 4 tabs daily for 3 days,then take 3 tabs daily for 3 days, then take 2 tabs daily for 3 days, then take 1 tab daily for 3 days. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: COPD exacerbation Pneumonia Discharge Condition: ambulatory O2 sat 90% on room air Discharge Instructions: You were admitted to the hospital for pneumonia, you were treated with antibiotics and steroids for your COPD. You should continue antibiotics and steroids as instructed. Please call your doctor or return to the emergency room if you have shortness of breath, worsening cough, fevers or chills, or any other symptoms that concern you. Followup Instructions: You have an appointment with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] ([**Telephone/Fax (1) 2205**]) on [**11-8**] Thursday at 2:45 p.m. at [**Apartment Address(1) **] in [**Location (un) **] MA. You have an appointment with a pulmonologist (lung doctor) on [**12-13**] at 8 a.m. with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**]. This is on located in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**]. You are also on the cancellation list so you may get called for an earlier appointment. Please call ([**Telephone/Fax (1) 513**] if you need to reschedule. Please arrive 20 minutes early for pulmonary function tests.

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Discharge summary

report

Admission Date: [**2115-1-15**] Discharge Date: [**2115-2-23**] Date of Birth: [**2055-7-5**] Sex: F Service: SURGERY Allergies: Latex Attending:[**First Name3 (LF) 473**] Chief Complaint: Duodenal mass Metastatic renal cell carcinoma Major Surgical or Invasive Procedure: [**2115-1-15**]: 1. Resection of duodenal tumor with primary duodenorrhaphy. 2. Open cholecystectomy. 3. Gastrojejunostomy without vagotomy. 4. Right hemicolectomy. 5. Small bowel resection with primary enteroenterostomy. 6. Feeding jejunostomy. . [**2115-2-8**] EGD. . [**2115-2-16**]: Bedside wound VAC placement . [**2115-2-21**] EGD and colonoscopy History of Present Illness: 59 year old woman with known metastatic RCC who presents for surgical resection of bleeding duodenal mass prior to initiating chemotherapy. Of note is that she underwent extensive surgery in [**2114-9-3**] where she had her IVC ligated in addition to a right nephrectomy. The patient was evaluated by Dr. [**Last Name (STitle) 468**] in his clinic and Ms. [**Known lastname **] was scheduled for elective, palliative surgical resection on [**2115-1-15**]. Past Medical History: Past Medical History: --clear cell renal cell carcinoma, grade 3 with extensive necrosis, extension into the perinephric grade 3, pT3b,pN0(0 of 11),pM1 with metastatic renal cell carcinoma and intravascular tumor thrombus in the fibroconnective tissue (duodenal thrombus). -- Hyperlipidemia -- Osteopenia, currently holding Evista. -- Superficial melanoma status post excision [**2093**]. -- Basal cell carcinoma status post excision forehead. -- Basal cell carcinoma status post excision with positive margin [**2114**] to be followed up by dermatology. -- Cervical cancer status post hysterectomy [**2081**], status post appendectomy at the same time. Ovaries intact -- history of H. pylori and PUD. -- History of hepatitis A as young adult, requiring hospitalization. -- History of pneumonia as young adult, requiring hospitalization. -- exsmoker, smoked 30 pack years and quit in [**2102**] Social History: She is married and retired. She worked various jobs throughout her adult life. She smoked 30 pack years and quit in [**2102**]. Occasionally drinks alcohol socially. No IV drug use. Family History: Mother died at 64 from MI and father died from MI at 79. Neither had cancer. Sisterdiagnosed with breast cancer. Sister diagnosed with lung cancer metastasized to lung, recently passed away. Physical Exam: On Discharge: VS: T 98.1 HR 108 BP 142/68 RR 18 02Sat 94% on RA GEN: AOx3, NAD, Comfortable CV: tachycardic, regulary rythym, nl S1 and S2 PULM: CTA b/l, no repsiratory distress ABD: Soft, non-tedner, non-distended. JP site closed, c/d/i. J-tube site covered with DSD, c/d/i. Subcostal incision open on right lateral aspect, dressed with wet to dry dressings - fascia intact, clean, no active bleeding. The remaineder of the subcostal c/d/i without evidence of erythema or dishcarge. EXT: no c/c/e. MAE. Pertinent Results: [**2115-2-22**] 05:30AM BLOOD WBC-10.7 RBC-3.00* Hgb-9.1* Hct-27.2* MCV-90 MCH-30.2 MCHC-33.4 RDW-16.1* Plt Ct-464* [**2115-2-22**] 05:30AM BLOOD Glucose-112* UreaN-28* Creat-0.6 Na-137 K-4.5 Cl-106 HCO3-22 AnGap-14 [**2115-2-13**] 05:02AM BLOOD ALT-24 AST-24 AlkPhos-484* TotBili-0.8 [**2115-2-22**] 05:30AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1 [**2115-1-23**] 5:05 pm BLOOD CULTURE **FINAL REPORT [**2115-1-26**]** Blood Culture, Routine (Final [**2115-1-26**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2115-1-24**]): Reported to and read back by [**Doctor First Name **] ENGLISH @ 8:40 AM ON [**2115-1-24**]. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2115-1-24**]): GRAM NEGATIVE RODs [**2115-2-13**] ABD CT: IMPRESSION: 1. New subcutaneous hematoma at the wound site in the right upper quadrant. There is no evidence for active extravasation. 2. Fluid along the JP drain has slightly increased. A hematoma in the right lower quadrant is stable. A tiny 2.2 cm, also likely hematoma in the pelvis, is better identified with contrast than on the prior studies and is slightly smaller than on [**2115-1-24**]. 3. Portal vein thrombosis in the right posterior portal vein is slightly improved. The remainder of the involved branches are stable. Thrombosis of the SMV is roughly stable. [**2115-2-21**] COLONOSCOPY: Impression: Internal hemorrhoids Diverticulosis of the whole colon No acitve bleeding or old blood seen. Gastroscope had to be used to complete colonoscopy given extensive diverticulosis. Otherwise normal colonoscopy to anastomosis [**2115-2-21**] EGD: Impression: Mass in the second part of the duodenum Otherwise normal EGD to second part of the duodenum and efferent and afferent gastrojejunostomy limbs Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 91620**],[**Known firstname **] A [**2055-7-5**] 59 Female [**-1/5268**] [**Numeric Identifier 91621**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rate SPECIMEN SUBMITTED: Gallbladder, Right Colectomy, small bowel resection, duodenal tumor. Procedure date Tissue received Report Date Diagnosed by [**2115-1-15**] [**2115-1-15**] [**2115-1-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 15706**]/ttl Previous biopsies: [**-1/4896**] GI BX (1 JAR) [**-1/3632**] Inter aortic caval lymph node packet, Duodenal Thrombus, DIAGNOSIS: I. Gallbladder, cholecystectomy (A-B): 1. Gallbladder, within normal limits. 2. One lymph node with no malignancy identified (0/1). II. Ileum and colon, right hemicolectomy (C-U, AI-AK): 1. Metastatic renal cell carcinoma, conventional (clear cell) type with extensive intravascular tumor thrombosis. 2. All specimen resection margins free of tumor. 3. Six lymph nodes with no malignancy identified (0/6). III. Small bowel, resection (V-AE): 1. Serosal deposit of metastatic renal cell carcinoma. 2. Specimen resection margins free of tumor. IV. Duodenal tumor, resection (AF-AH): Duodenum with mural deposit of metastatic clear cell renal cell carcinoma. [**2115-1-15**]: CXR IMPRESSION: 1. Endotracheal tube tip between clavicular heads. 2. Right IJ line tip in lower SVC and endogastric tube side port well below the GE junction; no pneumothorax. [**2115-1-21**]: UGI IMPRESSION: No evidence of leaks or hold up. Preferential flow through the gastrojejunal anastomosis without contrast passing fully through the duodenum. [**2115-1-21**]: UGI/KUB IMPRESSION: Interval transit of contrast distally into the jejunum without evidence of definite leaks. [**2115-1-23**]: ECG Sinus tachycardia. Low precordial lead voltage. Non-specific ST segment changes in the inferolateral leads, new as compared to the previous tracing of [**2114-10-23**]. The rate has increased. Otherwise, no diagnostic interim change. [**2115-1-23**]: CXR FINDINGS: As compared to the previous radiograph, there is no relevant change. All monitoring and support devices have been removed with the exception of the nasogastric tube. No evidence of pneumonia, no pulmonary edema. No pleural effusions. Postoperative elevation of the right hemidiaphragm. [**2115-1-24**]: ECG: Sinus tachycardia. Short P-R interval. Diffuse non-specific ST-T wave changes. Low QRS voltages in the precordial leads. Compared to the previous tracing of [**2115-1-23**] there is no significant diagnostic change. TRACING #1 [**2115-1-24**]: ECG: Sinus tachycardia. Compared to tracing #1 there is no significant diagnostic change. TRACING #2 [**2115-1-24**]: CT Abd and Pelvis IMPRESSION: 1. New thrombus in the SMV and in the portal veins. 2. Stranding around the duodenum without a discrete fluid collection. The area of stranding abuts the SMV where the thrombus is located. 3. Small simple fluid collection in the right lower quadrant anterior to the psoas muscle does not appear infected and is likely not amenable to drainage given size and location. 4. No evidence of extraluminal contrast to suggest leak or perforation. 5. Stable size of left renal tumor. 6. Stable left renal vein thrombus. 7. Diverticulosis without diverticulitis. [**2115-1-24**]: CXR FINDINGS/IMPRESSION: There has been interval placement of an endogastric tube whose side port sits below the GE junction. There has also been interval placement of a left-sided internal jugular central venous catheter whose tip sits in the superior right atrium. The heart size is within normal limits and the mediastinal contours appear unremarkable. The lungs demonstrate increased consolidation of the retrocardiac space. There is no pleural effusion or pneumothorax. There is no apical capping. [**2115-1-26**]: CXR FINDINGS: The nasogastric tube on today's examination shows a normal course. The side port is located approximately 8 cm distal to the gastroesophageal junction. The tip of the tube, however, is redirected towards the gastroesophageal junction. No complications, notably no pneumothorax. Unchanged left central venous access line, unchanged platelike atelectasis at the left lung bases. [**2114-2-5**]: CT Abd and Pelvis IMPRESSION: 1. Trace foci of extraluminal air anterior to the duodenal sutures and posterior to the ileocolic anastomotic sutures are concerning for a leak. No evidence of extraluminal contrast noted. A delayed scan may be obtained once contrast has made its way into the colon to determine the exact site of leakage. 2. Small lytic lesions in the vertebral bodies are concerning for metastases. 3. Subacute compression fracture of the L2 vertebral body. 4. Interval increase in the size of a nonhemorrhagic fluid collection anterior to the right psoas muscle measuring 6 x 4 x 2 cm. [**2114-2-7**]: CXR IMPRESSION: PICC ends in right atrium 8-10 cm from the superior atriocaval junction. Results were communicated with the IV nurse at 7:30 p.m. on [**2115-2-7**] via telephone by Dr. [**Last Name (STitle) **]. 01/0511: CXR IMPRESSION: AP chest compared to [**2-7**], 6:20 p.m.: Left PIC line has been withdrawn to the level of the superior cavoatrial junction. Aside from linear atelectasis left lung is clear and there is no left pleural effusion. Elevation of the right lung base could be due to in part to small-to-moderate right pleural effusion. If that is of clinical concern right upper quadrant ultrasound is recommended. Nasogastric tube loops in the stomach. Heart size is normal. No pneumothorax. [**2115-2-8**] Pathology - Jejunum biopsy: DIAGNOSIS: No diagnostic abnormalities recognized. [**2115-2-13**] CT Abd and Pelvis IMPRESSION: 1. New subcutaneous hematoma at the wound site in the right upper quadrant. There is no evidence for active extravasation. 2. Fluid along the JP drain has slightly increased. A hematoma in the right lower quadrant is stable. A tiny 2.2 cm, also likely hematoma in the pelvis, is better identified with contrast than on the prior studies and is slightly smaller than on [**2115-1-24**]. 3. Portal vein thrombosis in the right posterior portal vein is slightly improved. The remainder of the involved branches are stable. Thrombosis of the SMV is roughly stable. 4. Osseous metastatic disease involving the lumbar spine from T12 through L2 demonstrates worsening with increasing soft tissue component extending into the spinal canal and pathologic fracture of L1 and L2 with L2 showing greater loss of height anteriorly than on the previous examinations. There is also infiltration of the psoas muscle bilaterally consistent with tumor infiltration. [**2115-2-23**] 05:53AM BLOOD Hct-27.9* [**2115-2-22**] 05:30AM BLOOD WBC-10.7 RBC-3.00* Hgb-9.1* Hct-27.2* MCV-90 MCH-30.2 MCHC-33.4 RDW-16.1* Plt Ct-464* [**2115-2-21**] 05:47AM BLOOD WBC-10.9 RBC-3.31* Hgb-9.7* Hct-29.9* MCV-90 MCH-29.3 MCHC-32.4 RDW-15.7* Plt Ct-477* [**2115-2-15**] 05:08AM BLOOD WBC-13.6* RBC-3.24* Hgb-9.6* Hct-28.9* MCV-89 MCH-29.5 MCHC-33.1 RDW-17.1* Plt Ct-416 [**2115-2-13**] 05:02AM BLOOD WBC-18.2* RBC-3.29*# Hgb-9.7*# Hct-29.1*# MCV-89 MCH-29.6 MCHC-33.4 RDW-16.5* Plt Ct-416 [**2115-2-12**] 07:44PM BLOOD WBC-18.7* RBC-2.44* Hgb-7.1* Hct-22.1* MCV-91 MCH-29.0 MCHC-31.9 RDW-16.4* Plt Ct-446* [**2115-2-7**] 06:20AM BLOOD WBC-11.6* RBC-3.22* Hgb-9.4* Hct-29.3* MCV-91 MCH-29.1 MCHC-32.0 RDW-15.2 Plt Ct-473* [**2115-2-4**] 04:59AM BLOOD WBC-16.9*# RBC-3.53* Hgb-10.1* Hct-31.8* MCV-90 MCH-28.6 MCHC-31.8 RDW-15.1 Plt Ct-596* [**2115-1-26**] 06:12AM BLOOD WBC-14.5* RBC-3.71* Hgb-10.7* Hct-33.0* MCV-89 MCH-28.8 MCHC-32.4 RDW-14.9 Plt Ct-492* [**2115-1-25**] 01:43AM BLOOD WBC-15.7* RBC-2.96* Hgb-8.6* Hct-26.5* MCV-90 MCH-29.2 MCHC-32.5 RDW-14.1 Plt Ct-375 [**2115-1-24**] 11:09AM BLOOD WBC-13.1* RBC-3.69* Hgb-10.6* Hct-33.5* MCV-91 MCH-28.7 MCHC-31.6 RDW-13.9 Plt Ct-493* [**2115-1-23**] 05:05PM BLOOD WBC-8.9 RBC-3.50* Hgb-10.1* Hct-31.6* MCV-90 MCH-29.0 MCHC-32.1 RDW-13.9 Plt Ct-415# [**2115-1-17**] 02:15AM BLOOD WBC-13.7* RBC-3.47* Hgb-10.3* Hct-30.7* MCV-88 MCH-29.5 MCHC-33.4 RDW-15.1 Plt Ct-198 [**2115-1-15**] 04:04PM BLOOD WBC-13.5* RBC-3.40* Hgb-10.2* Hct-29.1* MCV-86 MCH-30.0 MCHC-35.0 RDW-14.0 Plt Ct-202 [**2115-1-15**] 12:40PM BLOOD WBC-11.7*# RBC-3.64* Hgb-10.8* Hct-31.1* MCV-85 MCH-29.6 MCHC-34.7 RDW-14.0 Plt Ct-305 [**2115-1-24**] 12:54PM BLOOD Neuts-85.0* Lymphs-9.6* Monos-4.9 Eos-0.1 Baso-0.4 [**2115-1-15**] 04:04PM BLOOD Neuts-84.2* Lymphs-10.5* Monos-5.1 Eos-0.1 Baso-0.2 [**2115-2-15**] 05:08AM BLOOD PT-13.0* PTT-31.2 INR(PT)-1.2* [**2115-2-14**] 04:42AM BLOOD PT-13.3* PTT-29.1 INR(PT)-1.2* [**2115-1-30**] 03:44AM BLOOD PT-15.8* PTT-46.1* INR(PT)-1.5* [**2115-1-29**] 02:12PM BLOOD PTT-90.3* [**2115-1-28**] 08:00AM BLOOD PTT-26.4 [**2115-1-27**] 01:35PM BLOOD PTT-97.0* [**2115-1-26**] 12:17PM BLOOD PT-16.3* PTT-72.9* INR(PT)-1.5* [**2115-1-26**] 06:12AM BLOOD PT-16.0* PTT-56.8* INR(PT)-1.5* [**2115-1-25**] 01:43AM BLOOD PT-17.8* PTT-37.9* INR(PT)-1.7* [**2115-1-15**] 04:04PM BLOOD PT-14.2* PTT-26.2 INR(PT)-1.3* [**2115-1-15**] 12:40PM BLOOD Fibrino-311# [**2115-2-15**] 05:08AM BLOOD LMWH-0.84 [**2115-2-10**] 03:30PM BLOOD LMWH-0.76 [**2115-2-1**] 11:46AM BLOOD LMWH-0.54 [**2115-1-31**] 12:09AM BLOOD LMWH-0.36 [**2115-2-22**] 05:30AM BLOOD Glucose-112* UreaN-28* Creat-0.6 Na-137 K-4.5 Cl-106 HCO3-22 AnGap-14 [**2115-2-20**] 04:25AM BLOOD Glucose-160* UreaN-23* Creat-0.6 Na-137 K-4.1 Cl-107 HCO3-20* AnGap-14 [**2115-2-19**] 06:00AM BLOOD Glucose-176* UreaN-18 Creat-0.7 Na-134 K-3.7 Cl-104 HCO3-21* AnGap-13 [**2115-2-1**] 06:00AM BLOOD Glucose-209* UreaN-10 Creat-0.9 Na-139 K-4.7 Cl-102 HCO3-32 AnGap-10 [**2115-1-25**] 01:43AM BLOOD Glucose-95 UreaN-21* Creat-0.9 Na-134 K-4.2 Cl-99 HCO3-27 AnGap-12 [**2115-1-17**] 02:15AM BLOOD Glucose-102* UreaN-25* Creat-1.1 Na-140 K-4.5 Cl-112* HCO3-21* AnGap-12 [**2115-1-15**] 04:04PM BLOOD Glucose-169* UreaN-18 Creat-1.0 Na-137 K-5.9* Cl-109* HCO3-21* AnGap-13 [**2115-1-15**] 12:40PM BLOOD Glucose-206* UreaN-16 Creat-1.1 Na-140 K-5.3* Cl-111* HCO3-19* AnGap-15 [**2115-2-13**] 05:02AM BLOOD ALT-24 AST-24 AlkPhos-484* TotBili-0.8 [**2115-2-6**] 04:27AM BLOOD ALT-9 AST-15 AlkPhos-274* TotBili-0.3 [**2115-1-25**] 01:43AM BLOOD ALT-13 AST-20 LD(LDH)-197 AlkPhos-157* TotBili-0.9 [**2115-1-19**] 04:58AM BLOOD ALT-13 AST-18 AlkPhos-152* Amylase-41 TotBili-0.7 [**2115-1-19**] 04:58AM BLOOD Lipase-39 [**2115-2-18**] 04:53AM BLOOD cTropnT-0.01 [**2115-2-17**] 10:56PM BLOOD cTropnT-0.02* [**2115-2-17**] 06:01PM BLOOD CK-MB-2 cTropnT-0.03* [**2115-2-22**] 05:30AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1 [**2115-2-14**] 04:42AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.0 [**2115-2-13**] 05:02AM BLOOD Albumin-2.8* Calcium-8.5 Phos-2.2* Mg-2.4 Iron-75 [**2115-2-8**] 04:35AM BLOOD Albumin-2.9* Calcium-8.3* Phos-3.2 Mg-2.0 Iron-29* [**2115-2-1**] 06:00AM BLOOD Albumin-2.7* Calcium-8.5 Phos-3.5 Mg-2.1 Iron-27* [**2115-1-16**] 10:31AM BLOOD Calcium-8.0* Phos-4.0 Mg-2.3 [**2115-1-15**] 04:04PM BLOOD Calcium-9.2 Phos-4.7* Mg-1.4* [**2115-2-13**] 05:02AM BLOOD calTIBC-209* Ferritn-1079* TRF-161* [**2115-2-8**] 04:35AM BLOOD calTIBC-204* Ferritn-743* TRF-157* [**2115-2-1**] 06:00AM BLOOD calTIBC-159* Ferritn-674* TRF-122* [**2115-2-13**] 05:02AM BLOOD Triglyc-144 [**2115-2-8**] 04:35AM BLOOD Triglyc-114 [**2115-2-1**] 06:00AM BLOOD Triglyc-100 [**2115-2-18**] 06:21PM BLOOD Vanco-17.8 [**2115-2-17**] 05:14AM BLOOD Vanco-24.0* [**2115-2-15**] 08:12PM BLOOD Vanco-19.8 [**2115-2-15**] 04:30PM BLOOD Vanco-21.5* [**2115-2-15**] 05:08AM BLOOD Vanco-21.9* [**2115-1-25**] 07:35PM BLOOD Vanco-23.0* [**2115-1-24**] 04:05PM BLOOD Type-ART pH-7.46* [**2115-1-16**] 08:17AM BLOOD Type-ART pO2-193* pCO2-31* pH-7.35 calTCO2-18* Base XS--7 [**2115-1-15**] 09:55PM BLOOD pO2-186* pCO2-36 pH-7.32* calTCO2-19* Base XS--6 [**2115-1-15**] 02:44PM BLOOD Type-ART FiO2-50 pO2-197* pCO2-37 pH-7.33* calTCO2-20* Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [**2115-1-15**] 01:45PM BLOOD Type-ART pO2-203* pCO2-37 pH-7.33* calTCO2-20* Base XS--5 Intubat-INTUBATED [**2115-1-15**] 12:50PM BLOOD Type-ART pO2-206* pCO2-40 pH-7.29* calTCO2-20* Base XS--6 Intubat-INTUBATED Vent-CONTROLLED [**2115-1-15**] 09:03AM BLOOD Type-ART pO2-226* pCO2-36 pH-7.44 calTCO2-25 Base XS-1 Intubat-INTUBATED [**2115-1-24**] 04:05PM BLOOD Lactate-1.4 [**2115-1-24**] 03:46PM BLOOD Lactate-1.6 [**2115-1-16**] 08:17AM BLOOD Glucose-115* Lactate-0.9 [**2115-1-15**] 02:44PM BLOOD Glucose-149* Lactate-2.5* Na-134 K-5.2* Cl-112* [**2115-1-15**] 12:02PM BLOOD Glucose-215* Lactate-2.4* Na-132* K-5.4* Cl-108 [**2115-1-15**] 09:03AM BLOOD Glucose-152* Lactate-0.8 Na-136 K-4.5 Cl-103 Brief Hospital Course: Patient presented for elective resection of a duodenal mass to prepare for upcoming chemotherapy. She is known to have extensive RCC and had recently underwent a right nephrectomy and IVC ligation due to complete thrombus. On this admission she had resection of a duodenal mass seen on EGD that was thought to be high risk for bleeding complications if left alone and chemotherapy was initiated. The operation was difficult as expected but went well. The duodenal mass was excised and repaired primarily with an omental patch. Two JP drains were left in this area. She also had J-tube inserted. She had epidural placed pre-operatively and was kept intubated on POD 0 and sent to the ICU because of length of operation. Intra-operatively she required 6 units of blood and 7.5L of crystalloid and 750ml of colloid. Her urine output was noted to be low during the middle of the case but she was making greater than 30cc/hr by the end of the operation. Neuro: On POD 0 she was kept intubated and sedated but was extubated without difficulty on POD 1 in the morning. She had an epidural in place that was working well. On POD 2 she had her epidural split and was placed on dilaudid PCA with good pain control and was brought to the floor. She had her epidural removed on POD 5 and had her foley removed soon after. On POD 9, in setting of sepsis, she developed confusion that resolved over 24 hours after antibiotic therapy was initiated. She remained on a dilaudid PCA through POD 28 when she was transitioned to PO pain medication with IV for breakthrough. The patient's pain remains well controlled with PO pain medications prior discharge with minimal requirements. CV: During her initial stay in the unit and on the floor she was hemodynamically stable until POD 9 when she developed tachycardia and fever thought to be due to sepsis. She required metoprolol 5 IV Q4H to control her heart rate in the ICU and when returned to the floor for a short period of time. Once her infection was brought under control she became hemodynamically stable. On the floor patient was intermediately tachycardic with HR 100-120, her Lopressor was weaned off. She received multiple blood transfusions and after transfusions patient's HR was 80-100 and sinus. She was occasionally tachyarcardic at time of discharge but was asymptomatic and was refusing continued lopressor. Resp: After being intubated overnight for close monitoring she was extubated on POD 1 and was weaned off oxygen and onto room air by POD 2. She was transferred to the floor on POD 2 and had no oxygen requirements throughout her hospitalization despite having bacteremia. She remained on room air through the remainder of her admission and was using her incentive spirometer well. GI: A j-tube and NGT were placed during the case. There was a lot of bowel manipulation during this large operation. Her NGT output slowly declined over POD1 to POD4 but was kept because of the extent of the case. Trophic tube feeds through her J-tube were started on POD 4, which she tolerated well despite not passing flatus by this point. On POD 5 her NGT was pulled out accidentally and then replaced and she continued on trophic tube feeds. On POD 6 UGI study showed no leak and good flow on contrast through gastro-jejunostomy. On POD 7 clamp trials were started and residuals were 385-400s. On returning to the floor, POD 10, her NGT was discontinued but she was noted to have bilious output from her JP drain and so an NGT was replaced. In the setting of her ICU course her tube feeds were held but then restarted on POD 12 and advanced to 30cc/hr, which she tolerated well. She had been advanced to tube feeds goal of 60cc/hr and was started octreotide 150 TID in addition to reglan, but was noted to have increased NGT output and have tube feed coloring to NGT output and so tube feeds were reduced down to 30cc/hr. She was again clamp trailed on POD 19 and had increasing abdominal pain, increased JP output, and nausea and was put back on wall suction. She initially had two JP drains placed intra-operatively but then had the anterior drain removed on POD 18 after consistently low output. JP 2 continued to have bilious output which because more sanguineous on POD 29 but resolved and became scant on POD 31. JP x 2 was removed on POD # 35. The patient received TPN throughout hospitalization and regular diet. Her PO intake was monitored and was improving allower her TPN to be discontinued prior discharge. GU: Patient initially had low urine output during the case that picked back up post operatively. During her stay in the ICU her hourly urine output was adequate except for a transient drop that resolved after she was given 2 units of blood. As she has only one kidney that has tumor burden itself her output was monitored closely. Her creatinine peaked at 1.3 but was otherwise normal through hospitalization. Heme: She received multiple units intra-operatively. On POD 1 she received 2 units RBCs for Hct 24.2 and responded appropriately. On POD 4 she received an additional 1 unit for Hct of 26. On POD 9 she received 2 additional units of RBCs and required no further transfusions. On POD 9 she was also scanned and found to have new SMV and protal vein thrombosis and so was started on a heparin drip. She became therapeutic within 24 hours but then strangely became subtherapeutic on POD 12, despite increases in the heparin drip rate. A hematology consult was called in the setting of questionable resistance pattern and no clear etiology for this pseudo resistance could be elucidated, although by the time she was transitioned to Lovenox her PTT went from 20s to 90s. She had multiple factor xa levels checked, the second being 0.56, and was followed by the hematology team who agreed with dosing of 70mg [**Hospital1 **] Lovenox, thought that she would need lifelong anticoagulation, and argued that Lovenox is better than coumadin for cancer patients based on recent data. The patient required multiple blood transfusion for low HCT. Low HCT thought to be secondary to slow duodenal bleed and subcutaneous hematoma. The EGD on [**2115-2-21**] was negative for acute bleed, and hematoma was removed with wound VAC. Patient's HCT was low but stable prior to discharge and she recieved 1 unit of pRBCs before discharge. She will continue to have frequent HCT checks per VNA as outpatient. ID: Patient received kefzol and flagyl for 24 hours post operatively. She was afebrile until spiking to 104 on POD 9. CT scan that day showed fat stranding around the duodenum but no free air or clear fluid collection. She was started on vanc and zosyn after GNR found on blood cultures, which eventually grew out pan sensitive E. Coli, at which point vancomycin was stopped. She was continued on Zosyn until POD 27. On POD 28, her temperature rose to 102 and she had AMS. She was restarted on zosyn and vancomycin empirically and her AMS began to resolve on POD 29. She was kept on empiric vancomycin and zosyn until POD # 35. All surveillance cultures were negative and patient's WBC remained within normal limits prior discharge and patient remains afebrile. Endocrine: Her sugars were noted to be high in the setting of TPN and were monitored throughout hospitalization with appropriate adjustments to her TPN. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with walker, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Citalopram 10mg dialy, Famotidine 20mg [**Hospital1 **], Omeprazole 20mg [**Hospital1 **], Vicodin q6 PRN, Metoprolol tartrate 12.5mg [**Hospital1 **], Miralax PRN, Simvastatin 20mg daily, Zolipidem 6.25-13 qHS PRN, Senna Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*3* 2. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)) for 2 weeks. Disp:*56 Tablet(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: 1. Metastatic renal cell carcinoma 2. Duodenal stump leak 3. Sepsis with E. Coli 4. Portal vein and SMV thrombosis 5. Right upper quadrant subcutaneous hematoma at the wound site 6. [**Last Name (un) **] mass with stigmata of recent bleeding at the second part of the duodenum 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 following resection of your duodenal tumor. Your stay was complicated by sepsis, portal vein and superior mesenteric vein thrombosis, right upper quadrant hematoma at the wound site, tachycardia, and continued GI bleed requiring transufsions which have all been managed. You are now stable for discharge home with continued close follow up and care with a visiting nurse who will continue to monitor your blood levels (Hematocrit) as well as assist with dressing changes for your incisional wound. **Please contact us immediately if you note any new or worsening bleeding.** Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. You often had a rapid heart rate (tachycardia) during your admission which we initially treated with a medication called metoprolol (lopressor) which you recently wished to stop taking. Please follow up with your primary care doctor about this finding if it persists. Please alert the surgical team, your PCP, [**Name10 (NameIs) **] present to the ED if you start to experience chest pain or other concerning symptoms (dizziness, lightheadness, shortness of breath, pain raidiating down your left arm, palpitations (feeling that your heart is beating too fast), or sweating in the context of the above symptoms). *You develop new or worsening cough, shortness of breath, or wheeze. *You are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. You had this finding in the hospital - please notify if this gets worse (bright red blood in stools, increased amount of dark black stools) or if persists for more than 2 days. *You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Continue Lovenox twice a day as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-13**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: You will continue to have wound dressing change daily by VNA. Avoid swimming and baths until your follow-up appointment. You may shower but keep the open area of your incision covered, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions: Please call Dr. [**Last Name (STitle) 468**] office at [**Telephone/Fax (1) 2835**] to schedule a follow up appointment in [**3-8**] weeks after discharge. . Please follow up with Dr. [**Last Name (STitle) 67004**] (PCP) in [**3-8**] weeks after discharge

[ "272.4", "197.5", "733.90", "198.5", "198.89", "189.0", "998.59", "568.0", "455.0", "197.4", "V10.83", "V15.82", "V10.82", "557.0", "560.9", "V45.73", "V10.41", "V12.55", "997.49", "562.10", "452", "V88.01", "038.42", "E878.8", "578.9", "995.91", "785.0", "998.12" ]

icd9cm

[ [ [] ] ]

[ "38.91", "45.23", "38.97", "99.15", "45.13", "54.59", "46.71", "45.73", "51.22", "46.39", "45.91", "45.62", "96.6", "44.39", "45.16" ]

icd9pcs

[ [ [] ] ]

27330, 27385

18557, 26190

309, 664

27706, 27706

3024, 18534

31102, 31361

2287, 2482

26463, 27307

27406, 27685

26216, 26440

27889, 30792

30807, 31079

2497, 2497

2511, 3005

224, 271

692, 1149

27721, 27865

1193, 2068

2084, 2271

56,950

156,132

7816

Discharge summary

report

Admission Date: [**2120-1-17**] Discharge Date: [**2120-1-20**] Date of Birth: [**2071-3-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: Flu like illness Major Surgical or Invasive Procedure: None History of Present Illness: 48 yo female with history of hepatitis C, COPD, and hypothyroidism, presents with flu like symptoms for 5 days. The patient reports nausea and vomiting associated with poor PO intake for the past five days. She also reports right sided flank pain and myalgias for the same amount of time. Today, she developed cough that is productive of white sputum. She denies other upper respiratory symptoms. She denies urinary symptoms, headache, lightheadedness and fever. She denies sick contacts, however reports to a methadone clinic daily and has been spending much time with her husband who is admitted here at [**Hospital1 18**]. Today, she reported confusion, that she describes as similar to the prodrome of her seizure, but denies seizure activity today. Of note, the patient has not been taking her levothyroxine for the past few months, secondary to the stress of taking care of her husband. In the emergency department her initial vital signs were T 96 HR 53 BP 79/41 RR 18 O2 96. Her labs were significant for WBC 23.0, elevated CK 353, elevated BUN/Crn 47/2.3, elevation of AST to 846 (baseline 29), ALT to 712 (baseline 29), with normal AP and Tbili with a mild coagulopathy, INR 1.3. Her tox screen was positive for barbituates and methadone, she is on methadone as an outpatient. Of note her tylenol level was negative. She had an Abd US which showed evidence of an echogenic liver, but no source of intraabdominal infection. A CXR showed no evidence of pneumonia. A head CT showed a mass, which is likely stable from prior. She received a total of 5L of NS for hypotension, vancomycin and zosyn for empiric antibiotic coverage. She also received 100mg of hydrocortisone as well as 0.2mg of narcan when her blood pressures did not respond to IV fluids. She received a total of 2 amps of glucose for fsbg of 50. On transfer to the ICU her vital signs were T 96.5 BP 96/67 HR 63 RR 15 O2 94% on 4L. On arrival to the ICU she reports continued nausea and fatigue. Otherwise, she reports is very thirsty and feels better than when she arrived in the ED. REVIEW OF SYSTEMS: (+)ve: cough, myalgias, nausea, vomiting, diarrhea (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest pain, palpitations, rhinorrhea, nasal congestion, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: Chronic hepatitis C infection Hypothyroidism COPD Brain hemangioma Chronic lower back pain History of seizures Social History: She is married and has two children. The patient smokes ten cigarettes a day, does not drink alcohol and has a history of IVDU, on methadone, has been clean for 20 years. Family History: Mother is alive with a nonspecified arthropathy and hypothyroidism. Father died a long time ago. Two sisters, one with skin cancer. Physical Exam: T=96.2 BP=81/53 HR=69 RR=10 O2=97% GENERAL: Pleasant, well appearing female in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. dry MM. OP clear. Neck Supple, mild cervical lymphadenopathy, No thyromegaly. CARDIAC: Bradycardia, regular rhythm. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP flat LUNGS: bilateral expiratory wheezes, good air movement biaterally. No crackles or rhonchi ABDOMEN: NABS. Soft, NT, ND. Hepatomegaly approx 5cm below costal margin EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: scars bilaterally from history of IVDU, No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**2-10**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred. No asterixis PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: [**2120-1-17**] 04:40PM WBC-23.0*# RBC-3.79* HGB-11.3* HCT-35.0* MCV-92 MCH-29.8 MCHC-32.3 RDW-14.4 [**2120-1-17**] 04:40PM PLT COUNT-159 [**2120-1-17**] 04:40PM PT-14.5* PTT-35.1* INR(PT)-1.3* [**2120-1-17**] 04:40PM BLOOD UreaN-47* Creat-2.3*# [**2120-1-18**] 03:52AM BLOOD Glucose-114* UreaN-27* Creat-1.2*# Na-137 K-5.2* Cl-109* HCO3-20* AnGap-13 [**2120-1-17**] 04:40PM BLOOD ALT-712* AST-846* CK(CPK)-353* AlkPhos-104 TotBili-0.6 [**2120-1-18**] 03:52AM BLOOD ALT-503* AST-529* LD(LDH)-303* AlkPhos-95 TotBili-0.5 [**2120-1-18**] 03:52AM BLOOD Albumin-3.5 Calcium-8.0* Phos-4.6* Mg-2.3 [**2120-1-17**] 04:40PM BLOOD TSH-7.2* [**2120-1-17**] 04:40PM BLOOD T4-8.0 [**2120-1-17**] 04:40PM BLOOD Cortsol-11.4 [**2120-1-17**] 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-POS Tricycl-NEG [**2120-1-17**] 04:30PM BLOOD Glucose-51* Lactate-1.6 Na-123* K-3.7 Cl-88* calHCO3-22 Studies: [**2120-1-17**] Chest Xray: No acute intrathoracic process. [**2120-1-18**] Chest Xray: Bibasilar pneumonia. [**2120-1-18**] TTE: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal. Quantitative (3D) LVEF = 59%. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Brief Hospital Course: 48 year old female with history of chronic hepatitis c, seizure disorder, brain hemangiomas admitted for hypotension, acute hepatitis, and acute renal failure. #. Hypotension/Shock: She initially presented to the ED with hypotension that was responsive to aggressive fluid resuscitation. She was transiently on phenylephrine and dopamine on admission to the ICU, but was quickly weaned off pressors. It was felt that she had hypovolemic shock. The etiology of the hypovolemia was not entirely clear, but possibilities include toxic ingestion, infectious process, hypothyroidism, and adrenal insufficiency. After fluid resuscitation, her blood pressures stabilized and she was transferred to the floor. #. Pneumonia: She presented with history of cough and fatigue, and her initial chest xray on admission showed no acute process. A chest xray the day after admission showed bibasilar pneumonia. She was started on levofloxacin for community-acquired pneumonia. #. Hypothyroidism: She had not been taking her thyroid medication as an outpatient,and was restarted after admission. She was seen by the endocrinology team who did not feel that her presentation was related to her hypothyroidism, despite an elevated TSH to 7.5. #. Transaminitis: She had transaminitis on admission that was felt to be related to hypotension. Her transaminases downtrended. She was negative for acute EBV and other viral studies were pending (HIV, CMV, or Hep A, B, D, or E). She was asked to see her PCP in regards to the results #. Acute renal failure: Given her BUN to Crt ratio, granular and hyaline casts on sediment and picture of hypovolemia on presentation, her acute renal failure was most likely prerenal. It recovered completely #. Unlikely UTI/Pyelonephritis: She had a urinalysis consistent with a UTI on admission and was treated with levofloxacin as above. No urinary symptoms and this seemed unlikely #. Seizure Disorder/Brain Hemangioma: She was continued on her home phenobarbitol. # History of susbtance use: She was continued on home methadone dosing. There was some concern for toxic ingestion causing her presentation and psychiatry was consulted. She denied any toxic ingestion or overdose. #. COPD/Tobacco Abuse: She was given albuterol nebulizers Medications on Admission: Methadone 140mg QD Levothyroxine 25mg QD (not taking) Phenobarbital 100mg [**Hospital1 **] Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Phenobarbital 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Methadone 40 mg Tablet, Soluble Sig: One [**Age over 90 8821**]y (140) Tablet, Soluble PO DAILY (Daily). 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 5 days. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute hepatitis Acute renal failure Flu like symptoms Hypothyroidism Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had hypotension, acute hepatitis, and renal failure with unclear cause. You were treated emperically with antibiotics but we had no strong evidence of bacterial infection. However, continue to take them as prescribed. Your kidneys have recovered but you need to follow up with your PCP regarding pending tests including repeat liver function tests in 1 week. Followup Instructions: Please see your PCP in one week [**Last Name (LF) **],[**First Name3 (LF) 10348**] [**Telephone/Fax (1) 10349**]

[ "070.54", "276.1", "789.00", "486", "729.1", "496", "785.59", "348.30", "288.60", "228.02", "305.1", "599.0", "304.73", "724.2", "345.90", "244.9", "570", "584.9", "251.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9252, 9258

6116, 8401

332, 338

9370, 9370

4308, 4308

9901, 10016

3190, 3325

8542, 9229

9279, 9349

8427, 8519

9514, 9878

3340, 4289

2463, 2851

276, 294

366, 2444

4324, 6093

9384, 9490

2873, 2985

3001, 3174

1,623

151,791

25615

Discharge summary

report

Admission Date: [**2134-8-4**] Discharge Date: [**2134-8-7**] Date of Birth: [**2054-12-8**] Sex: F Service: [**Last Name (un) **] ADMISSION DIAGNOSIS: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is a 79-year-old female, without significant past medial history, brought to the emergency department in the morning, by her husband after being found on the floor unresponsive. The patient has not seen a physician in many years but had no known past medial history, no past surgical history, no known drug allergies and took no medications. PHYSICAL EXAMINATION: She had several lacerations and ecchymoses of the face and head. She was complaining of a headache as well as some abdominal pain and diarrhea for several days. Her abdomen was soft but tender and she was guaiac positive on rectal examination. HOSPITAL COURSE: The patient had routine labs ordered as well as CT scan of the head and C-spine. A Foley catheter was placed with a minimal amount of urine retrieved. She was noted to have pyuria. While the CT scan of the head and C-spine revealed no abnormalities. Laboratory tests revealed a white blood cell count of 43,000. Creatinine of 3.7. INR of 1.7 and lactate of 5.7. The emergency department ordered a renal ultrasound at this time to rule out an obstructive cause of anuria and a CT of the abdomen and pelvis with PO contrast were ordered. While awaiting the report of the CT scan however, the patient became acutely hypoxic with oxygen saturations in the 80's and was emergently intubated. The CT scan demonstrated thickened small bowel, and large amount of ascites (of note, the patient was severely hypoalbuminemic of uncertain etiology). A surgical consult was obtained at approximately 8 p.m. to evaluate the patient for possible ischemic bowel. The patient was septic but the source uncertain in this patient with pyuria. She was continued to be resuscitated and had received approximately 7 liters of crystalloid at this time. A repeat CT scan of the abdomen and pelvis with contrast down to the rectum now revealed stable small bowel thickening but also thickening of the transverse colon, sigmoid and rectum. The patient was brought to the surgical intensive care unit and rigid sigmoidoscopy was performed but the colon could not be seen proximally. There was a question of whether there was dusky discoloration at 15 cm but this was not clear. Therefore a stat GI consult was obtained to perform a colonoscopy and evaluate the extent of colonic involvement. The colonoscopy demonstrated an area of 15 to 20 cm of mucosal discoloration with more proximal mucosal edema and friability in the splenic flexure descending colon and sigmoid, consistent with ischemia. The terminal ileum was also abnormal. Based on the above as well as persistent acidosis the patient was taken emergently to the operating room for exploration. The patient underwent an exploratory laparotomy. On entering the abdomen, a large amount of ascites was discovered with turbid fluid in the pelvis. The liver was studded with multiple white/tan firm nodules, later confirmed to be metastatic adenocarcinoma. While the descending colon and proximal sigmoid were edematous with areas consistent with ischemia, there was no full-thickness involvement. However at the rectosigmoid junction there was an area of congested purple appearance of the bowel that felt circumferentially firm and worrisome for malignancy. The patient underwent a colectomy and Hartmann's procedure and was transferred back to the ICU on multiple pressors. She continued to have a large fluid requirement to maintain adequate filling pressures, cardiac index and tissue perfusion by SGO2 and received over 15 liters of crystalloid during the first 24 hours of her admission. By postoperative day No. 1, she was having increased peak airway pressures above 40 cc of water as well as multiple bladder pressure measurements over a 2 hour period, greater than 40 cm of water. Her abdominal compartment was emergently decompressed at the bed time with an almost immediate improvement in hemodynamics. Her abdomen was closed with [**Location (un) 5701**] bag technique. Unfortunately these improvements were short lived and she progressively deteriorated developing refractory hypotension and acidosis requiring maximal amounts of vasopressor and Levophed to maintain adequate blood pressure. On the morning of postoperative day No. 2, she had a cardiac arrest. DISCHARGE DIAGNOSES: 1. Ischemic colitis and enteritis. 2. Metastatic colorectal adenocarcinoma with malnutrition, ascites. 3. Pyuria. 3. Sepsis and shock. 4. Cardiac arrest and death. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 14981**] Dictated By:[**Last Name (NamePattern4) 25081**] MEDQUIST36 D: [**2134-10-19**] 22:41:10 T: [**2134-10-20**] 00:04:31 Job#: [**Job Number 63925**] cc:[**Last Name (NamePattern1) 19834**]

[ "584.5", "153.3", "873.43", "873.42", "427.5", "518.81", "995.92", "785.52", "196.2", "427.31", "276.2", "729.9", "197.7", "276.5", "599.0", "038.9", "557.0", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "99.62", "99.15", "08.81", "50.12", "89.64", "46.03", "27.51", "54.12", "45.23", "96.71", "00.17", "96.04", "45.79" ]

icd9pcs

[ [ [] ] ]

4490, 4972

854, 4469

591, 836

174, 191

220, 568

9,325

128,619

16884

Discharge summary

report

Admission Date: [**2130-12-8**] Discharge Date: [**2130-12-14**] Date of Birth: [**2066-8-3**] Sex: F Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old woman found down in her boarding house by tenant, unresponsive, taken to [**Hospital3 417**] Hospital where CT showed a large subarachnoid hemorrhage with a large amount of blood in the ventricles. The patient was intubated and PHYSICAL EXAM: On arrival, the patient's temp was 97.8, heart rate 76, BP 128/78, respiratory rate 12, sats 100%. The patient was intubated, unresponsive. Pupils on the right were 2.5, the left was 2, and fixed and dilated. Right hand posturing to painful stimulation and left upper extremity unresponsive. Flexor posturing bilateral lower extremities. rate and rhythm. Abdomen soft. No edema in the extremities. LABORATORY: White count 11.0, crit 35.7, INR 1.0, sodium 141, K 4.2, chloride 104, CO2 25, BUN 8, creatinine 0.8, glucose 178. Tox screen negative. CT scan showed interhemispheric blood collection and subarachnoid hemorrhage with ventricles filled with blood. HOSPITAL COURSE: The patient had a ventricular drain placed on [**2130-12-8**] without complication. The patient underwent an arteriogram which showed multiple aneurysms including a right ruptured A-COM aneurysm. The patient underwent coil embolization without interprocedural complication. Postop, the patient had a CPP of 65-74, ICP 14 and rose to 20 with stimulation. Pupils 1 mm and pinpoint and nonreactive bilaterally, positive gag, no grimacing or response to sternal rub, decerebrate extensor posturing in the left upper extremity, weak withdrawal in the right upper extremity, triple flexing in the lower extremities. On [**2130-12-11**], the patient's pupils were trace reactive, opened eyes partially to stimulation, positive doll's eyes, decorticate in the upper extremities, triple flexing in the lower extremities. The patient received interventricular TPA and repeat head CT was to be done. The patient's son was [**Name (NI) 653**] regarding her grave condition. The patient had TCD's done on [**12-11**] which showed no evidence of vasospasm. CT scan showed decreased ventricular blood and decreased size of the ventricles. No significant exam improvement since arrival. Poor prognosis was discussed with family. The patient's family made patient comfort measures only and support was withdrawn. The patient was pronounced dead at 4:30 am on [**2130-12-14**]. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2131-2-15**] 11:20 T: [**2131-2-15**] 10:26 JOB#: [**Job Number 47548**]

[ "447.1", "430", "518.81", "331.4", "458.2", "E936.1", "437.3", "431", "780.01" ]

icd9cm

[ [ [] ] ]

[ "02.2", "99.10", "96.6", "38.91", "96.07", "39.72", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

1131, 2761

445, 1113

170, 429

63,637

185,482

40158

Discharge summary

report

Admission Date: [**2183-10-14**] Discharge Date: [**2183-10-15**] Date of Birth: [**2119-11-18**] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracycline / IV Dye, Iodine Containing Contrast Media Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: carboplatin allergy coming in for desensitization Major Surgical or Invasive Procedure: none History of Present Illness: 63F with stage IIIC poorly differentiated primary peritoneal carcinoma, now with disease recurrence and participating in a [**Company 2860**] clinical trial. She is admitted to the ICU for cycle 4 [**Doctor Last Name **]/taxol therapy with carboplatin desensitization. When she last received chemotherapy on [**2183-9-2**], a third of the way through the infusion of carboplatin, she developed an intense feeling of heat and generalized body tingling, tingling and numbness of the lips, and chest tightness. Carboplatin was discontinued and she received 100 mg hydrocortisone and 50 mg of Benadryl IV. Her vital signs remained stable, but she later had vomiting and headache. Given her allergic reaction, she was admitted to the ICU on [**9-23**] to receive carboplatin per the desensitization protocol. She tolerated the treatment without incident. Today, she is directly admitted to the ICU again for carboplatin desensitization. She denies any complaints, feels fine without pain, fever, nausea, vomiting, abdominal pain. On arrival to the MICU, patient's VS. T 98.1, HR 90, BP 126/67, 94% on RA Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - CT abd/pelvis on [**2182-2-28**] revealed a large mass centered in the sigmoid colon with pelvic lymphadenopathy, retroperitoneal lymphadenopathy, and peritoneal carcinomatosis. - A colonoscopy revealed a fungating, ulcerated mass within the sigmoid colon causing a partial obstruction. The biopsy of this mass revealed adenocarcinoma with papillary formation, suggestive of an ovarian primary. - [**2182-3-14**] underwent exploratory laparotomy, hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with colorectal re-anastomosis and diverting loop ileostomy. This was a suboptimal tumor debulking. Intra-operatively, the uterus and bilateral adnexal were unremarkable. Extensive firm retroperitoneal lymphadenopathy was appreciated. There was no evidence of carcinomatosis. The tumor was noted to involve the sigmoid colon and rectum. Pathology examination revealed serous carcinoma involving full thickness of the rectal wall. Seven of eight lymph nodes were positive for malignancy. Uterus, cervix, fallopian tubes, and ovaries were negative for malignancy. - [**4-26**] start chemotherapy with Carboplatin q21d and weekly Taxol - [**2182-5-30**] Cycle 3 Carboplatin and Taxol - Thalassemia Social History: Imigrated from [**Country 3587**] in youth. Formerly employed in retail sales. No children, husband lives in [**Country 3587**]. Sister and [**Name2 (NI) 802**] in [**Name (NI) 86**] area. - Tobacco: Never - etOH: denies - Illicits: denies Family History: Uncle: diabetes. Mother and father lived in to 70's, she denies family history of cancer, CAD, hypertension. Physical Exam: Physical Exam on admission: Vitals: T 98.1, HR 90, BP 126/67, 94% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, 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: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, vertical midline scar 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. Skin: Right chest port in place Discharge Exam: Vitals: T 98.4, BP 149/86, HR 82, RR 22, 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, 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: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, vertical midline scar 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. Skin: Right chest port in place Pertinent Results: Admission labs: [**2183-10-14**] 01:45PM ALT(SGPT)-41* AST(SGOT)-27 ALK PHOS-116* TOT BILI-0.3 Discharge Labs: [**2183-10-15**] 03:18AM BLOOD WBC-7.6 RBC-3.70* Hgb-8.4* Hct-25.8* MCV-70* MCH-22.7* MCHC-32.6 RDW-20.0* Plt Ct-214 [**2183-10-15**] 03:18AM BLOOD Plt Ct-214 [**2183-10-15**] 03:18AM BLOOD Glucose-193* UreaN-24* Creat-0.9 Na-139 K-4.3 Cl-105 HCO3-24 AnGap-14 [**2183-10-15**] 03:18AM BLOOD ALT-33 AST-25 AlkPhos-106* TotBili-0.3 [**10-13**] EKG: Normal sinus rhythm. Tracing is within normal limits. Compared to the previous tracing of [**2183-9-24**] there are no significant changes. Micro: None Imaging: None Brief Hospital Course: Brief Hospital COurse: 63F with stage IIIC poorly differentiated primary peritoneal carcinoma, now with disease recurrence and participating in a [**Company 2860**] clinical trial admitted to ICU for carboplatin desensitization. Patient tolerated the treatment well without adverse effects. Active Issues: # Carboplatin desensitization: Patient has experienced feeling of heat, generalized body tingling, numbness of the lips, chest tightness,nausea, and headache with prior carboplatin infusion. She was last admitted to the ICU in [**Month (only) 216**] for carboplatin desensitization via protocol and tolerated in well. We followed the same protocol during this treatment course with premedication with diphenhydramine, famotidine, lorazepam and epinephrine and diphenhydramine prn ordered in event of reaction. The patient tolerated the treatment well and had no signs of hypersenstivity or adverse reaction. # Stage IIIc poorly differentiated primary peritoneal serous carcinoma: Status post sub-optimal debulking surgery ([**2182-3-14**]) and 6 cycles ofchemotherapy ([**4-/2182**]/[**2182**]). Five cycles with Carboplatin and weekly Taxol and 1 cycle with Carboplatin and Taxotere. CT torso on [**7-4**] documented disease recurrence. On [**8-11**] she started chemotherapy according to the clinical trial [**Company 2860**] #11-228 (Phase II, multi-center, double-blind, placebo controlled, randomized study of ombrabulin in patients with platinum-sensitive recurrent ovarian cancer treated with Carboplatin/Paclitaxel). The second cycle was complicated by an allergic reaction to Carboplatin and cycle 3 was administered without complication with desensitization protocol. The restaging CT torso performed on [**10-11**] showed stable disease with an overall increase in the tumor size of 17.8%. She was admitted to the ICU for cylce 4 of carboplatin/paclitaxel with desensitization and tolerated it well without adverse reaction. She will follow up with her oncologist to schedule further chemotherapy treatments. She will need to be readmitted to the ICU for future cycles for desensitization and monitoring. Transitional Care Issues: 1. Code Status; Full Code 2. Contact: Brother in law [**Name (NI) **] [**Name (NI) **] 3. Medication changes: None 4. Follow up: With primary oncologist 5. Pending studies: None Medications on Admission: Zofran for nausea Discharge Medications: Zofran for nausea Discharge Disposition: Home Discharge Diagnosis: -Stage IIIc poorly differentiated primary peritoneal serous carcinoma -Carboplatin desensitization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], You were admitted to the hospital because you previously had allergic reactions to your chemotherapy, carboplatin. You were treated with a regimen to decrease your allergic reaction to this medication, which worked well, and you were discharged home. You will need this treatment prior to each of your future treatments with this medication. We have not made any changes to any of your medications. Please continue to take them as previously prescribed. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2183-10-20**] at 8:45 AM With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2183-10-20**] at 9:30 AM With: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN [**Telephone/Fax (1) 9644**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2183-10-15**]

[ "282.40", "E933.1", "401.9", "154.8", "V70.7", "V07.1", "196.2" ]

icd9cm

[ [ [] ] ]

[ "99.12" ]

icd9pcs

[ [ [] ] ]

8157, 8163

5738, 6007

390, 397

8306, 8306

5059, 5059

9002, 9769

3469, 3579

8114, 8134

8184, 8285

8071, 8091

8457, 8979

5175, 5692

3594, 3608

4334, 5040

7995, 8045

1545, 1958

7976, 7984

301, 352

6022, 7840

7866, 7956

425, 1526

5076, 5158

3622, 4318

8321, 8433

1980, 3195

3211, 3453

3,183

193,649

43906

Discharge summary

report

Admission Date: [**2199-7-10**] Discharge Date: [**2199-7-13**] Date of Birth: [**2143-5-15**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old male with a past medical history of coronary artery disease, status post MI [**2-21**], history polycystic kidney disease status post unrelated donor kidney transplant in [**2193**]. Patient underwent cardiac catheterization on [**2199-6-3**] at [**Hospital6 **] which reportedly showed two vessel disease with 60% lesion in the proximal left anterior descending artery, 70% lesion in mid left anterior descending artery, 99% lesion distal left anterior descending artery that filled weakly via the left to right collaterals, 70% proximal left circumflex lesion, 40% proximal RCA lesion, 70% mid RCA lesion. [**Last Name (STitle) 53795**]went nuclear stress testing on [**2199-6-4**], where he exercised six minutes 30 seconds on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol with no EKG changes. He did have chest pain, however. Nuclear imaging revealed an apical infarction with some peri-infarct ischemia. Ejection fraction was 50%. Initially, the patient planned on having cardiac surgery in [**Hospital6 **], but came to [**Hospital1 69**] for second opinion. He was evaluated by Dr. [**Last Name (Prefixes) **] and referred for planned LAD intervention. He was admitted on [**2199-7-13**] for precatheterization hydration, Mucomyst therapy. After admission, he was found to have a potassium value of 5.6. EKG was done without any evidence of changes, and patient had a dose of Kayexalate. On [**2199-7-11**], he underwent left heart catheterization, right heart catheterization, angiography. On angiography, left anterior descending artery was shown to have diffuse disease with serial 50% stenoses proximally and 90% tortuous stenosis and diagonal with subtotal occlusion of the mid vessel. The distal vessel was found to fill the via collaterals, left circumflex, and mild luminal irregularities. Right coronary artery was extremely tortuous with mid vessel 90% stenosis. The patient underwent a complicated intervention. A stent could not be fully expanded in his left anterior descending artery. The cause for this was unknown since no visible calcium was seen and the lesion predilated easily with a 2.0 mm balloon. His diagonal branch was not engaged with the coronary wire. Discussion was made with cardiac surgery regarding whether to proceed at this point with CABG. Because the anterior was was not felt to be viable it was decided to revascularize the RCA and then perform elective CABG at a later date using a limited access procedure/off pump procedure if ischemia could be demonstrated in the area. His right coronary artery was stented with a drug eluting stent. There was ostial guding catheter dissection of the right coronary artery and this was successfully treated with a drug eluting stent as well. Postcatheterization, the patient had a vagal episode in the holding area with decreased heart rate and blood pressure. At that time, he also complained of lower back pain. His hemodynamic instability required initiation of dopamine therapy. A CT scan of the abdomen and pelvis was performed to rule out a retroperitoneal bleed and was negative. The patient was then transferred to the CCU for further hemodynamic monitoring. PAST MEDICAL HISTORY: 1. Polycystic kidney disease status post living unrelated donor kidney transplant in 07/98. 2. Status post one year history of CAPD in [**2192**] and [**2193**]. 3. Coronary artery disease status post myocardial infarction in [**2199-2-19**]. 4. Recent quadriceps tear. 5. History of hyperparathyroidism. 6. Hypertension. 7. Hypercholesterolemia. 8. Gout. 9. History of gastrointestinal bleed status post nonsteroidal anti-inflammatory use [**2-/2190**]. 10. Sciatica. 11. Status post bilateral nephrectomies and ureteral stent placement [**5-/2194**]. 12. Status post hernia repair in [**2194**]. ALLERGIES: No known drug allergies. MEDICATIONS PRIOR TO ADMISSION: 1. CellCept [**Pager number **] mg p.o. b.i.d. 2. Neoral 125 mg p.o. b.i.d. 3. Prednisone 5 mg p.o. q.d. 4. Lipitor 40 mg p.o. q.d. 5. Aspirin 325 mg p.o. q.d. 6. Zoloft 100 mg p.o. q.d. 7. Allopurinol 100 mg p.o. q.d. 8. Metoprolol 12.5 mg p.o. b.i.d. FAMILY HISTORY: [**Name (NI) **] mother, grandfather, sister all with adult polycystic kidney disease. Patient's history of coronary artery disease. SOCIAL HISTORY: Patient is married, retired, and now employed as a race car driver. Ambulates on crutches status post torn quadriceps muscle. Denied alcohol, tobacco, or drug use. PHYSICAL EXAMINATION: Vital signs on admission: Temperature 96.9, heart rate 61, blood pressure 109/65 on 1.0 mcg dopamine, respiratory rate 14, O2 saturation 100% on 2 liters nasal cannula. General appearance: Well-developed, well-nourished white male, comfortable in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Oral mucosa moist. Oropharynx clear. Neck: Supple. No masses and no lymphadenopathy, no carotid bruits. Cardiovascular: Regular, rate, and rhythm, S1, S2 heart sounds auscultated. No murmurs, rubs, or gallops. Lungs are clear to auscultation anterolaterally. Abdomen: Soft, obese, nontender, nondistended. Positive bowel sounds. No hepatosplenomegaly. Groin: Left groin with catheter in place. Area clean, dry, and intact, no serosanguinous ooze or discharge. Extremities: No clubbing, cyanosis, or edema. Two plus dorsalis pedal and posterior tibial pulses. LABORATORIES ON ADMISSION: Laboratories taken as an outpatient showed WBC 7.8, hemoglobin 13.5, hematocrit 42.5, platelet count 208. Repeat hematocrit on [**7-11**] was 34.7. Serum chemistry on [**2199-7-11**] was a sodium of 137, potassium 5.0, chloride 110, bicarbonate 21, BUN 43, creatinine 1.4, glucose 95, calcium 9.9, phosphorus 2.8, magnesium 1.7. EKG showed normal sinus rhythm at 65 beats per minute. Left axis deviation, left anterior fascicular blocker, borderline P-R interval, poor R-wave progression. T-wave inversion noted in the mid aVL. Old compared with previous EKGs. No acute ST-T wave changes were noted. SUMMARY OF HOSPITAL COURSE: 1. Coronary artery disease: Patient has a history of coronary artery disease with two vessel disease on multiple cardiac catheterizations. He was status post complicated intervention procedure, with underdeployment of stent to his LAD and successful stent placement in the RCA. He is transferred to the Coronary Care Unit for further monitoring and evaluation. There, he was continued on aspirin, Plavix, Lipitor, oxygen, and Integrilin with the Integrilin continued 18 hours status post stent placement. Cardiac enzymes were cycled with negative creatinine kinase and troponin-T levels x3. Serial EKGs were followed without evidence of acute changes. As the patient had a vagal episode in the holding area status post RCA stent placement, he arrived to the CCU on dopamine. Therefore, his outpatient antihypertensives were held initially. Dopamine was slowly weaned off as tolerated by his blood pressure. After cessation of dopamine therapy, after his blood pressure stabilized, patient's outpatient antihypertensives were added back as tolerated by his blood pressure. 2. Anemia: Possibly secondary to blood loss: As patient's previous hematocrit value on [**2199-6-25**] was 42.5, and then was found to be 34.7 on [**2199-7-11**], anemia secondary to blood loss status post cardiac catheterization was of a concern. He underwent a CT scan of the abdomen and pelvis to rule out retroperitoneal bleed. This was negative. He was transfused 1 unit of packed red blood cells and tolerated this well. He was monitored with serial hematocrits and serial hemodynamic monitoring. At the time of discharge, his hematocrit was stable at 33.2. 3. Adult polycystic kidney disease: Patient's history of adult polycystic kidney disease status post kidney transplant. For renal protection, he finished a course of Mucomyst therapy that was initiated to cardiac catheterization. He had aggressive postcatheterization hydration with normal saline. His BUN and creatinine values were monitored serially and did not increase. He was continued on his immunosuppressive regimen of CellCept, Neoral, and prednisone. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Patient was discharged to home. DISCHARGE DIAGNOSES: 1. Status post cardiac catheterization with stent to the right coronary artery. 2. Quadriceps tear. 3. Anemia secondary to blood loss status post blood transfusion. 4. Polycystic kidney disease status post living unrelated donor transplant. 5. Coronary artery disease status post myocardial infarction. 6. Hyperparathyroidism. 7. Hypertension. 8. Hypercholesterolemia. 9. Gout. 10. History of gastrointestinal bleed. 11. Status post bilateral nephrectomies and ureteral stent placement [**5-/2194**]. 12. Sciatica. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Prednisone 5 mg p.o. q.d. 3. Allopurinol 100 mg p.o. q.d. 4. Lipitor 60 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. 6. Cyclosporin 125 mg p.o. b.i.d. 7. CellCept [**Pager number **] mg p.o. b.i.d. 8. Metoprolol 50 mg 0.25 tablet p.o. b.i.d. FOLLOW-UP PLANS: Patient was scheduled for a followup stress test on [**2199-7-26**] for evaluation of his LAD lesion. Additionally, he was to followup with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] in one month after discharge. He was instructed to call for an appointment. Finally, he was to undergo repair of his quadriceps tear in the week following discharge. He is instructed to contact the [**Name (NI) 13355**] Orthopedic practice for further instructions. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Last Name (NamePattern1) 94272**] MEDQUIST36 D: [**2199-8-6**] 15:08 T: [**2199-8-8**] 15:07 JOB#: [**Job Number 94273**] cc:[**Last Name (Prefixes) 94274**]

[ "401.9", "276.5", "458.2", "427.89", "412", "414.01", "V42.0", "285.9", "998.2" ]

icd9cm

[ [ [] ] ]

[ "36.07", "36.05", "88.56", "37.22", "99.20" ]

icd9pcs

[ [ [] ] ]

4347, 4482

8526, 9042

9065, 9333

6298, 8419

4076, 4330

4689, 4701

9351, 10116

161, 3385

5663, 6270

3407, 4044

4499, 4666

8444, 8505

28,318

197,314

13034

Discharge summary

report

Admission Date: [**2119-9-12**] Discharge Date: [**2119-10-3**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: [**First Name3 (LF) 24785**] Right hip with DHS Right PICC line placement & removal History of Present Illness: Ms. [**Known lastname 39903**] is a [**Age over 90 **] year old female who presented to the [**Hospital1 18**] after a mechanical fall at home. She was walking to the bathroom when she tripped over the rug. She now presents for further evaluation. Past Medical History: Blindness HTN Hypercholesterolemia Significant smoking history (~180PYs) Social History: Lives with son Family History: n/a Physical Exam: Upon admission Alert Russian speaking Cardiac: Regular rate rhythm Chest: Lungs clear bilaterally Abdomen: Soft non-tender non-distended Extremities: RLE + pulses, skin inctact, + pain with logroll Pertinent Results: Admission labs [**2119-9-12**] 9.1 10.8 >-------< 211 26.6 142 112 27 ---+----+----<129 4.2 22 1.3 . Urinalysis negative on admission . EKG 08/[**0-0-**]: Sinus rhythm and occasional atrial ectopy. Left anterior fascicular block. Right bundle-branch block. . Xray femur/pelvis, right [**2119-9-12**]: Minimally displaced intertrochanteric fracture of the proximal right femur. Prominent multilevel degenerative changes of the lower lumbar spine . [**2119-9-15**]: Video swallow evaluation: Recommended thin liquids and regular consistency solids. Assist with feedings as needed, pills to be given whole with thin liquids. . Echocardiogram [**2119-9-12**] Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mild to moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild valvular aortic stenosis. At least moderate pulmonary hypertension with normal right ventricular systolic function. Preserved regional/global biventricular systolic function. . . [**2119-9-26**] Chest xray: FINDINGS: Portable upright AP chest radiograph shows no significant radiographic change in bibasilar consolidation over the past five days. Right-sided PICC line tubing ends at the level of the mid superior vena cava. Cardiac and mediastinal contours including slightly hazy fullness in perihilar vasculature are unchanged. There is slight narrowing and leftward deviation of the trachea at the thoracic inlet, unchanged. Prominent S-shaped scoliosis is noted. Discharge labs [**2119-10-3**] 142 / 108 / 21 AGap=11 ----------------- 96 4.1 / 27 / 1.2 Source: Line-PICC WBC 13.8 HCT 25.3 PLT 452 Brief Hospital Course: Assessement/Plan: [**Age over 90 **] yo blind, Russsian speaking F with HTN and significant hx for smoking was admitted s/p mechanical fall, suffered a right hip fracture and underwent right hip [**Age over 90 24785**]. She tolerated the procedure well requiring 2U blood transfusion, however post op course was complicated by confusion, agitation as well as pneumonia/hypoxia requiring transfer to the ICU. In the setting of hypoxia/pneumonia she also went into atrial fibrillation, which has since resolved. Was oxygenated using NRB, did not require Bipap or intubation. After stabilization, she was transferred back to the floor, where she remained stable until discharge. . # R hip fracture s/p [**Age over 90 24785**]- R hip incision site was monitored for signs of infection; did not have drainage or erythema during duration of hospitalization. The staples were eventually removed and replaced with steristrips which are to be left in place until they fall off. Physical therapy was consulted to work with pt on her strength training, gait and mobility. We provided adequate pain control for the patient initially with oxycodone as needed, then standing tylenol as well as Lidocaine patches were added for the comfort of the patient. By the time of discharge she was no longer requiring prn oxycodone. She was continued on renally dosed Lovenox throughout hospitalization for prevention of DVT in setting of hip fracture. Lovenox will be stopped on [**2119-10-10**] to complete 4 week post fracture course. She was discharged to acute rehab for continued physical and occupational therapy prior to D/C home. She has follow up with Dr. [**Last Name (STitle) **] scheduled. . # MICU course: On [**2119-9-21**], POD #9 [**Name (NI) 24785**], pt was noted to be more somnolent with an O2 saturation of 82% on RA, she had increased O2 requirement up to NRB facemask. Her saturations then rose to 97%, however blood gas at 6L NC showed PaO2 of 53. Pt was transfered to the MICU for further monitoring. She did not require intubation, however she developed atrial fibrillation which was rate controlled with Diltiazem. Her therapy for pneumonia was also continued at this time. Once stable she was transferred to the [**Hospital1 **] for further monitoring. . # Aspiration pneumonia/hospital acquired: Sputum grew out gram negative rods postop and she was started on Levaquin for a 7day course. However, she decompensated with hypoxia requiring transfer to the unit before the therapy was completed. She was started on Vancomycin/Flagyl in addition to Levaquin. Vancomycin was discontinued after 4days of therapy, however the other antibiotics were to be continued to complete a 2wk course. Prior to discharge she was saturating well at 93-94% on room air. Given her extensive smoking hx nebulizers were administered and will be continued until post pneumonia wheezing resolves. She continued to improve as evidence by the decline of leukocytosis, as well as improvement in her oxygen saturation. . # Agitation/delirium: Progressively worsened after hip surgery in the setting of blindness as well as being Russian speaking only. Also, age and given that she was in a strange environment, agitation was to be expected. She was managed with Zyprexa initially then small doses of haldol IV, also required a family member to be at bedside to help orient pt. We also tried to limit lines and tubes by discontinuing her telemetry and foley when it was appropriate. At time of discharge, acute agitation resolved and she was more oriented and according to family close to her baseline. . # Anemia: Most likely related to surgery. Guaiac stool negative during admission. Required transfusions only in the immediate post operative phase. There was no evidence of active bleeding at any time. There was however, a large area of ecchymosis, ?resolving hematoma around area of surgery R hip; did not increase in size. Hematocrit remained stable through remainder of hospitalization. . # Atrial fibrillation: Developed after [**Hospital **] transfer to the MICU. Most likely in the setting of pneumonia/hypoxia and s/p surgery. EKG did not show evidence of ischemia. Diltiazem was initially started at 30 QID, then titrated up to 60mg QID. Changed to long acting diltiazem 240mg daily prior to discharge to simplify her medication regimen. She remained rate controlled on this regimen. Given age and fall risk, pt not considered a good candidate for anticoagulation therapy. . # Acute renal failure: Unsure of pt's baseline, however admitted with Cr 1.6. Worsened slightly in light of surgery, hypovolemia, and infection however continued to improve during admission. Cr. is now stable at 1.2 at discharge. . # Hypertension: Pt was initially on Lisinopril 40mg on admission, however, we continued Diltiazem, also for rate control. Patients primary care doctor may decide to restart lisinopril after discharge. . #Urinary Retention/Incontinence - developed prior to D/C of foley. Prior to admission she had no problems with incontinence. At time of discharge urinary retention resolved however continued to have episodes of incontinence. Retention ruled out by bladder scan and no evidence of UTI on urinalysis. Possible secondary to limited mobility. Would expect to improve as her functional status continues to improve. . #Access - PICC line was placed during admission as she had limited access. Will be removed prior to discharge. . # Communication: With son, [**Name (NI) **] [**Telephone/Fax (1) 39904**] (cell), [**Telephone/Fax (1) 39905**] (home), or his wife [**Name (NI) **] [**Telephone/Fax (1) 39906**]. Of note, the patient is BLIND and speaks RUSSIAN. . # Code status - Full code confirmed with patient and son . Pt has reached maximal hospital benefit and is ready for discharge to a rehabilitation facility. Medications on Admission: Lisinopril 40 daily Diltiazem 300 daily Aspirin 81 daily Temazepam 30 qhs Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours). Disp:*14 14* Refills:*0* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q 24 (). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 4. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). Disp:*240 Tablet(s)* Refills:*2* 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for Insomia. Disp:*30 Tablet(s)* Refills:*0* 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnoses: Right hip fracture Post operative anemia Atrial Fibrillation Pneumonia . Secondary Diagnoses: Chronic Renal Insufficiency Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted after your right hip fracture. You also developed pneumonia and a fast heart rate (atrial fibrillation) while in hospital. . We have made some changes to your medications. Diltiazem has been added to your medication regimen. In addition we stopped the lisinopril that you have been taking for your blood pressure. Your primary care doctor may want to restart this medicine after you leave the hospital. Please discuss these changes with your physician. [**Name10 (NameIs) **] all other medications as directed. . You are being discharged . If you notice any increased redness, drainage, swelling, or if you have a temperature greater than 101 please call the office or come to the emergency department. . Please follow up on all your appointments. If unable, please call and cancel or reschedule. Followup Instructions: 1. You have an appointment with Dr. [**Last Name (STitle) **] (orthopedic surgeon) on [**2119-10-19**]. Please arrive at 10:50 for xrays, you are scheduled to the the doctor at 11:10. If you need directions or to reschedule the phone number is [**Telephone/Fax (1) 1228**]. 2. You should follow up with your primary care doctor 2 weeks after discharge from rehab.

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icd9cm

[ [ [] ] ]

[ "99.04", "79.35", "38.93" ]

icd9pcs

[ [ [] ] ]

10224, 10294

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276, 362

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54394

Discharge summary

report

Admission Date: [**2197-8-29**] Discharge Date: [**2197-9-4**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: I am here for surgery Major Surgical or Invasive Procedure: Lumbar laminectomy and fusion s/p lumbar decompression and fusion right side L2345, left side L245 History of Present Illness: 84-year-old World War II veteran who presents with back pain. He has had a progressive decline in his ability to ambulate. He comes to the office in a wheelchair. He was walking in [**Month (only) 958**] and has progressively had the use a cane and a walker followed by the wheelchair. He has been involved in physical therapy but this has not helped to any appreciable way. As we delve further into his history, it seems that he has been using a shopping cart for sometime and he gives a history that is suggestive of, although not pathognomonic for claudication. He describes getting some benefit from using a shopping cart when ambulating. He rests for two or three minutes before being able to continue on. He certainly had a progressive decline in his endurance. He has no pain at rest. Past Medical History: Long standing CAD. s/p 2 vessel CABG [**2177**] (left internal mammary artery to the left anterior descending and saphenous vein to the obtuse marginal); s/p catheterization in [**2177**], which revealed EF of 74%, normal wall motion, 100% proximal right coronary artery lesion, normal left main, 100% mid left anterior descending lesion, 90% proximal left circumflex, and a dominant left system. Cath in [**2193**] showed patent grafts. ECG 11/[**2194**]. Normal exercise test [**9-/2195**], normal persantine stress test [**12-6**]. Several episodes of unstable angina. Long standing hypertension (diagnosed in [**2150**]) Type 2 diabetes mellitus (diet controlled) Hypercholesterolemia Sigmoid diverticulitis Hemorrhoids (negative colonoscopy [**2194**]) Previous hiatal hernia. Peptic ulcer disease Transient vertigo Glaucoma, s/p cataract resection [**2185**], s/p left iridectomy [**2182**], dx [**2181**] Social History: Patient lives at home with wife; good support. Now retired, former firefighter. Veteran (from World War II) Occassional EtOH, drinks socially Former tobacco. Quit 50 years ago. Has also smoked cigars Denies drug use. Family History: Father died of myocardial infarction at age 45. Had an aunt with type 2 diabetes mellitus Physical Exam: pre-operatively [**2197-6-22**] On examination, his motor strength was normal in the hip flexion, extension, quadriceps, hamstrings, and plantarflexion bilaterally. Dorsiflexion was graded at 4/5 and the extensor hallucis longus was 2-3/5 bilaterally. His sensory examination showed a decreased appreciation to light touch in the right foot, both medially and laterally. His reflexes were hypoactive but symmetric in the patellar and Achilles bilaterally. No pulses were appreciable in his feet on either side. The straight leg raise was negative bilaterally as was the [**Doctor Last Name **] maneuver. His back was flat and nontender. today - day of discharge VSS afebriel (* temp, 136/70, 74,18 - 97% RA awake alert oriented with fluent speech. Neuro - motor full except bilteral DF 3+/5,and [**Last Name (un) 938**] [**2-5**], sensation grossly intact. Iincision _ clean dry and intact with staples in place - no drainage Pertinent Results: [**2197-8-29**] 03:22PM freeCa-1.21 [**2197-8-29**] 03:22PM HGB-11.3* calcHCT-34 O2 SAT-99 [**2197-8-29**] 03:22PM GLUCOSE-98 LACTATE-1.9 NA+-140 K+-5.5* CL--108 [**2197-8-29**] 03:22PM TYPE-ART RATES-/8 TIDAL VOL-575 O2-100 PO2-305* PCO2-54* PH-7.31* TOTAL CO2-28 BASE XS-0 AADO2-370 REQ O2-64 INTUBATED-INTUBATED VENT-CONTROLLED [**2197-8-29**] 05:21PM HGB-10.3* calcHCT-31 [**2197-8-29**] 05:21PM LACTATE-1.2 [**2197-8-29**] 05:21PM TYPE-ART PO2-224* PCO2-52* PH-7.30* TOTAL CO2-27 BASE XS--1 [**2197-8-29**] 06:45PM freeCa-1.00* [**2197-8-29**] 06:45PM HGB-10.2* calcHCT-31 [**2197-8-29**] 06:45PM GLUCOSE-134* LACTATE-1.7 NA+-140 K+-4.0 CL--115* [**2197-8-29**] 06:45PM TYPE-ART PO2-232* PCO2-47* PH-7.30* TOTAL CO2-24 BASE XS--3 [**2197-8-29**] 07:11PM URINE RBC-21-50* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2197-8-29**] 07:11PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2197-8-29**] 07:11PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2197-8-29**] 09:11PM freeCa-1.14 [**2197-8-29**] 09:11PM HGB-8.9* calcHCT-27 [**2197-8-29**] 09:11PM GLUCOSE-154* LACTATE-1.9 NA+-140 K+-4.1 CL--112 AP and lateral views of the lumbar spine are obtained following fusion of L2 through L5. Apart from the recent posterior fusion the appearance of the spine, alignment, and disk spaces does not appear to have markedly changed since the prior study of [**2197-6-22**]. There is mild retrolisthesis of L2 on L3 and minimal anterolisthesis of L5 on S1. Marked degenerative changes are seen with narrowing of the L2-L3 disk space and adjacent subchondral sclerosis. [**8-30**] Sinus rhythm with PVCs with PACs. Poor R wave progression - probable normal variant Since previous tracing, no significant change Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J. Intervals Axes Rate PR QRS QT/QTc P QRS T 94 164 82 [**Telephone/Fax (2) 111348**] -13 31 Brief Hospital Course: This 84 y/o white male was admitted through same day surgery for the noted procedure: lumbar decompression and fusion. His srugery date was postponed once as an o/p for medical optimizing. ( he was anemic and had a rise in his creat to 1.8 ) His arthrotec, furosemide and spironolactone were discontinued pre-operatively and he was re-assessed. He was deemed medically stable for surgery after re-eval on [**2197-8-2**]. [**2197-8-29**] He underwent anesthesia and the procedure was performed. During the surgery he had blood loss that required transfusion. During one of the transfusions he had a reaction resulting severe hyptotension. This reaction was controlled by anesthesia team. His surgery went longer than expected and given that the pt was prone for approx 8 hours it was decided that he should remain intubated overnight. Upon transfer to the SICU from the OR the pt had some difficulty maintaining his blood pressure - he was treated by anesthesia with meds and fluid boluses. He was also showing some ST segment depression on the bedside monitor and a formal serial ekg's were obtained. His ST segment depression improved and CE X 3 were obtained all of which were negative. The pt had a drain in place (lumbar ) that was removed on [**Doctor Last Name **] day #3. He had a total of 1500ml of blood loss intraoperatively with 5 units transfused inrtaop and post op that same day into the following day. His HCT has stabilized since then. He was MAE and following commands during the post-op check and he was extubated later that day. He was later transferred to the floor and PT/OT evals were obtained. AP and lateral lumbar films were obtained while in his TLSO brace. PT and OT determined the pt would be best served being discharged to Rehab. Pt was made aware of the plan and agrees with it. Pt to be discharged to rehab today. Medications on Admission: ANUSOL-HC 2.5 %--apply rectally [**Hospital1 **], as needed for prn ASPIRIN 325 MG--One every day CLARITIN 10MG--One every day FLOMAX 0.4MG--One every day IMDUR 60MG--One by mouth every day LIPITOR 20MG--One tablet every day LISINOPRIL 20MG--One by mouth twice a day LOTRISONE 1-0.05 %--apply three times a day METOPROLOL 50 MG--Take one pill by mouth twice a day MYCOSTATIN 100MU/G--Use as directed twice a day to affected areas NEURONTIN 100MG--One tablet by mouth at bedtime and increase to 2 tablets if tolerated in [**12-5**] wks PRAMOSONE 2.5%-1%--Twice a day to itchy area on scrotum for 7-10 days, then 2 times per week as needed PROCARDIA XL 60MG--One by mouth every day PROTONIX 40MG--Every day - twice a day as needed to control symptoms TIMOLOL 0.5 %--One drop each eye every day VYTONE 1%-1%--Twice a day to the scrotum or groin for 14 days, then 2-3 times per week as needed WRIST BRACE SPLINT --Apply at bedtime XALATAN 0.005%--One drop in each eye at bedtime Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO every eight (8) hours. 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for consitpation. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: s/p lumbar decompression and fusion Discharge Condition: good/ neurologically stable Discharge Instructions: Please call the office if the patient experiences any new numbness tingling or weakness, if he has any pain that is worseing or not relieved by pain medicine. Call if there is any drainage from the incision, redness, foul odor or if he has fever 101.5 or greater. Followup Instructions: Please call the office to make an appointment to have your staples removed. They should be removed on [**9-8**]. You will also need to make an appointment to see Dr. [**Last Name (STitle) 548**] in 6 weeks. Tell the secretary that you will need AP/Lateral lumbar Xrays at that time. Completed by:[**2197-9-4**]

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icd9cm

[ [ [] ] ]

[ "81.08", "81.63", "77.79" ]

icd9pcs

[ [ [] ] ]

9642, 9727

5477, 7340

287, 388

9807, 9837

3466, 5454

10150, 10465

2408, 2499

8366, 9619

9748, 9786

7366, 8343

9861, 10127

2514, 3447

226, 249

416, 1215

1237, 2154

2170, 2392

77,135

173,844

38603

Discharge summary

report

Admission Date: [**2165-2-8**] Discharge Date: [**2165-2-18**] Date of Birth: [**2089-4-28**] Sex: M Service: CARDIOTHORACIC Allergies: Statins-Hmg-Coa Reductase Inhibitors / Morphine / Citalopram / Thiazides Attending:[**First Name3 (LF) 1406**] Chief Complaint: Cough, dyspnea on exertion Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram, left ventriculogram [**2165-2-11**] coronary artery bypass grafts x4(LIMA-LAD, SVG-dg, SVG-OM,SVG-PDA) [**2165-2-12**] History of Present Illness: This is a 75 year old man with chronic obstructive pulmonary disease, hypertension and Hepatitis C who presented to the [**Hospital 882**] Hospital with 4-5 days of increasing cough and shortness of breath. He has not seen a doctor for a year [**First Name8 (NamePattern2) **] [**Hospital1 882**] report. He reported that dysnea is typical for him but that it had been worse in the last 4-5 days and that his sputum is typical but had been darker and yellow-green in the last 4-5 days. He reported that his baseline is to be able to walk 1 block before getting short of breath.. A CXR showed no clear signs of pneumonia. EKG showed sinus rhythm at 95,,no ST-T changes. In the [**Hospital1 882**] ED he was given 2L NS, 500 mg IV levofloxacin; albuterol; duonebs and 125 mg solumedrol. He was admitted to the medicine floor for further management. On the [**Hospital1 882**] medicine floor he had [**8-30**] SSCP on 2 AM of [**2-8**] which was relieved with nitro x3 and Maalox. He again had [**8-30**] SSCP which nitrox3 and Maalox only brought down to 3/10. On both of these occasions, EKG showed [**Street Address(2) 4793**] depressions in V4-6. He got Heparin 4000 units followed by drip of 1100 units/hr; Plavix 300 mg; and Metoprolol 12.5 mg. A statin allergy was listed in his chart so a statin was not given. (Pt denied allergies but was judged to be possibly an unreliable historian.) He had already received his home Aggrenox at 10 am; Enalapril 10 mg at 10:30 am; and Verapamil 40 mg at 2 pm. Transfer to [**Hospital1 18**] for cath was arranged. Cardiac surgery evaluated for coronary artery revascularization. Past Medical History: paroxysmal atrial fibrillation hypertension chronic obstructive pulmonary disease Hepatitis C gastroesophageal reflux anxiety/depression s/p herniorraphy s/p shoulder surgery Social History: edentulous 120pack year smoker, stopped 7 years ago heavy ETOH until 7 years ago lives in [**Hospital3 **] facility Family History: father died of MI in his 60s Physical Exam: admission: Pulse:64 Resp:20 O2 sat: 94%RA B/P Right:162/76 Left:170/91 Height:5'9" Weight:72.6kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur ii?vi sem Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: +1 Left: +1 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +1 Left: +1 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [**2165-2-17**] 03:32AM BLOOD WBC-8.1 RBC-3.07* Hgb-9.3* Hct-27.0* MCV-88 MCH-30.3 MCHC-34.6 RDW-15.0 Plt Ct-149* [**2165-2-9**] 07:25AM BLOOD WBC-13.4* RBC-4.06* Hgb-12.6* Hct-37.6* MCV-93 MCH-30.9 MCHC-33.4 RDW-13.8 Plt Ct-184 [**2165-2-12**] 12:41PM BLOOD PT-14.4* PTT-36.9* INR(PT)-1.2* [**2165-2-9**] 12:25AM BLOOD PT-13.9* PTT-67.2* INR(PT)-1.2* [**2165-2-17**] 03:32AM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-136 K-3.4 Cl-98 HCO3-34* AnGap-7* [**2165-2-9**] 07:25AM BLOOD Glucose-100 UreaN-18 Creat-0.8 Na-144 K-4.2 Cl-107 HCO3-30 AnGap-11 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 85808**] (Complete) Done [**2165-2-12**] at 10:31:10 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Cardiac S [**Last Name (NamePattern1) 439**], 2A [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2089-4-28**] Age (years): 75 M Hgt (in): 69 BP (mm Hg): / Wgt (lb): 160 HR (bpm): BSA (m2): 1.88 m2 Indication: Intraop CABG ?AVR. Evaluate valves, wall motion, aortic contours ICD-9 Codes: 424.0, 424.1 Test Information Date/Time: [**2165-2-12**] at 10:31 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW1-: Machine: AW 2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.3 m/s Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.4 cm Left Ventricle - Fractional Shortening: *0.17 >= 0.29 Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Left Ventricle - Stroke Volume: 76 ml/beat Aorta - Annulus: 2.7 cm <= 3.0 cm Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm Aorta - Ascending: *4.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 17 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 12 mm Hg Aortic Valve - LVOT pk vel: 0.80 m/sec Aortic Valve - LVOT VTI: 22 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *1.7 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 0.9 m/sec Mitral Valve - Mean Gradient: 1 mm Hg Mitral Valve - Pressure Half Time: 90 ms Mitral Valve - MVA (P [**12-22**] T): 2.4 cm2 Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Findings LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal LV cavity size. Mild regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Moderately dilated ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area 1.2-1.9cm2). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. The MR vena contracta is <0.3cm. Eccentric MR jet. Mild (1+) MR. [**Name13 (STitle) 15110**] 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 well seen. No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Pre Bypass: Left ventricular wall thicknesses and cavity size are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild to moderate anterior hypokinesis. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Mild (1+) 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. Post Bypass: Preserved biventricular function with some interval improvement in anterior wall motion. LVEF 50%. MR remains mild. Aortic valve gradients unchanged. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2165-2-13**] 14:53 ?????? [**2157**] CareGroup IS. All rights reserved. Brief Hospital Course: On [**2165-2-12**] Mr.[**Known lastname **] was taken to the operating room and under went quadruple vessel bypass (Left internal Mammary artery grafted to the Left Anterior Descending artery, Saphenous Vein Grafted to diag, SVG to Obtuse Marginal ,Saphenous Vein Grafted to Ppsterior Descending Artery).See operative note for details. He weaned from bypass on Neo Synephrine and Propofol. He awoke neurologically intact and was extubated on the first morning after surgery without difficulty. Pressors weaned easily. Beta-Blockers/Statin/Aspirin/diuresis was initiated. All lines and drains were discontinued in a timely fashion. He had atrial fibrillation post operatively which responded to Amiodarone and converted to sinus rhythm. Mr.[**Known lastname **] remained in the CVICU due to his tenuous pulmonary status. He remained hemodynamically stable and required aggressive diuresis and bronchdilators for dyspnea. Nutrition was consulted to evaluate his swallowing function and nutritional intake. Social work continued to follow postoperatively as well. He continued to progress and on POD#5 he was transferred to the step down unit for further monitoring. Physical therapy was consulted to evaluate strength and mobility. His respiratory status continued to improve and he was saturating 93% on room air at the time of discharge. A swallow evaluation was performed [**2165-2-18**] due to history of dysphagia and observed regurgiation of thin liquids. It was recommened he continue a regular diet with thin liquids with a video swallow follow up as an outpatient. The patient was informed of this recommendation and instructed to follow up with GI as an outpatient #[**Telephone/Fax (1) 3731**]. The remainder of his postoperative course was essentially uneventful. He continued to progress and on POD#he was cleared by Dr.[**Last Name (STitle) **] for discharge to rehab. All follow up appointments were advised. STOPPED [**2-17**] Medications on Admission: Enalapril 10mg po daily Omeprazole 20mg po daily Fluoxetine 20mg po TID Vesicare 5mg po daily Verapamil 120mg po daily Terazosin 2mg po BID Reglan 5mg po BID Aggrenox 1 tab po BID Trazadone 150mg po qHS Plavix - last dose:300mg [**2-8**] and 75 daily Discharge Medications: 1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:*60 Capsule(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*2* 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 * Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Tablet(s) 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 15. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 17. Vesicare 5 mg Tablet Sig: One (1) Tablet PO daily (). 18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. 22. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts paroxysmal atrial fibrillation hypertension chronic obstructive pulmonary disease Hepatitis C anxiety/ depression gastroesophageal reflux disease s/p repair right shoulder separation s/p hernia repair Discharge Condition: Alert and oriented x 3, nonfocal ambulating with steady gait sternal pain managed with Percocet 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 [**Telephone/Fax (1) 170**] Followup Instructions: Recommended Follow-up:Please call to schedule appointments Surgeon Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2165-3-27**] at 1PM Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**] on [**2165-4-4**] at 2:15 PM Cardiologist Dr [**Last Name (STitle) **] in [**12-22**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2165-2-18**]

[ "070.70", "491.21", "300.4", "600.00", "414.01", "410.71", "746.4", "427.31", "285.9", "486", "530.81", "401.9", "287.5" ]

icd9cm

[ [ [] ] ]

[ "36.13", "38.93", "36.15", "39.63", "99.04", "37.22", "39.61", "88.56" ]

icd9pcs

[ [ [] ] ]

13525, 13595

8976, 10922

365, 534

13898, 13995

3249, 7378

14536, 15037

2538, 2568

11224, 13502

13616, 13877

10948, 11201

14019, 14513

7422, 8953

2583, 3230

299, 327

562, 2190

2212, 2389

2405, 2522

26,212

199,124

22767

Discharge summary

report

Admission Date: [**2187-3-14**] Discharge Date: [**2187-3-19**] Date of Birth: [**2133-11-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 52 M, Cantonese-speaking only, with IgA nephropathy, nephrotic syndrome with anasarca, DM2, HTN, recently hospitalized in [**2187-2-23**] at [**Hospital1 18**] for anasarca from stopping his lasix 5 weeks ago (per [**Hospital 2793**] clinic), presents today with intractable nausea and vomiting x 3 days. He has been vomiting > 10x/day, no blood, no mucus. . Three days ago, he started feeling "ill", +chills, +rhinorrhea, +poor vision x 6 months. He denies HA, dizziness, acute vision or hearing changes, cough, sore throat, CP, SOB, abd pain, dysuria, hematuria, anuria, diarrhea, no pale or black stools, no melena. . Pt had a zoster rash on his back during last admission, and this is resolving now. In the [**Name (NI) **], pt's BP was 220-260/120-160. He received Reglan IV, Anzemet IV, Metoprolol 5 IV, Metoprolol 100 PO, Diltiazem 240 PO, Lisinopril 10 PO. Five min after taking these meds, pt vomited, and pills were witnessed as coming back up in the vomitus. Pt was given Labetalol 20 IV, and BP came down to 190/100, HR 92. Pt was started on Labetalol gtt. He did not receive any Lasix in the ED, but his usual dose is Lasix 20 PO QD. . Past Medical History: 1. DM recently dx'd [**2-8**] with hospital stay [**Date range (1) 58897**]/05 at [**Hospital1 18**] for hyperglycemia, scrotal and pedal edema (dx'd bilat epididymitis) 2. HTN recently dx'd [**2-8**] 3. Diabetic and IgA nephropathy - nephrotic range proteinuria with edema, renal bx [**4-8**] c/w severe DM/IgA nephropathy 4. Anemia of chronic dz 5. Recent EGD [**6-8**] with mild gastropathy, C-scope [**6-8**] nl Social History: Lives with wife and children, currently does not work, denies any tobacco, etoh or illicit drug use, immigrated to US 10 yrs ago Family History: No known family history of CAD, DM, CVA or CA Physical Exam: Vitals: T 98.4 BP 121/65 HR 71 R 12 Sat 99% RA * PE: G: NAD, WN, WD, hiccuping HEENT: Clear OP, MMM Neck: Supple, No JVD Lungs: BS BL, bibasilar crackles with no W/R Cardiac: Distant S1S2. No murmurs Abd: Soft, NT, ND. NL BS. Ext: 2+ pitting edema. 2+ DP pulses BL. Pertinent Results: [**2187-3-14**] Supine abd X-ray: Limited study especially for the evaluation of free air which does not include domes of the diaphragm. Unremarkable bowel gas pattern without evidence of obstruction. . [**2187-3-15**] ECG: Normal sinus rhythm. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2187-2-23**] no diagnostic interval change. . [**2187-3-14**] 10:00AM WBC-8.0 RBC-4.72 HGB-14.4 HCT-38.4* MCV-81* MCH-30.4 MCHC-37.4* RDW-15.6* [**2187-3-14**] 10:00AM NEUTS-81.2* LYMPHS-14.4* MONOS-4.1 EOS-0.1 BASOS-0.2 [**2187-3-14**] 10:00AM PLT COUNT-400 [**2187-3-14**] 10:00AM PT-10.4 PTT-20.1* INR(PT)-0.9 [**2187-3-14**] 10:00AM GLUCOSE-145* UREA N-36* CREAT-2.1* SODIUM-134 POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16 [**2187-3-14**] 10:00AM ACETONE-TRACE [**2187-3-14**] 03:00PM URINE RBC-[**7-14**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2187-3-14**] 03:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2187-3-14**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 Brief Hospital Course: 52 y/o with IgA nephropathy, DM2, HTN, admitted with malignant hypertension [**3-8**] unable to take po meds due to intractable N/V. . # Nausea/Vomiting: Most likely due to viral gastroenteritis. KUB showed no obstruction. The patient n/v improved with anzemet and compazine and eventually resolved. . # Malignant HTN: BP was 260/160 in the ED and labetalol gtt was started. The patient was transferred to the MICU and further received labetalol and Nitro gtt. As n/v resolved and the patient tolerated po, the patient weaned off of labetalol and Nitro gtt, and the outpatient medications (BB, [**Location (un) **], ACEIS, diliazem, and lasix) were gradually re-introduced. At the time of discharge, blood pressure is still elevated with SBP of 120s-150s but stable. . # DM2: Due to n/v and poor po intake, outpatient NPH was initially reduced by [**3-9**]. Despite the reduction of qhs NPH to [**2-5**] of outpatient dose and resolution of n/v, on the morning of [**3-18**], the patient was found unresponsive with FS of 32. With 2 amps of D50, the patient regained consciousness and remained neurologically non-focal. No signs of seizures noted. qhs NPH was further decreased by [**2-5**] to 4 units. Reglan was continued for gastroparesis. As the patient returns back to his usual diet, NPH will need to be increased. Pt is sent home with a VNA service for FS and BP checks and follow-up with PCP and titrate up NPH and BP meds as needed. . # IgA/DM nephropathy: Pitting edema/anasarca improved very much since the last discharge from the hospital. The patient was continued on outpatient ACEIS, [**Last Name (un) **], and lasix. . # Anemia: due to renal insufficiency, was stable and received Epo while hospitalized. . # FEN: 1g Na diet, [**Doctor First Name **] diet. Repleted 'lytes/prn. Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID with meals. 4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Losartan 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Five (25) units Subcutaneous qam. 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous at bedtime. 12. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Four (4) Tablet Sustained Release PO once a day. 13. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QPM (once a day (in the evening)). 8. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day. 9. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous qam. 12. Aranesp 60 mcg/mL Solution Sig: One (1) Injection see instruction: given at hem/onc clinic. . 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4) Subcutaneous at bedtime. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnoses: Malignant hypertension-resolved Nausea/vomiting- resolved Gastroparesis Secondary diagnoses: IgA/diabetic nephropathy Diabetes mellitus Chronic renal insufficiency Discharge Condition: Stable blood pressure, tolerating po well. Discharge Instructions: --Please decrease you salt intake at home. No added soy sauce. --Please take all medications as prescribed. --Please return to the hospital for any increasing abdominal pain, nausea/vomiting, headache, vision changes, fevers, chills, or increased swelling of your legs/abdomen. -- We decreased your NPH because of your poor po intake. Please check your fingerstick sugars four times a day (before breakfast, before lunch, before dinner and at bedtime), and record and take the log to your primary care physician and have him adjust your insulin as needed. -- Please keep your appointments with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], and [**Last Name (un) **]. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] on Thursday [**2187-3-22**] at 2:00 PM Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-3-26**] 11:00 Provider: [**Name10 (NameIs) 17515**] CHAIR 2C Date/Time:[**2187-3-26**] 11:00 Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], (your kidney doctor) M.D. Date/Time:[**2187-3-27**] 3:30. Phone:([**Telephone/Fax (1) 773**]

[ "250.42", "536.3", "250.62", "583.81", "008.8", "401.0", "285.21", "583.9", "585.9", "250.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7781, 7839

3609, 5412

331, 338

8067, 8112

2471, 3586

8844, 9364

2122, 2169

6613, 7758

7860, 7952

5438, 6590

8136, 8821

2184, 2452

7973, 8046

276, 293

366, 1517

1539, 1958

1974, 2106

1,982

141,198

20285

Discharge summary

report

Admission Date: [**2166-7-29**] Discharge Date: [**2166-8-15**] Date of Birth: [**2106-6-11**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing / Betadine / Shellfish Attending:[**First Name3 (LF) 297**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: central line ultrasound-guided biopsy of left lower quadrant abdominal/pelvic mass History of Present Illness: 60yo M with PMH of esophageal ca, melanoma, HTN, cirrhosis, and gout, brought from nursing home with altered mental status x 3d. Pt was noted to be confused and agitated, pulling out lines and talking to himself. He stated he was having hallucinations. He was alert and oriented to person and place only. He was also noted to have a rash on his neck and R arm. He was started on Dilaudid 3d PTA. Per nursing home, pt had no nausea, vomiting, fever, chills, or cough. Serum calcium was noted to be 15.1 on [**7-28**] and patient was brought to [**Hospital1 18**] ED. He was afebrile and hemodynamically stable at the nursing home. In the ED, he was noted to be awake but confused and disoriented. He received 1L NS, and K repletion. He also had labs, UA, EKG, CXR, and head CT w/o contrast. Unable to obtain history from patient due to mental status. Head CT showed a 17 mm low density area in the right lentiform nucleus, c/w prior hemorrhage vs old CVA. Following admission, he received NS @ 200 cc/hr, calcitonin and pamidronate. Given leukocytosis (wbc 15), there was concern that infection could be contributing to his delirium. CXR (-), U/A w/ hematuria (Foley) but no evidence of infection. Given h/o EtOH abuse, he had an abd U/S to evaluate for ascites. No ascites was visualized, however a 10 cm LLQ fluid collection was noted. Subsequent Abd CT showed that this mass was erroding into bone; also noted was a LLE DVT. Past Medical History: #. Amelonotic melanoma of the left shoulder s/p excision [**2-14**]. The sentinal lymph node was negative for metastatic disease. #. SCC of the left ankle s/p excision. Was metastatic for which the pt received radiation. #. Esophageal cancer s/p resection [**12/2165**] at [**Hospital3 **]. His oncologist is Dr. [**Last Name (STitle) **] at [**Hospital1 2177**]. #. HTN #. Gout #. Chronic Renal Insufficiency, and h/o Acute Tubular Necrosis. Baseline Cr 1.1-1.3. #. H/O multiple nonmelanoma skin cancers #. Multiple Gastric Ulcers daignosed during admission [**2-15**] for BRBPR treated with proton pump inhibitor. # Relative Adrenal Insufficiency during recent [**2-15**] admission to MICU for GIB diagnosed by inappropriate reponse to cosyntropin. Treated with Hydrocort and Fludricort x 7 days. # Alcoholic Cirrhosis # History of EtOH Dependence # Chronic LE Pain. Seen by Pain center [**2166-7-21**] felt to be neuropathic in origin. They recommended increasing Neurontin. Social History: from [**Location (un) **] NH since [**3-15**], h/o heavy EtOH use before in NH Family History: noncontributory Physical Exam: PE: AF 84 142/85 16 99%2LNC elderly man, alert, oriented only with repeated prompting NCAT, sclerae anicteric, PERRL no JVD or LAD CTAB RRR, nl S1/S2, no murmur/gallop soft, does not respond to palpation, ND, +BS 1+ LLE edema from groin to ankle, not erythematous or tender, no RLE edema, 2+DP pulses b/l Pertinent Results: 15.1>35.4<418 N:86.8 L:7.9 M:3.5 E:1.4 B:0.3 [**Age over 90 **]|92|29/117 3.2|31|1.1\ Ca:14.6 Mg:1.5 P:2.0 Alb:3.6 PT:13.6 PTT:29.1 INR:1.2 Brief Hospital Course: 60 year-old male with history of metastatic esophageal cancer, melanoma, and squamous cell skin cancer who was admitted for shock and mental status changes. He was initially admitted to the medicine floor, but was transferred to the MICU for declining respiratory status. 1) Respiratory failure: On arrival to the MICU, he was intubated for airway protection given his tenuous respiratory status. His respiratory status improved and he was weaned from the ventilator. He was extubated on hospital day 15. 2) DIC: He had profuse bleeding after subclavian line was placed. Laboratory results were consistent with DIC. The DIC resolved rapidly with aggressive treatment of sepsis with volume resuscitation and replacement of blood products. In total he received 4 units PRBCs, 6 units FFP, and 1 unit cryoprecipitate. . 3) Altered Mental Status: The etiology of his mental status change is unclear. The differential included hypercalcemia, other metabolic abnormality (TSH was normal), drug reaction (Dilaudid, MS Contin), brain metastasis (none visualized on head CT), infection. There was no evidence of urinary infection or pneumonia. There was no ascites so SBP was unlikely. Lumbar puncture was attempted twice without success, therefore meningitis could not be ruled out. Another source of infection could be infection in his pelvic mass. He received pamidronate and aggressive IVF to normalization of Calcium. His mental status improved throughout the admission and was alert and conversant upon extubation. . 4) Septic shock: He initially required Levophed to maintain his blood pressure and it was weaned off by hospital day 4. He also received aggressive fluid resuscitation Given that meningitis could not be ruled out, he was treated empirically with vancomycin/ceftriaxone/Flagyl for a 14 day course. His vancomycin was dosed by levels since he cleared the medication very slowly. The pelvic fluid collection was drained and was sterile, so this was not likely the cause of his sepsis. . 5) Hypercalcemia: Most likely secondary to malignancy, either due to large mass eroding into left pelvic bone or due to PTH-RP secretion from SCC. He received pamidronate and aggressive IVF to normalization of calcium. 6) LLE DVT: He was maintained on a heparin drip for his DVT once his DIC had resolved. . 7) Left pelvic mass: The mass is most likely metastatic SCC given this was the location of prior positive left inguinal node biopsy. The mass was drained under ultrasound and cytology was consistent with squamous cell cancer. Surgery was consulted and they felt that surgery was not feasible. Oncology was consulted and he was not a candidate for chemotherapy or palliative radiation during this admission. 8) Adrenal insufficiency: He was diagnosed with relative adrenal insufficiency in ICU [**2-15**] and was scheduled to only receive 7 days of stress dose steroids. It is unclear why hydrocortisone was restarted, but, he was on these steroids for several months. Given the concern for infection he was given stress dose steroids. . 9) Anemia: His hematocrit was low. During the periods of DIC, he required pRBC transfusion due to excess bleeding. Otherwise, his hematocrit remained stable throughout the admission. . 10) Seizure activity: During his admission, he had arm movements and eye deviations that were concerning for a seizure. An EEG showed slow wave focus suggesting fixed subcortical abnormality in left hemicortex, possible subclinical seizure activity, and he was loaded with phenytoin. He was maintained on dilantin throughout the rest of his hospital course without further seizure activity. . 10) ?Ileus: Towards the end of his hospital stay, he was not tolerating tube feeds and was not having bowel movements. Abdominal films were negative for obstruction. His lack of bowel movements was attributed to lack of oral intake. . 11) Aspiration: In the final days of this hospitalization, he began to aspirate copious amounts of bilious fluid. Three times, he aspirated large amounts of bilious fluid that resulted in [**10-30**] second periods of asystole. Aggressive suctioning reversed the asystole. A nasogastric tube was placed to suction to prevent aspiration. Later, he removed the nasogastric tube. Within hours, he had vomited/aspiration large amount of bilious fluid and expired shortly thereafter. . 12) Pain: During the admission, he was maintained on a fentanyl drip and morphine for breakthrough pain. His pain medications were titrated up throughout his hospital stay. . 13) TB Exposure: He had been exposed to [**Hospital1 2177**] intern. CXR showed no acute pulmonary and a PPD was negative. . 14) Chronic Renal Failure: He developed acute on chronic renal failure likely secondary to sepsis. His creatinine improved upon resolution of the sepsis. . 15) FEN: He was initially maintained on tube feeds. On hospital day 13, he was not tolerating po intake. He switched to TPN. 16) Prophylaxis. He was maintained on heparin, pneumoboots, and a PPI throughout the admission. . 17) Code: He is estranged from family, his daughter was recently in contact over the past few mouths, but she did not know his wishes clearly. His ex-wife also in communication. Once he was extubated, he was able to make his wishes know and he was made DNR/DNR. Later, upon discussion with his PCP, [**Name10 (NameIs) **] was made CMO. Medications on Admission: 1) HCTZ 50 mg PO daily 2) Atenolol 25 mg PO daily 3) Folic acid 1 mg PO daily 4) Hydrocortisone 20 mg PO qAM, 10 mg PO qPM 5) MV1 6) Quinapril 20 mg PO daily 7) Ultram prn 8) Protonix 40 mg PO BID 9) MSContin 60 mg PO q8h 10) Cymbalta 60 mg PO daily 11) MSIR 15 mg PO q4h prn Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: 1. Metastatic sqaumous cell cancer 2. Sepsis 3. Disseminated Intravascular Coagulation 4. Hypercalcemia 5. Acute on chronic renal failure 6. Seizure activity Discharge Condition: Expired. Discharge Instructions: None. Followup Instructions: None. Completed by:[**2166-8-16**]

[ "453.41", "410.71", "196.5", "V10.82", "560.1", "507.0", "286.6", "V10.03", "518.84", "275.42", "V10.83", "584.5", "198.5", "198.89", "403.91", "038.9", "780.39", "427.5", "785.52" ]

icd9cm

[ [ [] ] ]

[ "54.24", "96.6", "96.72", "99.07", "00.17", "96.04", "38.93", "99.04", "99.06", "03.31" ]

icd9pcs

[ [ [] ] ]

9288, 9297

3537, 4371

330, 414

9499, 9509

3367, 3514

9563, 9599

3002, 3019

9258, 9265

9318, 9478

8957, 9235

9533, 9540

3034, 3348

269, 292

442, 1887

4386, 8931

1909, 2890

2906, 2986

15,793

126,377

45294

Discharge summary

report

Admission Date: [**2164-4-14**] Discharge Date: [**2164-4-26**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female referred from [**Hospital **] Hospital Rehabilitation with a report of mental status changes today. Her son, physician, [**Name10 (NameIs) **] called the patient by phone this morning and first noted the mental status changes. He called the PCP and had the patient sent to the Emergency Room. The patient was recently at [**Hospital1 69**] inpatient admitted on [**2164-3-29**] with a small right sided subdural hematoma that was not drained. She underwent correction of her INR with fresh-frozen plasma. Patient developed pulmonary edema. She was diuresed with good result. She was discharged to [**Hospital **] Hospital on [**2164-4-2**]. The patient had been on Coumadin prior to admission secondary to atrial fibrillation. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Bilateral lower extremity edema. MEDICATIONS WHILE IN [**Location **]: 1. Cardizem CD 120 mg q day. 2. Iron 325 mg q day. 3. Lasix 40 mg q day. 4. Multivitamin one po q day. 5. K-Dur 20 mEq po q day. 6. Amoxicillin 250 mg po tid. 7. Detrol 2 mg po q hs. 8. Colace 100 mg po tid. 7. Remeron. 8. Trazodone. PHYSICAL EXAMINATION: Heart rate 74, blood pressure 156/90, respiratory rate 20. Patient in general is slightly obtunded, but easily arousable and responsive. She is disoriented to all, but her name. She moves all extremities, although the left seems weaker with decreased range of motion. The patient is not following commands. Pupils are postsurgical. They are reactive only minimally. Extraocular movements to gross examination, follows a few simple commands to open her eyes briefly shows two fingers bilaterally. Tongue is midline. Smile face symmetric. Lifts left forearm off bed, but not upper arm against gravity, withdraws left lower extremity, full range of motion right side upper extremities and lower extremities. Sensory is intact grossly to light touch and pin. Deep tendon reflexes symmetric. Toes move bilaterally. LABORATORIES: The patient had an INR of 1.5, hematocrit of 37.5. CT scan of the head showed a large right sided subacute and chronic subdural hematoma along most of the right hemisphere, 1.4 cm at widest diameter and 7-8 cm long with 1.25 cm midline shift and moderate preservation of [**Doctor Last Name 352**]-white interface. Positive compression of the right lateral ventricle. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] Surgical Intensive Care Unit on [**2164-4-14**]. She was started on q1h neurologic checks. She was treated with Nipride to keep her blood pressure below 150 at all times. Patient was treated also with fresh-frozen plasma to keep her coags below 1.4. Her platelets were also monitored in order to ensure that they stay below 100. While in the Intensive Care Unit, the Neurosurgery team placed a subdural drain to relieve the pressure in her head. A couple days into this treatment, the patient began to have seizures. She was loaded on Dilantin. When that did not seem to resolve her seizures, the patient received a Neurology consult. They recommended that we remove her drain as a possible stimulus to cause the seizures, that was also done. They also recommended that we load the patient on phenobarbital which was also done. After patient was loaded on phenobarbital, the seizures appeared to cease, and the patient was discontinued from the phenobarbital. During all of this, the patient also received Decadron to relieve the edema influencing her brain. After the phenobarbital was stopped and the seizures stopped, the patient remained virtually unresponsive with the exception of a few moans to excessive noxious stimuli. This lasted for a number of days until yesterday when the patient had an increase in white blood cells into the 50K. The patient's abdomen become distended. A KUB was performed. Large intestine measured approximately 9 cm in diameter. She then received a CT scan, which were limited to an air filled distended colon with asymmetric thickening of the rectosigmoid junction. Differential diagnosis included inflammatory and infectious etiologies such as Clostridium difficile, also possible ischemia. Patient also had hiatal hernia and cholelithiasis. No perforation was seen at that time. Over the course of the next 24 hours, the patient continued to deteriorate on [**2164-4-26**], the patient was placed on comfort measures only status. A few hours subsequently, the patient expired. After discussion with the family, they denied the request for autopsy. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern4) 8358**] MEDQUIST36 D: [**2164-4-26**] 17:43 T: [**2164-4-27**] 10:18 JOB#: [**Job Number 96767**]

[ "780.6", "458.9", "008.45", "276.2", "276.1", "780.39", "786.03", "427.31", "432.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "01.31", "38.93", "38.91", "93.90", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

2505, 4947

1279, 2487

111, 883

905, 1256

71,940

121,125

44634

Discharge summary

report

Admission Date: [**2134-8-5**] Discharge Date: [**2134-8-8**] Date of Birth: [**2074-9-10**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Bicycle versus motorist Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 59 year old transgender man with a past medical history of recurrent deep vein thrombosis and pulmonary embolism secondary to prothrombin gene mutation presenting after a bicycle versus [**Doctor Last Name **] collision with multiple traumatic injuries, mostly superficial lacerations and abrasions but also the possibility of a small left parafalcine SDH on initial NC Head CT. He was riding his bicycle this morning and was struck by a [**Doctor Last Name **], causing him to fall on his left side. He landed on his lower face but did not suffer loss of consciousness. Since the time of injury, he has had no significant headache, confusion, weakness, numbness, lethargy, convulsions, speech or comprehension difficulty, or vision changes. He was initially brought to [**Hospital 882**] Hospital where his NC Head CT on initial review was read as having a small parafalcine SDH, but on repeat review at our hospital appears to most likely represent volume averaging. Past Medical History: 1. Deviated septum s/p repair by ENT 2. DVT with PE in [**2119**], with recurrence, attributed to thrombophilia (prothrombin gene mutation, heterozygote, and "hyperactive factor VIII"). 3. Loss of consciousness status post bicycle accident. 4. Anxiety. 5. Insomnia. Social History: Works at the Smithsonian observatory at [**University/College **]. denies smoking, occasional EtOH. denies Family History: Significant for diabetes and Alzheimer's disease. There is no history of sleeping problems. Daughter also has prothrombin gene mutation. Physical Exam: VS T: 98.1 HR: 53 BP: 132/72 RR: 17 SaO2: 98RA General: Awake, NAD, lying in bed comfortably Head: NC, nose bridge laceration, chin laceration, no scleral icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Recalls a coherent history. Attention easily attained and maintained. Follows two step commands, midline and appendicular. Language fluent with intact verbal comprehension. Normal prosody. No paraphasic errors. No dysarthria. No neglect. - Cranial Nerves - [II] PERRL 3->2 brisk. VF full to confrontation. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light touch bilaterally. [VII] No facial asymmetry. [IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5 bilaterally. [XII] Tongue midline. - Motor - Normal bulk and tone. No pronation, no drift. No tremor or asterixis. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [[**Last Name (un) 938**]] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 - Sensory - No deficits to light touch bilaterally. - Reflexes Plantar response flexor bilaterally. Pertinent Results: [**2134-8-7**] 07:05AM BLOOD WBC-8.7 RBC-4.19* Hgb-13.7* Hct-38.1* MCV-91 MCH-32.7* MCHC-35.9* RDW-12.4 Plt Ct-218 [**2134-8-7**] 07:05AM BLOOD PT-15.4* PTT-22.9 INR(PT)-1.3* [**2134-8-8**] 07:08AM BLOOD Glucose-96 UreaN-13 Creat-0.8 Na-138 K-4.5 Cl-100 HCO3-30 AnGap-13 [**2134-8-6**] 02:11AM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.0 Mg-2.0 [**2134-8-7**] 07:05AM BLOOD Phenyto-13.4 CT Head: Tiny left parafalcine subdural hemorrhage is unchanged. Brief Hospital Course: Ms [**Known lastname **] was admitted to the NeuroICU for close neurological monitoring given traumatic SAH. On his first hospital day, he was found to be neurologically intact. A repeat CT showed stable appearance of small subfalicine TSAH. He complained of jaw pain and inability to chew, a OMFS consult was obtain they recommend panorex and facial films which showed: Non-displaced fracture of the lateral wall of the right nasal bone but panorex report is pending at the time of discharge. On [**2134-8-8**], patient was cleared per physical therapy. Given the pain, he is unable to chew and has been recommended for liquid and soft diet per nutrition. He is to follow-up as outpatient with Dr. [**Last Name (STitle) **] in 4 weeks. Also, he was recommended to restart Coumadin for his coagulopathy 1 week after his injury. He is also following up with Dr. [**First Name (STitle) **] in the [**Hospital **] clinic. Medications on Admission: Warfarin, Escitalopram 10, Spironolactone Discharge Medications: 1. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 9 days. Disp:*27 Capsule(s)* Refills:*0* 3. spironolactone Oral 4. Coumadin Oral Discharge Disposition: Home Discharge Diagnosis: Traumatic Subarachnoid Hemorrhage Discharge Condition: Neurologically stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? YOU [**Month (only) **] RESUME YOUR COUMADIN IN 1 WEEK FROM INJURY. ?????? If you have been prescribed Dilantin (Phenytoin) You only need to be on it for 10 days. Followup Instructions: Follow-Up Appointment Instructions ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] to be seen in 4 weeks. ?????? You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ?????? We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. - Have your facial sutures out in 7 days from accident. If your primary care does not feel comfortable removing them then you may go call our plastic surgery department. Completed by:[**2134-8-8**]

[ "873.43", "289.81", "852.31", "873.44", "V12.51", "873.20", "873.63", "V58.61", "E813.6", "300.00", "286.0" ]

icd9cm

[ [ [] ] ]

[ "27.59", "24.7", "86.59" ]

icd9pcs

[ [ [] ] ]

5001, 5007

3715, 4641

330, 337

5084, 5107

3242, 3625

5825, 6648

1790, 1931

4734, 4978

5028, 5063

4667, 4711

5131, 5802

1946, 2224

267, 292

365, 1360

3634, 3692

2249, 3223

1382, 1650

1666, 1774

24,043

142,624

23566

Discharge summary

report

Admission Date: [**2122-1-25**] Discharge Date: [**2122-1-28**] Date of Birth: [**2048-11-15**] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[**Known firstname 134**] Chief Complaint: Substernal chest pain Major Surgical or Invasive Procedure: Cardiac catheterization on [**2122-1-24**]: EF 45% Cypher stent to mid LAD History of Present Illness: The patient is a 73 year old male with a history of CAD s/p 2 prior MIs but no CABG or stents, history of 35-40 years of tobacco with COPD, HTN and HL who presented to [**Hospital3 **] via ambulance on [**2122-1-24**] after experiencing [**10-31**] substernal chest pain. The patient had been getting ready for bed when he experienced nausea and vomiting x diaphoresis and shortness of breath. He then experienced [**10-31**] substernal chest pain that was similar to his prior angina but much more severe. The pain radiated down his left arm. He took 2 SL nitros at home without relief and his wife called 911 and thus taken by ambulance to [**Hospital3 **]. In the ambulance, he was in atrial fibrillation and then suffered a vfib arrest and was shocked three times and went into torsades. The patient was then loaded with 150 mg IV amio and started on an amio gtt. At [**Hospital1 46**], he was found to have 2-[**Street Address(2) 2051**] elevations V2-V6. He was placed on Aggrastat, Plavix, Lopressor, Amio gtt at 1 mg, nitro gtt and morphine and Mg 2 mg. ^The nitro was increased to 70 mcg/hr and the patient states he became pain free. He was transferred to [**Hospital1 18**] for cath. Cardiac Cath [**2122-1-24**]: EF 45%, no MR, anterolateral, apical and inferoapical akinesis CO 4.6, CI 2.89 LVEDP 33, RA 13, PCW 22, PA 42/21 Left-dominant system Normal LMCA, 95% distal LAD, 70% OM2, small and non-dominant RCA ROS: occasional BRBPR with guaiac positive stool, no hematuria/hemetemesis Past Medical History: CAD s/p 2 prior MIs with medical management HTN COPD with h/o blebs and spontaneous pneumothoraceses Anorectal carcinoma with guaiac positive stool Social History: The patient lives with his wife. [**Name (NI) **] walks with a cane at baseline. He admits to a history of tobacco use ( quit 25 years ago) and used to smoke 1 ppd x 35-40 years. He denies any EtOH, IV or illicit drug use. However, he does use chronic oxycontin and suffers "withdrawal" symptoms when he doesn't get his fixed doses. Family History: Noncontributory. Physical Exam: Tc=97 P=70 BP=120/70 RR=16 97% on 2 liters O2 Gen - Anxious, AOX3 HEENT - PERLA, wears glasses, EOMI, no JVD Heart - Irregular, no M/R/G Lungs - CTAB Abdomen - Soft, NT, no masses or hepatosplenomegaly, active BS Ext - No C/C/E, right groin no hematoma or bruits, +2 d. pedis bilaterally Pertinent Results: [**2122-1-25**] 10:16PM CK(CPK)-3932* [**2122-1-25**] 10:16PM CK-MB-56* MB INDX-1.4 [**2122-1-25**] 10:16PM HCT-32.4* [**2122-1-25**] 03:41PM GLUCOSE-115* UREA N-20 CREAT-0.9 SODIUM-140 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14 [**2122-1-25**] 03:41PM CK(CPK)-3158* [**2122-1-25**] 03:41PM CK-MB-81* MB INDX-2.6 [**2122-1-25**] 03:41PM CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-2.2 [**2122-1-25**] 03:41PM WBC-8.5 RBC-3.88* HGB-11.6* HCT-33.5* MCV-86 MCH-29.8 MCHC-34.5 RDW-15.7* [**2122-1-25**] 03:41PM PLT COUNT-126* [**2122-1-25**] 04:44AM HCT-32.6* [**2122-1-25**] 01:28AM GLUCOSE-137* UREA N-17 CREAT-1.0 SODIUM-137 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-10 [**2122-1-25**] 01:28AM CK(CPK)-2127* [**2122-1-25**] 01:28AM CK-MB-83* MB INDX-3.9 [**2122-1-25**] 01:28AM CALCIUM-8.4 PHOSPHATE-2.4* MAGNESIUM-2.3 [**2122-1-25**] 01:28AM WBC-6.5 RBC-3.92* HGB-11.1* HCT-33.5* MCV-85 MCH-28.4 MCHC-33.3 RDW-16.1* [**2122-1-25**] 01:28AM PLT COUNT-137* [**2122-1-25**] 12:00AM TYPE-ART PO2-74* PCO2-45 PH-7.36 TOTAL CO2-26 BASE XS-0 [**2122-1-25**] 01:28AM PT-13.6 PTT-39.3* INR(PT)-1.2 [**2122-1-25**] 12:00AM HGB-10.8* calcHCT-32 O2 SAT-96 Cardiology Report ECG Study Date of [**2122-1-28**] 7:22:58 AM Sinus rhythm with PACs Extensive T wave changes suggest myocardial infarct Since previous tracing of [**2122-1-27**], QT interval decreased ECHO Study Date of [**2122-1-27**] Left Ventricle - Ejection Fraction: 30% (nl >=55%) Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed with akinesis of the distal septum and apex and severe hypokinesis of the inferior and infero-lateral walls. The basal anterior, antero-septal and lateral walls move best. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate regional LV systolic dysfunction c/w multivessel CAD. C.CATH Study Date of [**2122-1-24**] COMMENTS: 1. Selective coronary angiography revealed a left dominant system with two vessel CAD. The LMCA had no angiographic evidence of coronary artery disease. The LAD had a discrete distal 95% stenosis, which was stented (see below). The LCX was large and dominant. It gave off a large OM1 branch and a large OM 2 branch. The OM2 branch had a 70% stenosis proximally. The RCA was small and non-dominant. It did not have any angiographically apparent CAD. 2. Hemodynamics performed after the intervention revealed elevated left and right heart pressures and a preserved cardiac index. 3. Left ventriculography revealed anterolateral, apical and inferoapical akinesis. There was no mitral regurgitation. Calculated EF was 44%. 4. Successful direct stenting of the mid-LAD with a 3.0 x 18 mm Cypher DES. Final angiography revealed no residual stenosis, no apparent dissection, and TIMI 3 flow (see PTCA comments). 5. Successful closure of the right common femoral arteriotomy with a 6 French Angioseal device. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Mild systolic and diastolic ventricular dysfunction. 3. Acute myocardial infarction treated by primary PCI with placement of a drug-eluting stent in the mid-LAD. 4. Successful Angioseal. Brief Hospital Course: The patient is a 73 year old male with a history of CAD s/p 2 prior MIs with HTN and COPD who presented with an anterior STEMI c/b vfib arrest 1. CAD - The patient had suffered a large anterior STEMI complicated by V. fib arrest in the ambulance ride to the hospital. He had a Cypher stent placed to his mid-LAD and suffered no more chest pain. -The patient was originally started on ASA, aggrastat, Plavix and a statin. He was also placed on heparin due to akinesis of the apex. However, the patient developed a subsequent voluminous GI bleed and required 2 units of blood. He had reported bright red blood per rectum as an outpatient given his history of rectal carcinoma. As a result, the aggrastat and heparin were discontinued. Although the patient would benefit from coumadin due to his akinetic apex, it was decided not to initiate long-term anticoagulation as he did not tolerate this well. He should have a repeat echo in 4 weeks to reassess his wall motion and EF. - He was placed on metoprolol 25 mg [**Hospital1 **] and Lisinopril 5 mg. 2. CHF EF 45% - The patient remained euvolemic during his stay. - He had a repeat echo on [**2122-1-27**] which showed persistent akinesis of the distal septum and apex with an EF of 30%. - He was started on an ACE for cardiac remodeling. 3. HTN - The patient takes Norvasc 5 mg and Imdur 30 mg at home. We started Metoprolol 25 mg [**Hospital1 **] and Lisinopril 5 mg. His systolic blood pressure on presentation was in the 120s but remained in the 100s during the rest of his stay. He denied feeling dizzy or lightheaded and did well with PT. 4. COPD - The patient has a history of spontaneous pneumothoraces secondary to bullous lung disease. We continued the patient's outpatient inhaler regimen. He remained stable. 5. Gastrointestinal bleed - The morning after presentation on aggrastat and heparin as well as plavix, the patient developed a large acute GIB with bright red blood per rectum. He denied any abdominal pain. The heparin and aggrastat were discontinued and he was transfused with 2 units of blood. The patient has a history of anorectal carcinoma s/p chemo and radiation in [**2113**]. GI and surgery were consulted and both recommended conservative management. The patient states that he had a reportedly normal colonoscopy 2 months ago at an outside hospital ([**Doctor First Name 8125**]). However, we felt that his GI bleed was either from recurrent anorectal carcinoma or radiation proctitis. The patient will need another colonoscopy soon to confirm this. He also reports a recent 12 pound weight loss. - The patient thereafter, reported no GI bleeds and remained hemodynamically stable. 6. Non-sustained ventricular tachycardia - The patient had runs of NSVT on telemetry during his stay. He also exhibited atrial ectopic activity on EKG giving an irregular heart beat. Given his low EF, EP was asked to evaluate the patient for a question of an ICD. However, EP felt that he required a full GI workup to determine if he had recurrent rectal carcinoma and if so, determine his prognosis before they implanted an ICD with mortality benefits in the year following an MI. This would require an inpatient repeat colonoscopy. The patient decided against staying in the hospital to have a complete GI workup as he recently had a colonoscopy at [**Doctor First Name 8125**]. Instead, the patient decided to meet with Dr. [**Last Name (STitle) 174**], his outpatient cardiologist early the following week to discuss whether an ICD should be placed. 7. Dispo - The patient was seen by PT who recommended home PT. The patient qualifies for [**Hospital3 **] free care and case management believed he would benefit from outpatient rehabilitation. Medications on Admission: Oxycontin 80 mg [**Hospital1 **] Norvasc 5 mg PO QD Plavix 75 mg Celebrex 200 mg [**Hospital1 **] Pepcid 40 mg [**Hospital1 **] Resotril 30 mg QHS Flonase Serevent Flovent ventalin Imdur 30 mg QD Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*9* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: Two (2) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 4. Pantoprazole Sodium 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* 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 6. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:*60 Capsule(s)* Refills:*2* 7. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: [**11-23**] Disk with Devices Inhalation Q12H (every 12 hours). Disp:*1 Disk with Device(s)* Refills:*2* 8. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 9. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*2* 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. outpatient rehabilitation Discharge Disposition: Home Discharge Diagnosis: myocardial infarction v.fib arrest testicular mass lower Gi bleed Discharge Condition: good Discharge Instructions: Continue your medications as listed on the next page. Do not stop your plavix or aspirin unless you have spoken to your cardiologist Please return to the hospital or call your doctor if you have chest pain or shortness of breath or blood in your stool or if there are any concerns at all Followup Instructions: Please follow up with your PCP within the next two weeks. PCP: [**Name10 (NameIs) 60341**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 60342**]. Please follow up with your gastroenterologists within a month of your discharge Please follow up with your cardiologsit, Dr. [**Last Name (STitle) 174**] by next week. He will discuss with you regarding the rhythm of your heart and the possibility of a defibrillation

[ "410.11", "401.9", "578.9", "427.1", "428.0", "412", "427.41", "496", "427.31", "V10.06", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.20", "88.56", "36.07", "99.04", "88.53", "36.01", "37.23" ]

icd9pcs

[ [ [] ] ]

12088, 12094

6450, 10169

291, 367

12204, 12210

2780, 6179

12547, 12994

2436, 2454

10415, 12065

12115, 12183

10195, 10392

6196, 6427

12234, 12524

2469, 2761

230, 253

395, 1899

1921, 2070

2086, 2420

28,192

182,204

50729

Discharge summary

report

Admission Date: [**2167-4-11**] Discharge Date: [**2167-4-21**] Date of Birth: [**2118-5-5**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Tetracycline / Erythromycin Base / Lipitor / Zocor / Reglan Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain, tongue numbness, R arm numbness Major Surgical or Invasive Procedure: [**2167-4-14**] - CABGx3 (Left internal mammary-> Left anterior descending artery, Vein graft->Obtuse marginal artery, Vein graft->Right coronary artery) History of Present Illness: 48 year old diabetic patient with a history of ESRD s/p failing transplant, recently started on PD, awaiting repeat renal transplant, with diffuse CAD scheduled for CABG [**2167-4-14**] who presents with 4/10 intermittent chest discomfort. He was feeling well until this morning when he went to the store and felt fatigued and nauseated with an acid feeling in his chest. He came home and rested and continued to feel an intermittent acid feeling of chest discomfort [**4-2**] that would come and go without any identifiable precipitant. It was associated also with diaphoresis and SOB at rest. He has had chest discomfort like this in the past which he says has been worked up as atypical CP before. The last time he had it was about 2 weeks prior. He took a nap and when he woke up he felt the bottom of his tongue was numb and his right lateral wrist and his R tricep were numb. He has had this constillation of numbness before and has been attributed to his peripheral neuropathy, but the degree of numbness was worse than usual. It would come and go independent of his CP and would last 4-5 minutes. Given his overall feeling of being unwell he had his sister bring him into the [**Name (NI) **] for evaluation. No HA, visual changes. Of note, the patient says he had a recent retinal artery thrombus diagnosed 2 weeks ago, followed by [**Last Name (un) **], associated with R peripheral vision loss. FS this am was 569, high for him, he gave himself 8 units in am, additional 6units with his breakfast-->275. . ED Course: Initial vitals- T98.3 HR89 BP181/100-->232/108 RR18 O2Sat98% 4/10CP FS 258; EKG showed NSR@82 with no significant changes from prior. CE's were elevated with CK: 624 MB: 16 MBI: 2.6 Trop: 0.18. CXR was wnl. Nitro gtt was started for SBP 230/130-->176/93. Maalox was given and CP and symptoms resolved. ASA 325mg was given after getting the OK from CT [**Doctor First Name **]. CT head was which was negative for major infarct or bleed and he was started on a heparin gtt. He was given lopressor 5mg IVx3->151/86. He was also given maalox cocktail. Cards was consulted and felt this was a troponin leak in the setting of hypertension. Renal was contact[**Name (NI) **] and made aware of admission. He was admitted for management of hypertensive urgency before CABG scheduled [**4-14**]. He was guaiac neg. . He says his CP resolved with lowered blood pressure and his nausea/numbness resolved with maalox in the ED. . ROS: as above, also negative for fever, vomiting, diarrhea, cough. + runny nose + seasonal allergies. + baseline constipation. no BRBPR. no myalgias. . Past Medical History: -Type 1 Diabetes c/b retinopathy, neuropathy, nephropathy, and gastroparesis- HbA1c [**2167-4-1**] 9.1 -ESRD [**1-24**] DM: s/p renal transplant [**2148**], recently deteriorating renal function from chronic allograft nephropathy, started peritoneal dialysis on [**2167-1-14**], being evaluated for repeat renal transplant - CAD as noted on cath below - hypertension - hyperlipidemia- Cholest432* Trigly357* HDL58 CHOL/HD7.4 LDLcalc 303* - R retinal occlusion w/loss of peripheral vision - ulcer on his right hallux (big toe), treated with keflex a few weeks ago - orthostasis - depression, sees outpatient psychologist - ?GERD . Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension . Cardiac History: Future CABG, likely 3vessel with LIMA to LAD scheduled for [**2167-4-14**] . Percutaneous coronary intervention, in [**2167-4-1**] anatomy as follows: 1- Severe diffuse three vessel disease. The LMCA was free from angiographically-apparent disease. The LAD was diffusely diseased at mid-vessel (70-80%) and the D1 was diffusely diseased proximally (70-80%). The LCX was a large vessel. The OM1 and OM2 were severely and diffusely diseased vessels and the OM3 (likely a good target for grafting) was a good size vessel with proximal 70% stenosis. The RCA was totally occluded at the ostium with robust left-to-right collaterals. 2- Limited resting hemodynamic assessment revealed severe systemic arterial hypertension (220/103 mmHg). Nitroglycerine gtt was started for better BP control. 3- Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Left ventriculography was deferred. 3. Consult cardiothoracic surgery for CABG. Social History: Social history is significant for the absence of current tobacco use. Formerly smoked 1-2ppd, quit 10 y ago. There is no history of alcohol abuse. He lives with his sister, nephew and dog. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - 97.8 180/92->167/90 on nitro gtt, 66 16 100%RA 70kg Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. R PD catheter c/d/i Ext: 2+ pitting edema to knees, 2+DPs Skin: Healing ulcers on top of R big toe. Pertinent Results: [**2167-4-11**] 02:10PM BLOOD CK(CPK)-624* [**2167-4-11**] 02:10PM BLOOD CK-MB-16* MB Indx-2.6 [**2167-4-11**] 02:10PM BLOOD cTropnT-0.18* [**2167-4-11**] 09:37PM BLOOD CK(CPK)-395* [**2167-4-11**] 09:37PM BLOOD CK-MB-11* MB Indx-2.8 cTropnT-0.15* [**2167-4-12**] 05:59AM BLOOD CK(CPK)-292* [**2167-4-12**] 05:59AM BLOOD CK-MB-9 cTropnT-0.17* . EKG demonstrated NSR, NA/NI with no significant change compared with prior dated [**2167-4-1**]. TELEMETRY demonstrated: NSR 2D-ECHOCARDIOGRAM performed on [**2166-9-15**] demonstrated: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . PMIBI [**2166-9-15**]: No anginal type symptoms or ischemic EKG changes. 1) Probable moderate fixed defect of the mid and basal segments of the inferoseptal wall in the setting of diaphragmatic attenuation. 2) Mild global hypokinesis. Ejection fraction is 42%. [**2167-4-11**] CT Scan There is no acute intracranial hemorrhage or major vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation is preserved. The ventricles are normal in size and configuration. The visualized paranasal sinuses and mastoid air cells are well aerated. The osseous structures and soft tissues are unremarkable. [**2167-4-14**] ECHO PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Mild tricuspid regurgitation is seen. POSTBYPASS Preserved biventricular systolic function. The study is otherwise unchanged from prebypass. [**2167-4-21**] 05:05AM BLOOD WBC-14.2* RBC-3.23* Hgb-11.9* Hct-30.7* MCV-95 MCH-36.8*# MCHC-38.8* RDW-16.8* Plt Ct-317 [**2167-4-20**] 05:15AM BLOOD WBC-15.8* RBC-3.33*# Hgb-11.0*# Hct-31.1*# MCV-94 MCH-33.1* MCHC-35.4* RDW-17.0* Plt Ct-292 [**2167-4-17**] 01:16AM BLOOD PT-12.0 PTT-23.5 INR(PT)-1.0 [**2167-4-21**] 05:05AM BLOOD Glucose-306* UreaN-103* Creat-9.5* Na-130* K-5.2* Cl-95* HCO3-21* AnGap-19 [**2167-4-20**] 05:15AM BLOOD Glucose-201* UreaN-96* Creat-9.3* Na-131* K-5.1 Cl-95* HCO3-21* AnGap-20 [**2167-4-19**] 07:05AM BLOOD Glucose-64* UreaN-81* Creat-9.1* Na-132* K-4.4 Cl-95* HCO3-22 AnGap-19 CHEST (PA & LAT) [**2167-4-19**] 10:44 AM CHEST (PA & LAT) Reason: evaluate effusion - please arrange time with floor as the pa [**Hospital 93**] MEDICAL CONDITION: 48 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate effusion - please arrange time with floor as the patient is on peritoneal dialysis CLINICAL HISTORY: Status post CABG. Evaluate for effusion. CHEST: Heart is enlarged consistent with postoperative state. Atelectasis at the right base and the left lower lobe is present. A left pleural effusion is present. Some fluid is seen within the minor fissure or some atelectasis in the right upper lobe is present. IMPRESSION: Cardiomegaly, atelectasis, no failure. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2167-4-11**] for further management of his chest pain and NSTEMI. Aspirin, heparin, beta blockade and nitroglycerin were started. The cardiac surgical service was consulted as Mr. [**Known lastname **] was already scheduled for future bypass surgery. The nephrology service was consulted given his end stage renal disease and past renal transplant. Hemodialysis was continued. On [**2167-4-14**], Mr. [**Known lastname **] 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 cardiac surgical intensive care unit for monitoring. Within 24 hours, Mr. [**Known lastname **] [**Last Name (Titles) **]e neurologically intact and was extubated. He was seen by podiatry for f/u of his right hallux ulceration, underwent excisional debridement of skin and subcutaneous tissue and was started on wet-to-dry dressings [**Hospital1 **]. He was seen by [**Last Name (un) **] for management of his diabetes. His peritoneal dialysis was restarted. He was given stress dose steroids. He was transferred to the floor on POD #3. He was transfused for HCT 23. He was unable to manage his insulin pump and it was discontinued and he was started on humalog sliding scale and lantus, he will need to be restarted on his insulin pump when able. His tricor was discontinued and he was started on crestor both at renals request. He continues on peritoneal dialysis, he will use his cycler at night, in addition he should have 2 1.5% 2 liter/4 hour dwells during the day. A foley was placed for urinary retention on [**4-21**]. He was ready for discharge to rehab on POD #7. Medications on Admission: Imuran 100 mg a day Nephrocaps 1 cap daily Epogen injections 10,000u qweek prn, last inj last Thursday Prozac 40mg daily prednisone five milligrams Renagel 800 mg three times a day Novolog Insulin pump miralax once daily 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 DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Epoetin Alfa 2,000 unit/mL Solution Sig: Two (2) Injection QMOWEFR (Monday -Wednesday-Friday). 10. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 1 days: [**4-22**]. 13. Prednisone 1 mg Tablet Sig: Eighteen (18) mg PO daily () for 2 doses: After 20 mg tapered dose. 14. Prednisone 1 mg Tablet Sig: Sixteen (16) mg PO daily () for 2 doses: After 18 mg tapered dose. 15. Prednisone 1 mg Tablet Sig: Fourteen (14) mg PO daily () for 2 doses: After 16 mg tapered dose. 16. Prednisone 1 mg Tablet Sig: Twelve (12) mg PO daily () for 2 doses: After 14 mg tapered dose. . 17. Prednisone 5 mg Tablet Sig: Ten (10) mg PO daily () for 2 doses: After 12 mg tapered dose. 18. Prednisone 1 mg Tablet Sig: Eight (8) Tablet PO daily () for 2 doses: After 10 mg tapered dose. . 19. Prednisone 1 mg Tablet Sig: Six (6) mg PO daily () for 2 doses. 20. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily (): After 6 mg tapered dose. . 21. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 22. Insulin Lispro 100 unit/mL Insulin Pen Sig: sliding scale Subcutaneous four times a day. 23. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) Powder in Packet PO daily prn (). 24. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: CAD s/p CABGx3 Hyperlipidemia HTN IDDM ESRD s/p Renal transplant Retinal artery hemorrhage Discharge Condition: Stable 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 [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 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. 6) No driving for 1 month. 7) Call with any questions or concerns Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up Dr. [**Last Name (STitle) **] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) 14116**] in 2 week. [**Telephone/Fax (1) 12648**] Please call all providers for appointments. Scheduled appointments: Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2167-5-27**] 10:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2167-7-27**] 12:40 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2167-9-25**] 10:50 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2167-4-21**]

[ "707.15", "410.71", "255.41", "403.01", "V15.82", "585.6", "428.32", "311", "250.61", "362.01", "250.41", "250.51", "357.2", "428.0", "414.01", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.12", "89.60", "36.15", "86.22", "39.61", "54.98", "99.04" ]

icd9pcs

[ [ [] ] ]

14264, 14344

10076, 11823

382, 538

14479, 14488

5969, 9487

15223, 16158

5097, 5179

12095, 14241

9524, 9554

14365, 14458

11849, 12072

4749, 4875

14512, 15200

5194, 5950

299, 344

9583, 10053

566, 3168

3190, 4732

4891, 5081

30,731

184,324

6916

Discharge summary

report

Admission Date: [**2141-10-15**] Discharge Date: [**2141-11-9**] Date of Birth: [**2076-6-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: Craniotomy History of Present Illness: History of Present Illness: Mr. [**Known lastname **] is a 65yo male with PMH significant for alcohol abuse, HTN, and cirrhosis who presents s/p fall in the setting of EtOH intoxication. History obtained from ED records. Patient fell from standing position after drinking yesterday evening; noted to be unconscious. Upon arrival to the ED, he was responsive to painful stimuli. CT scan head showed diffused SDH. In the ED his initial vitals were T 97.8 BP 189/112 AR 101 RR 18 O2 sat 100% RA. Serum EtOH level was 442. He received 1L NS and was transferred to the MICU for closer monitoring. Of note, patient was recently admitted to [**Hospital1 18**] in [**8-19**] when he presented with chest pain. EtOH level at this time was also elevated and he was placed on CIWA scale. He did not show any signs of withdrawal at [**Last Name (un) **] time. Past Medical History: 1)Type 2 DM 2)Hypertension 3)Cirrhosis: secondary to EtOH abuse, followed here in liver clinic 3)Alcohol abuse 4)Cirrhosis - Followed at [**Hospital1 18**], from EtOH abuse, viral hepatitis negative in past. Currently compensated per notes, plan follow with MRI and EGD Social History: He lives alone. He is a retired cab driver. He does have his children around in [**Location (un) 86**] for support, however he is divorced. Patient denies any history of Tob use. Notes a history of heavy Etoh use, notes his last drink was the Saturday before admission and consisted of 2 beers. Denies any drug use. Lives alone. Family History: The patient denies any significant family medical history Physical Exam: admission Physical Exam: vitals T 99 BP 163/87 AR 110 RR 17 O2 sat 97% RA Gen: Patient arousable but falls back asleep quickly HEENT: PERRLA, NGT in place Heart: nl s1/s2, no s3/s4, +systolic murmur Lungs: CTAB Abdomen: soft, NT/ND, +BS Extremities: 2+ DP/PT pulses bilaterally, no edema Neuro: Arousable to voice, Pertinent Results: Relevant Imaging: [**2141-10-15**] CT C-spine: No evidence of cervical spine fracture. 2. Comminuted right temporal bone fracture as described above. Possible underlying left temporal bone fracture, however, assessment is limited. A probable 3mm bone island involving the left C6/7 articulation. [**2141-10-15**] CT Head: Diffuse bilateral subarachnoid hemorrhage as well as bilateral subdural hematoma as described above, and high density focus in the left basal ganglia representing parenchymal hemorrhage. Comminuted complex fracture of the right temporal bone, with opacified middle ear cavity, mastoid air cells, and external auditory canal. Opacified left external auditory canal and middle ear cavity. [**2141-10-15**] CT sella, orbits - 1. Minimally displaced comminuted fracture of the right temporal bone with small amount of pneumocephalus within the right temporal fossa. 2. Patient appears to be status post left mastoidectomy and although the left external auditory canal appears opacified, no definite fracture line is detected. [**2141-11-9**] CXR - 1. Too proximal position of the NG tube. 2. Too low position of the right subclavian line which will be pulled back for about 3 cm. 3. Interval development of mild pulmonary edema. [**2141-11-8**] KUB - Interval increase in distention of transverse colon which maintains a normal haustral pattern and contour. Correlate clinically to rule out underlying colitis. [**2141-11-8**] Scrotal U/S - No evidence of abscess or focal fluid collection. [**2141-11-3**] CT Head - 1. Interval increase in the herniation of the brain through the craniotomy site of the left parietal bone. 2. Stable size of the evolving bilateral frontoparietal subdural hematomas. Interval evolution of left temporal and the left midbrain-thalamus junction contusion. 3. Near complete resolution of subarachnoid hemorrhage and [**Hospital1 **]-tentorial subdural hematomas. Brief Hospital Course: The patient initially presented on [**2141-10-15**] after a fall while intoxicated. The patient was reportedly found unconscious but was responsive to painful stimuli. At the time of presentation, blood alcohol was 442. On head CT he was found to have diffuse bilateral subarachnoid hemorrhage as well as bilateral subdural hematoma and parynchemal hemorrhage in the left basal ganglia. The patient also had comminuted right temporal bone fracture. The patient was admitted to the medical ICU where he became unresponsive with bradycardia and hypotension to sbp 50. He was also seen to have active hematemesis. The patient was emergently intubated. The patient was found to have increased accumulation of blood on repeat head CT with midline shift. On [**2141-10-16**], the patient underwent craniotomy with hematoma evacuation. The patient was dilantin loaded for seizure prophylaxis. The patient had multiple complications during his hospital course, including fevers, nosocomial pneumonia requiring prolonged intubation and tracheostomy as well as an ileus. On [**2141-10-17**], the patient started an 8 day course of vanc/cefepime for gram positive blood culture (speciated as coag negative staph) growth and a nosocomial pneumonia requiring prolonged intubation. The patient underwent tracheostomy on [**2141-10-24**]. The [**Hospital 228**] hospital course was subsequently complicated by an ileus around [**2141-11-1**], thought to have resolved. In the setting of fever spikes, the patient was found on 09.22-23.07 to have E. Coli growth in the blood as well as coag negative staph growth on his central line catheter tip. The patient has been on piperacillin-tazobactam since [**2141-11-4**]. He last had fever spikes on [**2141-11-6**] as high as 101. Subsequent temps have run in the range of 99. A single subsequent blood culture on [**2141-11-6**] is without growth to date. His CXR at on [**2141-11-7**] also raised concern for a pneumonia. On the day of transfer, the patient had worsening oxygen requirement with severe acidosis on trach mask, improved on the ventilator. The patient also has ongoing electrolyte disturbances including hypernatremia, lactic acidosis and hyperbilirubinemia. The patient was transferred to the ICU on [**2141-11-9**]. At that point, the family decided to make the patient comfort measures only. The patient passed away at 11:45am on [**2141-11-9**]. The family was at the bedside and declined an autopsy. Medications on Admission: insulin, oral hypoglycemics Discharge Medications: The patient passed away on [**2141-11-9**] at 11:45am. Discharge Disposition: Expired Discharge Diagnosis: Sepsis secondary to E.coli bacteremia Respiratory failure Discharge Condition: The patient passed away on [**2141-11-9**] at 11:45am. Discharge Instructions: The patient passed away on [**2141-11-9**] at 11:45am.

[ "507.0", "995.92", "401.9", "801.36", "286.9", "571.2", "E888.9", "572.3", "250.00", "998.59", "518.81", "038.42", "303.91", "997.3", "801.26" ]

icd9cm

[ [ [] ] ]

[ "31.1", "99.15", "96.72", "96.04", "38.93", "96.6", "01.31" ]

icd9pcs

[ [ [] ] ]

6848, 6857

4232, 6691

324, 336

6958, 7014

2286, 2286

1877, 1936

6769, 6825

6878, 6937

6717, 6746

7038, 7095

1976, 2267

276, 286

2304, 2601

392, 1216

2610, 4209

1238, 1511

1527, 1861

41,373

132,954

5392

Discharge summary

report

Admission Date: [**2182-10-30**] Discharge Date: [**2182-11-4**] Date of Birth: [**2110-6-22**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin Attending:[**First Name3 (LF) 2108**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known firstname **] [**Known lastname **] is a 72 year old woman with a history of chronic hypoxemic respiratory failure, mild COPD, mild pulmonary hypertension, and diffuse lung disease related to her small cell lung cancer and radiation fibrosis. She presents today after waking up with significant difficulty breathing. She ultimately was able to get to her albuterol inhaler which gave her some relief. She reports always having oxygen saturation in the mid 80s, but that this morning she was in the 50s. She denies feeling any associated chest pain, headache, nausea, vomiting, fevers, chills, or URI prodrome. . In the ED vital signs were, T 98.2 HR 112 BP 124/79 RR 16 SpO2 70% RA. With oxygen saturation in the 70s patient was able to talk in full sentences. CXR performed suggested a left lower lobe consolidation. CTA showed no evidence of pulmonary embolism or dissection but suggested possible LUL and LLL consolidations. Patient remained afebrile and labs were notable for WBC 17. She was given vancomycin and levaquin empirically. . EKG on presentation showed afib with RVR and her baseline RBBB. Troponin returned elevated at 0.35. Due to her aspirin allergy she was not given aspirin. Cardiology was called and recommended trending cardiac enzymes and repeating EKG. They did not recommend clopidogrel at this time as they believed this enzyme leak was much more likely due to demand from her hypoxia and her atrial fibrillation with RVR. She was not started on a heparin gtt as her INR was therapeutic at 3.1. She subsequently received diltiazem 20 mg IV x 2 and diltiazem 30 mg po x 2 with minimal affect on rate control so she was started on a diltiazem gtt. . On arrival to the ICU, she reports feeling much better. She denies recent hospitalizations, steroid use, antibiotic use, sick contacts, or travel. She admits that this is a difficult time of year for her respiratory status every year. She reports being up to date on her influenza and pneumovax vaccinations (confirmed in OMR). She also reports that her baseline oxygen saturation on 3L NC is usually in the low 80%s. Per prior notes in OMR her goal SpO2 is > 85%. . On review of symptoms she denies chest pain, nausea, vomiting, diaphoresis, leg weakness, palpitations, lightheadedness, pleuritic chest pain, upper respiratory symptoms, black or bloody stools. She does admit to occasional leg cramping that she attributes to dehydration. Past Medical History: 1. COPD - on 3L home o2 at night and intermittently during day 2. Small cell lung cancer - diagnosed [**2-18**]; s/p chemo with cisplatin/Etoposide and radiation 3. Atrial fibrillation on coumadin 4. Rosacea 5. Sleep Apnea, CPAP 14 centimeters and 2L 6. Macular degeneration 7. Squamous cell skin cancer of the right arm status post excision 8. Hidradenitis of the inguinal area 9. Erythema nodosum 10. status post hysterectomy 11. status post cholecystectomy [**83**]. CVA at the age of 50 while on HRT 13. Patent foramen ovale Social History: Patient lives with her husband in a 2 story home. She is retired. She quit smoking in [**2180-2-12**] when diagnosed with lung cancer. She drinks 1 drink per week. She denies any use of illicit drugs or herbal medications. She denies needing any assistance with ambulation or carrying out her ADLs. Family History: Per OMR: Paternal Grandmother - died of a stroke Maternal grandfather - died of CHF Mother - died of CHF at 91 Maternal Grandmother - died of a stroke. Physical Exam: VS: Temp: 99.4 BP: 143/65 HR: 128 RR: 24 O2sat 85% 3L NC. GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, RESP: significant kyphosis, decreased bs at bases, poor air movement throughout, comfortable at rest, patient able to talk in complete sentences, after several sentences has pursed lip breathing CV: irregular rhythm, tachycardic, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses EXT: no c/c/e, warm, dry, 2 + distal pulses SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: ADMISSION LABS: . [**2182-10-30**] 01:44PM PT-31.1 PTT-34.5 INR(PT)-3.1 [**2182-10-30**] 01:44PM PLT COUNT-214 [**2182-10-30**] 01:44PM NEUTS-93.1 LYMPHS-2.1 MONOS-3.9 EOS-0.1 BASOS-0.8 [**2182-10-30**] 01:44PM WBC-17.7 RBC-4.81 HGB-14.2 HCT-45.0 MCV-94 MCH-29.6 MCHC-31.6 RDW-17.9 [**2182-10-30**] 01:44PM CALCIUM-8.6 PHOSPHATE-2.7 MAGNESIUM-1.7 [**2182-10-30**] 01:44PM CK-MB-4 ---> 4 [**2182-10-30**] 01:44PM cTropnT-0.35---> 0.16 [**2182-10-30**] 01:44PM CK(CPK)-89 ----> 100 [**2182-10-30**] 01:44PM GLUCOSE-160 UREA N-9 CREAT-0.9 SODIUM-138 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15 [**2182-10-30**] 01:49PM TYPE-ART PO2-51 PCO2-37 PH-7.49 TOTAL CO2-29 BASE XS-4 [**2182-10-30**] 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2182-10-30**] 08:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2182-11-2**] 03:20PM BLOOD WBC-6.6 RBC-4.59 Hgb-14.0 Hct-44.0 MCV-96 MCH-30.5 MCHC-31.8 RDW-18.5* Plt Ct-227 [**2182-11-4**] 07:56AM BLOOD PT-20.6* INR(PT)-1.9* [**2182-11-2**] 03:20PM BLOOD Glucose-95 UreaN-9 Creat-0.8 Na-142 K-4.7 Cl-104 HCO3-31 AnGap-12 MICRO: [**2182-10-30**] Urine Cx: Negative [**2182-10-31**] Urine Legionella: Negative [**2182-10-31**] 6:25 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2182-10-31**]): [**10-7**] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN CLUSTERS. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. [**2182-10-31**] Blood cx: Pending IMAGING: [**2182-10-30**] CXR: 1. Right hilar mass and medial right upper lobe opacity again seen without significant change. Increased left mid-to-lower lung opacity may be due to infectious process, although malignant involvement cannot be entirely excluded. [**2182-10-30**] CTA: 1. No pulmonary embolism or acute aortic dissection. 2. Moderate partially loculated right pleural effusion, not significantly changed since [**2175-4-30**]. 3. Left upper lobe and left lower lobe consolidations, which are new from prior study. The differential includes infection with possible areas of aspiration and/or inflammatory process, but new malignant foci cannot be entirely excluded. 4. Loculated fluid within the left major fissure is slightly increased from prior study. Brief Hospital Course: 71 year-old woman with limited stage small cell lung cancer, COPD, radiation pneumonitis, and obstructive sleep apnea was admitted with hypoxia. Hypoxemic respiratory failure: possible PNA as well as Afib RVR contributing to desaturation Patient reports increased work of breathing, increased cough, increased sputum production, and drop in SpO2 (to 50%) since waking up the morning of admission. She was found to be significantly hypoxic with a leukocytosis in the Emergency Department. She denies any fevers or chills. She did not appear clinically volume overloaded on exam. Her poor air movement on exam raises concern for a COPD exacerbation. CTA performed in the Emergency Department showed no evidence of PE to account for her hypoxia. The CT did, however, suggest two areas of consolidation that may represent infectious versus malignant processes. She was started on empiric antibiotic therapy in the [**Hospital Unit Name 153**] with vancomycin, levofloxacin, and aztreonam given her penicillin allergy, aztreonam d/c. Regimen simplified to levofloxacin alone as no evidence of MRSA. She was discharged after 6 total days of antibiotics. She is clinically much improved. Able to ambulate without significant dyspnea and feels close to her baseline. Atrial fibrillation: Patient presented in atrial fibrillation with RVR after missing her morning medications. She was started on a diltiazem drip until her home medications were given. Her rates are now controlled on oral metoprolol and diltiazem. Her INR was supratherapeutic at 3.1 on presentation. She will continue on her home dose of coumadin (INR 1.9 on discharge, will no longer be on abx) and on her home rate controlling agents without dosage change. Elevated Troponin: Patient denies any symptoms of chest pain, nausea, or diaphoresis. She denies any known history of CAD. She does describe difficulty breathing the morning of presentation which raises concern that this may be an anginal equivalent. Patient troponin likely signifies demand ischemia in the setting of significant hypoxia and poorly controlled heart rate (afib with RVR). CK-MB remained flat and troponin trended down. OSA: Patient describes history of significant daytime somnolence and nocturnal hypoxia that improved with initiation of CPAP. Continue home CPAP with 14 cm x 2L/min. Emergency Contact: [**Name (NI) **] (husband) [**Telephone/Fax (1) 21907**] Medications on Admission: Advair 250-mcg-50 mcg [**Hospital1 **] Spiriva one capsule daily Albuterol inhaler prn Fluticasone nasal spray [**Hospital1 **] Dexamethasone oral washes for aphthous ulcers Levothyroxine 25 mcg daily Metoprolol succinate 50 mg daily Diltiazem ER 360 mg po daily Warfarin 2.5 mg daily Calcium carbonate-Vitamin D [**Hospital1 **] Discharge Medications: 1. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. oxygen 3L home oxygen via nasal cannula, titrate O2 to keep oxygen saturations 88-92% 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 6. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. diltiazem HCl 360 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Hypoxemic Respiratory Failure Pneumonia, community acquired Atrial fibrillation with rapid venticular response Secondary: Small cell lung cancer [**1-/2180**] Chronic obstructive pulmonary disease Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with respiratory failure which was likely due to pneumonia as well as rapid heart rate from your atrial fibrillation. You have been treated with antibiotics and your heart rate is now controlled. NO MEDICATION CHANGES. Followup Instructions: Department: INTERNAL MEDICINE When: WEDNESDAY [**2182-11-6**] at 10:45 AM With: [**Last Name (NamePattern5) 6666**], MD, MPH [**Telephone/Fax (1) 4775**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Please arrive at 10:30am for this appointment. Please have your INR drawn at this visit (to check and see if you need adjustments to your coumadin dose) Department: CARDIAC SERVICES When: THURSDAY [**2183-1-2**] at 10:40 AM With: DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ADULT SPECIALTIES When: THURSDAY [**2183-3-13**] at 1 PM With: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD [**Telephone/Fax (1) 8645**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10908, 10914

6945, 9365

291, 297

11180, 11180

4526, 4526

11594, 12704

3653, 3806

9746, 10885

10935, 11159

9391, 9723

11331, 11571

3821, 4507

6071, 6922

244, 253

325, 2766

4542, 6030

11195, 11307

2788, 3318

3334, 3637

56,709

152,071

53518

Discharge summary

report

Admission Date: [**2172-4-8**] Discharge Date: [**2172-4-14**] Date of Birth: [**2093-1-30**] Sex: F Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 1943**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: NONE History of Present Illness: 79F hx/o HTN, HLD possible prior episode of pancreaitis who initially presented to OSH on [**2172-4-6**] with sudden onset abdominal pain radiation to the back associated with nausea & vomiting. The patient's pain originally started in her epigastrium and radiated to her R back & shoulder. She was unable to tolerate PO intake secondary to symptoms. There were no factors that relieved her pain. The patient also endorsed some diarrhea. Review of systems otherwise negative at OSH. On initial pressentation, 98 66 133/77 16 100% RA. Her exam was significant for poor dentition, mild tenderness to palpation in epigastrium with radiation to L flank. OSH labs revealed WBC 17.7, hemoglobin 13.6, amylase 3498, lipase [**Numeric Identifier **], creatinine 1.04, AST 86. At OSH, the patient was treated with IVF and IV morphine for pain control. Triglycerides noted to be 33 on [**2172-4-7**]. Imaging studies were obtained including a RUQ U/S which was read as being moderately distended without definitive wall thickening or stones. A CT abdomen on [**2172-4-7**] showed "extensive fluid around the pancrease compatible with acute pancreatitis. GB appears mildly distended some apparent wall thickening and pericholcystic fluid. GB findings may be related to adjacent pancreatitis. Acute cholcecystitis not excluded with certaintly. There is no obvious dilatation of the common duct." Finally, a HIDA scan was performed on [**2172-4-7**] which was "negative for cystic duct obstruction or active cholecystisis" it was, however abnormal for "moderaltely delayed bile transit time from BG and liver into small intestines" concerning for distal CBD obstruction or Sphincter of Oddi spasm (possibly related to morphine). At some point during her hospitalization at OSH she as startred on levothyroxine and flagyl. She was also on a morphine PCA. Today, lipase 724. She was noted to have an increasing oxygen requirement. Given the patient's ongoing pain and risk for ARDS, her family requested transfer to [**Location (un) 86**] for evaluation by a GI/pancreas team. On arrival to the ICU, VSS WNL. Reports improved pain compared to prior. REVIEW OF SYSTEMS: (+): Abdominal pain (-): HA, chest pain, SOB, diarrhea, nausea, vomiting, focal numbness or weakness, cough. Past Medical History: - HTN - HLD - Remote history of ? pancreatitis vs ulcers Social History: Lives with daughter. Denies smoking, alcohol, or illicit drug use Family History: Aunt: problems with gallbladder Father: stomach cancer, neck cancer Physical Exam: ADMISSION EXAM: GEN: Well-appearing female resting in bed in NAD HEENT: Small 0.5 cm in diameter excoriation on upper lip. Poor dentition. NECK: JVD at 9 cm. COR: +S1S2, possible S3. No m/g/r. PULM: Markedly diminished BS at bases. No c/w/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: +NABS in 4Q. Soft, tender to deep palpation in epigastrium & RUQ. Negative [**Doctor Last Name 515**]. EXT: Trace LE edema. NEURO: Awake, alert. DISCHARGE EXAM: Vitals: 98.3 98.1 120/40 90 18 94 RA GEN: Well-appearing female resting in bed in NAD HEENT: Small 0.5 cm in diameter excoriation on upper lip. Poor dentition. CV: PMI non-displaced, RRR, nl S1-S2, no MRG PULM: Diminished BS at bases. No c/w/r. [**Last Name (un) **]: soft, mildly diffusely tender, mildly distended, no rebound/guarding EXT: WWP, trace LE edema. NEURO: awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ADMISSION LABS: [**2172-4-8**] 01:50AM BLOOD WBC-15.4* RBC-4.23 Hgb-12.8 Hct-40.3 MCV-95 MCH-30.3 MCHC-31.8 RDW-12.6 Plt Ct-218 [**2172-4-8**] 01:50AM BLOOD Neuts-88.4* Lymphs-5.1* Monos-6.4 Eos-0 Baso-0.1 [**2172-4-8**] 01:50AM BLOOD PT-13.9* PTT-31.9 INR(PT)-1.3* [**2172-4-8**] 01:50AM BLOOD Glucose-113* UreaN-17 Creat-0.7 Na-139 K-4.3 Cl-107 HCO3-24 AnGap-12 [**2172-4-8**] 01:50AM BLOOD ALT-25 AST-28 LD(LDH)-187 AlkPhos-53 Amylase-436* TotBili-0.9 [**2172-4-8**] 01:50AM BLOOD Lipase-595* [**2172-4-8**] 01:50AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.1 [**2172-4-8**] 01:50AM BLOOD Triglyc-63 [**2172-4-8**] 02:48AM BLOOD Type-[**Last Name (un) **] pO2-29* pCO2-42 pH-7.39 calTCO2-26 Base XS--1 [**2172-4-8**] 02:48AM BLOOD Lactate-1.3 MICROBIOLOGY: [**4-8**] Urine culture LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2172-4-9**] 8:44 AM FINDINGS: The hepatic echotexture is unremarkable. No concerning liver lesion is identified. No biliary dilatation is seen in the common duct measures 0.5 cm. The portal vein is patent with hepatopetal flow. There is sludge seen within the lumen of the gallbladder. No gallstones are identified. No gallbladder wall edema or pericholecystic fluid is seen. The pancreas and midline structures including the aorta are obscured from view by overlying bowel gas. The spleen is unremarkable, measuring 7.0 cm. No hydronephrosis is seen on limited views of the kidneys. A trace of ascites is seen in the left upper quadrant, however, no ascites is seen in the lower quadrants. There is a small right pleural effusion. IMPRESSION: -> No gallstones identified. There is sludge within the lumen of the gallbladder. No signs of cholecystitis. -> The pancreas could not be visualized. -> Trace of ascites and small right pleural effusion. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2172-4-11**] 10:25 PM IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic injury. 2. Bilateral moderate pleural effusions with adjacent airspace atelectasis, left greater than right. 3. Sequela of pancreatitis are again noted in the limited visualized portions of the upper abdomen. [**2172-4-14**] 08:00AM BLOOD WBC-11.0 RBC-3.50* Hgb-10.5* Hct-33.2* MCV-95 MCH-30.0 MCHC-31.7 RDW-12.9 Plt Ct-345 [**2172-4-8**] 01:50AM BLOOD Neuts-88.4* Lymphs-5.1* Monos-6.4 Eos-0 Baso-0.1 [**2172-4-14**] 08:00AM BLOOD PT-13.5* PTT-37.5* INR(PT)-1.3* [**2172-4-14**] 08:00AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-137 K-3.9 Cl-101 HCO3-28 AnGap-12 [**2172-4-13**] 09:00AM BLOOD Glucose-97 UreaN-11 Creat-0.5 Na-138 K-3.4 Cl-99 HCO3-30 AnGap-12 [**2172-4-9**] 07:25AM BLOOD ALT-14 AST-21 TotBili-0.8 [**2172-4-8**] 01:50AM BLOOD Lipase-595* [**2172-4-14**] 08:00AM BLOOD Mg-2.1 [**2172-4-13**] 09:00AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8 [**2172-4-12**] 07:35AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.9 [**2172-4-8**] 01:50AM BLOOD Triglyc-63 Brief Hospital Course: 79 F with HTN, [**Hospital 33210**] transferred from OSH with acute pancreatitis with possible remote history of pancreatitis in the past. # Acute Pancreatitis: Lipase [**Numeric Identifier 961**]+ on admission to OSH; trending down prior to transfer. Etiology unclear in the absence of alcohol use or evidence of obstruction on OSH imaging. Biliary sludging vs Sphincter of Oddi spasm on the differential, although would not expect these to cause such profound pancreatitis (by lab analysis). Likely that patient has cholelithiasis, with stone not imaged on OSH scans. Her history of post-prandial intermittent RUQ pain would be c/w this diagnosis. Overnight, she was continued on IVF with NS @ 120cc/hr. This was increased to 150cc/hr the following morning. Pain was controlled with dilaudid prn pain. GI consulted recommended repeat RUQ U/S which showed some "No gallstones identified. There is sludge within the lumen of the gallbladder. No signs of cholecystitis." The etiology was never clear of why she had this epsidoe, but supportive care was done with bowel rest, pain control, IVF and ursodiol was started because of sludge. Lisinopril was stopped because of possible etiology contribution. She was diuresed secondary to pulmonary edema and was discharged tolerated a regular diet, pain controlled, ambulating on room air. # Hypoxia [**1-30**] Pulmonary edema and Pulmonary effusion: Pt was 96% on 2L of oxygen by NC at OSH. On arrival to ICU, sat 93% on RA, no complaints of SOB. No crackles or JVD to suggest volume overload. Unclear how much volume resucitation took place at OSH. Bibasilar dullness suspicious for effusions vs atelectasis vs. habitus (although no crackles). Overnight, patient was started on 2L supplemental oxygen. During the course of her stay on the floor, she was volume resuscitated and developed acute pulmonary edema and pulmonary effusion. This improved with lasix and autodiuresis. # Leukocytosis: Admitted with WBC 17 at OSH, subsequently trended down to 10. Possibly hemoconcentration vs. stress response in setting of acute pancreatitis. # HTN: lisinopril held. Toprol XL continued. # Hyperlipidemia: Continued statin. Transitions of care: -followup with gastroenterology regarding possible need for cholecystectomy. Medications on Admission: - Metoprolol 50 mg QD - Lisinopril 20 mg QD - Pravastatin 40 mg QD - Amlodipine 5 mg QD - Aspirin 81mg daily - MVI Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0* 7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. Disp:*60 Capsule(s)* Refills:*0* 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for diarrhea. Disp:*60 Tablet(s)* Refills:*0* 10. bisacodyl 5 mg Tablet Sig: [**12-30**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation: hold for diarrhea. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 11. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary: pancreatitis pleural effusions Secondary: hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the hospital for abdominal pain and found to have pancreatitis. The cause of this was still not entirely clear. You were treated with bowel rest, intravenous fluids and pain medicine and improved to the point where you could be discharged home. REGARDING YOUR MEDICATIONS... Medications STARTED that you should continue: ursodiol, colace, senna, bisacodyl, ibuprofen, tylenol Medications STOPPED this admission: lisinopril (may have caused the pancreatitis), amlodipine. Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. Followup Instructions: Name: [**Doctor Last Name **],SAYEEDA Location: [**Hospital 46644**] MEDICAL ASSOCIATES Address: [**Street Address(2) **], [**Location **],[**Numeric Identifier 21771**] Phone: [**Telephone/Fax (1) 82227**] When: Tuesday, [**2171-4-21**]:15 AM Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2172-4-22**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 22337**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Completed by:[**2172-4-14**]

[ "511.9", "401.9", "272.4", "518.4", "577.0", "799.02" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10379, 10385

6684, 8866

285, 291

10493, 10493

3775, 3775

11352, 11995

2787, 2856

9130, 10356

10406, 10472

8991, 9107

10643, 11329

2871, 3320

3336, 3756

2498, 2608

231, 247

319, 2479

3792, 6661

10508, 10619

8887, 8965

2630, 2688

2704, 2771

26,264

163,486

20485+57181

Discharge summary

report+addendum

Admission Date: [**2107-5-13**] Discharge Date: [**2107-5-23**] Date of Birth: [**2048-10-27**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 59-year-old gentleman, who apparently had a fall two days prior to admission with focal neurologic deficits, word finding difficulty, pronator drift, and cerebellar dysfunction. He came to the [**Hospital3 **] Emergency Room and was found to have a left subarachnoid hemorrhage. PHYSICAL EXAM: On admission, the patient's vital signs were 100.3, pulse 87, blood pressure 172/85, respirations 16, and 95%. Patient was awake, alert, and oriented times three. Speech was slightly dysarthric. Naming was intact. He had poor repetition, good comprehension. Cranial nerves II through XII were grossly intact. He had full EOMs except a right drift. Motor exam was [**6-1**] bilaterally. His right hamstrings were [**4-1**]. Otherwise, the remainder of his motor strength were intact. His reflexes were 2+ throughout. There was no Hoffmann's. ADMISSION LABORATORIES: White count was 13.4, hematocrit 45.3, platelets 257. INR was 1.2. Sodium 135, potassium 4.1, chloride 100, 22 for CO2. His outside film from his CAT scan showed a question left intercerebral hemorrhage and subarachnoid hemorrhage along the Sylvian fissure and left parietal area. HOSPITAL COURSE: The patient was admitted to the ICU, and a line was placed. He was loaded with Dilantin. A head CT and CTA were done. I will continue this dictation at a later time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 23588**] MEDQUIST36 D: [**2107-5-23**] 18:38 T: [**2107-5-24**] 11:08 JOB#: [**Job Number 54830**] Name: [**Last Name (LF) **], [**First Name3 (LF) 4240**] Unit No: [**Numeric Identifier 10316**] Admission Date: [**2107-5-13**] Discharge Date: [**2107-5-23**] Date of Birth: [**2048-10-27**] Sex: M Service: Neurosurgery This is a continuation of a previous discharge summary that was started on [**2107-5-23**]. On this first admission day, [**2107-5-13**], the patient did not have any headache. He was awake, alert, following commands. His strength was [**6-1**]. His blood pressure was kept less than 150. His white count was 11.1, hematocrit was 42.8, platelets was 241. Sodium 137, 4.0 for potassium, 102/25, 8 for BUN and 0.8 for creatinine. He had a CTA done to rule out left MCA aneurysm, which showed again the presence of an intraparenchymal hemorrhage in the left basal ganglia, which extended into the left Sylvian fissure into the subarachnoid space. The hemorrhage had been unchanged from his admission head CT. There were no abnormal vessels identified in the region of the hemorrhage. The anterior cerebral and anterior communicating and middle cerebral, posterior cerebral arteries were all normal in appearance. Patient's C spine was negative for any fracture. We wanted to obtain a MRI/MRA of his head to further assess for any vascular or arterial abnormalities. The patient during the day of [**5-13**] became more agitated and required to have intubation to complete his MRI/MRA. Later that day on [**5-14**], Dr. [**Last Name (STitle) 365**] had attempted to do a cerebral angiogram, however, the patient was foiund to have bilateral femoral artery occlusions. The MR that day showed absence of flow within both the internal carotid arteries, suprasellar, and craniocervical regions. MRA of the neck demonstrated occlusion of both internal carotid arteries at the bifurcation. The left vertebral artery demonstrates flow signal in the neck extending to the intracranial region. The right vertebral artery does not show flow signal in the proximal portion, but flow signal is identified in the distal portion through the cervical collaterals. Overall impression was he had occlusion of the bilateral internal carotid arteries and occlusion of the proximal right vertebral arteries. Patient remained to be intubated through his hospital stay. He initially had been receiving Ativan for his alcohol abuse. He was also receiving propofol while intubated. However, from the time he was intubated, he really never regained any level of consciousness. He began to spike fevers. He was requiring esmolol drip to keep his blood pressure in the 140-150 range. He was kept euvolemic, placed on Heparin subQ, and receiving multivitamins, thiamine, and folate IV. On [**2107-5-16**], patient remained having fevers to the 102 range. He was intubated with no spontaneous movement and not breathing over the vent. His eyes were closed. His pupils were 3.5 mm sluggish. He did have positive dolls and positive corneals, no obvious facial droop. He had flaccid tone throughout. He grimaced to pain, but he did not withdraw. Neurology saw the patient, and recommended an EEG, which was normal. Did not show any signs of seizure activity. They asked for a repeat MRI scan, which was completed on [**5-17**]. There was a small foci with restricted diffusion on left hemisphere consistent with small areas of infarction. However, Neurology felt it was related to just the actual bleed itself. Due to his fevers, he was placed on Levaquin and further fever workup was completed. His LFTs showed elevation consistent with alcoholism. His CPKs were also elevated, however, his ammonia level was within normal limits. Sedation medications were held as much as possible, however, they were sometimes required due to hypertensive episodes. Patient had a complete MRI series of his spine, which showed normal cord signal and no epidural hematomas. MRI was within normal limits, and that was completed due to no involuntary or voluntary movements of his upper and lower extremities. On [**5-17**], he was also placed on ampicillin for coverage of anaerobes for possible aspiration pneumonia. A Renal consult was obtained on [**2107-5-17**] due to question of rhabdomyolysis. They recommended to continue his CKs closely, to replete his electrolytes as needed, and to continue maintain an adequate urine output, and follow his renal function closely, and then monitor for DTs. Also on [**5-17**], a lumbar puncture was done, which showed an opening pressure of 42 after 30 cc of fluid drained went down to 16. He was kept on flat bed rest post procedure, and then later on the 21st, had a ventriculostomy drain placed, which showed an ICP in the range of 4 to 11. Patient had a central line placed on [**2107-5-18**] without any difficulty. On [**5-19**], the patient continued to have high fevers at 103.4 max. CVP was [**6-8**]. ICPs were [**5-10**]. Blood pressures were 108-164/50s-60s. His physical exam: Pupils were brisk 4 to 3. Turns head towards stimulation and had slight movement of his right arm. His blood pressure was kept in the 160-180 range. His drain was at this point was at 10 c of water. A transesophageal echocardiogram was ordered. His cultures from [**5-15**] showed Gram stain culture positive H. flu x2 samples. Chest x-ray at this point showed patchy bibasilar opacities, question atelectasis versus aspiration. He continued on ampicillin and Levaquin for coverage. He was seen by Infectious Disease, who recommended to stop ampicillin and to start Vancomycin 1 gram q.12, to check his stools for Clostridium difficile, lower extremity Dopplers to rule out DVT, and to change his A-line. On [**5-21**], his exam continued to be the same, but he was not following commands. He grimaced to pain. Was not moving his extremities. He had trace withdrawal of his left upper extremity and trace withdrawal of his right upper extremity. On [**5-22**], his source of fever was still unclear. ID continued to workup nosocomial processes. He was covered for Clostridium difficile. Continued on Vancomycin and Levaquin, and Flagyl was added for Clostridium difficile coverage. On [**2107-5-23**], the patient continued to spike very high fevers. Had a very poor neurologic exam despite being off sedation. His increased ICP was ruled out, and he should be more awake with systolic blood pressure greater than 140 due to his ICA and vertebral occlusions. However, patient continued to have a poor neuro exam despite maintaining adequate blood pressure, being off sedation, and having an ICP within normal limits. The family was discussed that his prognosis was grim, and they decided to make him comfort measures only. Patient passed away on [**2107-5-23**]. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**] Dictated By:[**Last Name (NamePattern1) 10062**] MEDQUIST36 D: [**2107-5-24**] 00:46 T: [**2107-5-24**] 12:15 JOB#: [**Job Number 10317**]

[ "349.82", "303.90", "401.9", "E888.9", "507.0", "728.88", "291.81", "852.01", "008.45" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "03.31", "38.93", "02.2", "96.72" ]

icd9pcs

[ [ [] ] ]

1356, 6764

6780, 8820

170, 461

28,346

196,623

24000

Discharge summary

report

Admission Date: [**2188-8-17**] Discharge Date: [**2188-8-17**] Date of Birth: [**2121-5-15**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1271**] Chief Complaint: unable to give - pt intubated Major Surgical or Invasive Procedure: none History of Present Illness: Asked to eval this 67 year old white male who is well known to this service for new ICH. Mr. [**Known lastname 61106**] presents with Large ICH in right temporal parietal region with MLS and IVH. He is currently on hold for his therapies for metestatic renal cell carcinoma secondary to an intracranial abscess that was recently evacuated [**7-8**]. He comes from rehab where he was DNR/DNI - the ED staff was not aware of this and he is currently intubated - the family is supportive of this but wishes now that he is DNR DNI and that he be made CMO when other daughters arrive. Past Medical History: PMHx: Past Medical History: -Renal cell carcinoma / metestatic - Coronary artery disease with an angioplasty and stent implant in [**2184-5-2**] - Diabetes - Hypercholesterolemia - Hypertension - Asthma - recent intracerebral abscess drainage Past Surgical Hx: - s/p craniectomy, evacuation of intracerebral abscess, and debridement of postoperative wound infection [**2188-7-29**] - s/p craniotomy for tumor resection [**2188-6-1**] - Colonoscopy and polypectomy w/complication of severe GI bleeding requiring admission to the hospital and several-units transfusion of blood. - Metastatic renal cell cancer s/p nephrectomy, - R tibia plating [**2187-6-27**] Social History: The patient is not currently working. He was previously employed as a real estate manager. He does not smoke, nor has he smoked in the past. He does not drink alcohol. He has three healthy grown daughters. Family History: There is a history of cancer, diabetes, and heart disease in the family. Physical Exam: PHYSICAL EXAM: on arrival O: T: AF BP:160-180's/80-90 HR: 60-90 R vented Gen: WD/WN, comfortable, NAD. HEENT: Pupils: trace rxn NCAT / No obvious trauma Neuro: No eye opening to voice or noxious, no grimace, extensor postures to noxious, no cough or gag, no localization. Pertinent Results: [**Month/Day/Year 706**] Final Report CT HEAD W/O CONTRAST [**2188-8-17**] 9:15 AM CT HEAD W/O CONTRAST Reason: eval for bleed [**Hospital 93**] MEDICAL CONDITION: 67 year old man with pt with recent hx of TBI/ craniotomy with 2nd hx of infected surgical site, recent declininng ms to only painful stimuli REASON FOR THIS EXAMINATION: eval for bleed CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Metastatic renal cell carcinoma status post surgery, XRT, postoperative scalp infection with declining mental status. No prior comparison exams are available. NON-CONTRAST HEAD CT FINDINGS: There is a large mixed density intraparenchymal hemorrhage within the right frontal lobe at the site of prior surgery displaying hematocrit levels. The size of the hemorrhage itself measures approximately 4.9 x 5.4 cm not including the marked adjacent edema. Additionally, there is interventricular extension of hemorrhage tracking down into the fourth ventricle and a mild-to- moderate sized right subdural likely acute on chronic hematoma measuring approximately 6 mm from the inner table with blood noted to track along the tentorium. Moderate amount of dilatation of the left ventricular system is noted. Subcutaneous air and a large subgaleal mixed density hematoma is present adjacent to the craniotomy site. There is approximately 11 mm of leftward subfalcine herniation as well as mass effect noted on the brainstem with slight effacement of the ambient cistern consistent with mild uncal herniation. Paranasal sinuses display mild amount of thickening within the left maxillary sinus but are otherwise unremarkable. Orogastric and endotracheal tubes are in place. IMPRESSION: 1. Large right frontal intraparenchymal hemorrhage with adjacent mass effect causing prominent leftward subfalcine herniation and mild uncal herniation. Intraventricular extension of hemorrhage with moderate left-sided hydrocephalus. 2. Acute on chronic right subdural hematoma over the right cerebrum and new acute subdural hematoma along the falx and tentorium. 3. Large mixed density subgaleal hematoma and subcutaneous air adjacent to craniotomy site. 4. Findings are most consistent with hemorrhagic conversion of patient's known metastatic renal cell carcinoma. Findings discussed with the ordering physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on date of exam at approximately 10:00 a.m. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SUN [**2188-8-17**] 3:04 PM Brief Hospital Course: Pt was admitted to the TICU after initial ED eval and family conversation not to pursue aggressive medical management. Pt was a DNR/DNI prior to admission however the ED was not aware on arrival. He was intubated. CT revealed massive IPH with MLS. His exam was morbid. He was admitted for end of life care/CMO. He wa extubated after remaining family members arrived. [**Name2 (NI) **] expired shortly after. Family support was provided to the pts wife and daughters. Medications on Admission: Medications prior to admission: Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* Verapamil 180 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Testosterone 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) Transdermal DAILY (Daily). Furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day: take while on steroids. Disp:*60 Tablet(s)* Refills:*2* Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 6 weeks Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: No driving while on narcotics. Disp:*60 Tablet(s)* Refills:*0* Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Take while on narcotics. Disp:*60 Capsule(s)* Refills:*0* Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 weeks. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: massive ICH Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2188-9-17**]

[ "493.90", "198.3", "401.9", "250.00", "272.0", "V49.75", "431", "V10.52" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

7057, 7066

4960, 5431

306, 312

7121, 7130

2245, 2378

7183, 7313

1853, 1927

7028, 7034

2415, 2557

7087, 7100

5460, 5460

7154, 7160

1957, 2223

5492, 7005

237, 268

2586, 4937

340, 924

976, 1609

1625, 1837

8,850

182,865

45410

Discharge summary

report

Admission Date: [**2185-8-25**] Discharge Date: [**2185-8-30**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10842**] Chief Complaint: N/V, poor PO intake x2-3 days Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, Ms. [**Known lastname 10446**] is an 84 year old woman with severe aortic stenosis and subsequent diastolic and systolic CHF, also with Rheumatoid Arthritis, coagulopathy on standing vitamin K, who presented on [**8-25**] with nausea, vomiting, and poor PO intake. In the ED, she was found to have stable vital signs but acute renal failure (creatinine 3.4), hyperkalemia (5.8), and acutely elevated LFT's (ALT 1253, AST 2409, LDH 2200). Ultrasound was consistent with acute hepatitis, without evidence of vascular throbmosis or cirrhosis. KUB was without evidence of any bowel obstruction. She was sent to the ICU for monitoring given concerning lab values, although hemodynamically she was never unstable. . In the MICU she was hydrated and her diuretics were held. Her hyperkalemia was managed with insulin, calcium gluconate, kayexalate and albuterol nebs. Her K slowly improved. Surgery team evaluated the abd CT which did not show evidence of obstrucion or ischemia despite elevated lactate of 5. Liver was consulted and thought her transaminitis was either due to autoimmune hepatitis vs. toxin induced. Renal was also consulted and thought her renal failure might be AIN given her ingestion of NSAIDs prior to admission, and by report they saw Eos in her urine. Over her stay, creatinine and transaminases trended down. Her N/V abated. She developed crackles 2 days into her hospitalization but did not require supplemental O2. She was deemed stable and transferred to the floor today. Past Medical History: -Severe Aortic stenosis [Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR] -Moderate to severe MR [**Name13 (STitle) **] to severe TR -H/O small bowel obstruction s/p resection [**2185-5-11**] -dCHF and mild sCHF with EF 45-50% [Mild global RV free wall hypokinesis. Mild global LV hypokinesis]. -? Hepatic congestion from R sided heart failure -Anemia of chronic disease baseline HCT 28-30 -coagulopathy on chronic Vit K -hyponatremia -CRI (Baseline Cr 0.6-2.0, last Cr 0.8 [**2185-6-11**]) . PSH: - 2 distant c-sections - SB volvulus s/p bowel resection 3 months ago [**2185-5-11**] featuring: 1. Exploratory laparotomy. 2. Lysis of adhesions. 3. Reduction of small bowel volvulus. 4. Small bowel resection, primary anastomosis. Social History: Widowed and lives alone, although has been living with one of her daughters since her recent surgery. She has 6 daughters and 2 sons. Denies EtOH, smoking. Family History: n/c Physical Exam: VS: T 95.9 BP 110/37 HR 62 RR 13 94%RA GEN: NAD HEENT: Dry MM, slightly icteric sclera RESP: CTABL with inspiratory crackles at R base, no wheezing CV: Reg Nml S1, S2, 3/6 SEM at loudest LUSB radiates throughout precordium, no carotid bruits or extension of murmur ABD: soft, distended, NT on palpation, no rebound, no guarding, diminished BS throughout. EXT: no peripheral edema, warm 1+DP pulses b/l, no tremor NEURO: A&O x3, no focal deficits, 5/5 strength throughout, normal sensation throughout Pertinent Results: [**2185-8-25**] ADMISSION LABS: CBC: WBC-12.3*# RBC-3.22* Hgb-10.6* Hct-30.9* MCV-96 MCH-32.8* MCHC-34.1 RDW-19.0* Plt Ct-215 . COAGS: PT-25.3* PTT-33.3 INR(PT)-2.6* . CHEM: Glucose-87 UreaN-67* Creat-3.4*# Na-126* K-5.8* Cl-84* HCO3-16* Calcium-8.0* Phos-10.4*# Mg-2.3 . LFTs: ALT-1253* AST-2409* LD(LDH)-2200* CK(CPK)-135 AlkPhos-86 TotBili-2.0* DirBili-1.5* IndBili-0.5 Lipase-42 . CEs: CK-MB-13* MB Indx-9.6* cTropnT-0.05* . IRON PANEL: calTIBC-306 TRF-235 Ferritn-1056* . TFTs: Free T4-1.1 TSH-9.0* . [**2185-8-25**] Liver U/S: IMPRESSION: Mild hyperemia and gallbladder wall thickening of a non-distended gallbladder is likely secondary to hepatitis or third spacing. Acute cholecystitis is not favored. . [**2185-8-25**] CXR: IMPRESSION: Improvement with resolution of previously noted pleural effusions. No frank failure or consolidation noted. Stable massive cardiomegaly as above. . [**2185-8-25**] KUB: FINDINGS: There is no free intraperitoneal air. The stomach is gas distended. No dilated loops of small bowel are evident. There is minimal stool noted likely in the region of the cecum. Stool is also noted in the sigmoid and rectal region. The descending colon is collapsed. IMPRESSION: No free air. Nonobstructive bowel gas pattern. . [**2185-8-26**] CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST IMPRESSION: 1. Liver demonstrates diffuse hypodensity. However, since the ultrasound performed on [**2185-8-25**], did not demonstrate any fatty change within the live, this appearance is suggestive of hepatitis. Small amount of ascites is surrounding the liver. Generalized anasarca is also visualized. 2. The duodenum is significantly thickened. This appearance might be due to intramural hematoma or due to inflammatory changes in adjacent structures like pancreatitis/hepatitis. 3. Small hypodense area between pancreatic head and duodenum likely representing a tiny amount of fluid. 3. Stable appearance of calcified mesenteric cyst within the right lower quadrant area. 4. Stable appearance of fluid-containing right inguinal hernia. 5. Small bilateral pleural effusions. 6. Severe degree of mitral annulus calcification. . [**2185-8-26**] DUPLEX DOP ABD/PEL LIMITED IMPRESSION: Normal hepatic vasculature . [**2185-8-26**] LFTs ALT-1707* AST-3356* LD(LDH)-2856* AlkPhos-75 Amylase-52 TotBili-1.1 . HEPATITIS WORKUP: HBsAg-NEGATIVE IgM HBc-NEGATIVE HBsAb-NEGATIVE HAV Ab-NEGATIVE AMA-NEGATIVE Smooth-NEGATIVE [**Doctor First Name **]-POSITIVE Titer-1:1280 IgG-[**2145**]* Acetmnp-9.4 . [**2185-8-30**] DISCHARGE LABS: CBC: WBC-8.5 RBC-2.88* Hgb-9.4* Hct-29.2* MCV-101* MCH-32.8* MCHC-32.4 RDW-20.2* Plt Ct-157 . CHEM: Glucose-98 UreaN-41* Creat-1.1 Na-135 K-4.0 Cl-100 HCO3-26 AnGap-13 Calcium-8.7 Phos-2.5* Mg-2.1 . LFTs: ALT-882* AST-676* LD(LDH)-366* AlkPhos-78 TotBili-1.6* [**2185-8-26**] 02:58AM BLOOD [**2185-8-28**] 03:43AM BLOOD Brief Hospital Course: AP: 84 yo F with severe AS, mod-severe MR/TR, diastolic CHF c/b hepatic congestion but with preserved EF (45-50%), now presents with N/V, poor PO intake x 2 days, found to have acute hepatitis and acute renal failure. . #. ARF: Pt with acute renal failure in setting of poor PO intake and persistent lasix use (prerenal picture) vs. ATN with low UOP vs. possible post obstructive etiology. Per pt she denied any excessive NSAID use, she had been taking about 3 advils for her back pain but nothing excessive. Her lasix regimen had recently been increased since her d/c from her bowel resection hospitalization in may to 80mg daily. Her PCP had decreased her Lasixe and Spironolactone dose on Tuesday, 2 days prior to admission. She was unable to take any meds 2-3 days prior to admission due to persistent N/V. She was carefully hydrated initially with 250cc bolus of 3amps NaHCO3 in D5W for a low HCO3 and metabolic acidosis. Renal was consulted who thought this was possibly ATN vs. NSAID toxicity. Her UOP improved 3 days into her hospitalization. A renal U/S did not show evidence of hydronephrosis. She had a unimpressive UA and UCulture was negative. She received a dose of Cipro 400mg IVx1 in the ED which was not continued in the MICU. Her diuretics were held and her Cr slowly improved. She was started on phos binders for elevated Phos. She initially received insulin, calcium gluconate, and kayexalate for HyperK-her EKG did not show hyperacute T waves and she had no dysrhythmias on tele. On the wards, her creatinine continued to trend downwards and was WNL at 1.1 at time of discharge. . #. Hepatititis: With levels that peaked at AST 3300, ALT 1700, this differential diagnosis is narrow: Acute viral hepatitis vs. toxic idiosyncratic drug reaction vs. tylenol overdose vs. ischemia vs. autoimmune hepatitis. Pt with prior diagnosis of hepatic congestion from CHF, so this may confound the picture. Acetaminophen level was normal. She did not appear to be in decompensated CHF and transaminases were markedly elevated, so this is less likely secondary to pure congestive hepatopathy. A liver U/S with doppler was negative for arterial or venous ischemia/thrombus. Hepatitis serologies for A, B, C were all negative. Interestingly, her IgG was slightly elevated, and the patient has a known personal autoimmune hisotry with a longstanding diagnosis of RA with [**First Name9 (NamePattern2) 87802**] [**Doctor First Name **]. She also has a family history of autoimmune disease. Her [**Last Name (un) 15412**] and AMA were both negative on this admission, but this does not entirely exclude the diagnosis of autoimmune hepatitis. The patient was not amenable to a biopsy, but we decided not to pursue this, or steroid treatment, but rather to observe her to see if the LFTs normalized. Indeed her LFTs trended down and continued to do so at time of d/c. She has PCP/cards followup arranged with Dr. [**Last Name (STitle) 1147**], where she should have her LFTs trended. . #. Severe AS: Not surgical candidate due to several comorbidities based on surgical evaluation from last admission. No peripheral edema but with some basilar rales developed during this admission. Her fluid balance was closely monitored. She did not require supplemental O2 during her MICU or [**Hospital1 **] course. Her BB was resumed but at a lower dose. Her diuretics were held, but on discharge we resumed the spironolactone and restarted lasix at a lower dose (20 mg po daily). . #. Nausea/Vomiting: Likely multifactorial and related to acute renal failure and acute hepatitis. Had a distended stomach with gas but no evidence of obstruction on KUB. She was initially kept NPO until she had a BM. Subsequent to the [**Doctor Last Name 96928**] and kayexalate, she had a normal BM. She was started on a reg diet and tolerated it quite well. Her N/V resolved by discharge. . # Elevated Blood Glucose: patient with no history of DM. Was not given steroids or other hyperglycemic agents. A Hgb A1c was 4.9%. This most likely represents an acute hepatic abberation of glucose regulation in the setting of a severe acute hepatitis. . #. Hyperkalemia: Pt on KCL repletion until recently, when switched to K sparing diuretic. With ARF, these diuretics were held. She did not have any hyperacute T waves or QRS changes on EKG, no dysrhythmias on tele in the MICU, and was initially managed with insulin, calcium gluconate, kayexalate and albuterol nebs. Her K slowly improved and was normal throughout her stay on the floor. . #. Hyponatremia: On diuretics chronically with hyponatremia. Diuretics were held and she became eunatremic. . # Back pain: Patient and daughter concerned that this could be her RA acting up. I was not inclined to prescribe her any narcotics, so instead I recommended tylenol, not to exceed 3 grams per day. I instructed her to avoid all NSAIDs as this was thought to be responsible for her ARF. She is interested in a rheum referral to assess if this is RA. . #. CODE: Full throughout . # Follow-up: arranged with Dr. [**Last Name (STitle) 1147**] on [**2185-9-9**]. Medications on Admission: 1. MVI 1 cap daily 2. Ferrous Sulfate 325 mg daily 3. Phytonadione 10 mg Tablet daily - OFF since [**8-23**] 4. Metoprolol Tartrate 25 mg [**Hospital1 **] 5. Spironolactone 25mg daily- changed to 25mg every other day [**8-23**] 6. Lasix 80 mg daily, changed to 40mg every other day on [**8-23**] 7. Aspirin 325mg daily 8. Propoxyphene-N 100 (new med for back pain, not taken yet) Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Phytonadione 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Acute Renal Failure Acute hepatitis . Secondary: Rheumatoid Arthritis Aortic Stenosis distolic CHF mitral and tricuspid regurgitation Discharge Condition: good, improved Discharge Instructions: You were admitted ot the hospital with nausea and vomiting. You were found to have acute renal (kidney) failure, as well as some acute damage to your liver. Also, the level of potassium in your blood was high. For these reasons, you were admitted to our Intensive Care Unit for further management. . You were rehydrated and your kidneys recovered quickly. We treated the high potassium level in your blood. We eliminated many possible diagnoses regarding the damage to you liver, including tylenol toxicity, viral hepatitis, hypoperfusion/shock, or venous clotting. Your liver damage may be due to either a bad reaction to the ibuprofen you took for back pain, or it may also be due to a process called autoimmune hepatitis. The only way to prove this diagnosis is by doing a liver biopsy, which we did not do on this admission. If your liver function does not normalize after your discharge, we recommend that your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**] refer you for a liver workup and possible biopsy. . We are restarting your Lasix, but at a smaller dose (20mg daily) than you are used to. Please continue to take all your other medicines as prescribed. . For back pain, we are giving you tylenol. Even with your liver injury, it is safe for you to take tylenol, up to 3 grams per day. Please do not exceed this amount. Also, please avoid any ibuprofen (Advil, Motrin, Alleve, etc), as these can cause serious damage to your recovering kidneys. . You blood sugars were slightly elevated on this admission. We are not sending you home with any medicines or insulin, but please follow-up on this issue with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**]. . If you feel any additional nausea or vomiting, or if you have any other complaints that are disturbing to you, please call your doctor or go to the ER. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**]. You have an appointment with him on [**Last Name (LF) 2974**], [**9-9**], at 1:15PM.

[ "285.21", "276.7", "428.0", "397.0", "570", "276.2", "396.8", "585.9", "584.9", "714.0", "428.42" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12400, 12406

6258, 11337

293, 300

12593, 12610

3363, 3379

14522, 14705

2823, 2828

11767, 12377

12427, 12572

11363, 11744

12634, 14499

5913, 6235

2843, 3344

224, 255

328, 1833

3395, 5897

1855, 2633

2649, 2807

52,533

110,767

43246

Discharge summary

report

Admission Date: [**2155-1-29**] Discharge Date: [**2155-2-16**] Date of Birth: [**2091-3-19**] Sex: M Service: CARDIOTHORACIC Allergies: Morphine / Dilaudid Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2155-2-3**] Coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein graft from aorta to first diagonal coronary artery; reverse saphenous vein graft from aorta to first obtuse marginal coronary artery; as well as reverse saphenous vein graft from aorta to posterior left ventricular coronary artery History of Present Illness: 63 year old male who presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with chest pain/shortness of breath for the last 2-3 days. The patient stated that three days ago he developed sudden onset of midsternal chest pain as a dull pain. He had intermittent pain; the longest one lasted around 2-3 hours. Next day woke up with shortness of breath and continued to have chest pain. Unable to catch his breath and EMS was activated on [**2154-11-20**]. Peak trop 0.52 [**2155-1-20**], trending down 0.42. Patient has bilateral Rales, he has been receiving IV bumex with good diuresis. Patient had an episode of chest pain this am, mid sternum, while at rest relived with one sublingual ntg. He was transferred to [**Hospital1 18**] for cardiac cath. Past Medical History: Diabetes Dyslipidemia Hypertension Chronic kidney disease DVT (no PE) Past Surgical History: s/p Left hip replacement s/p multiple knee surgeries in past Left and right Social History: Race:Caucadian Last Dental Exam:edentulous Lives with:wife Occupation:retired Tobacco:quit 25 years ago ETOH:occasionally Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse:83 Resp:24 O2 sat:97/2L B/P Right:189/94 Left:171/86 Height: 6'1" Weight:280 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [] chronic venous stasis + Edema +2 Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [**2155-2-12**] 03:19AM BLOOD WBC-10.9 RBC-3.06* Hgb-9.5* Hct-28.7* MCV-94 MCH-30.9 MCHC-33.0 RDW-14.8 Plt Ct-386 [**2155-2-11**] 03:32AM BLOOD WBC-10.3 RBC-3.03* Hgb-9.1* Hct-27.6* MCV-91 MCH-30.1 MCHC-33.0 RDW-15.0 Plt Ct-382 [**2155-2-12**] 03:19AM BLOOD Glucose-87 UreaN-88* Creat-3.1* Na-142 K-3.8 Cl-100 HCO3-27 AnGap-19 [**2155-2-11**] 03:32AM BLOOD Glucose-113* UreaN-84* Creat-2.9* Na-142 K-4.0 Cl-102 HCO3-29 AnGap-15 [**2155-2-10**] 03:07AM BLOOD Glucose-138* UreaN-80* Creat-3.0* Na-145 K-4.2 Cl-102 HCO3-28 AnGap-19 [**2155-2-9**] 03:20AM BLOOD Glucose-80 UreaN-74* Creat-3.3* Na-148* K-3.7 Cl-107 HCO3-28 AnGap-17 [**2155-2-8**] 02:39AM BLOOD Glucose-112* UreaN-73* Creat-3.8* Na-144 K-4.0 Cl-104 HCO3-28 AnGap-16 [**2155-2-3**] Intraop TEE PRE-CPB: 1. The left atrium is mildly dilated. A patent foramen ovale is present. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with inferoapical and anteroapical hypokinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 30-35 %). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. with mild global free wall hypokinesis. 3. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. 4. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6. There is a very small pericardial effusion. The pericardium may be thickened. POST-CPB: On infusion of epi and milrinone briefly. A-paced for bigeminy briefly. Improved biventricular systolic function after CPB with the LVEF = 40-45%. The anterior and inferior walls are improved. The MR is now trace. The aortic contour is normal post decannulation. [**2155-2-14**] 04:51AM BLOOD WBC-8.2 RBC-2.88* Hgb-8.9* Hct-26.8* MCV-93 MCH-30.9 MCHC-33.1 RDW-14.7 Plt Ct-331 [**2155-2-15**] 05:45AM BLOOD WBC-8.4 RBC-2.90* Hgb-9.1* Hct-26.5* MCV-92 MCH-31.4 MCHC-34.3 RDW-14.6 Plt Ct-400 [**2155-2-10**] 03:07AM BLOOD PT-18.0* PTT-29.7 INR(PT)-1.6* [**2155-2-16**] 04:56AM BLOOD Glucose-161* UreaN-112* Creat-4.1* Na-138 K-4.7 Cl-98 HCO3-27 AnGap-18 [**2155-2-14**] 04:51AM BLOOD Calcium-7.0* Phos-6.3* Mg-2.5 Brief Hospital Course: 63 yo male history of Diabetes Mellitus 2, Hypertension, Hyperlipidemia, Coronary artery disease s/p recent cath at [**Hospital1 18**] on [**2155-1-22**] after NSTEMI found to have three vessel disease with CABG planned on [**2155-2-7**] that presented with chest pain and shortness of breath consistent with unstable angina, acute on chronic heart failure exacerbation, and acute on chronic renal failure. On [**2155-2-3**] he was taken to the operating room and underwent coronary artery bypass grafting x four with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein graft from aorta to first diagonal coronary artery; reverse saphenous vein graft from aorta to first obtuse marginal coronary artery; as well as reverse saphenous vein graft from aorta to posterior left ventricular coronary artery with Dr.[**Last Name (STitle) 914**]. Cross clamp time= 83 minutes. Cardiopulmonary Bypass Time=110 minutes. [**2155-2-4**] he awoke neurologically intact and was weaned to extubation. The following day he was reintubated secondary to hypercapnea. All lines and drains were discontinued in a timely fashion. POD#4 he was weaned to extubation successfully. Beta-blocker/Statin/Aspirin/ and diuresis were initiated. All narcotics were discontinued due to postoperative delerium and confusion.Renal was consulted for acute on chronic renal failure. He continued to progress, mental status improved and on POD#7 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for strength and mobility. Pt was recommended to go to rehab, but refused. Pt decided to sign out against medical advice His BUN and cratinine remain high. He is making good urine. BUN 112 / Creatine 4.1. Renal recommended laasi and zaroxalyn. All follow up appointments were advised. Medications on Admission: Pro-air inhaler 2 puffs every 2 hours Simvastatin 40mg QD Lasix 40mg Daily Lostartan/potassium 50mg Daily MVI Vit. C 500mg Daily Vitamin D 50,000 units daily Allergies:Morphine/Diluadid (Confusion) 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. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Neurontin 400 mg Capsule Sig: One (1) Capsule PO once a day. 5. Lopid 600 mg Tablet Sig: One (1) Tablet PO once a day. 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): prn for pain. Disp:*240 Tablet(s)* Refills:*2* 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): untill follow up. Disp:*30 Tablet(s)* Refills:*0* 10. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 12. insulin Insulin SC Fixed Dose Orders Breakfast Bedtime Glargine 50 Units Glargine 40 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2 Units 2 Units 2 Units 0 Units 160-199 mg/dL 6 Units 6 Units 6 Units 3 Units 200-239 mg/dL 10 Units 10 Units 10 Units 5 Units 240-280 mg/dL 14 Units 14 Units 14 Units 7 Units > 280 mg/dL Notify M.D. 13. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day: 120 mg [**Hospital1 **]. Disp:*180 Tablet(s)* Refills:*2* 14. Zaroxolyn 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Outpatient Lab Work Daily chem 10, please fax the results to Dr [**Last Name (STitle) **] at ([**Telephone/Fax (1) 93163**] and Dr [**First Name (STitle) **] at ([**Telephone/Fax (1) 93164**] Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. 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 [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) 914**] on [**2155-2-25**] at 2:30 Cardiologist:[**Last Name (LF) 10543**], [**First Name3 (LF) **] Please call to schedule appointments with your Primary Care Dr. [**First Name (STitle) 19961**] in [**4-1**] weeks [**Telephone/Fax (1) 33016**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2155-2-16**]

[ "278.01", "428.0", "583.81", "411.0", "599.0", "250.60", "585.9", "428.23", "041.4", "458.29", "403.90", "440.20", "357.2", "423.3", "293.0", "584.5", "276.0", "V43.64", "V45.82", "414.01", "410.72", "250.40" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "36.13" ]

icd9pcs

[ [ [] ] ]

9451, 9502

5112, 6952

296, 681

9570, 9788

2632, 5089

10628, 11151

1836, 1951

7202, 9428

9523, 9549

6978, 7179

9812, 10605

1602, 1680

1966, 2613

246, 258

709, 1487

1509, 1579

1696, 1820

19,184

101,993

49457

Discharge summary

report

Admission Date: [**2188-4-11**] Discharge Date: [**2188-4-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: endotracheal intubation and mechanical ventilation History of Present Illness: This is an 88 y/o male with multiple medical problems who was recently hospitalized for a fall from [**2188-2-23**] to [**2188-4-2**]. The patient was discharged to [**Hospital 100**] Rehab. During this time the patient's family feels that his course has been deteriorating. Leading up to this presentation he was noted to be delirious this week. He became hypoxic today desatting down to 77% RA and tachypneic to the 40s. ABG 7.42/65/64/42. He was transferred to [**Hospital1 18**] for further mgt. . Upon arrival to the ED, the patient's vitals were as follows T 98, P76, BP 111/54, RR 17, 02 sat 100% on NRB. There was later concern that the patient had a weak gag reflex. He was intubated to protect his airway. Patient became transiently hypotensive with sedation which later improved with fluid boluses. . CXR showed parenchymal and reticular opacities c/w aspiration (seen on previous). Head CT was negative. The patient was transferred to the unit for further management. . In terms of his recent hospitalization, the patient's course was complicated. He originally presented with a fall during which time he was noted to have minimally displaced anterior column acetabular fractures with nondisplaced inferior pubic rami fractures. These fractures were deemed stable by orthopedics. Due to his poor nutritional status, PEG tube was placed. During the EGD the patient was noted to have duodenal crater ulcers which were cauterized. He was later bacteremic with Klebsiella ESBL, treated with Meropenem. The patient was also treated for aspiration pneumonia. He was initially started on levaquin and flagyll but later transitioned to zosyn. The patient was also kept on strict aspiration precautions. The patient had a prolong complicated course which later stabilized. He was discharged to [**Hospital 100**] Rehab. . ROS: Unable to obtain, patient is intubated and sedated Past Medical History: 1. Coronary artery disease. s/p MI and CABG [**93**] years ago, no events since 2. Mitral regurgitation. Mod - severe 3. Hypertension 4. Pagets disease 5. Pelvic fractures 6. Bacteremia 7. FTT 8. Duodenal ulcers. Social History: Pt lives with wife [**Name (NI) 8797**]. [**Name2 (NI) **] walks with a cane. Past tobacco use >40 years ago ([**2-13**] ppd). Rare EtOH. Family History: n/c Physical Exam: MICU Admission PE: T 97.9, BP 109/56, HR 67, RR 13-18, O2 100% AC 550 X 15/Fi02 .4/PEEP 5 Gen: Frail Elderly gentleman intubated and sedated HEENT: MM extremely dry Neck: Supple, no LVD, no bruits Heart: RRR, nl S1, S2 no S3/S4, II/VI SEM > LUSB Lungs: CTA b/l Spine: stage I decub along upper thoracic spine Sacrum: stage I-II along decub Extrem: thin, severe muscle wasting, no cyanosis, clubbing or edema Rectum: liquid greenish stool noted at rectum Pertinent Results: [**2188-4-11**] 08:00PM WBC-9.4 RBC-2.96* HGB-9.8* HCT-28.8* MCV-97 MCH-33.2* MCHC-34.2 RDW-16.5* [**2188-4-11**] 08:00PM PLT SMR-NORMAL PLT COUNT-379 [**2188-4-11**] 08:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL [**2188-4-11**] 08:00PM NEUTS-80.7* BANDS-0 LYMPHS-9.2* MONOS-6.8 EOS-2.7 BASOS-0.5 [**2188-4-11**] 08:00PM PT-13.1 PTT-36.9* INR(PT)-1.1 [**2188-4-11**] 08:00PM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-2.4 [**2188-4-11**] 08:00PM proBNP-869* [**2188-4-11**] 08:00PM GLUCOSE-120* UREA N-54* CREAT-1.1 SODIUM-137 POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-36* ANION GAP-12 [**2188-4-11**] 08:32PM LACTATE-1.4 . Micro [**4-13**] sputum cx negative [**4-12**] sputum MRSA, GNRS (speciation *** PENDING *** as of discharge) [**4-12**] C. difficile toxin assay POSITIVE [**4-12**] blood cx NGTD [**3-/2109**] blood cx ** PENDING ** as of discharge . Imaging [**3-/2109**] CXR COMPARISON: Multiple priors, the most recent dated [**2188-3-27**]. FINDINGS: Extensive reticular nodular interstitial opacities along with more nodular opacities are noted again predominantly in the left upper lobe and to a lesser degree in the right upper lobe and left perihilar regions. Lung volumes are markedly diminished reducing the evaluation of the lung bases. The right upper extremity PICC line has been replaced with a left upper extremity- approach PICC line with the distal tip at the superior cavoatrial junction. Again noted are clips and median sternotomy wires consistent with prior CABG. No definite effusion or pneumothorax is evident. Consistent with the given history, an endotracheal tube is evident with the distal tip approximately 6.2 cm from the carina. IMPRESSION: Endotracheal tube as above. New left upper extremity PICC line. Extensive parenchymal reticular and nodular opacities previously ascribed to aspiration pneumonia. Given their persistence, a non-emergent chest CT is recommended to assess for interval change. . [**3-/2109**] CT head FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of normally midline structures. The ventricles, cisterns, and sulci are enlarged, unchanged in appearance. Extensive periventricular and subcortical white matter hypodensities as well as multiple lacunar infarcts are redemonstrated. The visualized paranasal sinus is clear aside from mild ethmoid sinus mucus thickening, and the mastoid air cells are clear. Note of bilateral lens replacements. IMPRESSION: No intracranial hemorrhage or mass effect. . [**3-/2109**] EKG Sinus arrhythmia. Left atrial abnormality. Right bundle-branch block. Left anterior fascicular block. Compared to the previous tracing of [**2188-3-26**] no diagnostic interim change. . [**4-12**] CTA chest 1. Negative examination for pulmonary embolism. 2. Slight decrease in the scattered consolidations/ground-glass opacities predominantly seen in the dependent most portion of both lungs associated with mild bronchiectasis and impacted bronchioles. The appearances although slightly decreased on today's examination suggest a chronic process like aspiration 3.Retained secretion are seen in the carinal bifurcation.Bronchoscopy is recommended. 3. The previously noted pleural effusions have resolved. Brief Hospital Course: 1. Pneumonia The patient's respiratory failure was thought to be due to an aspiration pneumonia. CTA chest showed no evidence of PE, and cardiac enzymes showed no evidence of myocardial ischemia. Sputum grew MRSA and GNRs, the speciation of which was pending at discharge and should be followed up by his physicians at his rehabilitation facility. He was started empirically on vancomycin and zosyn, which he will continue pending return of the final culture data. He should complete a 14day course of therapy to end on [**2188-4-25**]. . 2. C. difficile colitis Patient's stool came back positive for C. diff toxin, was started on flagyl. He should continue flagyl and continue for an additional 2 weeks following completion of meropenem and vancomycin to reduce risk of recurrence. Patient was afebrile with minimal abdominal tenderness and no leukocytosis at discharge. . 3. History of delirium: Per patient's family leading up to his admission he appeared confused. During his last admission, he was found to have a PCA infarct. An EEG during the last admission also showed encephalopathy. A family meeting was held and the patient's code status was changed to DNR/DNI. Health care proxy is [**Name (NI) **] [**Name (NI) 25989**], patient's daughter-in-law. Documentation has been provided and is in chart. Medications on Admission: lopressor 12.5mg [**Hospital1 **] senna thiamine 100mg via g tube Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): hold sbp<100, hr<60 per G tube. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): per G tube. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): per G tube. 5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: no more than 4 grams of acetaminophen in all forms daily. per G tube. 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold sbp<100 per G tube. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: per G tube. 10. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray Nasal DAILY (Daily): one spray in one nostril alternating daily . 11. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension Sig: 1000 (1000) mg PO BID (2 times a day): via peg. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day): per G tube. 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: hold for excess sedation. give via G tube. 14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: see below ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous Q 12H (Every 12 Hours) for 8 days. 16. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 8 days. 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Continue for two weeks following completion of vancomycin and meropenem. Give via G tube. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary 1. Pneumonia 2. C. difficile colitis Secondary 1. Hypertension 2. Paget's disease 3. CAD Discharge Condition: Fair, with improved respiratory status and hemodynamically stable Discharge Instructions: You came into the hospital because of trouble breathing. You were found to have a pneumonia. You were treated with antibiotics, and initially placed on a breathing machine (ventilator) in the intensive care unit. Your breathing and pneumonia were improved by the time you left the hospital for your rehab facility. You also developed diarrhea in the hospital, for which you will need to take antibiotics. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 2204**] [**Telephone/Fax (1) 2205**] as needed. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "401.9", "V44.1", "518.81", "507.0", "482.41", "V09.0", "707.03", "V45.81", "424.0", "707.02", "008.45", "731.0", "293.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

10004, 10070

6455, 7771

281, 333

10211, 10279

3166, 6432

10732, 10918

2671, 2676

7887, 9981

10091, 10190

7797, 7864

10303, 10709

2691, 3147

222, 243

361, 2262

2284, 2499

2515, 2655

2,262

107,796

15683

Discharge summary

report

Admission Date: [**2118-1-1**] Discharge Date: [**2118-1-11**] Date of Birth: [**2072-1-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: weakness, SOB with exertion and left sided chest pain Major Surgical or Invasive Procedure: Pericardial drainage with pigtail catheter Left thoracentesis History of Present Illness: Pt is a 46 y/o man with a hx of positive PPD, and a recently diagnosed NSCLC who presents with 3 day hx of weakness, SOB with exertion and left sided chest pain which radiates to his back and he describes saying "it feels like someone is poking me." He reports that his cough is not productive of sputum, but that when he coughs, he feels like he needs to vomit. This cough is unchanged from the cough he has had since [**Month (only) **]. He estimates that from his last admission he has lost apporximately 10 pounds. He denies fever, dizziness, light-headedness, HA, abd pain, leg pain, leg swelling. . Pt was healthy until [**Month (only) **] when he began to notice blood in his sputum. He also reported night sweats and weight loss, but denied fever and shortness of breath. A chest CT was performed in [**11-15**] which showed a 3.1 x 1.7 cm cavitary mass in the superior segment of the right lower lobe in addition to multiple large mediastinal lymph nodes. There were also several lytic lesions in the thoracic and lumbar spine which were concerning for metastases. Given the pt's hx of a positive PPD, pt was also evaluated for TB. Spirometry was performed and was consistent with a severe obstructive defect. Sputum cytology was negative for AFB and malignant cells but transbronchial needle aspiration showed atypical epithelioid and inflammatory cells suspicious for malignancy and precarinal LN and bronchial washings were both positive for malignant cells, consistent with NSCLC. . In the ED, the pt was found to have an elevated pulsus paradoxus at 15-20. An echo showed a large echodense pericardial effusion consistent with blood, inflammation or other cellular elements. There was RV diastolic collapse, consistent with tamponade. In the cath lab, 1500cc of grossly bloody pericardial fluid was drained and a pericardial drain was sutured in place. A repeat echo showed that the effusion had decreased in size and the RV collapse had resolved. The pericardial fluid cytology was positive for malignant cells consistent with non-small cell metastatic carcinoma. . The pt was also found by CXR to have a large consolidation in the left lower lobe with small bilateral pleural effusions, and evidence of pulmonary edema. . The patient was transferred to the MICU for further monitoring. In the MICU, pt was treated with CTX/azithromycin for his L. lobe PNA. His repeat ECHO showed greatly decreased size of pericardial effusion and the pericardial drain was pulled. Pt no longer complains of any SOB. In the MICU, pt has also had 2 episodes of episode of A-fib. The first episode was reverted to sinus rhythm with amiodarone. Lopressor was added after the second episode. Amiodarone was continued as pt will likely continue to be at risk for further episodes of a-fib. Finally, the pt had thoracentesis before coming to the floor. Past Medical History: 1. Positive PPD last month. 2. Asthma. 3. No history of hypertension, diabetes, or coronary artery disease. Social History: Born and raised in [**Country 651**] and came to the United States in [**2100**]. He works in construction, primarily installing sheetrock and plumbing. Reports possible exposure to asbestos and other chemicals. Lives with wife and 2 daughters [**Name (NI) **] smoked one to two packs of cigarettes a day for 22 years, however, quit two to three years ago. He drinks alcohol socially. Family History: His father died at 67 from an unknown cause. His mother is 73 and alive and well. He has two brothers and one sister, who are also healthy. Physical Exam: Exam: 98.1 (100.8 in ED), BP 115/80, HR 118, R 28, O2 100% on NRB Gen: ill appearing but no acute distress HEENT: EOMI, MMM Neck: elevated JVD CV: tachy, regular, no murmur Chest: decreased breath sounds at left base with bronchial breath sounds; decreased breath sounds at right apex Abd: +BS, soft, NT Ext: trace edema bilaterally, 2+ DP Neuro: 5/5 strength in upper and lower ext bilaterally Pertinent Results: Chest CT [**11-15**]: * A 3 cm spiculated mass with cavitation, adjacent tethering and pleural thickening with multiple enlarged conglomerate lymph nodes, most worrisome for primary pulmonary neoplasm and less likely infection. * Scattered lytic lesions in the thoracic spine, worrisome for metastases. * Moderate pericardial effusion. . Studies: [**12-31**] AP CXR - 1. Left lower lobe pneumonia. 2. Congestive heart failure. 3. Small bilateral pleural effusions. . [**12-31**] EKG Sinus tachycardia Atrial premature complexes Atrial fibrillation with rapid ventricular response Indeterminate QRS axis Generalized low voltage Modest right ventricular conduction delay pattern Findings are nonspecific but suggest in part chronic pulmonary disease or possible ventricular overload No previous tracing available for comparison . [**1-1**] ECHO 1. The left atrium is normal in size. 2.Left ventricular wall thicknesses are normal. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF:50-55%). 3.The aortic valve is not well seen. 4.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5.There is a large pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . [**1-1**] Post-Procedure ECHO Left Ventricle - Ejection Fraction: 45% to 55% (nl >=55%) Conclusions: 1. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. The views are limited but the overall left ventricular systolic function is mildly depressed with global hypokinesis. 2.The mitral valve leaflets are mildly thickened. 3.There is a moderate sized pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. No rightventricular diastolic collapse is seen. . [**1-1**] CXR Compared with the findings of the prior study (images reviewed) of the earlier study of [**1-1**], the pericardial effusion is much less but remains moderate. Large left sided pleural effusion present. Decrease in the size of the cardiac silhouette. However, it remains enlarged. This is consistent with the pericardiocentesis. There is overlying catheter seen across the left chest. There remains a persistent left retrocardiac opacity which opacifies the left lower half of the chest. There is an opacity seen within the right base which is better seen on today's study. . [**1-1**] EKG Sinus tachycardia Indeterminate QRS axis Generalized low voltage Modest right ventricular conduction delay pattern Findings are nonspecific but suggest in part chronic pulmonary disease or possible right ventricular overload . [**1-1**] EKG Baseline artifact Atrial fibrillation with rapid ventricular response Generalized low voltage Modest right ventricular conduction delay pattern Findings are nonspecific but suggest in part chronic pulmonary disease or possible right ventricular overload . [**1-2**] ECHO 1.There is low normal to mildly decreased LV function with global hypokinesis. 2.There is a moderate sized pericardial effusion. No evidence of cardiac tamponade. 3.There is a L sided pleural effusion w/ evidence of collapsed lung. . [**1-3**] CT 1. Irregular area of consolidation in the right upper lobe probably pneumonia/aspiration. 2. 3-cm mass in the right lower lobe c/w known lung cancer. 3. Extensive mediastinal lymphadenopathy. 4. Large left and moderate right pleural effusion with bilateral lower lobe atelectasis. 5. Small pericardial effusion. 6. Increasing size of the osteolytic bony lesions consistent with metastasis. . [**1-4**] ECHO Left Ventricle - Ejection Fraction: 30% (nl >=55%) Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis. Right ventricular chamber size is normal with mild global free wall hypokinesis. There is a small, circumferential, partially echo-filled pericardial effusion. . MRI Brain: No significant abnormalities detected in the MRI of the brain with and without gadolinium [**2117-12-31**] 04:53PM BLOOD WBC-19.2* RBC-3.54*# Hgb-10.1*# Hct-30.0*# MCV-85 MCH-28.6 MCHC-33.7 RDW-13.8 Plt Ct-534* [**2117-12-31**] 04:53PM BLOOD Neuts-92.6* Lymphs-4.5* Monos-2.6 Eos-0.2 Baso-0.1 [**2117-12-31**] 07:28PM BLOOD PT-15.4* PTT-29.7 INR(PT)-1.6 [**2117-12-31**] 04:53PM BLOOD CK(CPK)-141 [**2117-12-31**] 04:53PM BLOOD CK-MB-2 cTropnT-<0.01 [**2117-12-31**] 09:02PM BLOOD Lactate-3.4* [**2118-1-3**] 04:04AM BLOOD WBC-33.3* RBC-4.04* Hgb-11.4* Hct-34.3* MCV-85 MCH-28.1 MCHC-33.2 RDW-14.5 Plt Ct-535* [**2118-1-1**] 04:47AM BLOOD ALT-285* AST-326* LD(LDH)-414* AlkPhos-158* TotBili-0.7 [**2118-1-7**] 07:00AM BLOOD TotProt-6.5 Albumin-2.9* Globuln-3.6 Calcium-8.2* Phos-3.6 Mg-2.1 [**2118-1-5**] 04:55AM HBsAg NEG HBsAb POS HBcAb NEG HAV Ab POS [**2118-1-5**] 04:55AM BLOOD HCV Ab-NEGATIVE [**2118-1-7**] BLOOD PEP - NO SPECIFIC ABNORMALITIES SEEN UPEP - MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING IFE - NO MONOCLONAL IMMUNOGLOBULIN SEEN, NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN . Pericardial Fluid - cytology POSITIVE FOR MALIGNANT CELLS consistent with non-small cell metastatic carcinoma, AFB Neg [**1-4**] Pleural fluid - POSITIVE FOR MALIGNANT CELLS, AFB Neg . [**1-9**] CXR Bibasilar opacities are slightly improved in the interval. Previously evident small bilateral pleural effusions have resolved. . [**1-10**] Echo LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). PERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential. Effusion echo dense, c/w blood, inflammation or other cellular elements. No echocardiographic signs of tamponade. [**2118-1-9**] BLOOD CULTURE - AEROBIC NGTD; ANAEROBIC NGTD [**2118-1-9**] URINE CULTURE - NGTD [**2118-1-9**] BLOOD CULTURE AEROBIC NGTD; ANAEROBIC NGTD [**2118-1-9**] ACID FAST SMEAR-Neg; ACID FAST CULTURE-PENDING [**2118-1-9**] STOOL CLOSTRIDIUM DIFFICILE TOXIN Neg [**2118-1-8**] ACID FAST SMEAR - Neg; ACID FAST CULTURE-PENDING [**2118-1-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN Neg [**2118-1-7**] ACID FAST SMEAR - Neg; ACID FAST CULTURE-PENDING [**2118-1-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN Neg [**2118-1-4**] Pleural fluid GRAM STAIN - 1+ :POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2118-1-7**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2118-1-10**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2118-1-5**]): NO ACID FAST BACILLI ACID FAST CULTURE (Pending): [**2117-12-31**] - Pericardial fluid GRAM STAIN - 4+ POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2118-1-5**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2118-1-7**]): NO GROWTH. ACID FAST CULTURE (Pending): ACID FAST SMEAR (Final [**2118-1-3**]): NO ACID FAST BACILLI FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Brief Hospital Course: # Pericardial effusion - Pt is a 46 y/o man with a hx of positive PPD, and a recently diagnosed NSCLC who presents with 3 day hx of weakness, SOB with exertion and left sided chest pain which radiates to his back and he describes saying "it feels like someone is poking me." In the ED, the pt was found to have an elevated pulsus paradoxus at 15-20. An echo showed a large echodense pericardial effusion consistent with blood, inflammation or other cellular elements. There was RV diastolic collapse, consistent with tamponade. In the cath lab, 1500cc of grossly bloody pericardial fluid was drained and a pericardial drain was sutured in place. A repeat echo showed that the effusion had decreased in size and the RV collapse had resolved. The pericardial fluid cytology was positive for malignant cells consistent with non-small cell metastatic carcinoma. It was negative for AFB. A post-drainage echo showed a moderate sized residual pericardial effusion with no signs of tamponade. Pt has been hemodynamically since drainage, w/ no complaints of any SOB, with a normal pulsus and with repeat echos showing no change in size of the pericardial effusion. Pt will have a follow up echo on [**2-16**] to assess for reaccumulation. . # PNA - On presentation, the pt was also found by CXR to have a large consolidation in the left lower lobe. Pt was treated with 7 days of CTX and 4 days of azithromycin for his Left lobe PNA. Pt continues to have non-productive cough and reports left sided chest pain with coughing, but this cough is unchanged from the pt's prior cough. He was afebrile from [**1-5**]. His WBC went from 17.7 on presentation to 33.3 on [**1-3**] but came down to 16.2 on [**1-11**] on discharge. . # Positive PPD - Pt with recent history of positive PPD. Bronchial washings from time of diagnosis with NSCLC were negative for AFB. In the setting of a new infiltrate on CXR, and relative immunosuppression with metastatic cancer, patient needed to be ruled out for active TB. 3 induced sputums were obtained. Three AFB smears have been negative. Mycobacterial cultures will be followed up by ID. Pt will follow up with [**Hospital **] clinic on [**2-16**] for treatment for his latent TB. Per ID, pt will not require any treatment for latent TB prior to commencing chemo. . # Afib - In the MICU, pt has also had 2 episodes of episodes of A-fib. The first episode was reverted to sinus rhythm with amiodarone. Lopressor was added after the second episode. Amiodarone dose was decreased to 200mg [**Hospital1 **] prior to discharge. In 2 weeks, we would recommend decreasing Amiodarone dose to 200mg per day. Pt will continue Amiodarone as he is at risk for further episodes of a-fib secondary to irritation of the RA from his pericardial effusion. Pt will follow up with cardiology on [**2-16**]. . # Low EF - Pt noted on inital echo to have a normal EF, but on poist-drainage echo to have a low EF at 30%. Etiology of systolic dysfuntion is unclear. Cardiology was not planning to investigate etiology further at this time. A repeat echo on [**1-10**] showed a normal EF. Pt will follow up with cardiology on [**2-16**]. . # NSCLC - Pt diagnosed w/ NSCLC [**12-22**] and is followed by Heme/Onc. Pt likely has stage IV disease given presence of malignant pericardial effusion and osteolytic lesions in spine. Head MRI showed no evidence of brain metastases. Pt will follow up with Heme/Onc [**1-20**] to discuss beginning outpatient chemo. For ostoeolytic lesions, pt was loaded with Vitamin D and Calcium and received one dose of Zometa on [**1-9**]. . # Pleural Effusions - Bilateral pleural effusions were noted on presentation. Pt is s/p thoracentesis of left effusion, found to be exuadative by protein criteria and positive for malignant cells, with no AFB staining. Since pt was not symptomatic with pleural effusions, no drainage of rt sided effusion or pleurodesis was required at this time. A repeat CXR on [**1-9**] showed resolution of bilateral pleural effusions. . # Thrombophlebitis - Pt developed L forearm thrombophlebitis, with a warm, erythematous, tender cord. Pt was treated symptomatically with warm compresses and the eryethema and tenderness resolved. . # Elevated LFTs - Pt's LFTs increased the day following admission. Etiolgy likely hepatic congestion secondary to cardiac tamponade/failure. LFTs increased prior to beginning [**Last Name (LF) 45231**], [**First Name3 (LF) **] amio is likely not the cause. Pt negative for HCV, HBV and HAV is positive. LFTs are now trending down. . # Anemia - Hct drop likely from bleed into pericardial space. Plan was to transfuse pt for Hct<21 but pt's Hct has increased without transfusion. Nl SPEP, UPEP, so no evidence of myeloma. . # Difficulty walking - On admission, pt's wife reported that he was having leg pain and difficulty walking. Pt reports that he has had ankle pain but that he had been able to walk without difficulty. Pt's neuro exam appears intact. Patient worked with PT to improve his balance and endurance with ambulation. PT reports that no further acute PT is needed at this time. Pt able wot ambulate without difficulty. . # Code - Status changed to DNR/DNI, but pt requests aggressive treatment for NSCLC Medications on Admission: cough medicine Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 13 days: take 200mg twice a day until [**1-24**]; starting [**1-25**], take 200mg once a day. Disp:*60 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*28 Tablet(s)* Refills:*0* 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*0* 4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). Disp:*300 ML(s)* Refills:*0* 5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*28 Tablet(s)* Refills:*0* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*56 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. Disp:*60 Tablet(s)* Refills:*0* 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain: DO NOT TAKE WITH TYLENOL Do not drive or operate heavy machinery while taking this medication. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Cardiac tamponade PNA Pleural effusions **************** NSCLC +PPD Discharge Condition: Stable, pericardial effusion stable with no signs of tamponade Discharge Instructions: Please seek medical care if you develop lightheadedness, shortness of breath, increasing chest pain, or any other concerning symptoms. Please keep the follow-up appointments listed below. Followup Instructions: Please go to your primary care doctor, Dr. [**Last Name (STitle) **], at [**Hospital3 **] clinic anytime on Friday [**2118-1-14**] Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Date/Time:[**2118-1-20**] 10:30 Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD - Infectious Disease - Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2118-2-16**] 10:30 You are scheduled for an outpatient [**Year/Month/Day 461**] on [**2-16**] at 9am. Afterwards, you are scheduled for followup with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**](cardiology) at 10:30am the same day. Both appointments are in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**]. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2118-2-16**] 9:00 Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2118-2-16**] 10:30

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Discharge summary

report+addendum

Admission Date: [**2182-10-23**] Discharge Date: [**2182-11-10**] Service: Medicine, [**Hospital1 139**] Firm HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old female who was originally admitted to the Vascular Service for arteriography. She was noted to be anemic with a hematocrit of 24 and to have an evaluated creatinine level of 2.3. She was transfused with 2 units of packed red blood cells and began to experience shortness of breath. An electrocardiogram at that time revealed ST depressions in V5 through V6, and a chest x-ray showed congestive heart failure. The patient was transferred to the Medicine Service on [**2182-10-24**]. The patient did not complain of chest pain, nausea, or vomiting. During a previous myocardial infarction, the patient did experience chest pressure in addition to her shortness of breath. At that time, a cardiac catheterization in [**2182-4-24**] revealed significant 3-vessel disease. The patient declined cardiac catheterization for stenting at that time. PAST MEDICAL HISTORY: 1. Non-insulin-dependent diabetes mellitus. 2. Coronary artery disease; status post myocardial infarction in [**2182-3-25**]. 3. Hypertension. 4. Peripheral vascular disease; status post right ileofemoral bypass graft in [**2182-6-24**]. 5. Status post right great toe amputation in [**2182-6-24**]. 6. Osteoarthritis. 7. Status post cholecystectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Lopressor 12.5 mg p.o. q.d. 3. Colace 100 mg p.o. q.h.s. 4. Lasix 40 mg p.o. q.d. 5. Sodium bicarbonate 1300 mg p.o. t.i.d. 6. Levofloxacin 250 mg p.o. q.d. 7. Flagyl 500 mg p.o. t.i.d. 8. Zantac 150 mg p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient was afebrile with a heart rate in the 80s, blood pressure was 120s/60s, respiratory rate was 20, oxygen saturation was 100% on a 100% nonrebreather. In general, the patient was an obese female who was uncomfortable and tachypneic. Head and neck examination revealed no icterus. Mucous membranes were moist. Pupils were equal, round, and reactive to light. Neck showed an elevated jugular venous pulse of 10 cm. Pulmonary examination revealed crackles up to two-thirds bilaterally. Cardiovascular examination revealed a regular rate and rhythm with no murmurs, and distant heart sounds. Abdominal examination revealed positive bowel sounds, and no tenderness or distention. Extremities had 2+ edema bilaterally. The right great toe with an area of eschar and granulation tissue, and was clean and dressed. The left heel showed a stage I pressure ulcer. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory examination was significant for an initial creatine kinase of 468, a MB fraction of 94, and a troponin I level of greater than 50. Her Chemistry-7 panel was significant for a blood urea nitrogen of 20 and a creatinine of 2.3. Following transfusion, the patient's hematocrit increased to 33.7 after 2 units of packed red blood cells. RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm at 80 beats per minute, normal axis, first-degree heart block, no Q waves, and ST depressions in V4 through V6. HOSPITAL COURSE: 1. CARDIOVASCULAR SYSTEM: The patient was initially treated with aspirin, a heparin drip, and Integrilin. The heparin drip and Integrilin were maintained for 72 hours. The patient was treated with a nitroglycerin drip which was discontinued secondary to hypotension on [**2182-10-27**]. She was maintained on telemetry, and her cardiac enzymes were cycled. Her creatine kinase peaked on [**10-24**] at a level of 468. Her CK/MB peaked at 94. Troponin levels were greater than 50. Repeat chest x-rays showed persistent and slightly worsening congestive heart failure for several days. The patient was aggressively diuresed with Lasix and was initially resistant. Metolazone was added to her diuretic regimen, and the patient responded. Her congestive heart failure gradually improved over the course of one week. An arterial blood gas on [**2182-10-25**] showed a pH of 7.31, PCO2 of 51, PO2 of 219, on a 100% nonrebreather mask. Her oxygen requirement was slowly weaned down to 3 liters by nasal cannula. A transthoracic echocardiogram on [**2182-10-25**] revealed mild symmetric left ventricular hypertrophy, mildly dilated left atrium, and severely depressed left ventricular systolic function. The ejection fraction was estimated at 25%. There was severe hypokinesis to akinesis of the lower two thirds of the left ventricle with relative sparing of the base of posterolateral wall. Moderate mitral regurgitation was noted. On [**2182-10-26**], the patient experienced atrial fibrillation with a rapid ventricular response. She was rate controlled with diltiazem and was somewhat hypotensive prior to rate control. At this time, she was started on metoprolol at 25 mg p.o. t.i.d. Due to the new onset paroxysmal atrial fibrillation, the patient was anticoagulated with heparin. She was being slowly converted to Coumadin at the time of this dictation. A brief trial of dopamine was attempted for increased blood pressures; however, the patient had rapid ventricular rates and did not tolerate this. She was started on amiodarone for chemical conversion of her atrial fibrillation, and spontaneously converted to a sinus rhythm on [**2182-11-10**]. At this time, she became bradycardic with rates in the 50s to upper 40s and had decreased blood pressures to the 90s. New electrocardiogram changes of T wave inversions in the precordial leads were noted. At this time, the patient was still being medicated with aspirin and heparin, but her beta blocker was withheld secondary to low heart rates and blood pressures. Cardiac enzymes were cycled again and were pending at the time of this dictation. 2. RENAL SYSTEM: The patient's creatinine continued to climb following her non-Q-wave myocardial infarction. It peaked at 5.8, then receded to a level of 3.7 at the time of this dictation. She was initially resistant to diuresis with Lasix; however, she soon began to respond to intravenous Lasix with metolazone given b.i.d. After one week, the patient continued to diuresis without the need for diuretics and maintained a urine output of 1000 cc per day. 3. INFECTIOUS DISEASE: The patient was treated prior to hospitalization with Bactrim, followed by levofloxacin and Flagyl for her right toe amputation which failed to heal. In the hospital, the Flagyl was converted to clindamycin, and the patient was maintained on levofloxacin throughout. Superficial wound swabs from the right toe showed mixed flora with gram-positive rods, gram-negative rods, and gram-positive cocci. The patient was maintained on clindamycin and levofloxacin throughout her hospitalization up until the time of this dictation. On her initial transfer to the Medicine Service, a chest x-ray showed a new opacification in the right and left upper lobes which were consistent with aspiration or atypical pulmonary edema. These infiltrates improved while the patient was maintained on her antibiotic regimen. A urine culture on [**10-28**] revealed enterococcus species, and the patient was treated with a 7-day course of ampicillin. Right foot films showed irregular and indistinct bony margins of the metatarsal, suspicious for osteomyelitis. Given the patient's cardiac status, revascularization was determined to be a poor option as was deep bone biopsy. The patient will likely require a 6-week course of intravenous antibiotics and may not be able to heal her wound fully. 4. ENDOCRINE SYSTEM: The patient was noted to have a low thyroid-stimulating hormone level of 0.06. Further studies revealed a normal T4 level of 8.3, and a normal free T4 level of 1.2. Her T3 level was less than 30, and her free T3 level was 182. Both of these T3 levels were low. A radioactive iodine uptake test and scan showed decreased uptake by the thyroid. An Endocrine consultation believed that these results were consistent with euthyroid sick syndrome as well as nonthyroidal illness. They recommended checking a total T4, total T3, and T uptake test around [**2182-11-23**]. They also recommended checking a thyroglobulin antibody examination to help establish her risk for hypothyroidism. The patient had elevated blood sugars early in her hospitalization and was started on a standing dose of NPH insulin. She maintained good glycemic control on doses of 7 units NPH q.a.m. and 6 units NPH q.p.m. 5. CODE STATUS: The patient restated her wishes that she be do not resuscitate/do not intubate throughout her hospitalization. NOTE: This dictation will be completed by the intern taking over the service at a later date. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Last Name (NamePattern1) 6916**] MEDQUIST36 D: [**2182-11-10**] 15:58 T: [**2182-11-11**] 13:26 JOB#: [**Job Number 43447**] Name: [**Known lastname 7733**], [**Known firstname 2868**] Unit No: [**Numeric Identifier 7734**] Admission Date: Discharge Date: [**2182-11-15**] Date of Birth: [**2097-9-13**] Sex: F Service: Internal Medicine During the last four hospital days, the continued to do relatively well. Her renal function significantly improved, and her discharge creatinine was 3.1. Of note, her blood pressure significantly improved in the 120s-130s which assured better perfusion in her kidneys. She received intermittent doses of Lasix to assure overall negative intakes and outputs. She progressed beautifully with physical therapy and occupational therapy and was able to ambulate with assistance. She has very mild left lower extremity pain which is largely unchanged. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Congestive heart failure. 3. Acute renal failure. 4. Acute myocardial infarction. 5. Osteomyelitis. 6. Diabetes mellitus. DISPOSITION: Discharged to a rehabilitation facility. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q day. 2. Warfarin 3 mg p.o. q h.s. 3. Renagel 1600 mg p.o. t.i.d. 4. Aspirin 325 mg p.o. q day. 5. Miconazole powder 2% t.i.d. 6. Levofloxacin 250 mg p.o. q48 hours for the next five weeks for osteomyelitis. 7. Flagyl 500 mg p.o. t.i.d. for the next five weeks for osteomyelitis. 8. Protonix 40 mg p.o. q day. 9. Magnesium Oxide 800 mg p.o. b.i.d. 10. Epogen 5000 units two times weekly, on Monday and Thursday. 11. Colace 100 mg p.o. b.i.d. 12. Lasix 80 mg p.o. b.i.d. 13. NPH insulin 7 units in the morning and 5 units at night. 14. Regular insulin sliding scale. [**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**], M.D. [**MD Number(1) 29**] Dictated By:[**Name8 (MD) 2940**] MEDQUIST36 D: [**2182-11-15**] 13:13 T: [**2182-11-15**] 13:45 JOB#: [**Job Number 6273**]

[ "730.27", "428.0", "458.2", "427.31", "997.69", "584.9", "599.0", "410.91", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.48" ]

icd9pcs

[ [ [] ] ]

9922, 9931

9952, 10168

10191, 11064

1472, 3238

3256, 9900

148, 1027

1049, 1446

6,883

145,256

23439

Discharge summary

report

Admission Date: [**2163-11-19**] Discharge Date: [**2163-12-2**] Date of Birth: [**2113-8-26**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2090**] Chief Complaint: Progressive weakness Major Surgical or Invasive Procedure: 1) Plasmaphoresis - 5 rounds; placement of subclavian line 2) Thymectomy for removal of 6 x 3 cm anterior mediastinal mass [**2163-11-24**] 3) s/p Intubation History of Present Illness: 50 yo man with progressive weakness. Symptoms started one month ago with slurred speech . Then he noticed difficulty lifting a 2 pound rope at work (fisherman, labor intensive work). Was "weak all over" and was worse in the afternoon. + blurry vision, fatigue. No diplopia. + difficulty chewing a steak dinner, got worse the longer he was chewing. 2 weeks ago noted a right hand cramp when washing his face. He began to isolate himself. His son brought him to the [**Hospital1 18**] ER as he was so weak he was bobbing his head, unable to keep it upright, and could not talk. He presented to an OSH ED 2 times, and then to his PCP with workup including negative lyme titers and MRI brain (normal). His PCP diagnosed him with depression and he was started on lexapro several days before admission. No SOB or respiratory compromise. No fevers, chills, sweats, tick bites, trauma, rash, recent infections. Past Medical History: -"depression" just diagnosed as cause of his weakness -cholesystectomy ([**2158**]) Social History: Mr. [**Known lastname 60090**] runs his own fishing company in the town in which he lives, [**Location (un) 14663**]. He is married and has 3 children, ages 16, 21, and 27. He is married and denies ever using tobacco products, alcohol, and drug use. Family History: Brother: early cardiac death at age 31 Father: Diabetes, hypertension, coronary artery disease (multiple bypass surgeries) Physical Exam: PHYSICAL EXAM: VITALS: 97.8, 118/80, 72, 16, 98%RA NIFs: -75 x 3, VC: 2.5L, 2.5L, 3.2L GEN: no acute distress, pleasant SKIN: no rash HEENT: NC/AT, anicteric sclera, mmm NECK: supple CHEST: normal respiratory pattern, CTA bilat CV: regular rate and rhythm without murmurs ABD: rotund, soft, nontender, nondistended, +BS, no HSM EXTREM: no edema NEURO: Mental status: Patient is alert, awake, pleasant affect. Oriented to person, place, time and president. Good attention. Language is fluent with good comprehension, repitition, no dysarthria. No apraxia, agnosias, no neglect. Cranial Nerves: Visual fields: full to left/right/upper/lower fields. Pupils: 3->2 mm, consenual constriction to light. EOMS almost full - does not [**Last Name (un) **] the white in the left eye on left lateral gaze, gaze conjugate. + right ptosis, worsens on sustained gaze. Facial sensation intact over V1/2/3 to light touch and pin prick. Jaw closing strengh normal. Symmetric face today (s/p mestinon) Hearing intact to finger rubs Symmetric elevation of palate. SCM and trapezius [**4-20**] bilaterally Tongue midline without atrophy or fasciulations. Sensory: Normal touch, vibration, pinprick. Motor: Normal bulk, tone. No fasciculations or drift. No adventitious Movements. Strength: Neck Flexors: 4, Neck extensors: 5. Rt deltoid 4+, left deltoid 4. Rt triceps initially 5 but weakens to 4 with repetitive movements. Otherwise full throughout. Reflexes: [**Hospital1 **] BR Tri Pat Ach Toes RT: 2 2 1* 2 2 down LEFT: 2 2 2 2 2 down * = after repetitive movements at the right triceps Coordination: Normal finger-to-nose. Gait: Normal narrow gait, tandems well, hops on each foot well. Pertinent Results: Admission Labs CBC: 7/45/203, diff 54N, 33L, 6M, 5E Chem: 141/4.3/102/31/15/0.8/103 CK 228 Cal 9.5, phos 3.8, mag 2.1 TSH 3.4 ACH R Ab >28 Radiology MRI brain (from [**Hospital 1474**] hospital): some tiny white spots on T2 bilaterally on FLAIR lateral to ventricles on one slice only, otherwise clear to my read. CXR: unusual contour CT chest: 6x3cm mass anterior mediastinum Abdominal x-ray: Suboptimal study. No evidence of ischemia. EKG Results: Sinus rhythm, Possible left atrial abnormality, Poor R wave progression possible anterior infarct, inferior T wave changes are nonspecific Echocardiogram: Mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Brief Hospital Course: 50 year old man with worsening weakness over one month that appears consistent with myasthenia [**Last Name (un) 2902**]. Diagnosis was confirmed by observing rapidly worsening fatigue with repeated movements, tensilon test, and positive anti-acetylcholine receptor antibody test. Chest CT evaluating for presence of MG-associated thymoma was positive for a 6 x 3 cm mass. This patient was treated as follows: A) Myasthenia [**Last Name (un) **] 1) Mestinon: Received course of mestinon with marked relief of symptoms. Dose increased gradually to discharge dose of 90 mg ever 4 hours. 2) Plasmapheresis: Underwent two rounds of plasmapheresis via peripheral route on [**11-21**] and [**11-23**]. During first round had transient episode of hypotension and diaphoresis. This was followed by transient elevation of pancreatic enzymes (AST, ALT, Amylase, Lipase) that resolved; a KUB was performed to rule out the possbility of bowel ischemia. Second round completed without difficulty. Strength appeared to improve following each round. Three additional rounds of plasmapheresis were given as described below. 3) Surgery: Underwent successful resection of 6 x 3 cm anterior mediastinal mass on [**11-24**] via a medial sternotomy. Pathology completed by Dr. [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] showed no capsular invasion and a benign pattern. The patient recovered under care of cardiothoracic surgery team and returned to care of neurology team. 4) Myesthenic Crisis and Pneumonia: On post-op day [**11-27**], Mr. [**Known lastname 60090**] had some difficulty breathing and was noted to have marked fatigue of his muscles, consistent with a myesthenic crisis. He was intubated to preserve his airway and transfered to the surgical intensive care unit, where he received 2 additional rounds of plasmapheresis. During his SICU admission, Mr. [**Known lastname 60090**] was noted to have coarse sounds in his right hemithorax; a portable chest x-ray showed a pattern that was suspicious for pneumonia. A sputum culture was obtained and was positive for S. pneumoniae. Mr. [**Known lastname 60090**] was initally treated empirically with vancomycin and levoquin pending culture results, and was then changed to ceftriaxone once species and sensitivities were established. Mestinon dosing was also increased, and respiratory failure improved and pt was extubated and transferred back to the care of the neurology team. 5) Post-SICU Care: Mr. [**Known lastname **] returned to the neurology service where he continued recovery. He was noted to have cough, surgical site pain, and difficulty sleeping. He also complained of diarrhea. He was given Guaifenesin for his cough, percoset for pain, trazadone for sleep, and loperamide for diarrhea; each of these problems subsequently resolved. Improvement in pain control resulted in marked improvement in his breathing, as it became apparent that he had difficulty breathing earlier because of his pain. B) Cardiovascular Prior to surgery, a cardiovascular workup was performed given Mr. [**Known lastname 60091**] family history of early cardiac death. Lipid profile was normal. EKG showed slowed R wave progression. Echocardiogram was reassuring, but showed mild symmetric left ventricular hypertrophy. Mr and Mrs [**Known lastname 60090**] were advised about the eventual need for stress test after current hospitalizationa and advised to follow up with about cardiovascular health. He was also started on metoprolol for some peri-operative hypertension, which we will continue given his family history, and allow his PCP to make changes as needed. C) Depression Continued lexapro per primary care physician's prescription. Patient should follow-up after discharge to determine if further treatment is necessary. On the day of discharge, Mr. [**Known lastname 60090**] is pain-free on percoset and has been counseled about the importance of following up with his neurologist, surgeon, and primary care doctor. Mr. [**Known lastname 60090**] and his family are aware that they need to pay close attention to changes in his strength and seek care from a neurologist or emergency room as needed. Medications on Admission: lexapro 10mg Discharge Medications: 1. Pyridostigmine Bromide 60 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4 hours): Contact your neurologist if you begin to develop muscle weakness. Disp:*180 Tablet(s)* Refills:*2* 2. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 3. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 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. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 7. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. Lomotil 2.5-0.025 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for diarrhea. Disp:*50 Tablet(s)* Refills:*0* 9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Myasthenia [**Last Name (un) **], c/b myasthenic crisis and respiratory failure requiring intubation Benign thymoma, s/p resection Pneumococcal pneumonia Transient pancreatitis secondary to transient hypotension, now resolved Discharge Condition: Mr. [**Known lastname 60091**] condition has improved. His muscles are no longer fatiguable with no residual neurological deficits. His thymoma was detected and resected via a medial sternotomy. He developed streptococcal pneumonia post-surgically that was successfully treated using a course of antibiotics. Discharge Instructions: Carefully monitor your strength. If you feel any weakness or change in your ability to swallow food, breathe, speak, or if the appearance of your face changes, immediately contact the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your neurologist. His telephone number is [**Telephone/Fax (1) **]. If for some reason, you are not able to contact Dr. [**Last Name (STitle) **] or a covering neurologist, please report to the emergency room at the [**Hospital1 69**] and report that you have myasthenia [**Last Name (un) 2902**] that is treated with mestinon and have received therapeutic benefit from plasmapheresis. It is important that you follow-up carefully with Dr. [**Last Name (STitle) **] in neurology and Dr. [**Last Name (STitle) 952**] in Thoracic Surgery. Continue to take all medications as prescribed and keep all follow-up appointments. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. (NEUROLOGY) Where: [**Hospital 273**] NEUROLOGY Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2163-12-6**] 1:30. Please discuss frequency of visitation with Dr. [**Last Name (STitle) **] and set up appropriate frequency of appointments on this follow-up visit. Please also discuss and obtain prednisone steroid prescription and confirm the dose frequency and starting date for taking medication. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (THORACIC SURGERY) Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[**2163-12-8**] 3:00. Discuss post-surgical healing and frequency of necessary follow-up for resection of thymoma. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD (INTERNAL MEDICINE) Where: [**Hospital 4054**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2164-2-16**] 10:00. Please call in advance of your appointment to complete patient registration. When meeting with Dr. [**Last Name (STitle) 5717**], please dicuss your family history of early cardiac death, the need for continuation of high blood pressure medication that was initiated during your ICU stay, and the need for continuing the Lexapro anti-depressant medication that was prescribed by your previous primary care provider. [**Name10 (NameIs) 357**] inform Dr. [**Last Name (STitle) 5717**] that an echocardiogram performed at the [**Hospital1 **] showed symmetric hypertrophy of your heart's left ventricle in discussions of your cardiac health. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]

[ "746.89", "358.01", "429.3", "481", "518.81", "577.0" ]

icd9cm

[ [ [] ] ]

[ "99.71", "96.04", "96.71", "07.82", "38.93" ]

icd9pcs

[ [ [] ] ]

9879, 9885

4450, 8651

338, 498

10154, 10464

3662, 4427

11402, 13164

1824, 1948

8714, 9856

9906, 10133

8677, 8691

10488, 11379

1978, 2316

278, 300

526, 1431

2558, 3643

2331, 2542

1453, 1538

1554, 1808

51,482

173,323

45648

Discharge summary

report

Admission Date: [**2182-8-28**] Discharge Date: [**2182-9-17**] Date of Birth: [**2129-1-14**] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 3705**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2182-8-29**] nephrotube placed left kidney [**2182-8-30**] perinephric tube placed for left kidney decompression [**2182-8-30**] Right IJ central line replaced with a right IJ temp HD line + VIP port. [**2182-8-30**] Trauma line placed left IJ. [**2182-8-30**] arterial line left femoral artery [**2182-9-2**] Placement of a tunneled hemodialysis vein catheter via the right internal jugular vein under ultrasound and fluoroscopic guidance [**2182-9-2**] Placement of the double-lumen PICC line into the distal superior vena cava under ultrasound and fluoroscopic visualization. History of Present Illness: 53 yof h/o HIV/AIDS CD4 at 602, VL 66 in [**7-/2182**], history of type 2 diabetes, diet controlled, remote Castleman's disease, hepatitis C status post failed prior attempt at treatment, hypertension, and renal insufficiency who presents to ED via triage clinic with R flank pain, N/V that awoke her from sleep 0100 day of presentation. Upon arrival in ED, found to have R hydro by U/S and R mid-ureteral calculus by CT a/p, presumed a protease inhibitor stone per radiology. Also noted that there was gallstones but no signs of cholecystitis. Initially temp 99.6 -> 101.6, got tylenol, systolics in the 130s with progressive tachycardia 80s -> 110s despite IVF. Found to have Cr 2.2 from baseline 1.4-1.5, U/A many bac with <1 epis. Urology was consulted and preemptively requested 2g ceftriaxone (prior e.coli UTIs res to cipro), vanco given possibility of percutaneous procedure, coags. Patient has become increasingly tachycardic during her emergency department stay and is now spiking fevers consistent with an obstructed pyelonephritis. Patient underwent a perc nephrostomy via IR, will but admitted to MICU for close monitoring given the risk of patient getting dramatically sicker. EKG showed SR@99 NA NI STD V4-6 (new). 20G PIV R/L. Past Medical History: - Castleman's Disease - HIV, diagnosed in [**2158**], CD4 of 668 and viral load undetectable on [**2182-4-29**] at an outside hospital - Hepatitis C - Shingles - Migraines - HTN - DM II - MRSA - Recurrent UTI - HSV - Pancytopenia [**1-23**] HAART medications Social History: - Lives at home in [**Location (un) 745**] - Has a daughter with hydrocephalus/seizure disorder, and is in a nursing home ([**Location (un) 511**] Pediatric Care). - Works as a councilor - Former heavy smoker, currently 1 pack q2 weeks. Taking Wellbutrin - Former EOTH abuse, none since [**2174**] - Former IVDU, none since [**2174**] Family History: - Father died of MI - Mother with diabetes - Sister with lung cancer at age 38 and was a heavy smoker. - Bother with diabetes - She had a second daughter, who was HIV positive and who died at age 3 Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: BP:132/62 P:123 R: 18 O2: 96 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge PE: Vitals: T 98.2 (Tmax 98.6) 141/69 90 18 96% on RA General: Awake, alert, and oriented to place and date, lying supine in bed, in some pain but no distress. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple without LAD Lungs/chest: CTAB CV: Regular rate and rhythm, normal S1 + S2, S4 noted at apex, I-VI holosystolic murmur heard at the base. Abdomen: +BS. L side of her abd was soft without TTP or guarding, but R side was firm to palpation with guarding. Pt had a liver edge palpable 4-5 cm below the costal margin as well as a firm clotted hematoma palpable on the R side from the costal margin to the iliac crest. [**7-31**] TTP on the R side without rebound. No splenomegaly. Mild suprapubic TTP in R groin. Ext: warm, well perfused. No c/c/e. 2+ peripheral pulses. Neuro: CN II-XII intact. Neuromuscularly grossly intact throughout. Pertinent Results: LABS -- . CBC: [**2182-8-28**] 02:30PM BLOOD WBC-7.9 RBC-2.93* Hgb-9.9* Hct-28.7* MCV-98 MCH-33.7* MCHC-34.4 RDW-14.3 Plt Ct-119* [**2182-8-30**] 04:23AM BLOOD WBC-9.6 RBC-1.83* Hgb-6.3* Hct-18.0* MCV-98 MCH-34.2* MCHC-34.9 RDW-14.8 Plt Ct-64* [**2182-8-30**] 01:52PM BLOOD WBC-12.6* RBC-2.41* Hgb-7.8* Hct-21.3* MCV-88 MCH-32.2* MCHC-36.6* RDW-16.3* Plt Ct-46* [**2182-8-31**] 04:13AM BLOOD WBC-10.2 RBC-3.85* Hgb-11.9* Hct-32.0* MCV-83 MCH-31.0 MCHC-37.2* RDW-15.1 Plt Ct-84* [**2182-9-3**] 04:00AM BLOOD WBC-7.2 RBC-3.28* Hgb-10.2* Hct-27.9* MCV-85 MCH-31.1 MCHC-36.5* RDW-16.6* Plt Ct-61* [**2182-9-5**] 04:12AM BLOOD WBC-13.6* RBC-3.76* Hgb-11.4* Hct-34.0* MCV-91 MCH-30.4 MCHC-33.6 RDW-16.0* Plt Ct-90* [**2182-9-7**] 09:49PM BLOOD WBC-9.9 RBC-3.55* Hgb-11.1* Hct-31.5* MCV-89 MCH-31.3 MCHC-35.3* RDW-15.9* Plt Ct-102* [**2182-9-15**] 05:29AM BLOOD WBC-9.1 RBC-3.04* Hgb-9.5* Hct-27.7* MCV-91 MCH-31.2 MCHC-34.1 RDW-17.4* Plt Ct-127* . CHEM-7: [**2182-8-28**] 11:30AM BLOOD Glucose-146* UreaN-35* Creat-2.2* Na-128* K-> 10 Cl-104 HCO3-21* [**2182-8-30**] 03:47PM BLOOD Glucose-228* UreaN-53* Creat-3.5* Na-131* K-6.5* Cl-105 HCO3-17* AnGap-16 [**2182-8-30**] 03:47PM BLOOD Glucose-228* UreaN-53* Creat-3.5* Na-131* K-6.5* Cl-105 HCO3-17* AnGap-16 [**2182-9-1**] 04:01AM BLOOD Glucose-109* UreaN-23* Creat-2.0* Na-136 K-4.1 Cl-102 HCO3-21* AnGap-17 [**2182-9-3**] 04:09PM BLOOD Glucose-107* UreaN-12 Creat-1.5* Na-135 K-4.4 Cl-100 HCO3-23 AnGap-16 [**2182-9-5**] 04:12AM BLOOD Glucose-97 UreaN-13 Creat-2.2* Na-135 K-4.3 Cl-101 HCO3-24 AnGap-14 [**2182-9-5**] 01:56PM BLOOD Glucose-81 Creat-3.3* Na-137 K-5.1 Cl-102 HCO3-23 AnGap-17 [**2182-9-7**] 06:03AM BLOOD Glucose-62* UreaN-29* Creat-4.1*# Na-135 K-4.8 Cl-97 HCO3-26 AnGap-17 [**2182-9-10**] 06:08AM BLOOD Glucose-74 UreaN-24* Creat-4.4*# Na-128* K-4.0 Cl-91* HCO3-30 AnGap-11 [**2182-9-11**] 05:43AM BLOOD Glucose-74 UreaN-38* Creat-5.6*# Na-126* K-5.6* Cl-91* HCO3-27 AnGap-14 [**2182-9-15**] 05:29AM BLOOD Glucose-84 UreaN-22* Creat-4.1*# Na-126* K-4.4 Cl-87* HCO3-26 AnGap-17 . LIVER ENZYMES: [**2182-8-28**] 11:30AM BLOOD ALT-55* AST-150* AlkPhos-93 TotBili-0.6 [**2182-8-31**] 04:13AM BLOOD ALT-240* AST-856* AlkPhos-70 TotBili-1.3 [**2182-9-3**] 04:00AM BLOOD ALT-71* AST-152* AlkPhos-109* TotBili-2.5* [**2182-9-6**] 03:39AM BLOOD ALT-6 AST-87* LD(LDH)-365* AlkPhos-135* TotBili-3.5* [**2182-9-10**] 06:08AM BLOOD ALT-3 AST-75* AlkPhos-129* TotBili-2.3* [**2182-9-15**] 05:29AM BLOOD ALT-5 AST-79* AlkPhos-120* TotBili-2.9* DirBili-1.6* IndBili-1.3 . ABG: [**2182-8-30**] 02:02PM BLOOD Type-ART pO2-348* pCO2-40 pH-7.25* calTCO2-18* Base XS--9 [**2182-9-1**] 04:07AM BLOOD Type-ART pO2-115* pCO2-30* pH-7.48* calTCO2-23 Base XS-0 [**2182-9-2**] 04:06AM BLOOD Type-ART pO2-130* pCO2-37 pH-7.42 calTCO2-25 Base XS-0 [**2182-9-3**] 10:29PM BLOOD Type-ART Temp-36.1 Tidal V-450 FiO2-40 pO2-155* pCO2-47* pH-7.32* calTCO2-25 Base XS--2 Intubat-INTUBATED [**2182-9-5**] 04:22AM BLOOD Type-ART pO2-115* pCO2-51* pH-7.33* calTCO2-28 Base XS-0 . LACTATE: [**2182-8-28**] 11:31AM BLOOD Lactate-1.2 K-7.6* [**2182-8-30**] 02:02PM BLOOD Lactate-2.8* [**2182-9-2**] 04:07PM BLOOD Lactate-0.9 . COAGS: [**2182-8-28**] 03:19PM BLOOD PT-12.4 PTT-33.0 INR(PT)-1.0 [**2182-8-29**] 03:55AM BLOOD PT-13.0 PTT-56.6* INR(PT)-1.1 [**2182-8-30**] 04:23AM BLOOD PT-14.4* PTT-43.3* INR(PT)-1.2* [**2182-8-30**] 02:13PM BLOOD PT-15.8* PTT-31.7 INR(PT)-1.4* [**2182-9-2**] 04:01AM BLOOD PT-13.2 PTT-26.9 INR(PT)-1.1 [**2182-9-6**] 03:39AM BLOOD PT-13.9* PTT-28.6 INR(PT)-1.2* [**2182-9-15**] 05:29AM BLOOD PT-13.7* PTT-29.2 INR(PT)-1.2* . URINE CHEMISTRY: [**2182-8-29**] 10:10AM URINE Hours-RANDOM Creat-74 Na-38 K-24 Cl-10 [**2182-9-9**] 09:07AM URINE Hours-RANDOM Creat-132 Na-37 K-30 Cl-20 [**2182-9-13**] 06:45PM URINE Hours-RANDOM Creat-4 . URINALYSIS: [**2182-8-28**] 10:35AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG [**2182-8-28**] 04:14PM URINE Blood-TR Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [**2182-9-9**] 11:30AM URINE Blood-LG Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-7.0 Leuks-LG . MICROSCOPIC URINE: [**2182-8-28**] 10:35AM URINE RBC-5* WBC-64* Bacteri-MANY Yeast-NONE Epi-<1 [**2182-8-28**] 04:14PM URINE RBC-1 WBC-25* Bacteri-FEW Yeast-NONE Epi-0 [**2182-9-9**] 11:30AM URINE RBC-63* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 . MICROBIOLOGY: [**2182-8-28**] 11:25 am BLOOD CULTURE **FINAL REPORT [**2182-9-1**]** Blood Culture, Routine (Final [**2182-9-1**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 330-0553B #1 [**2182-8-28**]. ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 330-0553B #2 [**2182-8-28**]. SECOND MORPHOLOGY. ESCHERICHIA COLI. TYPE 3 . FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- =>64 R AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [**2182-8-29**]): GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2182-8-29**]): GRAM NEGATIVE ROD(S). . [**2182-8-28**] 10:45 am BLOOD CULTURE **FINAL REPORT [**2182-9-1**]** Blood Culture, Routine (Final [**2182-9-1**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 8 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R Aerobic Bottle Gram Stain (Final [**2182-8-29**]): Reported to and read back by DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2182-8-29**] AT 0400. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2182-8-29**]): GRAM NEGATIVE ROD(S). . [**2182-8-28**] 10:35 am URINE Site: CLEAN CATCH **FINAL REPORT [**2182-8-31**]** URINE CULTURE (Final [**2182-8-31**]): 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.. PREDOMINATING ORGANISM. INTERPRET RESULTS WITH CAUTION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . . IMAGING -- . RUQ ultrasound [**8-28**]: Right hydronephrosis which could be secondary to a ureteral stone though none is clearly seen. CT may be performed to further assess as needed. Cholelithiasis without signs of cholecystitis. Trace free fluid. . CT abd/pelvis [**8-29**]: Right hydroureteronephrosis secondary to a 5-mm stone in the mid to distal right ureter. Protease-inhibitor related urolithiasis should be considered. A subtle hyperdense focus in the lower pole of the right kidney may represent an additional intra-renal stone. Cholelithiasis without cholecystitis. Normal appendix. . Renal ultrasound [**8-29**]: Mild residual hydronephrosis of the right kidney. The kidneys are noted to be diffusely echogenic bilaterally suggestive of diffuse parenchymal disease. . TTE [**8-31**]: Symmetric LVH with normal global and regional biventricular systolic function. Mild to moderate aortic regurgitation. Mild mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2177-7-14**], aortic regurgitation severity has increased. The other findings are similar . CT abd/pelvis [**9-5**]: Right hydroureteronephrosis secondary to a 5-mm stone in the mid to distal right ureter. Protease-inhibitor related urolithiasis should be considered. A subtle hyperdense focus in the lower pole of the right kidney may represent an additional intra-renal stone. Cholelithiasis without cholecystitis. Normal appendix. . CT abd/pelvis [**9-12**]: Overall size of retroperitoneal/extraperitoneal hematoma is unchanged or possibly slightly smaller than the examination from [**9-5**], [**2181**]. Exact measurements are difficult to compare given the very lobulated contour of this hematoma. Assessment for active extravasation or bleeding is limited without IV contrast, although size stability over the last week is reassuring. Appropriate positioning of both the percutaneous nephrostomy catheter and the perinephric drain, the latter within portion of the hematoma. Cholelithiasis. Punctate renal stone on the left. Known vaguely demarcated 7 mm stone as previously described in the region of the right ureter as it crosses the iliac vessels. Labs on discharge: [**2182-9-17**] 04:46AM BLOOD WBC-6.9 RBC-2.94* Hgb-9.0* Hct-27.2* MCV-93 MCH-30.6 MCHC-33.1 RDW-17.7* Plt Ct-109* [**2182-9-17**] 04:46AM BLOOD Glucose-107* UreaN-19 Creat-4.1*# Na-129* K-4.7 Cl-92* HCO3-29 AnGap-13 [**2182-9-16**] 06:07AM BLOOD ALT-8 AST-82* AlkPhos-118* TotBili-2.7* [**2182-9-17**] 04:46AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8 Brief Hospital Course: 53yo immunocompromised F with DM, HIV on HAART, Hep C, and CKD p/w obstructing R ureteral calculus and ARF s/p nephrostomy tube placement c/b perinephric hematoma and hemorrhagic shock, as well as initial presentation of urosepsis requiring extended ICU course, pressors, and respiratory support. She also developed acute on chronic renal failure with a multifactorial etiology, requiring HD. At discharge patient was requiring three time weekly HD. ACTIVE ISSUES # Urosepsis: [**1-23**] to pyelonephritis resulting from obstructive uropathy of the right kidney in the setting of mid-ureteral stone (see below for ddx/management of stone). Blood and urine Cx grew E.coli sensitive to cefazolin (treated w/ceftriaxone f/b meropenem f/b cefazolin). Infection was complicated by septic shock requiring pressors in the ICU. After coming to the floor she was consistently hemodynamically stable and afebrile. Repeat urine cx were negative. As her ureteral stone was still present at discharge and likely was infiltrated with bacteria, and given her baseline immunosuppressed state, she was discharged on indefinite cefpodoxime until she has the stone removed by urology. # Acute on Chronic RF: Baseline creatinine is 1.5. Was 2.2 on presentation and went to 3.9 in the ICU. The etiology was multifactorial, likely [**1-23**] to pre-renal failure and ATN in the setting of septic shock and hypotension, heavy contrast dye loads, compressive nephropathy [**1-23**] to large perinephric hematoma, and obstructive nephropathy in the setting of ureteral stone. Etiology of baseline CKD is unknown, thought possibly [**1-23**] glucose intolerance w/ proteinuria, with HIV nephropathy thought to be less likely. She had a nephrostomy placed by IR to decompress the R ureter and received CVVHD in the ICU. She then had a tunneled IJ cath placed and received HD while on the floor. Creatinine rose as high as 5.7 on the floor. Her UOP increased somewhat but she was still HD-dependent at the time of discharge. It is unclear what kind of renal recovery she will have. # R perinephric retroperitoneal hematoma: [**1-23**] to nephrostomy tube drain placement. Her Hct dropped from 28 on admission to 18 and she required transfusion of 14 units pRBCs, 4 units platelets, and 2 units of FFP in the ICU. IR placed a perc tube drain in the hematoma which drained consistently old-appearing blood. Her Hct remained stable in the high 20's to low 30's and she was consistently hemodynamically stable and not tachycardic. CT abd/pelvis on [**9-12**] showed no growth in size of the hematoma, along with evidence of organization. Perc drain continues to drain. It needs to drain less than 10 cc's per 8 hours for it to be ready to be pulled. # R hydronephrosis and R mid-ureteral calculus: This was seen on CT and renal US. Likely [**1-23**] to a protease inhibitor. It led to obstructive nephropathy and resultant pyelonephritis and urosepsis (see discussion above). IR placed a R nephrostomy tube to decompress the ureter which consistently drained non-bloody fluid. Urology was consulted and they plan to remove the stone at a later date when she is farther removed from her ICU stay and more fully recovered, as this procedure can generate a significant bacteremia. # Shock: [**1-23**] urosepsis (distributive) and hemorrhagic (volume), requiring pressors in the ICU. Complicated by volume overload (including right pleural effusion), respiratory failure, and intubation. After extubation she remained hemodynamically stable in the ICU and on the floor. # Delirium: Was delirious in the ICU, consistent with the CAM-ICU criteria (acute onset w/ fluctuating course, inattention, and altered level of consciousness). Likely [**1-23**] to pain, infection, prolonged ICU stay, liver dysfunction, and medication. She was treated with haldol in the ICU and her potentially deliriogenic drugs were discontinued. After coming to the floor she became awake and attentive and no longer delirious # Elevated liver enzymes: LFT's rose to AST/ALT 200's/800 with Tbili to [**1-24**] (direct). Likely a combination of sepsis (was not high enough to be frank shock liver) in the setting of underlying HCV, with HIV meds possibly contributing. High direct Tbili and alk phos could have indicated cholestasis but US showed no biliary dilation. Liver enzymes trended back to baseline during the course of her admission, though Tbili remained slightly elevated. CHRONIC ISSUES: # HIV: HAART was initially held during her ICU course per ID recommendations and was restarted when she was stable on the floor. As discussed above, her ureteral stone was thought to be [**1-23**] to a protease inhibitor. Her new regimen at discharge included lamivudine, abacavir, ritonavir, and darunavir. # Diffuse pruritis: Per pt this is a chronic problem for which she has seen a dermatologist in the past. She said it has been attributed to chronically dry skin. Her Tbili, though elevated, was likely not high enough to produce this pruritis and she was not uremic. The pruritis improved with sarna lotion. . TRANSITION ISSUES - Pt is being discharged to [**Name (NI) 1319**] [**Name (NI) 8**] - Pt will f/u with her nephrologist, Dr. [**Last Name (STitle) 118**], which will be arranged by PCP [**Last Name (NamePattern4) **]. [**Name (NI) **] [**Name (NI) **] - Pt will require outpatient f/u with urology re. ureteral stone removal, also to be arranged by Dr. [**Last Name (STitle) **]. - She is being discharged on cefpodoxime for retained ureteral stone. -Pt will f/u with IR for eventual removal of perinephric drain. Pt will be contact[**Name (NI) **] by IR. Medications on Admission: Medications: ABACAVIR-LAMIVUDINE 600 mg-300 mg Tablet by mouth once a day ALBUTEROL SULFATE 90 mcg Inh 1-2 puffs po q4-6hr PRN cough ATAZANAVIR 300 mg Capsule by mouth once a day with ritonavir RITONAVIR 100 mg Tablet by mouth once a day\ BUPROPION HCL 150 mg Tablet ER PO BID hold trazodone while taking TRAZODONE 100 mg Tablet PO at bedtime CLONAZEPAM 0.5 mg Tablet PO BID PRN Anxiety DIPHENHYDRAMINE HCL 25 mg Capsule PO QHS PRN itching FAMCICLOVIR 500 mg Tablet 1 Tab PO daily inc to PO bid prn outbreaks FREESTYLE LITE TEST STRIPS - - use as directed once a day HYDROCHLOROTHIAZIDE 25 mg Tablet PO once a day VALSARTAN 320 mg Tablet PO once a day ASPIRIN 81 mg Tablet PO once a day LOPERAMIDE 2 mg Tablet PO PRN diarrhea not to exceed 16 mg in 24 hour period UREA 10 % Lotion - apply to feet twice a day Discharge Medications: 1. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 6. diphenhydramine HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Itching. 7. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO QHD (each hemodialysis). 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for itching. 11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 12. nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO four times a day as needed for thrush. 13. ondansetron 4 mg Film Sig: One (1) PO every eight (8) hours as needed for nausea. 14. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 15. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application Topical four times a day as needed for itching. 16. lamivudine 25 mg/5 mL (5 mg/mL) Solution Sig: Five (5) mL PO once a day: 25 mg (which is 5 mL daily). 17. famciclovir 125 mg Tablet Sig: One (1) Tablet PO QHD (with hemodialysis). 18. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**3-27**] hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 **] in [**Hospital1 8**] Discharge Diagnosis: Ureteral stone Hydronephrosis Pyelonephritis with subsequent sepsis retroperitoneal bleed Urosepsis Hemorrhagic shock Acute tubular necrosis Acute on chronic renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 97330**], It was a pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were found to have a stone in one of the tubes in your body that helps you get rid of urine. This led to a back-up of urine that then became infected. You were treated with antibiotics to kill the infection. You also needed drainage of the blocked urine, which required the emergent placement of a nephrostomy tube (a tube placed in your kidney). You also had bleeding into your belly, which required transfusions of blood and other substances usually present in blood (platelets and clotting factors). Because you were so sick, you required a breathing tube. Once you were strong enough to breathe on your own, this was pulled. You were eventually transferred from the ICU to the medical floor. The interventional radiologists (the people who placed the drain into your kidney and the drain into the blood clot in your belly) will help us to determine when to pull the drain in the clot in your belly. They will contact you at the rehab facility to arrange when to pull the drain. Please call Dr. [**Last Name (STitle) **], a urologist, to schedule an appointment within the next few weeks to discuss the management of the tube placed in your kidney. Because of the infection and the stone, your kidneys were injured, and you required dialysis to help get rid of fluid and the normal substances that are excreted by the kidneys. Unfortunately, you will require dialysis for a least the near future. They will give you dialysis at the rehab facility. You will be contact[**Name (NI) **] in the next few days with a urology appt. . You should note the following medication changes: 1. STOP ATAZANAVIR 300 mg daily 2. STOP hydrochlorothiazide 25 mg Tablet PO once a day 3. STOP valsartan 320 mg daily 4. STOP aspirin 81 mg daily 5. START cefpodoxime 200 mg PO daily - you will need to take this until you have the stone removed from your ureter 6. START darunavir 800 mg daily 7. START nystatin oral suspension 5 mL PO QID:PRN thrush 8. START nephrocaps 1 cap daily 9. START ondansetron 4 mg every 8 hours as needed for nausea 10. START senna 1 tab twice a day as needed for constipation 11. START sarna cream as neede for itching Followup Instructions: Please follow-up with your primary care doctor within one week of being discharged from the extended care facility. Name: [**Last Name (LF) **], [**First Name3 (LF) **] K. MD Location: [**Hospital1 **] Address: [**Location (un) **], [**Hospital Ward Name **] 3RD FL, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 921**] *It is recommended that you see Dr. [**Last Name (STitle) **] [**Last Name (STitle) 176**] a couple weeks. Please call his office to schedule an appointment. The Interventional Radiologists will call you to arrange follow-up to remove the percutaneous hematoma drainage catheter. We will contact you at rehab tomorrow with appointments to see Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 118**].

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4754

Discharge summary

report

Admission Date: [**2144-3-14**] Discharge Date: [**2144-3-19**] Date of Birth: [**2081-1-11**] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Fever, tachycardia Major Surgical or Invasive Procedure: Central venous line Swan-Ganz catheter Arterial Line Endotracheal Intubation History of Present Illness: Mr. [**Known lastname **] is a 63 year-old gentleman with recently diagnosed anaplastic T-cell lymphoma status post 1 cycle of CVP with radiographic improvement, also with a history of DM type 2 and CAD status post CABG in [**2129**] and recent NSTEMI, who presents from rehab with fever. He was recently discharged from [**Hospital1 18**] following a prolonged hospitalization during which the diagnosis of anaplastic T-cell lymphoma was made in the setting of clinical B symptoms and periportal lymphadenopathy, confirmed on lymph node biopsy. His hospital course was further complicated by a troponin leak consistent with probable NSTEMI with new WMA on echo and systolic dysfunction. He had persistent fevers which improved following chemotherapy, presumed secondary to lymphoma. Other events of note included spontaneous bilateral retroperitoneal bleeds (while on anticoagulation) with a requirement for transfusional support (required about 17U PRBC). He was discharged on [**2144-3-3**], and seen in follow-up on [**2144-3-10**] with plan to pursue [**Hospital1 **] next week. A CT scan showed radiographic response. . He now returns with fever and hypoxia at [**Hospital1 **] (88% RA, T-102.5). Workup in the ED showed bilateral pna (was given vanc/levo/flagyl), and he was febrile to as high as 103.9. In this setting, he had a troponin leak to 1.04 (with no ischemic EKG changes, no symptoms). Cardiology was consulted and felt that this was likely demand in the setting of pna; they did not recommend anticoagulation with heparin given recent RP bleed (recommended ASA +/- Plavix). He was given some IVF (2.5 L), but was intermittently tachycardic with fevers so was admitted to the ICU for closer monitoring. SBP remained stable (90-100s) throughout. . Currently, he denies any symptoms, stating that he feels fine. Specifically, he has no dyspnea, no cough, no chest pain, no palpitations, no dysuria, no hematuria, no nausea/vomiting, no diarrhea Past Medical History: ONCOLOGIC HISTORY: As noted above, Mr. [**Known lastname **] was diagnosed with anaplastic large cell lymphoma in [**1-/2144**] after he presented with B symptoms and periportal lymphadenopathy. Immunophenotyping on a lymph node biopsy specimen was consistent with anaplastic T-cell lymphoma. He is status post 1 cycle of CVP with radiographic response, and awaiting probable initiation of [**Hospital1 **] chemotherapy. . PAST MEDICAL HISTORY: 1. Anaplastic T-cell lymphoma as detailed above. 2. Type 2 diabetes (HgbA1c 8.2 in [**2142-8-6**]) complicated by retinopathy and neuropathy, as well as autonomic dysfunction. He was previously on fludrocortisone and midodrine. 3. CAD status post 4-vessel CABG in [**2129**], recent NSTEMI 4. CHF: Systolic dysfunction, presumed ischemic cardiomyopathy with EF 40-45% on last echo [**2144-2-21**], regional WMA. Persantine MIBI in [**1-/2144**] with no ischemic EKG changes or anginal symptoms, new mild fixed inferior perfusion defect. 5. Ulcerative colitis times 15 years. Last C-scope [**5-/2143**] normal. 6. GERD 7. Status post Nissen fundoplication for hiatal hernia [**2136**]. 8. Cataract status post left phacoemulsification with posterior chamber lens implant. 9. RP bleed s/p fall [**2-12**] in setting of anticoagulation; required 17 U PRBC Social History: Recently retired from work running autobody shop, following multiple knee surgeries. Lives in [**Location (un) **] with his wife. Adult son lives on [**Name (NI) 1456**]. Approximate 30 pack year smoking history, but quit in [**2121**]. Denies current alcohol or IVDU. Monogomous with wife of 37 years. No known blood transfusions. Family History: Notable for diabetes. [**Name (NI) **] mother had coronary artery disease and sister has [**Name (NI) 4522**] disease. Physical Exam: VITALS: 97.6F 91 93/57 17 97% 4L NC GEN: NAD. AAOx3. HEENT: EOMI. PERRL. dry MM. Healing abrasion on forehead. Neck: No JVD. Supple, no meningismus. Lungs: Crackles over R mid-field and R base. CV: RRR no m/r/g Abd: Soft NTND. BS normoactive. Extr: 1+ edema. 2+ DP. Extensive bilateral flank hematomas Neuro: Moves all extremities. Pertinent Results: Hematology:[**2144-3-14**] 12:15PM BLOOD WBC-17.4*# RBC-3.37* Hgb-10.6* Hct-30.8* MCV-91 MCH-31.4 MCHC-34.4 RDW-16.3* Plt Ct-307 [**2144-3-19**] 04:13AM BLOOD WBC-44.2* RBC-3.79* Hgb-11.5* Hct-35.2* MCV-93 MCH-30.4 MCHC-32.8 RDW-17.2* Plt Ct-53* [**2144-3-14**] 12:15PM BLOOD Neuts-93.2* Lymphs-2.6* Monos-3.9 Eos-0.2 Baso-0.2 [**2144-3-18**] 05:03AM BLOOD Neuts-86* Bands-12* Lymphs-0 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2144-3-19**] 04:13AM BLOOD Neuts-100* Bands-0 Lymphs-0 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2144-3-14**] 12:15PM BLOOD PT-15.0* PTT-31.9 INR(PT)-1.3* [**2144-3-19**] 04:13AM BLOOD PT-18.3* PTT-38.6* INR(PT)-1.7* . Chemistry: [**2144-3-14**] 12:15PM BLOOD Glucose-85 UreaN-15 Creat-0.9 Na-125* K-4.4 Cl-90* HCO3-24 AnGap-15 [**2144-3-19**] 04:13AM BLOOD Glucose-299* UreaN-72* Creat-2.6* Na-128* K-5.6* Cl-89* HCO3-12* AnGap-33* [**2144-3-14**] 12:15PM BLOOD ALT-45* AST-44* LD(LDH)-653* CK(CPK)-94 AlkPhos-289* Amylase-14 TotBili-2.6* [**2144-3-18**] 05:03AM BLOOD ALT-90* AST-266* LD(LDH)-764* CK(CPK)-49 AlkPhos-261* TotBili-8.9* DirBili-7.3* IndBili-1.6 [**2144-3-19**] 04:13AM BLOOD ALT-119* AST-252* LD(LDH)-803* AlkPhos-278* TotBili-10.6* [**2144-3-14**] 12:15PM BLOOD Lipase-14 [**2144-3-14**] 12:15PM BLOOD CK-MB-NotDone cTropnT-1.04* [**2144-3-14**] 07:00PM BLOOD CK-MB-NotDone cTropnT-0.77* [**2144-3-15**] 05:19AM BLOOD CK-MB-NotDone cTropnT-0.71* [**2144-3-15**] 05:00PM BLOOD CK-MB-3 [**2144-3-16**] 03:55AM BLOOD CK-MB-2 proBNP-[**Numeric Identifier 19972**]* [**2144-3-17**] 03:47AM BLOOD CK-MB-2 cTropnT-1.15* [**2144-3-18**] 05:03AM BLOOD CK-MB-7 cTropnT-1.96* [**2144-3-14**] 12:15PM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.1 Mg-2.0 [**2144-3-19**] 04:13AM BLOOD Calcium-7.5* Phos-5.8* Mg-2.4 [**2144-3-17**] 11:46PM BLOOD Cortsol-53.7* [**2144-3-16**] 03:55AM BLOOD Osmolal-260* [**2144-3-16**] 04:43PM BLOOD HCV Ab-NEGATIVE [**2144-3-16**] 12:13PM BLOOD Type-ART Temp-40.4 pO2-152* pCO2-33* pH-7.41 calTCO2-22 Base XS--2 Intubat-NOT INTUBA [**2144-3-19**] 05:52AM BLOOD Temp-39.8 Rates-36/ Tidal V-650 PEEP-17 FiO2-60 pO2-201* pCO2-27* pH-7.22* calTCO2-12* Base XS--15 Intubat-INTUBATED Vent-CONTROLLED [**2144-3-14**] 12:18PM BLOOD Lactate-1.9 K-4.1 [**2144-3-17**] 03:26AM BLOOD Lactate-4.0* [**2144-3-18**] 03:00PM BLOOD Lactate-8.7* [**2144-3-19**] 05:52AM BLOOD Lactate-12.6* . RELEVANT IMAGING DATA: [**2144-3-14**] CXR: Ill-defined bibasilar opacities are seen, more severe on the left, suggestive of pneumonia. No large pleural effusion. The mediastinum and hila are unremarkable. Mild stable cardiomegaly. . [**2144-3-12**] CT [**Last Name (un) **] W/ CONTRAST: 1. Interval improvement in abdominal and pelvic [**Doctor First Name **] consistent with response to treatment. 2. Persistent inflammatory infiltration of the RP fat surrounding the pancreas and RP vascular structures. 3. Interval increase in size of left pelvic retroperitoneal hematoma without evidence of active bleeding. No significant change in bilateral psoas hematomas. 4. Cholelithiasis. 5. Patchy atelectasis and minimal left pleural effusion at the lung bases. 6. Fat containing left inguinal hernia. . [**2144-3-17**] CT CHEST/ABDOMEN/PELVIS: 1. Study is limited for evaluation of potential abscess or lymphadenopathy given lack of IV contrast administration. That said, there are no definite intra-abdominal abscesses identified. The bilateral retroperitonal hematomas have slightly decreased in size since previous study. 2. Diffuse bilateral patchy airspace opacity consistent with pneumonia. Bilateral small pleural effusions, more prominent on the left. 3. No definite liver lesions identified on this noncontrast view and no definite intra- or extra-hepatic biliary ductal dilatation identified. 4. Cholelithiasis. 5. Small amount of free pelvic fluid. 6. Diffuse pelvic subcutaneous edema. . [**2144-3-18**] U/S LIVER: 1. Moderate gallbladder wall thickening without evidence of pericholecystic fluid, wall distention or other signs for acute cholecystitis. Findings may reflect third spacing given the ascites seen on the recent CT study. Apparent wall thickening may also be due to the relatively [**Name2 (NI) 19973**] gall bladder. If there remains clinical concern for cholecystitis, a HIDA scan could be performed. 2. Normal son[**Name (NI) 493**] appearance of the liver without evidence of mass or biliary ductal dilatation. . EKG: Sinus tach at 112 bpm, nl axis, IVCD, TWI in II, III, aVF, V5-V6, slightly more pronounced when compared to prior. Brief Hospital Course: 63M with anaplastic T-cell lymphoma, DM2, CAD s/p CABG in '[**29**], CHF, hyponatremia, retroperitoneal bleeding s/p fall admitted from [**Hospital1 **] after a prolonged hospitalization for new diagnosis of anaplastic T-cell lymphoma s/p CVP with fevers, hypotension and troponin elevation, found to have multifocal pneumonia with the development of severe septic shock. . #) Sepsis. Likely source was multifocal PNA. CT torso and RUQ ultrasound without evidence of intra-abdominal pathology. The patient was started on vanco/[**Last Name (un) 2830**]/flagyl/azithro for multifocal PNA and caspofungin added for fungal coverage. No organisms were recovered from BAL, sputum, blood, or urine cultures. Stress dose steroids were initiated and then discontinued given appropriately elevated serum cortisol. MICU Course as follows - [**3-15**]: Increasing respiratory distress, CXR revealed worsened pulmonary edema and he was given lasix with symptomatic improvement. Metoprolol was restarted given tachycardia. Flagyl added given concern for potential aspiration. The patient had a brief asymptomatic run of SVT (170's). Demeclocycline restarted for SIADH. [**3-16**]: Patient given albumin infusion and lasix drip with little increase in UOP. SBP's continued decreasing. Given increased O2 demand and poor UOP,he was bolused with NS total [**2137**] cc with some improvement in symptoms and UOP. [**3-17**]: Overnight, intubated for respiratory distress and started on levophed for hypotension. Swan-Ganz catheter placed to aide in volume status management (CVP 17, PCWP 18, low CO, low SVR). CT Torso performed, no obvious abdominal abscess or liver/biliary pathology. Demeclocycline discontinued. [**3-18**]: Worsening lactic acidosis and multi-organ dysfunction. Renal consult for acid-base management. Continued bicarb push q1h. Required 3 pressors (levophed, neosynephrine, vasopressin) to maintain MAP. ARDSnet ventilation initiated. RUQ U/S negative. [**3-19**]: Family was contact[**Name (NI) **] given worsening sepsis and poor prognosis. After discussion with team and family, pressors were withdrawn and the patient expired. . #) Respiratory failure. Multifocal PNA, sepsis, ARDS. Also with pulmonary edema. - Increased PEEP, ARDSnet protocol - Sedated with Fentanyl and Versed . #) CV: CAD, HTN, CHF, and troponin elevation. Echo with worsened EF and significant hypo-/akinesis of ventricles. Seen by cardiology in the ED and is felt to have demand ischemia, not acute infarct. Of note, the patient is a poor anticoagulation candidate given his retroperitoneal bleeding. Elevated filling pressures on Swan-Ganz suggest some component of heart failure but predominately septic physiology. Brief runs of SVT, likely atrial tach, as well as frequent PVCs noted. . #) Acute Renal Failure. Oliguric. Likely ATN [**2-7**] hypotension from sepsis. Renal consulted for acid-base management. . #) Hyponatremia. Likely SIADH. . #) Anemia. s/p RP bleed after fall while anticoagulated. No evidence hemolysis; haptoglobin has been high in past, indirect bilirubin not high. B12 and folate normal in [**Month (only) 404**]. CT torso with stable hematomas. . #) Anaplastic T-Cell Lymphoma. s/p CVP chemotherapy on recent admission. Recent CT abd/pelvis suggestive of systemic response with reduced lymphadenopathy. Given depressed EF, the patient was not a good candidate for anthracycline. . #) Diabetes. Complicated by gastroparesis. Fingersticks qid with HISS coverage, standing NPH. Continued on reglan, ativan prn for gastroparesis. . #) Ulcerative Colitis. No GI complaints during admission. Held sulfasalazine given recent RP bleeding. . #) GERD, s/p Nissen fundoplication. Continued on PPI. . #) Elevated LDH and T Bili. Likely secondary to retroperitoneal bleeding (vs. elev LDH [**2-7**] malignancy), then worsened during sepsis. CT abdomen and RUQ U/S unrevealing. . #) Coagulopathy: Likely nutritional. Repleted with vitamin K. . #) Dispo: Expired Medications on Admission: Folic Acid 1 mg PO DAILY Lasix 40 mg SSI, NPH 24/6 Losartan 35 mg Reglan 20 mg TID Lopressor 25 mg TID Nystatin swish Protonix 40 mg Senna Trazodone 75 mg qhs Zinc Ambien Albuterol ASA 81 mg Dulcolax Oxycodone PRN pain Vanco/Levo/flagyl (started [**3-13**]) Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Sepsis Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

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icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "38.93", "96.71", "89.68", "89.64", "38.91", "96.07" ]

icd9pcs

[ [ [] ] ]

13391, 13400

9091, 13054

295, 373

13450, 13460

4545, 9068

13513, 13520

4056, 4177

13362, 13368

13421, 13429

13080, 13339

13484, 13490

4192, 4526

237, 257

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3701, 4040

66,162

175,541

38091

Discharge summary

report

Admission Date: [**2141-7-13**] Discharge Date: [**2141-8-4**] Date of Birth: [**2084-8-14**] Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5667**] Chief Complaint: Poorly differentiated carcinoma right facial region, metastatic to right neck. Major Surgical or Invasive Procedure: 1. Facial nerve monitoring. 2. Right modified radical neck dissection. 3. Total parotidectomy with facial nerve dissection. 4. Resection of the zygomatic bone. 5. Right muscle sparing vertical rectus abdominis myocutaneous perforator flap. 6. Reconstruction of total facial nerve resection. 7. Harvest of sural nerve graft 19 cm. 8. Microvascular microsurgical repair of facial nerve, branches of the pes anserinus three major divisions of the facial nerve. 9. Local tissue rearrangement 40 square cm of postauricular skin and auricle to reconstruct postauricular and preauricular defect. 10. Harvest of the skin graft. 11. 3 inches x 10 cm for closure of the anterior wall chest defect as well as right preauricular area. 12. Right lateral tarsorrhaphy. History of Present Illness: 56-year-old female with a history of having a right facial mass that has been developing over the past five to six years. The patient reports the lesion is not painful, but that it has been growing more recently with changing characteristics in the last month. She reports it does not bleed but occasionally oozes liquid from the lesion. She also states that her forehead is asymmetric with decreased ability to raise the forehead on the right side as compared to the left side. She recalls about 10 years ago, that she noticed a patch of dry skin in the right preauricular region that would come and go. About 1 year ago, she noticed significant growth of the lesion. It started as dime-sized and she was able to cover it with a regular-sized bandaid. Then it grew until it reached the present size of 6 cm in diameter, with cauliflower surface, slight smell, and occasional bleeding. Additionally, she began noticing high anterior right neck lymph node swellings a few months ago. Unfortunately, she did not seek medical attention in [**State 108**] due to "lack of health insurance" until [**2141-4-12**] when she met dermatologist Dr. [**First Name8 (NamePattern2) 13740**] [**Last Name (NamePattern1) 4469**] who perfomed a shave biopsy of the large mass, as well as shave biopsy of a much smaller asymptomatic lesion on her anterior chest at the base of the V of her neck. Past Medical History: squamous cell carcinoma of the right face COPD . PSH: hysterctomy tubal ligation [**Last Name (un) 3907**] augmentation Social History: She is originally from [**State 1727**], but has lived in [**State 108**] for the past 16 years and has worked as a caregiver for the past 4-1/2 years. She returned to [**State 1727**] to live with her son and seek treatment. Currently smokes. She has a 35-pack-year history. Does not drink. Family History: Significant for breast cancer, diabetes, and depression. Physical Exam: Preprocedure/Admission PE as documented in Anesthesia Record [**2141-7-13**]: General: wd petite woman Mental/psych; a/o Airway: as documented in detail on anesthesie record Dental; dentures (partial upper) Head/neck range of motion: free range of motion Heart: rrr Lungs: clear to auscultation Abdomen: soft nt Extremties: no ankle edema Other: no cerv lad Pertinent Results: [**2141-7-13**] 10:52AM freeCa-1.09* [**2141-7-13**] 10:52AM HGB-12.8 calcHCT-38 [**2141-7-13**] 10:52AM GLUCOSE-132* LACTATE-1.6 NA+-140 K+-2.6* CL--108 [**2141-7-13**] 09:41PM freeCa-1.04* [**2141-7-13**] 09:41PM HGB-10.3* calcHCT-31 [**2141-7-13**] 09:41PM GLUCOSE-161* LACTATE-1.6 NA+-139 K+-3.7 CL--102 [**2141-7-16**] 02:59AM BLOOD WBC-12.4* RBC-2.87* Hgb-8.8* Hct-25.3* MCV-88 MCH-30.8 MCHC-34.9 RDW-15.1 Plt Ct-150# [**2141-7-24**] 08:10AM BLOOD WBC-19.6* RBC-2.24* Hgb-6.7* Hct-20.2* MCV-90 MCH-29.8 MCHC-33.0 RDW-18.9* Plt Ct-832*# [**2141-7-26**] 08:31AM BLOOD WBC-17.9* RBC-3.64* Hgb-10.9* Hct-32.2* MCV-89 MCH-29.9 MCHC-33.8 RDW-18.8* Plt Ct-805* . MICROBIOLOGY [**2141-7-24**] 1:32 pm URINE Source: CVS. **FINAL REPORT [**2141-7-28**]** URINE CULTURE (Final [**2141-7-28**]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S . [**2141-7-26**] 5:21 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2141-7-26**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-7-26**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: Pt was admitted to the Plastic Surgery Service on [**2141-7-14**] following radical resection of R neck mass and subsequent free TRAM flap w/ skin and nerve grafting. . POD#1 [**2141-7-14**]: Patient was admitted directly to Trauma ICU (TICU) from the operating room given lengthy surgery and precariousness of free flap. Flap head good capillary refill throughout ([**12-28**] sec) with small area at superior pole demonstrating sluggish refill and slight duskiness. Patient with continuous Vioptix monitoring of free flap. BP dipping to low 70s/40s with HR 100-120. Pt received multiple fluid boluses (~3.5L NS) and 1 unit albumin with some response but not sustained. Urine output remained high. In the setting of low BP, tachycardia, and HCT 19.9 (from 25.9) pt received 2 units of PRBCs with resolution of symptoms (one in am and one overnight). She remained intubated on propofol. . POD#2 [**2141-7-15**] Upper pole of free flap remained dusky with sluggish cap refill, 3-4 seconds. Pulses remained dopplerable in lower portion of flap. Donor site for STSG and recipient site continued to look healthy with good amount of oozing. Pt continued to require frequent fluid boluses to maintain HR < 100. BP 80-90/40s. Tolerating large amount of fluid with large urine output. Patient maintained on strict 'no roll' precautions given tenuousness of neck flap. Propofol was weaned and fentanyl increased to help with possible pain induced tachycardia and sedative induced hypotension. . POD#3 [**2141-7-16**] Patient remained in TICU. She was rolled to change bedding and inspected for pressure ulcers in am with plastics present and providing axial support of the neck. Pt did not tolerate the procedure well and sats dropped to high 80s with increased fluid oozing from around flap site. Vioptix replaced with maximum % in low 60s (94% sig quality) . POD#4 [**2141-7-17**] Right thigh STSG donor site was open to air and drying out well. Right lateral lower extremity sutures s/p sural nerve harvesting remained dry and intact. Flap with + doppler signal and vioptix stable. Patient remained intubated and on 'no roll precautions. A multipodus boot was applied to right foot to elevate heel off of bed and prevent foot drop. Abdominal steri strips remained dry and intact. A left brachial PICC line was placed to maintain long term access. A Dobhoff tube was placed so that patient could be started on tube feeds. . POD#5 [**2141-7-18**] Patient remained in TICU and was extubated and tolerated well. . POD#6 [**2141-7-19**] Patient remained in TICU and her neck JP drain was removed for low output. She was maintained on the heparin gtt for flap protection. The bolster over the central chest STSG site was removed, site appeared healthy and graft adherent and Xeroform dressing placed. An anterior neck hematoma had accumulated and was aspirated at bedside and iodoform gauze tape placed to wick wound. . POD#7 [**2141-7-20**] The anterior neck hematoma wick continued to drain moderate amount of bloody fluid. The abdominal JP drain was pulled. Chest PT and pulmonary toilet initiated. Patient was transfused 1 unit of PRBC's for HCT < 21. . POD#8 [**2141-7-21**] Abd JP site with large amount of serosang drainage leak, pressure dressing placed and oozing stopped. Patient transferred to floor today. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID initiated for eye protection due to inability to completely close eye. Occupational and Physical therapy initiated. Heparin gtt was discontinued. Heparin subcutaneous injections TID initiated. . POD#9 [**2141-7-22**] Posterior edge of flap with dehiscence of 2x4x1.5cm (indurated, but no purulence), wet to dry dressings initiated. Anterior neck with open wound (remained clean with some oozing, repacked loosely) & STSG with Xeroform dressings QD. R thigh donor site healing well. Right posterior lower leg with some eschar formation (3x3cm), no fluctuance, no drainage)-topical applied. Old abdominal drain site with decreased drainage. Patient OOB to chair with assist. Ipratropium Bromide Neb 1 NEB IH Q6H and Albuterol 0.083% Neb Soln 1 NEB IH Q6H initiated. . POD#10 [**2141-7-23**] Post edge of flap unchanged, wet to dry continued. Anterior neck wound more open laterally, packed with gauze. Foley was discontinued and patient began using bedside commode with assist. Nocturnal feeds at 100cc/hr 7p-7a (nutrition following). Patient with some episodes of diarrhea. . POD#11 [**2141-7-24**] Posterior flap area with open area...packed with W-D. Right inferior neck skin graft area dead and left open to air, no creams, ointments. Transverse open area (s/p hematoma I+D) base of neck: Packed with loose sterile gauze and covered. Xeroform QD to chest STSG site continued. RLE sutures intact. RLE posterior pressure ulcer from multipodus boot (?)-->Ordered softer posterior resting splint from orthotech. Calorie count initiated...pt with POOR po intake. Nocturnal TFs goal 100cc/hr x 12h continued. Lopressor 12.5 [**Hospital1 **] for tachycardia initiated. IV fluids discontinued and free water via NGT (800cc QD) initiated. Cefazolin IV discontinued and Flagyl initiated for continued and increasing episodes of diarrhea. C.diff stool testing ordered. Social Work consult requested for patient and family coping. Vioptix monitoring continued and flap checks Q4h continued. Patient agitated today...dilaudid discontinued and trial of oxycodone initiated. Occupational therapy working with patient on methods of taking PO nutrition. Patient transfused with 2 units of PRBCs for HCT < 21. . POD#12 [**2141-7-25**] Hemoglobin/hematocrit 10.3/31.2 s/p 2 units. Lopressor increased to 25mg [**Hospital1 **] for better control of heart rate. RLE lateral sutures by foot with para-incisional erythema and TTP. Some sutures removed and hematoma drained at bedside. Flap vioptix removed/discontinued. Psych consult-->for delirium, sundowning. Psych recommendations: d/c hydroxyzine, re-orient at night, initiate Haldol. Speech/swallow consult-->no mechanical reason patient is not eating. Santyl [**Hospital1 **] to posterior leg wound eschar area and boot from ortho tech-->Plantar fascia night splint with [**Doctor First Name **] cloth lining for RLE. . POD#13 [**2141-7-26**] Agitation last PM despite Haldol. Psych recommendations-->Haldol 2.5mg QHS repeat dose x1 if still agitated and difficulty sleeping. Increased lopressor to 37.5 [**Hospital1 **] for improved rate control. RLE erythema and swelling around sutures improved. PO intake encouraged but continued poor appetite. . POD#14 [**2141-7-27**] Went to OR for debridement, STSG to scalp, gold weight Rt eye. + Pseudomonas UTI--->cipro 500 [**Hospital1 **] x 3 days. C.diff negative but continued to treat with flagyl PO. Diarrhea x 2. Protein shakes with trays: ordered Ensure plus shakes for lunch and dinner. Nocturnal tube feeds continued. Wound VAC to right face skin graft site. . POD#15/#1 [**2141-7-28**] Patient ambulated 2 times today with PT around part of floor with walker. PT recommended increased ROM exercises for R foot. Increased PO intake today. Nocturnal tube feeds continued. . POD#16/#2 [**2141-7-29**] Patient pulled out her Dobhoff overnight. Calorie counts continued and increased PO intake encouraged with good effect. Eschar debrided from R lateral ankle exposing a 1 cm deep hematoma that was washed out. Wound then packed with wet/dry dressing. VAC with clot at suction tip (lollipop). Excised and replaced with good suction. . POD#17/#3 [**2141-7-30**] Patient taking moderate amounts of POs. Calorie counts in progress. Pt ambulating QID. VAC holding adequate suction. . POD#18/#4 [**2141-7-31**] Patient continuing to increase PO intake, ambulating. . POD#19/#5 [**2141-8-1**] AVSS, wound VAC in place and patent to right face STSG site. Wet to wet dsg changes QID to neck wound. Bacitracin ointment to chest STSG site. Right thigh STSG donor site open to air. W-D dsg changes to 2 RLE wounds. Calorie ct continues with good PO intake. . POD#20/#6 [**2141-8-2**] VAC removed from R scalp. Underlying flap with healthy granulation tissue but STSG appears non-adherent and de-vitalized. Curisol gel and Adaptic applied over the R neck and scalp wounds [**Hospital1 **], ensuring that both sites remain moist. PO intake stable (calories ~1400-1700 kcal/day), pt taking high calorie shakes as additional supplement. Flagyl discontinued, no further episodes of diarrhea x 5 days. . POD#21/#7 [**2141-8-3**] Pt wants to go home. Feels comfortable with daily activities/wound dressing changes with her daughter-in-law. Continues to eat regular meals with additional caloric supplements (ensure+). . At the time of discharge on POD#22/#8 ([**2141-8-4**]), the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Her right eye and face remain slack with the right eye hanging open (gold weight in place). Ointment well applied and covering the cornea. Her right scalp wound is well healing with good granulation. The aquacel and underlying tissue remain damp and there are no signs of further skin breakdown or infection. Suprasternal split thickness skin graft site is well healing and without signs of infection. Abdominal wounds are all but healed completely with no signs of cellulitis. R thigh is CDI with Xeroform dried to the most recent donor site (which will remain on until it falls off on its own). The R ankle wounds are clean and dry with wet/dry packing at the proximal and distal most wounds. All wounds have had sutures removed. Medications on Admission: hydroxyzine, citalopram Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily) for 10 days: Take aspirin until [**2141-8-13**] which would finish one month of aspirin therapy. Disp:*15 Tablet, Chewable(s)* Refills:*0* 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Max 8/day. Do not exceed 4gms/4000mg of tylenol per day. Disp:*180 Tablet(s)* Refills:*2* 3. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day: 2 INHALATIONS 4 times per day; MAX 12 inhalations/day. Disp:*1 HFA inhaler* Refills:*2* 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours: 2 ORAL INHALATIONS every 4 to 6 hr or 1 ORAL INHALATION every 4 hr as needed. Disp:*1 HFA inhaler* Refills:*2* 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day) as needed for corneal protection. Disp:*1 bottle/tube* Refills:*3* 8. Erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5 inch ribbon Ophthalmic Q4H (every 4 hours): Apply to right eye. Disp:*1 tube* Refills:*3* 9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: 1. Poorly differentiated carcinoma right facial region. 2. Metastatic carcinoma right neck. 3. facial nerve paralysis, status post resection. 4. Large facial wound defect (defect measured at least 7 x 12 x 10 cm) 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 may shower/bathe daily but do not let shower water onto your facial/neck wounds. Shower from neck down only. You may remove the wet to dry packing/dressings used on your right leg wounds, shower, and then apply fresh dressings. . Activity: 1. You may resume your regular diet. Please try to have some supplemental shakes/smoothies between meals to build up your nutrition and proteins for good wound healing. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softerner if you wish. 6. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Wounds: You will have a visiting nurse (VNA) help you with daily dressing changes and wound care. However, you will need to have your dressings changed at least one additional time during the day without nursing help (ie by a family member or friend). These dressings include: 1. Please apply prescribed eye drops and eye ointment to the Right eye four times a day. The right eye should be taped shut every night to prevent corneal abrasions. 2. Right scalp and Right neck wounds should be covered with curisol gel two times a day. Ensure that the tissue is relatively damp at all times. A dry gauze sponge can be taped over the damp dressing with paper tape. 3. Suprasternal split-thickness skin graft site should be covered with bacitracin ointment two times a day (cleaning off by dabbing in between). 4. Right thigh wounds should be left to air to dry. Loose edges of the Xeroform can be trimmed back if they are bothering the pt. 5. Right ankle wound should be packed with wet-to-dry dressings two times a day. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Separation of the incision. 4. Severe nausea and vomiting and lack of bowel movement or gas for several days. 5. Fever greater than 101.5 oF 6. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Please follow up with your Plastic Surgeon, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: ([**Telephone/Fax (1) 9144**] Dr.[**Name (NI) 27488**] office is located on the [**Hospital Ward Name **], in the [**Hospital Unit Name **], on the [**Location (un) 442**], [**Hospital Unit Name 6333**]. . Please follow up with Dr. [**Last Name (STitle) 1837**]: ([**Telephone/Fax (1) 6213**] Office Location: [**Last Name (NamePattern1) **], [**Hospital Unit Name **] Suite 6E

[ "198.89", "293.9", "518.5", "496", "709.9", "196.0", "997.09", "351.0", "173.3" ]

icd9cm

[ [ [] ] ]

[ "08.52", "96.72", "76.2", "38.93", "86.69", "40.41", "86.74", "18.79", "26.32", "96.6" ]

icd9pcs

[ [ [] ] ]

16361, 16411

5219, 14880

393, 1174

16668, 16668

3512, 5196

20142, 20638

3059, 3118

14954, 16338

16432, 16647

14906, 14931

16851, 20119

3133, 3493

274, 355

1202, 2588

16683, 16827

2610, 2731

2747, 3043

70,924

119,848

37866

Discharge summary

report

Admission Date: [**2132-10-11**] Discharge Date: [**2132-11-4**] Date of Birth: [**2090-1-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: Central venous line placement Intubation Mechanical ventilation History of Present Illness: 42F with chronic alcoholic pancreatitis transferred from OSH for acute on chronic pancreatitis. Pt had been sober for one year but started drinking again after her mother passed away recently. Pt states that she drank about a gallon of wine between Tuesday and Thursday. Her pain began Friday night. At the OSH, pt received 8mg IV dilaudid, 8mg zofran, 40mg po potassium and 1L NS. . On arrival to our ED, vitals 98 108 101/52 20 98%RA. Pt got an additioanl 3L NS, 4mg IV dilaudid and 4mg IV zofran x2. CT scan showed peripancreatitc stranding consistent with pancreatitis without evidence of pancreatic necrosis or pseudocyst. Labs significant for a lipase of 1334, triglyceride 683. . On arrival to floor, vitals 98.8 104 124/72 25 93% on 2L. Pt complains of abdominal pain, nausea, and vomiting. ROS also significant for chest pain and shortness of breath. Pt denies diarrhea, constipation, dysuria and headache. Past Medical History: Chronic Pancreatitis, started 3 years ago, had 3 prior episodes, last episode [**7-26**]. Has been sober since, until now. Alcoholism - sober from [**7-26**] until now Depression Anxiety/Panic Attacks Brain aneurysm (Dx [**9-25**])/VP shunt for hydrocephalus (placed [**12-28**] at [**Hospital1 112**]) Tonsillectomy C-Section Social History: Smokes [**12-21**] cigarettes/day. Had been sober for 1 year but drank from Tues-Thurs after mother passed away. Unemployed since aneurysm. Had worked as a housekeeper. Lives with boyfriend, daughter and [**Name2 (NI) 8526**]. HCP, [**Name (NI) 7019**] [**Name (NI) 84689**], sister-in-;[**Name2 (NI) **] [**Telephone/Fax (1) 84690**]. Family History: M - Deceased [**2132-10-3**] [**1-21**] old age, Emphysema, MI, Dementia F - Living, PAD, Cancer in 2 ribs Brother, [**Name (NI) 12239**] - Deceased [**1-21**] MI, also had colon cancer in remission Brother, [**Name (NI) 68925**] - Deceased [**1-21**] Alcoholic liver disease Physical Exam: GENERAL: NAD. Oriented x2-3 (orientation to time is intermittent). Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no discernible JVP or thyromegaly CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp unlabored, no accessory muscle use. CTAB, crackles only at bases, largely cleared with coughing ABDOMEN: Soft, distended, tender at the epiastrium with no rebound or guarding. Bowel sounds present. No abdominial bruits. EXTREMITIES: Pitting edema over lower legs, extremities warm. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 1+ PT 1+ Left: Carotid 2+ DP 1+ PT 1+ BP RANGE: 115/50-140/75 HR RANGE: 100-125, AVG 110 Pertinent Results: Admission labs: [**2132-10-11**] 05:55PM WBC-19.5* RBC-3.72* HGB-11.8* HCT-35.0* MCV-93 MCH-31.6 MCHC-34.4 [**2132-10-11**] 05:55PM NEUTS-89.6* BANDS-0 LYMPHS-6.7* MONOS-2.7 EOS-0.3 BASOS-0.3 [**2132-10-11**] 05:55PM PLT COUNT-231 [**2132-10-11**] 05:55PM GLUCOSE-131* UREA N-12 CREAT-0.8 SODIUM-141 POTASSIUM-4.0 CHLORIDE-113* TOTAL CO2-13* ANION GAP-19 [**2132-10-11**] 05:55PM ALT(SGPT)-29 AST(SGOT)-44* LD(LDH)-426* CK(CPK)-106 ALK PHOS-105 TOT BILI-0.3 [**2132-10-11**] 05:55PM LIPASE-1334* [**2132-10-11**] 05:55PM ALBUMIN-4.1 CALCIUM-6.2* PHOSPHATE-2.4* MAGNESIUM-1.5* CHOLEST-1285* [**2132-10-11**] 05:55PM TRIGLYCER-683* HDL CHOL-70 CHOL/HDL-18.4 . DISCHARGE LABS [**2132-10-30**] 04:22AM BLOOD WBC-25.5* RBC-2.54* Hgb-8.2* Hct-23.7* MCV-93 MCH-32.1* MCHC-34.5 RDW-14.1 Plt Ct-455* [**2132-10-30**] 10:28AM BLOOD Hct-25.6* [**2132-10-28**] 04:03AM BLOOD PT-14.2* PTT-24.8 INR(PT)-1.2* [**2132-10-30**] 04:22AM BLOOD Glucose-103 UreaN-29* Creat-1.2* Na-137 K-3.1* Cl-90* HCO3-35* AnGap-15 [**2132-10-26**] 03:59AM BLOOD ALT-8 AST-21 AlkPhos-94 TotBili-0.2 [**2132-10-16**] 06:05AM BLOOD Lipase-35 . ADMISSION CT ABDOMEN [**10-12**]: 1. Large amount of peripancreatic stranding and fluid consistent acute pancreatitis. No evidence of organized pseudocyst, pancreatic necrosis, venous thrombosis or arterial pseudoaneurysm formation. 2. Bibasilar atelectasis. 3. Fatty infiltration of the liver. . CT ABDOMEN [**10-21**] 1. Limited examination secondary to lack of intravenous contrast. 2. No evidence of acute hemorrhage within the abdomen or pelvis. 3. New air-space consolidation within the right middle lobe and lingula concerning for aspiration or developing pneumonia. Interval increase in small to moderate left pleural effusion. 4. Extensive peripancreatic inflammatory changes and intra-abdominal fluid slightly worsened in the interval compared to eight days prior. 5. Extensive third spacing. . CT ABDOMEN [**10-26**] 1. Pancreatitis with decreased pancreatic enhancement suggestive of necrosis; copious peripancreatic, retroperitoneal and mesenteric fluid without evidence of hemorrhage or pseudocyst formation. 2. Right middle lobe pneumonia and left-sided pleural effusion. [S/P TREATMENT OF VAP, RADIOGRAPHIC FINDINGS ATTRIBUTE TO RESOLVING ARDS/TREATED VAP]. 3. Extensive third spacing. . CT HEAD [**10-26**] 1. Mild hydrocephalus with left transfrontal ventriculoperitoneal shunt in situ, and no transependymal migration of CSF. No (outside) study is currently available with which to assess change. 2. Post-operative changes, likely related to right-sided aneurysm clipping, with no hemorrhage seen. 3. Mucosal sinus disease. . [**10-26**] BETA GLUCAN NEGATIVE . LUMBAR PUNCTURE: [**2132-10-28**] wbc=1 rbc=1 protein=15 glucose=94 . Urine culture (from foley) one day prior to d/c notable for 50+ reds, 20-50 whites, trace leukesterase and negative nitrites Brief Hospital Course: 42F with acute on chronic alcoholic pancreaitis developed hypotension and ARDS requiring intubation. She did not tolerate ARDSnet volumes and was on pressure support for two weeks until tracheostomy was placed after which she weaned to trach mask rapidly. She was persistently febrile with WBC over 20 throughout her ICU course even after completing a course of broad spectrum Abx for ventilator associated PNA, she defervesced 36-48 hours prior to discharge. All cultures were negative, neither we nor the surgical team beleived that her pancreas had become infected. These fevers were attributed to pancreatic inflammation. . 1. Necrotizing pancreatitis: Pt presented with acute on chronic pancreatitis, likely [**1-21**] to binge alcohol consumption. Initially, pt had an APACHEII score 7, which corresponds to a predicted death rate of 7.6%. 48 hours after admission, her [**Last Name (un) 5063**] criteria predicted a 40% mortality. She became hypotensive requiring aggressive fluid resuscitation and vasopressors. Initially her CT showed large amount of peripancreatic stranding and fluid consistent acute pancreatitis and progressed to severe pancreatitis with concern for widespread necrosis involving the body and tail, extending into the neck within 48 hours. A NJ tube was placed to start TFs. Complications included hypertriglyceridemia and hyperglycemia. Her TG were noted to be elevated to 7,000, and pt was started on gemfibrozil. She was empirically treated with broad spectrum antibiotics for 14 days (meropenem + ciprofloxacin) given necrotic pancreatitis. She also required an insulin gtt to control her blood glucose. The surgical service was involved throughout her MICU stay. The most recent CT prior to discharge was notable for decreased enhancement of 75% of the pancreas suggesting 75% necrosis. There was extensive peri-pancreatic fluid but no pseudocyst or abcess. Lipase peaked at 1300 on the day of admission, but had trended down to 35 within 5 days. She was transferred to the floor for further management. Given persistent abdominal distension and worsening leukocytosis, a repeat CT was obtained which showed a possible abscess forming to the right of the uterus potentially communicating with peripancreatic fluid. General surgery was reconsulted however they did not feel a need to intervene. Over the next day, she became afebrile and her WBC count trended down from 35 to 25. She remained stable at this white count for 48 hours prior to discharge. She was continued on sliding scale insulin as well as evening lantus (40 units) to maintain sugars given hypo-endocrine function and started on pancrease replacement for hypo-exocrine function. She was scheduled for follow up with general surgery on [**12-5**] at 1015 AM for follow up following discharge from rehab. We were not worried about the question of abscess due to resolving fevers and return of leukocytosis from 35 to 25, however we have suggested daily abdominal examinations with repeat evaluation with imaging should she become acutely febrile or have any elevation in WBC or other inflammatory markers. Her pain was well managed on dilaudid PO. . 2. Acute respiratory distress syndrome & ventilator associated PNA: Pt had hypoxemic respiratory failure, likely [**1-21**] to ARDS from pancreatitis. She required brief paralysis an esophageal balloon to maximize PEEP given initial difficulties with oxygenation. She never tolerate AC to achieve ARDSNet volumes for a prolonged time; therefore, she was largely on pressure support pulling high volumes. Given her diffuse bilateral intersitial infiltrates, leukoctyosis in the mid-20 range, and persistent fevers, she was emprically treated for VAP with vancomycin, cefepime, cipro for two weeks. Initial intubation was [**10-12**]. Tracheostomy placed [**10-24**]. Speech and swallow service saw pt on the day of discharge and fitted her for a passy-muir valve. On the floor, she continued to saturate well with humidified trach mask. . 3. Persistent fevers: These were most likely secondary to alcoholic pancreatitis, we did not belive that there was an infectious process in the abdomen. She completed a course 2 week course of vancomycin, cefepime, and cipro for ventilator assocaiated PNA (which also would have covered pancreatic infection) given her diffuse bilateral opacities, WBC~25, and fever although this was all most likely driven by ARDS secondary to pancreatitis. Lumbar puncture was performed to rule out infection of her VP shunt: 1wbc, 1rbc, glucose of 90, and protein of 15. She was afebrile for 36-48 hours prior to discharge. Yeast grew from [**Last Name (un) 29828**] her sputum and urine; Beta-glucan was negative and fungal cultures were negative at the time of discharge. A repeat abdominal CT showed development of small area of wall thickening near uterus communicative with peripancreatic fluid as above however our suspicion for intervention was low given that her WBC trended back down and remained afebrile. At time of discharge WBCs were near 25 which we suspect is due to continued resolution of pancreatitis. PO vancomycin was continued as above given her loose stools. C diff toxin X 2 was negative. No other infectious etiologies were suspected at time of discharge. . 4. Fluid overload: In the setting of aggressive fluid resuscitation for pancreatitis and diffuse third spacing. At the time of discharge, the pt was still net 15 liters positive. Excellent diuresis was achived with lasix drip and metolazone. This was converted to IV lasix by bolus prior to transfer to floor. On the floor, she continued to be somewhat volume overloaded however we felt that this was secondary to inflammatory changes due to underlying pancreatitis. Her IV lasix drip was stopped prior to transfer to floor and her PO lasix was discontinued after one day. She began to auto-diurese net -2 to -3 L per day without any diuretics. We suggested that further diuresis with diuretics is not indicating since she is self-diuresing, and given her significant metabolic alkalosis, she is likely quite volume depleted intravascularly. At time of discharge she was -3 L net over 24 hours, was saturating well on humidified trach mask, with evidence of continued fluid overload in abdominal compartment. . 5. Acute renal failure: Developed after initial pancreatic inflammation had subsided and after aggresive fluid resuscitation. Urine lytes were c/w intra-renal etiology. Cr peaked above 2 and trended down to baseline by time of discharge. Electrolytes have also been difficult to manage with refractory hypokalemia. Magnesium and K repleted daily with K goal > 3.5. Concomittant metabolic alkalosis also makes repletion of K somewhat refractory. . 6. Nutrition - Was getting tube feeds for high caloric demand given pancreatitis, however upon transfer to floor pulled out NG tube. Nutrition was consulted and they proceeded with calorie count. Was tolerating PO intake. Would recommend continued assessment of nutritional intake in rehab facility and would consider nutritional consultation for further input given that she still has continued caloric demands secondary to resolving pancreatitis. . 7. Dispo - Discharge to rehab facility. Medications on Admission: Citalopram Wellbutrim Ativan Discharge Medications: 1. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 6. Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous once a day: take 40 units at night . 7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO every six (6) hours as needed for fever or pain. 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. 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. 10. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): day 1: [**10-31**], continue until [**11-13**]. 13. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] Rehab Hospital Discharge Diagnosis: Acute on chronic alcoholic pancreatitis Acute respiratory distress syndrome Ventilator Associated PNA Discharge Condition: Medically stable for discharge to rehabilitation Discharge Instructions: Dear Ms. [**Known lastname 84691**], You were admitted to the hospital with acute on chronic pancreatitis. The inflammation caused by your pancreas was severe enough to cause damage to your lungs requiring intubation for two weeks. A tracheostomy was placed in your neck because we had difficulty getting you off the breathing machine. If all goes well, your doctors [**Name5 (PTitle) **] be [**Name5 (PTitle) 460**] to remove this tracheostomy within the next few months. We also noted that you had loose stools while you were hospitalized. There are a couple of reasons you may have this. One cause could be an infection in your gut called Clostridium difficile. We started you on a medicine to treat this called vancomycin which you should continue to complete 10 days of it on [**2132-11-10**]. The other possible cause of your loose stools is that when your pancreas gets damaged, it can become difficult for you to digest food. For this reason, we started you on some medicine that helps you with digestion, called pancrease. You should take this medicine with meals. While you were in the hospital, you also had higher blood sugars than usual which is probably because your pancreas has been damaged. For this reason, we started you on insulin which they can continue to give you at the rehabilitation facility. Your blood sugars should improve over time as your pancreas heals. You still have significant amounts of edema (swelling) as a consequence of the fluid you received for the pancreatitis. This will take several weeks to resolve and could require further use of diuretics. It is very important that you not drink alcohol again as this could trigger another episode similar to this one. The medication changes we made during this hospitalization are in summary: (1) Started vancomycin by mouth, which you should take for your loose stools. You should complete this course until [**11-14**] to complete a 14 day course. (2) Started insulin as needed on a sliding scale to manage your sugars. Over time, you will likely be able to come off insulin as your pancreas heals. You should continue to take lantus 40 units at night with dinner. (3) Started pancrelipase, a medicine which helps you with digestion, because your pancreas is damaged. This should also address your issue of loose stools. You should continue to take this medicine as long as you continue to have loose stools. (4) Started gemfibrozil, a medicine that helps lower cholesterol. Your cholesterol probably went up because of your pancreatitis. You should continue to take this medicine. (5) Started dilaudid which you can continue to take to manage your pain. The doctors [**Name5 (PTitle) **] help [**Name5 (PTitle) **] get off this medicine as your pain improves. (6) Started nystatin which you can continue to use for your oral thrush. You can stop this after your thrush clears. (7) Started a nicotine patch, which will help you to quit smoking. (8) Started pantoprazole, which helps protect your stomach from acid. You should continue to take this medicine. (9) Started trazadone, which you should take for helping you sleep at night as necessary. (10) Started a fentanyl patch, which helps keep you comfortable since you were recently intubated. The fentanyl patch can be discontinued over time at the discretion of the rehab facility. (11) We had held your citalopram and wellbutrin while you were here because they can make you sleepy on top of the other medicines. You can restart these at the rehab facility at the discretion of their physicians. (12) You can continue your other home medicines as per your home regimen. Followup Instructions: 1. Please follow up with surgery on [**12-5**] at 1015 AM at the [**Hospital Ward Name 23**] Bldg on the [**Location (un) 470**]. 2. Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week after discharge from the rehab facility.

[ "311", "038.9", "584.9", "599.0", "995.92", "577.1", "041.4", "276.0", "787.91", "518.81", "285.1", "790.29", "303.92", "785.52", "V45.2", "577.0", "276.2", "997.31", "275.41" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.6", "96.04", "03.31", "38.93", "31.1", "96.72" ]

icd9pcs

[ [ [] ] ]

15081, 15142

6177, 13419

329, 394

15288, 15339

3252, 3252

19030, 19296

2060, 2338

13499, 15058

15163, 15267

13445, 13476

15363, 19007

2353, 3233

277, 291

422, 1340

3268, 6154

1362, 1691

1707, 2044

80,905

157,841

40238

Discharge summary

report

Admission Date: [**2115-12-4**] Discharge Date: [**2115-12-10**] Date of Birth: [**2054-7-17**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3200**] Chief Complaint: Trauma: MVC with loss of consciousness Major Surgical or Invasive Procedure: [**2115-12-5**] ex lap distal SBR w/ ileocolic [**Last Name (un) 1236**] evac hematoma ICP bolt placed intra-op History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 61 year old male who complains of INTUBATED MVC +LOC. The patient is a 61-year-old gentleman with a past medical history of hepatitis B, is on Coumadin for protein S deficiency, who comes in following a high-speed motor vehicle collision. The patient was increasingly confused and consequently intubated. By report CT scan at the other hospital shows a subarachnoid hemorrhage and some intra-abdominal bleeding source unclear. The patient has been intermittently hypotensive in transport has received at least one unit of blood. Past Medical History: Past Medical History: Hep C, protein S deficiency Social History: Social History: We have no report of substance issues at present. Patient lives with wife who is been contact[**Name (NI) **]. We're attempting to contact his brother who is a physician. Family History: NC Physical Exam: PHYSICAL EXAMINATION Constitutional: Patient adequately sedated Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft Extr/Back: No extremity injury apparent Pertinent Results: [**2115-12-8**] 05:31AM BLOOD WBC-6.3 RBC-2.82* Hgb-8.9* Hct-24.6* MCV-88 MCH-31.6 MCHC-36.1* RDW-14.4 Plt Ct-144* [**2115-12-7**] 04:45PM BLOOD Hct-24.9* [**2115-12-7**] 04:42AM BLOOD WBC-7.4 RBC-2.76* Hgb-8.6* Hct-23.9* MCV-87 MCH-31.0 MCHC-35.8* RDW-14.1 Plt Ct-126* [**2115-12-6**] 02:15AM BLOOD WBC-7.4 RBC-3.11* Hgb-9.7* Hct-27.0* MCV-87 MCH-31.4 MCHC-36.1* RDW-14.2 Plt Ct-131* [**2115-12-5**] 04:45PM BLOOD Hct-28.3* [**2115-12-5**] 07:37AM BLOOD WBC-6.6# RBC-3.69* Hgb-11.4* Hct-32.5* MCV-88 MCH-31.0 MCHC-35.2* RDW-14.1 Plt Ct-182 [**2115-12-10**] 05:22AM BLOOD PT-15.3* PTT-23.5 INR(PT)-1.3* [**2115-12-8**] 05:31AM BLOOD Plt Ct-144* [**2115-12-7**] 04:42AM BLOOD Plt Ct-126* [**2115-12-5**] 07:37AM BLOOD PT-16.2* PTT-25.6 INR(PT)-1.4* [**2115-12-4**] 10:25PM BLOOD PT-27.8* PTT-39.4* INR(PT)-2.7* [**2115-12-5**] 02:28AM BLOOD Fibrino-154 [**2115-12-4**] 10:25PM BLOOD Fibrino-130* [**2115-12-10**] 07:19AM BLOOD Na-139 K-3.2* Cl-102 [**2115-12-10**] 05:22AM BLOOD Na-139 K-3.0* Cl-103 [**2115-12-8**] 05:31AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-141 K-3.2* Cl-104 HCO3-28 AnGap-12 [**2115-12-7**] 04:42AM BLOOD Glucose-122* UreaN-13 Creat-0.9 Na-137 K-3.4 Cl-103 HCO3-28 AnGap-9 [**2115-12-5**] 04:45PM BLOOD CK(CPK)-1146* [**2115-12-5**] 07:37AM BLOOD CK(CPK)-456* [**2115-12-5**] 02:28AM BLOOD ALT-23 AST-28 CK(CPK)-310 AlkPhos-36* TotBili-1.4 [**2115-12-5**] 04:45PM BLOOD CK-MB-8 cTropnT-0.03* [**2115-12-5**] 07:37AM BLOOD CK-MB-10 MB Indx-2.2 cTropnT-0.05* [**2115-12-10**] 07:19AM BLOOD Phos-2.8 Mg-2.1 [**2115-12-9**] 05:30AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.1 [**2115-12-8**] 05:31AM BLOOD Calcium-7.8* Phos-1.9* Mg-2.0 [**2115-12-6**] 02:26AM BLOOD Type-ART pO2-151* pCO2-45 pH-7.36 calTCO2-26 Base XS-0 [**2115-12-5**] 12:01PM BLOOD Type-ART Temp-38.8 PEEP-0 FiO2-50 pO2-104 pCO2-41 pH-7.32* calTCO2-22 Base XS--4 Intubat-INTUBATED Vent-SPONTANEOU [**2115-12-6**] 02:26AM BLOOD freeCa-1.12 [**2115-12-5**] 07:49AM BLOOD freeCa-1.16 [**2115-12-4**]: head cat scan: IMPRESSION: Stable small areas of SAH. No new hemorrhage. [**2115-12-5**]: Head cat scan: IMPRESSION: No change from [**2115-12-4**] at 22:27 p.m. with subarachnoid hemorrhage at the falx cerebri and the left parietal lobe. [**2115-12-5**]: chest x-ray: IMPRESSION: Diffuse pulmonary edema, possibly secondary to neurogenic edema, crystalloid fluid overload, and/or prolonged recumbent position. Given the normal heart size and lack of vascular congestion, cardiogenic edema is less likely [**2115-12-5**]: Head cat scan: IMPRESSION: 1. Stable appearance of subarachnoid hemorrhage. 2. Sinus disease [**2115-12-6**]: Chest x-ray: Moderate pulmonary edema has changed in distribution, more global than one on [**12-5**], but probably not more severe. Pleural effusions are presumed, but not large. Heart is top normal size, and mediastinal veins remain dilated. Left subclavian catheter ends in the low SVC. No pneumothorax. Nasogastric tube passes into the stomach and out of view. [**2115-12-9**]: Head cat scan: IMPRESSION: 1. Interval resolution of previously noted subarachnoid hemorrhage. 2. Persistent mild prominence of the bifrontal extra-axial spaces which may represent small bilateral subdural hygromas. Brief Hospital Course: 61 year old gentleman admitted to the Acute Care Service after being involved in a MVC with +LOC. He was intubated at the scene related to confusion, vomitting, and unstable vital signs. Upon admission to the hospital, he was made NPO, had intravenous fluids started, and imaging of his head and abdomen. His head cat scan did show a subarachnoid hemorrhage and a left parietal bleed. While in the emergency, he was evaluated by Neurosurgery who recommended placement of an ICP bolt. Hematology was also consulted and made recommendations regarding his history of VTE. His abdominal scan showed bleeding in his abdomen and for this reason he was taken to the operating room on [**12-4**] where he had an exploratory laparotomy, evacuation of hemo-peritoneum, and small bowel resection. His operative blood loss was 1 liter and he required blood product replacement. His post-operative course was monitored in the intensive care unit. His ICP was within normal limits and was discontinued on [**12-5**]. He was extubated on [**12-6**], his c-spine was cleared and his cervical collar discontinued. His hematocrit has been stable at 24.6. Since his transfer to the surgical floor, his vital signs have been stable. He is tolerating a regular diet and is voiding without difficulty. He is afebrile and his vital signs are stable. He has been cleared by Neurosurgery to start lovenox and coumadin for anticoagulation. HE has been evaluated by physical therapy and he is clear for discharge. He is preparing for discharge home with VNA services who will monitor his PT/INR and relay the information to his primary care provider. [**Name10 (NameIs) **] will have his abdominal staples removed in 10 days and will follow up with the Acute Care Service in 2 weeks and Dr. [**First Name (STitle) **] in 4 weeks. He will also follow-up with Neurosurgery with a repeat cat scan of his head. This patient was cared for by the rotating surgical attendings of the acute care surgical service. Medications on Admission: Coumadin - Plavix - Quinalapril - Atenolol 50' Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for systolic bp <100, hr <55. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool. 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous EVERY 12 HOURS (): bridge to coumadin. 5. warfarin 5 mg Tablet Sig: One (1) Tablet PO EVERY MON, WED,FRI (): please follow PT, INR. 6. warfarin 5 mg Tablet Sig: 1.5 Tablets PO EVERY TUES, THURS, SAT, SUN (): please follow PT, INR. 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. fentanyl 25 mcg/hr Patch 72 hr Sig: 25 mcg Patch 72 hrs Transdermal Q72H (every 72 hours). Disp:*12 Patch 72 hr(s)* Refills:*0* 9. Outpatient [**Name (NI) **] Work PT/INR SIG: daily and prn until INR goal [**1-2**] reached DX: h/o VTE and protein S def. Please call and fax results to primary care provider: [**Last Name (LF) 3310**],[**First Name3 (LF) 177**] A Address: [**Street Address(2) 88332**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 88333**] Phone: [**Telephone/Fax (1) 79581**] Fax: [**Telephone/Fax (1) 88334**] 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): as needed for pain. Discharge Disposition: Home With Service Facility: [**Location (un) 5450**] VNA Discharge Diagnosis: L parietal bleed and SAH mesenteric bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged from the hospital after you were admitted after you were involved in a motor vehicle accident in which you sustained a small bleed in your head and a bleed in the blood vessels in your abdomen. You were taken to the operating room where you had an exploratory laparotomy and had a portion of your bowel resected. You are now preparing for discharge home with the following 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 [**9-12**] pounds for 6 weeks. You may resume walking at your discretion. NO abdominal exercises. Wound Care: You may shower, no tub baths or swimming. Your staples may be removed by the VNA [**12-13**]...closure wound with steri-strips If there is clear drainage from your incisions, cover with clean, dry gauze. Because of your head injury, please report the following: *increased headache *visual changes *numbness/weakness one side of your body *difficulty speaking Followup Instructions: Please follow up with the Acute Care Service in 2 weeks. You can schedule this appointment by calling #[**Telephone/Fax (1) 600**]. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 4 weeks. You can schedule this appointment by calling # [**Telephone/Fax (1) 1690**] Please follow up with : Dr.[**First Name (STitle) **] of Neurosurgery in 4 weeks with a Head CT w/o contrast. Please call [**Telephone/Fax (1) 3231**] to make this appointment. Please let them know that you will need a head CT prior to your visit. Completed by:[**2115-12-17**]

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icd9cm

[ [ [] ] ]

[ "45.93", "45.62", "96.71", "47.09", "54.19", "01.10", "38.93", "54.75" ]

icd9pcs

[ [ [] ] ]

8478, 8537

4995, 6993

343, 457

8624, 8624

1747, 4970

10781, 11379

1517, 1521

7091, 8455

8558, 8603

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1536, 1728

265, 305

10393, 10758

485, 1066

8639, 8751

1110, 1140

1172, 1501

23,707

142,270

5339

Discharge summary

report

Admission Date: [**2152-2-14**] Discharge Date: [**2152-2-19**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Sulfonamides / Gadolinium-Containing Agents / Demerol / Morphine Attending:[**First Name3 (LF) 338**] Chief Complaint: abd pain, itching, and throat tightness Major Surgical or Invasive Procedure: None. History of Present Illness: 59F w/ hx of mast cell degranulation syndrome (MCDS) who drove herself to the emergency department w/ worsening abdominal pain, nausea, itching, and the sensation of her throat was starting to tighten. This is the typical presentation for a mast cell flare. Her abdominal pain is constant, waxing and [**Doctor Last Name 688**] in intensity, and located in the epigastric region, radiating to her back. She states the abdominal pain is chronic and gets worse with flares of her MCDS. She denied fever, chills, cough, dysuria, or chest pain. She admits to shortness of [**Doctor Last Name 1440**], puritis, and nausea/vomiting. . The patient used her epi pen at home. In ED she received benadryl 150mg iv x 2, solumedrol 125mcg IV x 1, pepcid 20mg iv x 1, dilaudid 2mg iv x 2, anzemet 12.5mg iv x 2. She was placed on obs status in the ED, but after several hours the patient stated that her abdominal pain was still severe and she wanted to be admitted to the hospital. . Once on the floor, she was initially doing well. During the interview, she became acutely itchy, had worsening abdominal pain, shortness of [**Doctor Last Name 1440**]. She had audible stridor. She was placed on a venti-mask and had stable vitals (100% saturation). She was given epinephrine IM, IV benadryl, solumedrol, nebs (atrovent and albuterol), and ativan. She improved and was satting 98% on 1.5L. Past Medical History: - Mast cell activation syndrome: Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice. - Depression/anxiety/bipolar d/o, hx of SI - MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi - HTN - Erosive osteoarthritis - GERD, gastritis and esophagitis on recent EGD [**2151-1-8**] - Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy - Anemia, iron studies c/w AOCD - Hemorrhoids - pt reports recent EGD demonstrated vegetable bezoar (?[**12-6**]). - Status post hysterectomy and oophorectomy - h/o MRSA infection (porthacath associated) - portacath placed [**3-7**] - d/c'd [**2-4**] MRSA infection - portacath placed [**2151-6-9**] Social History: Pt is divorced. She works as an ER tech in [**Hospital3 **], son and daughter in ?other states. No tobacco or EtOH. Son is HCP [**Telephone/Fax (1) 21738**] Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: T 97.2 BP 120/82 HR 94 RR 18 100% 2L Gen: patient uncomfortable at first, scratching her arms, legs, chest. Then became acutely SOB HEENT: perrl, eomi, dry mucous membranes, OP clear Neck: no JVD, no LAD Cor: RRR, S1S2, no M/R/G Pulm: b/l inspiratory wheezes throughout lung fields Abd: soft, mild-mod tenderness epigastric. No rebound. + guarding Ext: no c/c/e, 2+ dp bilaterally Skin: no rashes noted, bruising noted over lower abdomen Access: R portacath Pertinent Results: [**2152-2-14**] 12:00AM PLT COUNT-299 [**2152-2-14**] 12:00AM NEUTS-51.6 LYMPHS-32.7 MONOS-6.6 EOS-8.4* BASOS-0.7 [**2152-2-14**] 12:00AM WBC-5.4 RBC-4.36 HGB-13.1 HCT-37.6 MCV-86 MCH-30.0 MCHC-34.8 RDW-13.5 [**2152-2-14**] 12:00AM ALBUMIN-4.2 [**2152-2-14**] 12:00AM LIPASE-32 [**2152-2-14**] 12:00AM ALT(SGPT)-16 AST(SGOT)-20 LD(LDH)-254* ALK PHOS-88 AMYLASE-54 TOT BILI-0.1 [**2152-2-14**] 12:00AM estGFR-Using this [**2152-2-14**] 12:00AM GLUCOSE-111* UREA N-16 CREAT-1.2* SODIUM-139 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12 . [**2152-2-14**] pCXR: Low lung volumes are present. There is a right-sided Port-A-Cath terminating in the distal SVC/RA junction. Calcified left AP window lymph node is seen. Cardiac, mediastinal, and hilar contours are otherwise normal. Lungs are clear. No pleural effusion or pneumothorax. Small opacity in the right upper lobe is again seen, unchanged. Osseous structures are also unchanged. Right upper quadrant clips again noted. . EKG: sinus tach at 100, QIII and F (old), TWF III,I,F (old) Brief Hospital Course: 59yo woman with h/o Mast Cell Activation Syndrome presented with typical constellation of symptoms. Transferred to MICU for respiratory distress, then to medicine wards once stabilized. . # Mast Cell Activating Syndrome: Multiple episodes since admission per floor team. Each time she has itching, abdominal pain, shortness of [**Month/Day/Year 1440**], chest tightness, and wheezing. Stridor appears to be a less prominent feature and was not noted during the event that precipitated her MICU transfer. Now stable. Continued cromylyn, started on singular. Received benadryl, nebs prn for pruritis/stridor. Given history of previous MI likely secondary to epinephrine while inpatient, she was notified that epinephrine would be a medication of last resort, only if she did not have relief from symptomatic treatment and standing outpatient regimen. Patient was in agreement. . # Respiratory distress: Thought to be secondary to MCDGS. ABG not suggestive of other underlying pathology. CXR consistent w/previous and no evidence of acute cardiopulmonary disease. Stable respiratory function, sats >95% on RA. Received nebs as needed for symptomatic relief. . # Abdominal pain/nausea: Consistent with her MCGS. On last admission, the patient had elevated LFTs, which have now normalized. CT abdomen done to evaluate pain and unremarkable. Anzemet and ativan prn for nausea. . # HTN: Continue diltiazem and monitor. Well controlled. . # Depression/anxiety/bipolar: Continue outpt cymbalta, seroquel and adderall. Anxiety may trigger her symptoms. Ativan PRN. . # Postmenopausal symptoms: Holding pt's outpt vivelle until discharge. . # Osteoarthritis: Continued on plaquenil. . # FEN: regular diet . # PPX: on ppi, bowel regimen, heparin sq . # CODE: **FULL CODE** . # Dispo: Respiratory status stable, without distress, DC'd home. Medications on Admission: gastrocrom "3 amps" qid (oral cromylin 100mg q6) cardizem CD 120mg po qday atarax 25mg po bid zantac 300mg po daily seroquel 200mg po qhs cymbalta 60mg po qhs plaquenil 200mg po bid adderal xr 15mg po qday fexofenadine 180mg po bid omeprazole 20mg po bid ambien 10mg po prn zofran 8mg po prn dilaudid 2mg po prn percocet 5/325 po prn klonopin 0.5mg po prn fioricet prn Discharge Medications: 1. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Amphetamine-Dextroamphetamine 5 mg Capsule, Sust. Release 24HR Sig: Three (3) Capsule, Sust. Release 24HR PO daily (). 6. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. 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* 8. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for headace. Disp:*60 Tablet(s)* Refills:*0* 10. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO daily (). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 15. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1) Packet PO Daily PRN (). 16. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. Cromolyn 100 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours). Disp:*1 bottle* Refills:*2* 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for stridor, wheeze. Disp:*2 inhaler* Refills:*2* 19. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for nausea, anxiety. Disp:*60 Tablet(s)* Refills:*0* 20. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 21. Benadryl Allergy 25 mg Tablet Sig: One (1) Tablet PO every 6-8 hours. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Chest Pain 2. Abdominal Pain 3. Mast cell activation syndrome 4. Anxiety 5. Hypertension 6. GERD 7. Anemia Discharge Condition: Stable. Discharge Instructions: Continue to take all medications as prescribed. You have had heart attack in the past from use of epinephrine. You should avoid using the epinephrine pen unless absolutely necessary, in cases of severe stridor, respiratory distress. Contact a physician for fever > 101.5, increased chest pain, palpitations, shortness of [**Medical Record Number 1440**], loss of conciousness, dizziness, worsening abdominal pain, persistent nausea and vomiting, diarrhea, blood in your stool, or any other concerns. Followup Instructions: Please see your PCP [**Name Initial (PRE) 176**] 2 weeks of discharge for further medical mangement. PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**0-0-**]. Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2152-2-25**] 11:45 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2152-3-8**] 11:35

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9233, 9239

4568, 6397

389, 397

9393, 9403

3486, 4545

9952, 10431

2909, 2984

6816, 9210

9260, 9372

6423, 6793

9427, 9929

2999, 3467

310, 351

425, 1812

1834, 2718

2734, 2893

9,216

128,878

23778

Discharge summary

report

Admission Date: [**2199-6-12**] Discharge Date: [**2199-6-18**] Date of Birth: [**2170-4-19**] Sex: M Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 1973**] Chief Complaint: nausea, vomiting of coffee grounds Major Surgical or Invasive Procedure: Endoscopic GastroDuodenography History of Present Illness: This is a 29 year-old man with history of diabetes mellitus, severe gastroparesis, erosive gastritis and esophagitis who presents with nausea and vomiting consistent with his gastroparesis and coffee ground emesis which often accompanies these other symptoms. Multiple recent hospitalizations for same. Patient says these symptoms are exactly the same as his usual symptoms. Denies fever, chills, cough, CP, palpatations, urinary sx. During admission [**Date range (1) 60709**] had gastric pacer adjusted. Most recently admitted end of [**Month (only) 116**], discharged [**6-1**], managed with iv anti-emetics. In the ED: initial vitals: 99.1, 128, 163/104, 97% RA 16 He was given: Ativan, Zofran, protonix, tylenol, 2.5L NS The patient refused NG lavage and rectal exam. He was admitted to the ICU for further evaluation Past Medical History: 1. Diabetes Mellitus 2. Gastroparesis, failed [**Month/Year (2) **] and gastric pacer 3. Erosive gastritis, esophagitis--last EGD in [**3-/2198**] 4. Fe deficiency anemia 5. hypercholesterolemia 6. Hypertension 7. Chronic Renal insufficiency--evaluated by transplant surgery, awaiting GFR to fall<20, will get pancreas transplant as well Social History: Patient lives with his wife who is very dedicated to his care. Denies tobacco, alcohol, and illicit drug use. He is currently unemployed and on disability. Family History: Paternal grandfather with [**Name (NI) 59282**] Mother and sister with thyroid disease Physical Exam: Physical exam on admission Temp: 99.6, 134/88, 101, 18, 98% general: uncomfortable, diaphorectic. HEENT: PERLLA, EOMI, anicteric, no scleral icterus, no sinus tenderness, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules lungs: CTA b/l with good air movement throughout heart: tachy, RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: diffuse mild tenderness, nd, +b/s, soft extremities: no cyanosis, clubbing or edema skin/nails: no rashes/no jaundice/no splinters neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. rectal:patient refused Pertinent Results: [**2199-6-18**] 12:51AM BLOOD WBC-7.0 RBC-2.86* Hgb-7.8* Hct-24.3* MCV-85# MCH-27.4 MCHC-32.2 RDW-13.3 Plt Ct-273 [**2199-6-12**] 09:50PM BLOOD Neuts-84.8* Lymphs-11.8* Monos-2.5 Eos-0.2 Baso-0.7 [**2199-6-14**] 05:20AM BLOOD PT-13.4* PTT-27.9 INR(PT)-1.2* [**2199-6-18**] 06:36AM BLOOD Glucose-97 UreaN-5* Creat-1.5* Na-142 K-3.4 Cl-106 HCO3-27 AnGap-12 [**2199-6-18**] 12:51AM BLOOD ALT-6 AST-11 [**2199-6-18**] 12:51AM BLOOD Albumin-3.1* Calcium-7.2* Phos-2.9 Mg-1.4* [**2199-6-16**] 12:00PM BLOOD Lactate-1.4 CXR: IMPRESSION: Chest x-ray examination within normal limits. No focal infiltrate to suggest aspiration pneumonitis. PICC line noted. AXR: IMPRESSION: 1. Doubt obstruction, though assessment for fluid-filled dilated loops of small bowel is limited. 2. Two small curvilinear focis of air in the right upper quadrant, of uncertain etiology or significance. If there is any clinical reason to suspect abnormal portal venous gas, then further evaluation with CT scan would be recommended. EGD: Findings: Esophagus: Mucosa: Grade 3 esophagitis was seen in the gastroesophageal junction. Stomach: Mucosa: Segmental erythema of the mucosa was noted in the stomach body. These findings are compatible with gastritis. Duodenum: Normal duodenum. Impression: Grade 3 esophagitis in the gastroesophageal junction Erythema in the stomach body compatible with gastritis Otherwise normal EGD to second part of the duodenum Brief Hospital Course: Initially to MICU with ARF on CKD and acute blood loss anemia. Patient transferred from MICU to [**Hospital Ward Name 516**] Hospitalist Service after hydration and stabilization. 1. Acute Gastritis/Grade 3 Esophagitis - EGD done as above - [**Hospital1 **] PPI - H Pylori serologies pending at D/C to f/u as outpatient - Tolerating full PO - Patient never had chest or abdominal pain due to his gastritis/esophagitis - GI Consultation feels may need additional gastric pacemaker adjustment as an outpatient 2. Iron Deficiency/Acute Blood Loss Anemias - Patient given IV Ferrlicet 125mg infusion - Folate and Thiamine - Did not need transfusion 3. Acute Renal Failure on Chronic Kidney Disease - Resolved in ICU with IV hydration - Baseline 1.5 - Renal dosing of medications - presumed due to Diabetes and hypertension 4. Benign Hypertension - Valsartan, Clonidine, Metoprolol 5. Type 1 DM uncontrolled with complications - Glargine - HISS - [**Doctor First Name **]/Gastroparesis Diet Medications on Admission: 1. clonidine patch q wednesday 2. protonix 40mg [**Hospital1 **] 3. valsartan 80mg [**Hospital1 **] 4. metoprolol 25mg [**Hospital1 **] 5. reglan 10mg qid 6. promethazine prn nausea 7. ativan prn nausea 8. Lantus 32 units daily 9. humalog ss Discharge Medications: 1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Grade 3 Esophagitis Acute Gastritis Iron Deficiency Anemia Acute Blood Loss Anemia Type 1 DM uncontrolled with complications Chronic Kidney Disease Discharge Condition: Good Discharge Instructions: Return to the hospital if you have an inability to eat, further bloody or coffee-ground vomitting, nausea/vomitting, fevers, black/tarry stool You have grade 3 esophagitis and gastritis. You should make sure that you eat a low residue diet and remain seated or standing for some time after eating to reduce your reflux. When you see your doctor he should follow up on the studies of your endoscopy here Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-6-24**] 11:00 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-6-24**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2199-8-12**] 12:10

[ "276.51", "285.1", "530.10", "250.63", "584.9", "536.3", "250.53", "250.43", "272.0", "280.9", "535.01", "362.01", "585.9", "403.90" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.93" ]

icd9pcs

[ [ [] ] ]

6053, 6059

4022, 5015

313, 345

6250, 6256

2571, 3999

6709, 7139

1752, 1841

5307, 6030

6080, 6229

5041, 5284

6280, 6686

1856, 2552

239, 275

373, 1201

1223, 1562

1578, 1736

60,362

139,209

37567

Discharge summary

report

Admission Date: [**2133-11-19**] Discharge Date: [**2133-11-26**] Date of Birth: [**2059-4-21**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Cephalosporins Attending:[**First Name3 (LF) 2569**] Chief Complaint: Code stroke, speech difficulty, right sided weakness Major Surgical or Invasive Procedure: IA tPA on [**2133-11-20**] History of Present Illness: Reason for Consult: Code stroke Symptom onset: 5:45pm ivTPA bolus given at OSH: 7:45pm Stroke Code activated : 8:03pm Neurology resident at bedside: 8:05pm HPI: History was obtained form doctor at OSH, ambulance sheet, and patients husband.Pt is a 74 year old Right handed woman with PMH of atrial fibrillation on coumadin,HTN, CHF, pacemaker and CAD who was transfered from OSH for evaluation of stroke. She was in her usual state of health until 5:45pm this evening, when while chatting with her husband she suddenly stopped speaking. She was not responding to any of his questions. He noticed that her right arm and leg was weaker and there was some facial asymmetry. EMS was called and transported her to an outside hospital. As she was being seen IN ED at OSH, she became more and more drowsy and she was intubated for airway protection. There, INR was found to be subtherapeutic at 1.4 and CT head reavealed "no hemorrhage." She was given labetalol, fentanyl, propofol and was started on IV tpa after tele stroke assesment at 7.45 pm. TPA infusion was nearly completed upon arrival to our ED. Here, her examination was limited due to intubation and sedation with propofol. Approximate NIHSS = 13 at 8:15pm. LOC - N/A: on propofol Questions - 2 Commands - 2 Gaze 0 Visual 0 Face - 2 Motor - 5 (3 for R arm and 2 for R leg) Ataxia - 0 Sensory - 0 Language - 2 Dystrthria - UN Extinction/Inattention - 0 Past Medical History: -Afib since age of 15 -HTN -CHF -CAD -Has PPM Social History: -Lives with husband -Rare EtOH -No tobacco Family History: No early stroke, hads family h/o Afib insiblings one of them having pacer Physical Exam: Physical Exam: 172/92, 84, 98 , on ventilator Intubated, prefers to keep eyes closed, opens to commands HEENT- [**Last Name (LF) 12476**], [**First Name3 (LF) 13775**] neck- no JVD/bruit cards- Afib with controled rate , no m/r/g RS- clear abd- soft NT ND Neurologic Exam: Intubated, sedated on propofol. Does not follow commands ( sometimes follows and sometimes does not , like oepens her eyes but immediately closes, dose not follow any appendicular commands) pupils [**1-19**] BL sluggishly reactive Doll's eyes present. . Right facial droop in UMN pattern. Occasional spontaneous movement LUE, LLE, and RLE. No spontaneous movement RUE. tone appears to have decreased in RUE Localizes to noxious stimuli to the LUE and LLE. No response to noxious stimuli RUE. Triple flexion to noxious stimuli RLE. Toes upgoing on right and mute on left Cordination and gait cannot be tested. Pertinent Results: [**2133-11-24**] 04:35AM BLOOD WBC-14.4* RBC-3.76* Hgb-10.9* Hct-32.8* MCV-87 MCH-29.1 MCHC-33.3 RDW-13.7 Plt Ct-270 [**2133-11-23**] 03:55AM BLOOD WBC-18.9* RBC-3.60* Hgb-10.4* Hct-31.5* MCV-87 MCH-28.8 MCHC-32.9 RDW-13.8 Plt Ct-243 [**2133-11-24**] 04:35AM BLOOD PT-14.9* PTT-27.7 INR(PT)-1.3* [**2133-11-24**] 04:35AM BLOOD Glucose-172* UreaN-24* Creat-0.7 Na-146* K-3.8 Cl-111* HCO3-23 AnGap-16 [**2133-11-23**] 03:55AM BLOOD ALT-23 AST-27 AlkPhos-85 TotBili-2.0* [**2133-11-23**] 07:25PM BLOOD proBNP-3200* [**2133-11-20**] 02:16AM BLOOD Lipase-19 [**2133-11-24**] 04:35AM BLOOD Calcium-9.6 Phos-2.1* Mg-2.1 [**2133-11-20**] 02:16AM BLOOD Triglyc-100 HDL-32 CHOL/HD-3.4 LDLcalc-56 [**2133-11-20**] 02:16AM BLOOD %HbA1c-6.0* [**2133-11-19**] 08:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging: CXR [**2133-11-22**]: Feeding tube with a wire stylet in place passes into the stomach and out of view. Persistent asymmetry in consolidation affecting predominantly the right upper lobe could be due to aspiration following improvement elsewhere in pulmonary edema. Moderate cardiomegaly, small bilateral pleural effusions are unchanged. Mediastinal vascular engorgement has worsened indicating elevated central venous pressure or volume. Atrial and ventricular pacer leads traverse left-sided superior vena cava. No pneumothorax. Echo [**2133-11-21**]: The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. The coronary sinus is dilated (diameter >15mm). There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The 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. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Biatrial enlargement. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. CT Torso [**2133-11-21**]: Small amount of ascites, but low in density without definite evidence for hemoperitoneum, although a degree of hemorrhage cannot be entirely excluded. CT [**2133-11-20**]: Slightly limited study secondary to motion artifact. Interval decrease in size and conspicuity of left frontal lobe hemorrhage. Evaluation for subtle loss of [**Doctor Last Name 352**]-white matter differentiation is limited secondary to motion artifact. The rapid reduction in hypderdensity suggests that some of the dense material see earlier on [**11-20**] reflected contrast enhancement. However, the persistent high density represents hemorrhage. CT [**2133-11-20**] Status post thrombolysis and clot retrieval with new hyperdense focus and surrounding edema in the left frontal lobe concerning for acute hemorrhage. Mild mass effect on the left lateral ventricle without shift of the normally midline structures. CTA/Perfusion ([**2133-11-19**]): The CT examination demonstrates hyperdensity, implying thrombosis, of the left middle cerebral artery. In addition, there is marked hypodensity in the insular cortex and subinsular white matter on the left as well as a broader area of hypodensity throughout the left middle cerebral artery distribution. These findings suggest embolic occlusion and acute infarction in the distribution of the left middle cerebral artery. The CT perfusion study demonstrates an elevated transit time and reduced blood volume and blood flow throughout most of the left temporal lobe, extending into the left parietal lobe. These findings are also consistent with severe ischemia and likely irreversible injury. The CTA confirms occlusion of the left middle cerebral artery. There is extensive filling of the cortical branches through collaterals. Images of the remainder of the intracranial major arteries appear normal with no other areas of stenosis or occlusion and no evidence of aneurysm formation. Images of the neck demonstrate bilateral pleural effusions. Incidentally noted is an inhomogeneous appearance of the right lobe of the thyroid gland with two apparent cysts within it. These both have irregular enhancing walls and hypodense centers. Correlation with thyroid ultrasound may be helpful. CTA of the neck demonstrates partially calcified plaques bilaterally at the carotid bifurcations. The left bifurcation plaque contains a large hypodense component, perhaps reflecting fatty necrosis within the plaque. Neither internal carotid demonstrates significant stenosis. At its narrowest, the left internal carotid artery measures approximately 3.6 mm in diameter which is 4.9 mm diameter for the distal left cervical internal carotid artery. The distal right cervical internal carotid artery also measures 3.9 mm in diameter. CONCLUSION: Findings indicate occlusion of the proximal left middle cerebral artery with extensive left middle cerebral artery distribution infarction. The study and the report were reviewed by the staff radiologist. EKG: Atrial fibrillation with slow ventricular response and escape ventricular pacing noted. T wave abnormalities inferolaterally which are non-diagnostic. No previous tracing available for comparison. Brief Hospital Course: The patient is a 74 year old Right handed woman with PMH of atrial fibrillation on coumadin (was subtherapuetic),HTN, CHF, pacemaker and CAD who was transfered from OSH for evaluation of stroke. She initially presented with sudden onset speech arrest and right sided weakness. The deficits localized to the left MCA destribution and was thought to be likely embolic given her afib. She was given iv tPA at the outside hospital and transferred to [**Hospital1 18**] for further care. On arrival here she had a CTA which was notable for a persistent L-MCA clot in the mid-distal M1 segment, and neurologic exam - though compromised by intubation and sedation - suggestive of persistent R hemiparesis and aphasia. Patient had already recieved tPA IV at the outside hospital and it was felt that she was a candidate for intra-arterial tPA. She was taken to the angio swuite and the procedure was performed with a successful removal of the clot and re-estabilishing blood flow to the affected area. The patient was then sent to the ICU for post-operative care. She was extubated on [**2132-11-22**]. A follow up head CT showed that there had been a small amount of hemorrhagic transformation in the area of the stroke, so restarting anti-coagulation was delayed. The hemorrhagic conversion was likely on account of thrombolysis but was small and not of clinical relevance (apart for he decision to correct INR). The edema was also mild and not of much clinical significance. She was also noted to have an increase in her white count and a new RLL opacity on CXR. She had gram positive and negative cultures growing in her respiratory culture. The decision was made to start her on broad spectrum antibiotics. She was started on Vanco/Aztrenam/Cipro for a hospital associated pnuemonia. She was transfered out to the floor on [**2132-11-23**]. The patient likely had an acute exacerbation of systolic CHF as well. The following day she was noted to be tachypneic and was having oxygen desaturations to the low 80s, with tachycardia. She was sent back to the ICU. In the ICU she had deep suctioning and improved. Her heart rate returned to baseline and she had oxygen saturations in the mid-nineties. She was also noted to have sleep apnea, (which per husband was a long standing issue) and was started on CPAP while in the hospital. She continued to have breathing issues requiring continued CPAP. The family decided to make her DNR/DNI, as they beleive she would not want re-intubation. They decided that her goals of care would be comfort The patient expired on [**2133-11-26**] Medications on Admission: -Lisinopril 5mg -Coumadin 5mg -Nadolol 400mg -Lasix 40mg -Digoxin 0.125mg Discharge Disposition: Expired Discharge Diagnosis: L MCA stroke Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "V58.61", "342.01", "V45.88", "434.01", "784.3", "428.23", "427.31", "997.31", "428.0", "327.23", "401.9", "414.01", "V45.01", "041.85" ]

icd9cm

[ [ [] ] ]

[ "39.74", "38.91", "96.6", "88.41", "00.40", "96.71", "93.90", "99.10" ]

icd9pcs

[ [ [] ] ]

11392, 11401

8662, 11267

345, 373

11457, 11466

2962, 8639

11519, 11637

1962, 2038

11422, 11436

11293, 11369

11490, 11496

2068, 2310

253, 307

401, 1814

2327, 2943

1836, 1885

1901, 1946

42,496

111,693

42736

Discharge summary

report

Admission Date: [**2111-1-10**] Discharge Date: [**2111-1-14**] Date of Birth: [**2061-4-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2782**] Chief Complaint: hypotension and left hip pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 92355**] is a 49yo man who presented to the ED after transfer from OSH with atraumatic left hip pain and hypotension. Pt reports taking viagra, alcohol, oxycodone, and new prescription meds of Maloxicam, Lisinopril, and Gabapentin on the night of [**2111-1-9**]. He went to sleep at 1am [**1-10**] and woke up at 10am with a severe pain in his left gluteal region. He reports that the pain was so bad that he immediatedly told his fiance, who was asleep beside him, to call 911. He was taken away in an ambulance to [**Hospital3 4107**]. At the OSH they found him to be profoundly hypotensive 70s sbps and gave him dopamine but no record of IVFs given. A non contrast CT showed no acute process in the left hip. Labs were notable for troponin 1.39, INR 2.1, hct 35.5, wbc 13.9, creatinine 2.4 and K of 6.0. He received vancomycin and ASA and was transferred to [**Hospital1 18**] for further management. . (adopted from MICU admit note) In the ED, initial vs were: 124/82, 116, 18, and 98% on 3L on peripheral dopamine. Patient was taken off dopamine and initial blood pressures were notable for systolics in the 80s. He received 3 L of fluid with improvement in pressures to the 110s systolically. Labs were notable for EtOH level of 33 and lactate of 3.6. WBC 12.8 with bands and Hct 36.6. INR was 1.8, creatinine 2.4, ALT 341, AST 1428, AlkP 133. Troponin was 0.41 without any ischemic changes on EKG. Urine tox was positive for methadone. Also had serum positive alcohol tox. He was given one dose of cefepime for broad spectrum coverage and was admitted to the MICU for further management. In the MICU VS on transfer were: HR 101 BP 112/63 RR 12 and O2 sat 95% on 3L. He was found to have a CK [**Numeric Identifier 41242**] -> [**Numeric Identifier 14123**] -> [**Numeric Identifier 81081**]. He was given IVFs. Lactic acid decreased to 1.4, Cr decreased to 2.2. Troponins have remained elevated, CKMBI corrected normal. He was taken off vancomycin and cefepime and started on ceftriaxone for presumed UTI. Of note, Mr. [**Known lastname 92355**] mentioned that he had been getting surveillance colonoscopies "every three months or so" for malignant polyps that he is prone to getting. He also mentioned that he has had radiation for this "cancer" in the past, but has never had any surgery. He denies chemotherapy. He also mentioned that his urine started to change color "about a week ago." He denies being on the ground for a long period of time prior to his hip pain. His histories have been contradictory in regard to the medicines that he was taking on the night he developed his hip pain per his nurse. Review of systems: (+) Per HPI, otherwise negative. Past Medical History: -Obstructive Sleep Apnea -Hypertension -Chronic back pain, on opiates -possible substance abuse (opiates) -alcoholism ([**3-31**] drinks/day) -equivocal result exercise stress test [**11/2110**] Social History: Divorced 2 years ago, has three children who live in [**Doctor Last Name **] Island. Recently engaged. Lives with fiancee and her mother. [**Name (NI) 1403**] as a flood restoration tech adn in recruiting. Denies h/o tobacco abuse. Reports drinks 5-8 drinks nightly- vodka. No history of blackouts or alcohol withdrawal. Reports has only been drinking for one year. Reports remote use of cocaine 15 years ago, remote use of marijuana. Denies h/o IVDU. Family History: Father died of rheumatic heart disease. Mother died of pancreatic cancer. Physical Exam: Physical Exam on Admission Vitals: T: 97.9 BP: 136/83 P: 97 RR: 15 O2: 98% on RA General: obese man sitting up in chair, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI Neck: supple, no JVP CV: Distant heart sounds, but regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally. Air movement ends high up back, no wheezes, rales, ronchi Abdomen: obese, soft, mildly tender to palpation in RUQ, non-distended, bowel sounds present, no organomegaly GU: Foley in place draining yellow urine with some trace brown sediment Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema L Hip: full motion in tact but 4/5 strength with hip flexion and hip extension. Area of swelling/edema firm over lateral left hip. No visible signs of trauma at this time Neuro: CNII-XII grossly intact Physical Exam at Discharge Vitals: T: 98.7,98.5 BP: 140-176/68-86 P: 93 RR:20 O2: 95% on RA I/O: since 12a 920cc in 1.85L out ; past 24hrs 2.2L in, 3.2L out General: obese man standing up in room, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI Neck: supple, no JVP CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally. Air movement ends high up back, no wheezes, rales, ronchi Abdomen: obese, soft, non tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema L Hip: full motion in tact. Area of swelling/edema still firm over lateral left hip. Pertinent Results: Admission Labs [**2111-1-10**] 09:42PM BLOOD WBC-10.3 RBC-3.99* Hgb-11.4* Hct-35.3* MCV-89 MCH-28.6 MCHC-32.3 RDW-15.0 Plt Ct-153 [**2111-1-10**] 04:30PM BLOOD Neuts-80* Bands-4 Lymphs-3* Monos-13* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2111-1-10**] 04:30PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL [**2111-1-10**] 04:30PM BLOOD PT-18.9* PTT-36.7* INR(PT)-1.8* [**2111-1-10**] 04:30PM BLOOD ESR-28* [**2111-1-10**] 04:30PM BLOOD CRP-22.5* [**2111-1-10**] 04:30PM BLOOD Glucose-146* UreaN-15 Creat-2.4* Na-136 K-6.5* Cl-105 HCO3-18* AnGap-20 [**2111-1-10**] 09:42PM BLOOD Calcium-7.2* Phos-4.6* Mg-1.9 [**2111-1-10**] 04:30PM BLOOD Albumin-3.3* [**2111-1-10**] 04:30PM BLOOD ALT-341* AST-1428* CK(CPK)-[**Numeric Identifier 41242**]* AlkPhos-133* TotBili-1.0 [**2111-1-11**] 04:50AM BLOOD Lipase-25 [**2111-1-10**] 09:42PM BLOOD CK-MB-226* MB Indx-0.6 cTropnT-0.31* [**2111-1-10**] 09:42PM BLOOD CK(CPK)-[**Numeric Identifier 92356**]* [**2111-1-11**] 11:18AM BLOOD %HbA1c-5.8 eAG-120 [**2111-1-11**] 04:50AM BLOOD Triglyc-125 HDL-22 CHOL/HD-6.1 LDLcalc-87 [**2111-1-10**] 09:42PM BLOOD TSH-3.0 [**2111-1-11**] 04:50AM BLOOD Cortsol-33.8* [**2111-1-10**] 09:42PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-NEGATIVE [**2111-1-10**] 09:42PM BLOOD HCV Ab-NEGATIVE [**2111-1-10**] 04:30PM BLOOD ASA-NEG Ethanol-33* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2111-1-10**] 04:30PM BLOOD Lactate-3.6* [**2111-1-10**] 05:30PM BLOOD K-4.8 Discharge Labs [**2111-1-14**] 05:00AM BLOOD WBC-6.7 RBC-4.10* Hgb-11.8* Hct-35.4* MCV-87 MCH-28.8 MCHC-33.3 RDW-15.7* Plt Ct-135* [**2111-1-14**] 05:00AM BLOOD Neuts-72.8* Lymphs-15.8* Monos-7.4 Eos-3.0 Baso-0.9 [**2111-1-14**] 05:00AM BLOOD PT-17.5* PTT-39.3* INR(PT)-1.6* [**2111-1-14**] 05:00AM BLOOD Glucose-108* UreaN-20 Creat-1.3* Na-141 K-3.7 Cl-101 HCO3-32 AnGap-12 [**2111-1-13**] 08:40AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7 [**2111-1-14**] 05:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.5* [**2111-1-13**] 08:40AM BLOOD ALT-282* AST-782* LD(LDH)-564* CK(CPK)-6411* AlkPhos-141* TotBili-1.9* DirBili-1.1* IndBili-0.8 [**2111-1-14**] 05:00AM BLOOD ALT-227* AST-609* CK(CPK)-4076* AlkPhos-158* TotBili-2.0* [**2111-1-13**] 08:40AM BLOOD CK-MB-16* MB Indx-0.2 cTropnT-0.36* [**2111-1-14**] 05:00AM BLOOD CK-MB-8 cTropnT-0.27* LIVER US Study Date of [**2111-1-11**] 10:55 AM IMPRESSION: Significant increased echogenicity of the liver consistent with fatty deposition. More advanced liver disease including hepatic fibrosis/cirrhosis cannot be excluded. No ascites and no acute hepatobiliary pathology. Splenomegaly. CHEST (PORTABLE AP)Study Date of [**2111-1-10**] 9:45 PM Some enlargement of the cardiac silhouette without vascular congestion or pleural effusion. This raises the possibility of cardiomyopathy or pericardial effusion. No evidence of acute focal pneumonia. HIP UNILAT MIN 2 VIEWS LEFT Study Date of [**2111-1-10**] 5:01 PM No lytic or sclerotic lesions are present. No definite osseous destruction is seen. US EXTREMITY NONVASCULAR LEFT Study Date of [**2111-1-12**] 9:52 AM (wet read) Dedicated limited examination over the gluteus maximus on the left demonstrates edema with no distinct focal collections Portable TTE (Complete) Done [**2111-1-13**] at 4:27:16 PM The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No definite valvular pathology identified Brief Hospital Course: 49 yo M with a questionable history of substance abuse who presented with R hip pain and hypotension now with resolving [**Last Name (un) **], acidosis, and clinical picture suggestive of resolving rhabdomyolysis. #) Hypotension: Patient was briefly on peripheral pressors at OSH, but responded to fluid boluses in the ICU, and was able to wean off peripheral dopamine. There was a thought he might be in distriubtive shock, as he did have some bandemia on his WBC count; the source was felt most likely his urine, given that he had no infiltrates on OSH CT torso, no ascites to suggest SBP, no h/o diarrhea, no signs of meningitis). L hip as possible focal source of infection, but no obvious evidence of septic joint on exam or imaging. Urine cultures were negative. Hypotension was also thought possibly secondary to poor PO intake while possibly being down, although the patient denied having been down for any period of time. The patient did report taking Viagra and in the setting of alcohol and percocet ingestion. This combination could have caused his hypotension especially because of the potential vasodilatory effect of viagra with an unclear dose. He responded well to fluids in the MICU and hydration was continued on the floor with resolution of hypotension. #) Rhabdomyolisis: Differential for patient's rhabdo picture included nontraumatic muscle compression or Nontraumatic nonexertional causes(drugs or toxins, infections, or electrolyte disorders) Although patient's history is inconsistent with muscle compression, prolonged immobilization is likely given that patient awoke with his left hip pain. He also had urine tox studies positive for methadone and serum tox studies positive for alcohol. Per his fiance, he had "six drinks and three percocets". Prolonged immobilization/crush from drug consumption +/- fall injury is likely given the quantity of mind altering substances the patient consumed and the unilateral nature of his pain. However, nontramatic nonexertional causes are possible given the patient's multiple prescription drugs. Methadone is a known cause of rhabdomyolisis. TSH was normal. The patient's rhabdomyolisis picture resolved with hydration (Ck [**Numeric Identifier 14123**] -> 4000 at discharge) #Acute renal failure: Caused by rhabdomyolysis and perhaps some ATN in the setting of hypotension. His medication cocktail of meloxicam, lisinopril undoubtedly contributed. We held his home hold lisinopril, gabapentin, raloxicam. Cr resolved from 2.4 to 1.3 at discharge with hydration and avoidance of nephrotoxins. . #) Transaminitis/elevated CK: Likely [**12-25**] muscle breakdown given rising CK over 20,000, which occurred in setting of dehydration and possible occult trauma. Other etiologies for transaminitis include hypoperfusion during hypotensive episode +/- alcohol related liver disease given history and serum tox. Has signs of synthetic dysfunction given high INR and low albumin, slight increase in bili. No jaundice or significant RUQ pain or anorexia to suggest dx of alcoholic hepatitis. RUQ U/S also suggests fatty infiltration versus cirrhosis. He will need further liver f/u as an outpatient for possible cirrhosis. Hep serologies negative. Chol levels were WNL, and A1c is 5.8%. . #) Alcohol abuse: EtOH level 33 in our ED. Patient endorses h/o heavy alcohol abuse. Drinks anywhere from [**3-31**] drinks per night. Last drink was [**1-10**] at 00:00 and denies h/o withdrawal. Not currently in window for withdrawal given alcohol level, but will get there in the day or so. We started him on a CIWA scale in house, and have given him 5 mg Valium prior to his floor transfer. He was given oral thiamine, folate, and multivitamin while in the hospital. He had a SW consult to discuss his alcohol abuse. #)Demand NSTEMI: positive troponin in the setting of rhabdo/hypotension, less likely ACS. Trop peak of 0.41 at [**Hospital1 18**]. He had ST depressions at [**Hospital1 **] on initial EKG which was done in setting of tachycardia and hypotension. EKG in house with less dramatic ST depressions 2hrs later. Given patient's h/o palpitations, report of recent positive exercise stress, and this "stress" test likely has underlying CAD though no evidence of ACS. We started him on an aspirin, but tropinins were also likely elevated in the setting of renal failure; in addition, the MBI was WNL, makinga caridac etiology less likely. Echo was performed and showed normal biventricular cavity sizes with preserved global biventricular systolic function. No definite valvular pathology identified. #) Left hip pain: Unclear etiology- no history of trauma and films w/o any evidence of inflammation or injury. On exam, hard and swollen but with good range of motion and pain primarily in lateral aspect of hip, not in joint- more muscular in area. U/S of area showed no fluid collections. We also used a lidocaine patch with PRN oxycodone in house and he was discharged on brief regimen of oxycodone to supplement his chronic pain regimen. #) Hypertension: we held lisinopril during his ongoing renal recovery, and started 5mg amlodipine on discharge. #) Colonic Polyposis: he described on admission a history of colon cancer- this was actually a history of multiple colonic polyps for which he gets q6monthly f/u. He is unaware of family polyposis, and appears to have frequent followup. #) ?Substance Abuse: he "borrowed" a methadone tab prior to admission which he admitted to only after his tox revealed its presence. He also had a high opiate tolerance in house. Further steps in patient care management: -Please check LFTs including Tbili to ensure downtrending after plateau at discharge -Please check Cr, CK to ensure that they are normalized. Medications on Admission: Viagra 100 mg PRN Maloxicam 15 mg Lisinopril 5 mg Gabapentin 300 mg Oxycodone 10 mg q6hr PRN pain Adderal 30 mg qAM, 20 mg qPM Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Viagra 25 mg Tablet Sig: One (1) Tablet PO once a day as needed for sexual intimacy: Do not take if taking nitrates for chest pain, are light headed, or having low blood pressure. 3. Adderall 10 mg Tablet Sig: 2-3 Tablets PO 30 mg qAM, 20 mg qPM . 4. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO every six (6) hours for 3 days: Do not take if driving, do not take if operating machinery, do not take if respiratory rate < 12 breaths per minute. Disp:*30 Tablet(s)* Refills:*0* 5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Outpatient Lab Work please check chem7, AST, ALT, Tbili, Dbili, LDH, AlkPhos on Tuesday [**1-20**] and fax to Dr. [**Last Name (STitle) 13972**] [**Telephone/Fax (1) 92357**] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Rhabdomyolsis, R hip Acute Kidney Injury Liver Injury with Transaminitis and cholestasis Hypotension requiring pressor support NSTEMI, demand related Fatty Liver Substance Abuse Secondary Diagnosis Hypertension Obstructive Sleep Apnea Chronic Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Thank you for allowing us to take part in your care. You were admitted to the hospital because you had very low blood pressure and injury to your kidneys and liver. You were given fluids to raise your blood pressure and your kidney and liver function were monitored closely. You began to recovered and are now able to leave the hospital with close follow up with your primary doctor. We made the following changes to your medications: - We STOPPED your Lisinopril, Meloxicam, and Gabapentin because they may be harmful to your kidneys at this time. - We INCREASED your Oxycodone to help you with your hip pain. - We STARTED Amlodipine to treat your blood pressure - We STARTED Aspirin to help prevent heart injury Followup Instructions: We recommend that you follow up with your primary doctor, Dr. [**Last Name (STitle) 13972**], on Tuesday, [**1-20**] at 9:45 am. Name: [**Last Name (LF) **],[**First Name3 (LF) **] B. Address: [**Street Address(2) 92358**], WEST, [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 21975**] Appt: [**1-20**] at 9:45am You should also see a liver specialist due to your liver injury from this hospitalization: When: WEDNESDAY [**2111-1-28**] at 8:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 92359**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2138-1-24**] Discharge Date: [**2138-2-7**] Date of Birth: [**2090-7-30**] Sex: F Service: MEDICINE Allergies: Morphine / Iodine; Iodine Containing Attending:[**First Name3 (LF) 689**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 47 year old female with a history of metastatic breast cancer and two prior episodes of pancreatitis thought to be secondary to hypertriglyceridemia who presents with abdominal pain. The patient was in her usual state of health until this morning when she began to feel epigastric abdominal pain, associated with nausea and vomiting. Does not report hematemesis or diarrhea. She denies recent fever, chills, head ache, chest pain, back pain, sob, cough. Patient had a similar episode one month ago and one in [**2130**]. She denies history of EtOH use and had CCY in [**2132**] with no subsequent history of gallstones. She is on a new course of chemo (Navelbine and Neuslasta). Past Medical History: Past medical hx: s/p ccy ovarian clot- requiring coumadin hypertrigylceridemia pancreatitis metastatic breast cancer onc hx: Primary Onc: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Metastatic Breast ca- in past, undewent chemo w/ adriamycin/cytoxan, then taxol. Then, she received 5FU/leukovorin and Zometa. Her course has been complicated by compression fractures in T1-T6 and T9. She underwent radiation treatment for T1 and developed more pain and T6 then was found to have a compression fracture with cord compression. She was hospitalized while she started radiation treatment. The decision had initially been made to continue her chemotherapy through her radiation treatment as a radiation sensitizer; however, the patient had episodes of severe nausea and vomiting and diarrhea resulting in additional hospitalizations. She is finishing off her radiation treatments with the omission of 5-FU leucovorin. She was restarted weekly taxol on [**2137-5-23**] until [**9-30**]. Pt was switched to gemzar since [**10-22**] due to apparent progression of disease. CT on [**10-18**] showed progression in size of liver mets and development of new right sided pulmonary nodules. PET [**10-21**] showed widespread metastatic bone lesions which were stable in intensity and number. Social History: Lives with her husband and 3 children in [**Location (un) 1459**]. She works as a radiology tech as [**Hospital3 2576**]. She denies any EtOH use, drug use or smoking. Family History: Aunt with breast cancer on father's side. Mother with bladder cancer. Uncle with unknown type of cancer. Physical Exam: On Admission: VITALS: 98.3 100/60 rr: 18 hr: 83 SpO2 100 on RA -Gen- 47 year old woman who appears stated age in obvious distress -HEENT: anicteric, mmm -cv- regular rate, s1s2, no m/r/g --no new murmurs auscultated -pulm: deeper breaths than previously, decreased breath sounds in left lower lung field, otherwise CTA B back: 6 cm x 4 cm ecchymosis approx over T4 (result of radiation) abd- scar across abdomen suprapubically, soft, diffusely tender, especially tender to deep palpation in mid epigastric area, +rebound, voluntary guarding -extrm- no cyanosis or edema, -nails- no clubbing, no pitting/color changes/indentations -neuro- a&ox 3 Pertinent Results: Admission labs: [**2138-1-24**] GLUCOSE-158* UREA N-7 CREAT-0.6 SODIUM-139 POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-15* ANION GAP-16 CALCIUM-5.5* PHOSPHATE-1.3*# MAGNESIUM-1.4* WBC-32.2* RBC-4.72# HGB-14.7# HCT-41.1 MCV-87 MCH-31.2 MCHC-35.9* RDW-19.5* NEUTS-88* BANDS-4 LYMPHS-1* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 HYPERSEG-1* . ALT(SGPT)-44* AST(SGOT)-42* ALK PHOS-93 AMYLASE-625* TOT BILI-0.5 LIPASE-2113* . [**2138-1-25**] Triglyc-957* HDL-30 CHOL/HD-6.3 LDLmeas-<50 . Imaging: CXR ([**2138-1-24**]): Lungs are clear without infiltrate, effusion, or pneumothorax. Abdominal CT ([**2138-1-25**]): Marked peripancreatic inflammatory change, with free fluid in the retroperitoneum, and extending into the pelvis. Findings compatible with known history of pancreatitis. No loculated fluid collection, pancreatic necrosis, or vascular complications identified. Stable hepatic and osseous metastases. MRCP ([**2138-1-27**]): Small bilateral pleural effusions, left greater than right, extensive peripancreatic inflammatory change without evidence of pancreatic necrosis or pseudocyst formation. Normal appearance of the biliary tree and pancreatic duct, stable appearance of multiple hepatic metastases, diffuse fatty infiltration of liver. [**2137-1-29**] Rib Film ([**2138-1-29**]): No definite lytic or sclerotic rib or shoulder metastases identified. Bone scan is recommended for further evaluation due to its greater sensitivity for detection for metastases. Small left pleural effusion and left lower lobe atelectasis. Bone scan: ([**2138-1-31**]) Numerous metastatic bone lesions as described above which are stable compared to the most recent prior study. . Micro: [**2138-1-30**] Blood culture: AEROBIC BOTTLE (Final [**2138-2-5**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. . [**2138-2-2**] Blood culture(Final [**2138-2-5**]): AEROBIC BOTTLE (Final [**2138-2-5**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. . [**2138-2-3**] Blood culture: ANAEROBIC BOTTLE (Preliminary): GRAM POSITIVE RODS. Brief Hospital Course: 47 female with metastatic breast cancer and two prior episodes of pancreatitis (98 and [**11-30**]) thought to be to be secondary to hypertriglyceridemia admitted for acute pancreatitis most likely secondary to hypertriglyceridemia v. chemotherapy. 1) Pancreatitis: In the ED ([**2139-1-25**]) the patient reported diffuse abdominal pain, nausea and vomiting. Her amylase (825), lipase (2113) and WBC (32.2) were all elevated. Abdominal CT showed marked peripancreatic inflammatory change, with free fluid in the retroperitoneum, and extending into the pelvis. No loculated fluid collection, pancreatic necrosis, or vascular complications were identified. The radiological findings, lab values and patient's presentation was compatible with pancreatitis, and she was subsequently admitted to medicine for acute pancreatitis believed secondary to hypertriglyceridemia v. chemotherapy. She was given morphine for pain, put on bowel rest with continued agressive IV hydration. The evening after admission, the patient had MS changes, became tachycardic to 150's, required increased IVF and had rectal temp to 103.8. She was subsequently transferred to the MICU for closer observation. In the MICU, she reported LUQ pain which was initally attributed to pancreatitis (See discussion below). MRCP showed extensive peripancreatic inflammatory change without evidence of pancreatic necrosis or pseudocyst formation. The pancreatic duct and biliary tree appeared normal. Metastases were unchanged from prior studies. Patient's WBC, amylase and lipase continued to trend downwards, but she continued to have intermittant fevers (see discussion below). She was transferred to [**Hospital Ward Name 121**] for continued management. A PICC line was placed for TPN and later removed (see discussion below). At the time of discharge, the patient was afebrile and WBC, amylase and lipase were wnl and she was on only PO pain meds. She was able to tolerate soft solids. 2) LUQ/left lower rib pain: Thiswas most likely secondary to pleural irritation due to pancreatitis. Rib films and bone scan swere negative for fractures or rib mestases that could be contributing to her pain, CTA was negative for PE, and, although CT scan showed small bilateral pleural effusion, their low volume prevented thoracentesis. The patient was initially started on a dilaudid PCA Dilaudid, from which she was transitioned to Oxycontin, hydromorphone, and gabapentin. At time of discharge, her pain was adequately controlled. . 3)Bacteremia: Blood cultures from [**2138-1-30**] (resulted [**2138-2-1**]) grew two morphologies of coag (-) staph (1/4 bottles). These were believed to be a contaminant, but given the patient remained febrile, she was begun on vancomycin ([**2138-2-1**]) pending subsequent blood cultures. On [**2138-1-31**] a PICC line was placed for TPN delivery (see discussion below). BCx from [**2138-2-2**] (resulted [**2138-2-3**]) also grew coag (-) staph. Upon receiving these results on [**2138-2-3**], BCx were drawn from the PICC and then the PICC was removed (the tip grew coag negative staph). Those blood cultures resulted on [**2138-2-5**] and grew gram + rods (coryneobacterium; likely a contaminant). TTE was performed and was (-) for mass/vegetation (limited study). Given concern for the possibility of portacath infection, blood cultures were drawn from the portocath, which were negative at time of discharge. The infectious disease service was consulted, who recommended that she complete a 10 day course of vancomycin (to complete [**2138-2-13**]) to treat presumed PICC line infection. She will have repeat blood cultures drawn after completing this her antibiotic course. 4)Fever: The patient was febrile for the first week and a half of her hospital stay, which was most likely secondary to resolving pancreatitis, with possible contributor of coagulase negative staph bacteremia (see above). She underwent a thorough infectious disease work-up which, aside from the bacteremia noted above, was negative. At time of discharge, the patient has been afebrile for >72 hours. 5) Anemia: The patient's hematocrit dropped from 37.4 to 24.8, which was attributed primarily to hemodilution. There were no schistocytes on smear and no clinical evidence of bleeding. She received 4 units of blood, and her hematocrit has since remained stable in the low 30's. Prior iron studies were consistent with anemia of chronic disease. On this admission, folate and vitamin B12 were found to be nl/high. 6) Hypertriglyceridemia: The patient has a longstanding history of hypertriglyceridemia and two prior bouts of pancreatitis thought to be secondary to hypertriglyceridemia. The patient will restart her Tricor upon discharge home. 7) Metastatic breast cancer: Prior to admission, patient was a chemotherapeutic regimen of neulasta and navelbine (two weeks on/ one weeks off). Oncologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) is concerned that one or both of these agents may have precipitated the two most recent bouts of pancreatitis. Patient will follow up with Dr. [**First Name (STitle) **] to discuss potential treatment alternatives. 8) FEN Following diagnosis of pancreatitis, the patient was kept on bowel rest with aggressive hydration. On HD 8, a PICC line was placed and the patient was begun on TPN on HD 9 to augment her nutritional status, which was discontinued on [**2-3**] after removal of her PICC line. At time of discharge, she was able to tolerate soft POs and hydrate herself without difficulty 9) Full Code Medications on Admission: Buproprion 75 mg [**Hospital1 **] Pantoprazole 40 mg PO daily Tricor 145 mg daily Warfarin 1 mg daily Oxycodone SR 60 mg PO BID Vicodin prn Navelbine and neulasta (chemotherapeutics) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. Vancomycin in Dextrose 1 g/250 mL Solution Sig: One (1) 1000 mg IV (via portacath) Intravenous every twelve (12) hours for 1 weeks: [**Date range (1) 5064**]. Disp:*qs qs* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for shooting LUQ pain. Disp:*90 Capsule(s)* Refills:*0* 6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Portocath care Heparin and saline flushes per standard protocol 9. Outpatient Lab Work Blood cultures after completion of 10 day course of vancomycin ([**2138-2-13**]) 10. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*84 Tablet(s)* Refills:*0* 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for nausea/anxiety. Disp:*30 Tablet(s)* Refills:*0* 12. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* 13. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO twice a day. 14. OxyContin 10 mg Tablet Sustained Release 12HR Sig: Three (3) Tablet Sustained Release 12HR PO three times a day. Disp:*63 Tablet Sustained Release 12HR(s)* Refills:*0* 15. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Primary: Pancreatitis Secondary: pleuritic irritation, coag- staph bacteremia, metastatic breast cancer Discharge Condition: Stable Discharge Instructions: Please call your PCP or return to the ED if you have a fever,chills, muscles aches, pain around your portocath insertion point, abdominal pain or worsening left lower rib pain. Followup Instructions: 1) Primary Care Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 1395**] ([**Telephone/Fax (1) 2936**]) Wednesday [**2138-2-12**] 1:45 p.m. - you will need to have blood cultures drawn after you complete your 10 day vancomycin course ([**2138-2-13**]) to ensure that the bacteremia has cleared 2) Oncology Please make an appointment with your oncologist, Dr. [**First Name (STitle) **] within the week - chemotherapy should not be initiated until you have completed your antibiotic course and repeat blood cultures are negative Completed by:[**2138-2-28**]

[ "198.5", "V16.3", "780.6", "V10.3", "V16.59", "272.1", "511.9", "276.51", "428.0", "276.2", "V15.3", "577.0", "197.7", "790.7", "285.29", "V12.51" ]

icd9cm

[ [ [] ] ]

[ "99.15", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

12990, 13051

5468, 11031

310, 332

13199, 13208

3365, 3365

13433, 14013

2574, 2681

11264, 12967

13072, 13178

11057, 11241

13232, 13410

2696, 2696

256, 272

360, 1041

3382, 5445

2710, 3346

1063, 2372

2388, 2558

21,506

151,413

9526+9527

Discharge summary

report+report

Admission Date: [**2147-7-21**] Discharge Date: [**2147-7-22**] Date of Birth: [**2106-2-20**] Sex: F Service: CCU CHIEF COMPLAINT: Hypertension and chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old with a history of lupus, end-stage renal disease times 12 years, severe hypertension, recently hospitalized for hypertension and chest pain management in the setting of volume overload who went to Radiology for arteriovenous fistulogram this morning in preparation for a renal transplant evaluation. Since discharge, her systolic blood pressures have ranged between 190 to 200. She did not take her blood pressure medications this morning secondary to instructions. NOTE: Dictation ended after 1.6 minutes. [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 7944**] MEDQUIST36 D: [**2147-7-27**] 11:32 T: [**2147-8-1**] 12:05 JOB#: [**Job Number 9693**] Admission Date: [**2147-7-21**] Discharge Date: [**2147-7-22**] Date of Birth: [**2106-2-20**] Sex: F Service: CCU CHIEF COMPLAINT: Hypertension and chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old female with a history of lupus, end-stage renal disease times 12 years, severe hypertension who recently hospitalized for high blood pressure and chest pain management in the setting of volume overload who went to Radiology for arteriovenous fistulogram in preparation for a renal transplant evaluation this morning. Since her last hospital admission, the patient's blood pressures at home have been ranging from 190 to 200 systolically. The patient did not take her blood pressure medications this morning secondary to instructions; and at procedure was noted to have chest pain described to 7/10 chest pain that was left-sided, radiating to back; which is her usual pain distribution. At this time, her blood pressure was noted to be 230/120 and was sent to the Emergency Room at this time. In the Emergency Department, the patient was started on Nipride initially and then was switched to nitroglycerin. In the Emergency Department, she was found to have atypical chest pain without electrocardiogram changes, and her initial cardiac enzymes were negative. The patient was also given 1 mg of morphine sulfate with relief. The patient had a CT angiogram of her chest that was negative for dissection. Her systolic blood pressure became elevated again, as the patient did not get her evening times medications, and pressure rose to 270/130 in the Emergency Room. The patient then received her nightly medications. Of note, her blood pressure decreased to 202/100 in the Emergency Room. She was admitted to the Coronary Care Unit for monitoring. On examination currently, has a headache since starting the nitroglycerin drip; but has since then slightly improved. PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus. 2. End-stage renal disease; the patient receives hemodialysis on Tuesday, Thursday, and on Saturday. 3. Severe hypertension. 4. Gastroesophageal reflux disease. 5. Hyperparathyroidism. 6. Endometrial cyst. 7. Migraines. 8. Gout. MEDICATIONS ON ADMISSION: 1. Prevacid 30 mg p.o. q.d. 2. Claritin 10 mg p.o. q.d. 3. Accupril 30 mg p.o. b.i.d. 4. Nifedipine-XR 120 mg p.o. q.h.s. 5. Clonidine 0.2-patch q.h.s. 6. Hydralazine 10 mg p.o. t.i.d. 7. Lopressor 125 mg p.o. b.i.d. 8. Aldomet 500 mg p.o. t.i.d. 9. Allopurinol 100 mg p.o. q.d. 10. Fioricet as needed for migraines. 11. Klonopin p.o. q.h.s. as needed. 12. Singulair 10 mg p.o. q.d. 13. Paxil 10 mg p.o. q.d. ALLERGIES: PENICILLIN, VANCOMYCIN, LEVAQUIN, KEFZOL. SOCIAL HISTORY: The patient denies tobacco, alcohol, or intravenous drug use. FAMILY HISTORY: Family history is notable for systemic lupus erythematosus and hypertension. REVIEW OF SYSTEMS: Review of systems was notable for atypical chest pain about three times per week. The patient denies shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema. The patient denies fevers, chills, cough, palpitations, nausea, vomiting, and diaphoresis. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were temperature of 96.4, heart rate was 89, blood pressure was 202/96, respiratory rate was 12, oxygen saturation was 100% on room air. In general, the patient was a pleasant woman in no acute distress. Head, eyes, ears, nose, and throat revealed pupils were equally round and reactive to light. Extraocular muscles were intact. She had anicteric sclerae. The oropharynx was clear. Neck examination revealed the neck was supple. No lymphadenopathy. Plus carotid bruit down the left side. No jugular venous distention. Chest was clear to auscultation bilaterally. Cardiovascular had a regular rate and rhythm. Second heart sound and second heart sound. There was a 2/6 systolic ejection murmur at the right upper sternal border. No rubs or gallops. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. No hepatosplenomegaly. No costovertebral angle pain. Extremities revealed there was no clubbing, cyanosis or edema. She had 2+ dorsalis pedis and posterior tibialis pulses. Her neurologic examination revealed alert and oriented times three. Normal strength and sensation. Normal deep tendon reflexes and a decreased Babinski. PERTINENT LABORATORY DATA ON PRESENTATION: Her laboratories on admission were white blood cell count of 5.2, hematocrit was 39.5, platelets were 155. The differential was 59 neutrophils, 0 bands, 25 lymphocytes, 10 monocytes, 4 eosinophils. Her Chemistry-7 revealed her sodium was 135, potassium was 4.9, chloride was 96, bicarbonate was 20, blood urea nitrogen was 34, creatinine was 6.9, blood glucose was 85. Her calcium was 9.9. Her phosphate was 5.1. Her magnesium was 3.5. Her initial cardiac enzymes were creatine kinase of 16. The second creatine kinase was 14. Her initial troponin was less than 0.3. RADIOLOGY/IMAGING: A chest x-ray showed no failure and a normal mediastinum. Her CT angiogram showed no dissection. There was a small right pleural effusion, small kidneys with multiple cysts, splenomegaly. Electrocardiogram was normal sinus rhythm at 64, with a normal axis, normal intervals, left ventricular hypertrophy, with J-point elevation of 0.5 mm to 1 mm in V1 through V3. There were no changes from her baseline electrocardiogram. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit for monitoring of blood pressure medications. 1. CARDIOVASCULAR: (a) Coronary artery disease: There was no evidence of ischemia throughout the hospital stay. Her remaining cardiac enzymes remained negative with a creatine kinase of 17 and a troponin of less than 0.3. At this time, it was felt that there was no need for risk stratification of this patient as she had a very recent MIBI, and it was felt that her hypertension was believed secondary to her not taking her medications. The patient was continued on aspirin, a beta blocker, and ACE inhibitor throughout the course of her stay. (b) Hypertension: Given the patient's refractory hypertension at baseline with recent home blood pressures with systolics in the range of 90 to 200, it was felt that this patient was not considered to be in hypertensive urgency or emergency at this time. The patient was continued on her current home medication regimen with a good response. 2. RENAL: The patient did not receive hemodialysis while she was in the hospital and was to receive her Saturday hemodialysis upon discharge from the hospital. Of note, the patient was seen by the Renal team, and they were aware of her plans to receive hemodialysis upon discharge. It was felt the patient would be okay to be discharged today as her blood pressures were at baseline after receiving her usual doses of antihypertensive medications. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE DIAGNOSES: High blood pressure. MEDICATIONS ON DISCHARGE: (Same regimen as on admission) 1. Prevacid 30 mg p.o. q.d. 2. Claritin 10 mg p.o. q.d. 3. Accupril 30 mg p.o. b.i.d. 4. Nifedipine-XR 120 mg p.o. q.h.s. 5. Clonidine 0.2-patch q.h.s. 6. Hydralazine 10 mg p.o. t.i.d. 7. Lopressor 125 mg p.o. b.i.d. 8. Aldomet 500 mg p.o. t.i.d. 9. Allopurinol 100 mg p.o. q.d. 10. Fioricet as needed for migraines. 11. Klonopin p.o. q.h.s. as needed. 12. Singulair 10 mg p.o. q.d. 13. Paxil 10 mg p.o. q.d. [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 7944**] MEDQUIST36 D: [**2147-7-27**] 11:49 T: [**2147-8-1**] 12:07 JOB#: [**Job Number 32374**]

[ "274.9", "582.81", "786.50", "403.91", "710.0" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

3843, 3921

8059, 8081

8108, 8847

3260, 3746

6529, 7988

8003, 8037

3941, 6511

1175, 1205

1234, 2940

2962, 3233

3763, 3826

70,517

186,828

13037

Discharge summary

report

Admission Date: [**2135-9-20**] Discharge Date: [**2135-9-29**] Date of Birth: [**2052-8-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: [**2135-9-21**] - Left thoracotomy with LV epicardial lead placement and pacemaker generator change [**2135-9-27**] - exploratory laporatomy History of Present Illness: 83 year old male with known coronary artery disease, status post CABG [**41**] years ago, hypertension, hypercholesterolemia, moderate to severe Mitral regurgitation, diastolic CHF, Atrial Fibrillation (with no anticoagulation until recent hospital admission), recently became hemodialysis dependent was found to have new tachy/brady syndrome following a syncopal episode after a dialysis run at an OSH. Mr.[**Known lastname 6382**] was transferred to [**Hospital1 18**] for a subxiphoid RV epicardial lead/generator placement with Dr.[**Last Name (STitle) 914**]. Past Medical History: CAD - CABG 15yrs ago at [**Location (un) 511**] [**Hospital1 **] CHF with diastolic dysfunction AF, not previously not on coumadin until this admission CKD Hyperlipidemia Prostate Ca MIld dementia Gout COPD Social History: Smoked for 15-20 years, quit 40 yrs ago. ETOH Lives with daughter Family History: Uncle with premature heart disease Physical Exam: Pulse:76 Atrial Fibrillation Resp: 18 O2 sat: 92% on 4Lpm B/P Right: 90/66 Left: Height: 5'3" Weight:133LB General:A&O x3,NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs : [(B) Crackles-(R)>(L)]: well healed sternotomy scar Heart: RRR [] Irregular [x] Murmur: SEM IV/VI Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x]:(L)UE fistula. (R)LE well healed Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: Left: PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit :none Right: 2+ Left:2+ Pertinent Results: [**2135-9-29**] 05:49AM BLOOD Hct-31.0* [**2135-9-29**] 12:24AM BLOOD WBC-13.6* RBC-3.46* Hgb-9.6* Hct-31.6* MCV-91 MCH-27.8 MCHC-30.4* RDW-18.0* Plt Ct-58* [**2135-9-20**] 09:35PM BLOOD WBC-8.1 RBC-3.62* Hgb-10.2* Hct-33.7* MCV-93 MCH-28.1 MCHC-30.2* RDW-18.6* Plt Ct-117* [**2135-9-29**] 10:32AM BLOOD Plt Ct-92*# [**2135-9-29**] 12:24AM BLOOD PT-22.6* PTT-46.5* INR(PT)-2.1* [**2135-9-20**] 09:35PM BLOOD Plt Ct-117* [**2135-9-20**] 09:35PM BLOOD PT-16.6* PTT-35.8* INR(PT)-1.5* [**2135-9-27**] 06:40PM BLOOD Fibrino-264 [**2135-9-27**] 09:39AM BLOOD Fibrino-291 [**2135-9-29**] 12:24AM BLOOD Glucose-85 UreaN-20 Creat-2.0* Na-134 K-4.8 Cl-105 HCO3-18* AnGap-16 [**2135-9-28**] 11:57AM BLOOD Glucose-129* UreaN-29* Creat-2.9* Na-134 K-5.5* Cl-103 HCO3-21* AnGap-16 [**2135-9-26**] 04:20AM BLOOD Glucose-127* UreaN-45* Creat-4.2* Na-134 K-4.6 Cl-94* HCO3-20* AnGap-25* [**2135-9-20**] 09:35PM BLOOD Glucose-78 UreaN-32* Creat-3.2* Na-137 K-4.4 Cl-100 HCO3-23 AnGap-18 [**2135-9-29**] 12:24AM BLOOD ALT-93* AST-166* LD(LDH)-341* AlkPhos-113 TotBili-5.3* [**2135-9-27**] 02:08PM BLOOD ALT-83* AST-195* LD(LDH)-370* CK(CPK)-181* AlkPhos-120* Amylase-50 TotBili-2.8* [**2135-9-28**] 11:57AM BLOOD Lipase-51 [**2135-9-28**] 01:51AM BLOOD CK-MB-10 MB Indx-7.7* cTropnT-0.98* [**2135-9-29**] 12:24AM BLOOD Mg-2.4 [**2135-9-20**] 09:35PM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.6 Mg-1.9 [**2135-9-20**] 09:35PM BLOOD %HbA1c-6.6* [**2135-9-22**] 11:45AM BLOOD TSH-1.7 [**2135-9-28**] 11:57AM BLOOD Cortsol-30.8* [**2135-9-27**] 10:14AM BLOOD Lactate-12.1* [**2135-9-27**] 08:23AM BLOOD Lactate-7.2* [**2135-9-21**] 09:50AM BLOOD Glucose-82 Lactate-2.3* Na-131* K-4.9 Cl-99* [**2135-9-29**] 05:58AM BLOOD O2 Sat-98 [**2135-9-27**] 10:46AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Brief Hospital Course: Transfered in and underwent preoperative workup. On [**2135-9-21**] he was taken to the operating room where he underwent a left thoracotomy with placement of an LV lead and a pacer generator change. Please see operative note for details. Postoperatively he was taken to the intensive care unit for hemodynamic monitoring on epinephrine and milirone due to right ventricular failure noted on TEE in operating room. He required fluid and additional vasopressin for blood pressure management. Urology was consulted for foley placement and he was noted to have urethral stricture, cystoscopy was done for placement of foley by urology. He developed hematuria and bladder required intermittent irrigation. He was progressively weaned from the milirone, ephineprine and vasopressin. On post operative day two all drips were off and he underwent dialysis. He continued to progress and was transferred to the floor on postoperative day three. He continued to receive hemodialysis but had issues over the next few days with hypotension and hypoglycemia which were treated. On postoperative day five was transferred back to the intensive care unit due to hypotension and not feeling well. Echocardiogram was obtained and ruled out pericardial effusion, and fluid bolus given on transfer with blood pressure improved. On postoperative day six he complained of abdominal pain with increased LFT and lactate, ultrasound was obtained and surgery consulted. He arrested which was witnessed by the ultrasound tech requiring intubation and chest compressions see arrest sheet. Echocardiogram was obtained immediately which revealed right ventricular failure. He was started on milirone, epinephrine, levophed and vasopressin for hemodynamic management. He was taken to the operating room for exploratory laporatory and returned with open abdomen. See operative report for further details, there was no ischemia found. He continued to remain on multiple pressors and after discussions with family he was made a DNR. He continued on ventilator support and mutliple pressors and CVVHD for diaylsis. On [**2135-9-29**] there was a family meeting and based on his wishes that were known by his family he was made comfort measures. He passed away [**9-29**] with family at bedside. Medications on Admission: ASA 162 mg daily Zocor 40 mg daily Zetia 10 mg daily Flomax 0.4 mg daily Trazadone 75mg QHS prn insomnia Allopurinol 100mg daily Discharge Disposition: Expired Discharge Diagnosis: Tachy-brady syndrome s/p left thoracotomy LV lead placement Urethral striction s/p cystoscopy for catheter placement Renal Failure on hemadialysis Hematuria Diabetes Prostate Cancer Aortic abdominal aneurysm Dementia Gout Chronic obstructive pulmonary disease Coronary artery disease s/p CABG Atrial fibrillation Hyperlipidemia hypertension Discharge Condition: deceased Completed by:[**2135-9-29**]

[ "428.0", "518.5", "403.91", "V10.46", "286.9", "427.5", "427.31", "250.80", "570", "564.7", "496", "397.0", "593.2", "274.9", "E884.6", "285.21", "441.4", "598.9", "789.59", "276.1", "E849.7", "585.6", "427.81", "294.8", "428.32", "276.2", "272.4", "424.0", "V45.81", "785.51" ]

icd9cm

[ [ [] ] ]

[ "54.11", "96.71", "38.93", "57.94", "37.82", "37.74", "57.32", "39.95", "38.91", "96.04", "99.60" ]

icd9pcs

[ [ [] ] ]

6422, 6431

3966, 6242

328, 471

6816, 6856

2178, 3943

1397, 1433

6452, 6795

6268, 6399

1448, 2159

281, 290

499, 1066

1088, 1297

1313, 1381

57,767

102,931

18895

Discharge summary

report

Admission Date: [**2176-12-13**] Discharge Date: [**2176-12-19**] Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Ativan Attending:[**First Name3 (LF) 2569**] Chief Complaint: Right visual field cut and confusion. Major Surgical or Invasive Procedure: None. History of Present Illness: 88 year old woman with history of HTN initially presenting this morning with an occipital stroke. Per report she was an active healthy woman who painted a fence last week. She was brought in to the hospital this morning after a syncopal episode and acute onset of neurological deficits and was diagnosed with a large left PCA territory stroke. She was transferred to [**Hospital1 18**] for further workup and treatment. Yesterday morning the patient had 1 episode of desaturations to 80% but had just gotten 1 dose of ativan. They gave her 3L NC and she bounced back to 90s. At 2am this morning (1 hour ago) she triggered on the floor for desaturations briefly down to 80%. She was placed on 4L NC then 5L NC and then on a non-rebreather on which she was sating ~88% and then increased to 97% when the head of the bed was raised. An ABG and CXR were normal. Lungs were clear on exam. She was noted to be tachypneic and hypertensive and in a sinus tach at 95. BPs ranging 175/120, EKG showed no evidence of right heart strain. No fever or chills. Denies any current shortness of breath or cough although cough noted by neurology team this evening. No witnessed aspiration event. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: hypertension h/o Shingles in [**2176-10-9**] Left macular degeneration hearing loss with hearing aids Mild cognitive loss s/p LLE phlebitis in [**2167**] Varicose veins Osteoarthritis s/p Foot surgery in [**2165**] Social History: No smoking, ETOH, illicits. Son and daughter at bedside. Son is HCP ([**Telephone/Fax (1) 51694**]) Patient lives with her daughter, who previously worked as a nurse. Complicated social family history. Family History: Mom died of colon cancer. Dad died of MI. No h/o strokes. Physical Exam: Summary of Neurologic Exam Findings: Mrs.[**Known lastname 51695**] key exam findings are: Right homonymous hemianopia, anomia, anterograde amnesia. Please see brief hospital course for anatomical correlation of these findings and realtionship to her stroke. Admission Examination: 96.8 73 150/104 18 96% 2L Gen: Lying in bed, NAD HEENT: Normocephalic, atraumatic. Mucous membranes moist. Neck: Supple Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: +BS soft, nontender Skin: No rash Ext: No edema Neurologic examination: Mental status: General: Alert, awake, agitated. Orientation: Oriented to person, "hospital" (doesn't know which one). Cannot name month of year. Attention: Says days of the week forwards but stops after 5 days; unable to to say days of the week backwards Executive Function: Follows simple axial and appendicular commands. Requires step-by-step prompts for complex commands. Memory: Registration [**4-10**]. Recall 0/3 at 5 minutes. Speech/Language: When lying down, speech is fluent w/o paraphasic (phonemic or semantic) error. When sitting up, however, patient has significant word substitution and invents words. When asked to name objects on the stroke card, she makes up words. Then she says, "I can't see anything without my roof." Appears frustrated by inability to come up with the correct word. Comprehension seems intact. Unable to read. Praxis: Able to demonstrate how to brush teeth. Calculations: Unable to calculate 9 quarters. Cranial Nerves: II: Pupils equally round and reactive to light, 2 to 1.5 mm bilaterally. Dense right visual field cut. Looks at $20 [**Doctor First Name **] in left visual field and follows it. She also is able to copy the examiner when shown how to do various parts of the exam (this was often done due to difficulty hearing). However, later in the exam when testing finger-nose-finger in the sitting position, the patient was unable to find the examiner's finger regardless of visual field. III, IV, VI: Extraocular movements intact without nystagmus. V1-3: Sensation intact V1-V3. VII: Facial movement symmetric. VIII: Significant hearing difficulty throughout exam; examiner needs to yell for patient to understand. IX & X: Palate elevation symmetric. Uvula is midline. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally. XII: Good bulk. No fasciculations. Tongue midline, movements intact. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor. No pronator drift Delt; C5 Bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 5 5 5 5 5 Right 5 5 5 5 5 IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex Left 5 5 5 5 5 5 Right 5 5 5 5 5 5 Deep tendon Reflexes: Biceps: Tric: Brachial: Patellar: Achilles Toes: Right 1 1 1 1 1 WITHDRAW Left 1 1 1 1 1 WITHDRAW Sensation: Intact to light touch throughout. No extinction to double simultaneous stimulation. Coordination: Finger-nose-finger limited as patient appears unable to see the examiner's finger; she is able to touch her nose with very mild right-sided dysmetria. Heel to shin normal, RAMs normal. Gait: Not tested due to pressure-dependent exam. Pertinent Results: On admission: [**2176-12-12**] 09:45PM BLOOD WBC-6.0 RBC-4.44 Hgb-14.0 Hct-40.3 MCV-91 MCH-31.4 MCHC-34.7 RDW-15.7* Plt Ct-148* [**2176-12-12**] 09:45PM BLOOD Neuts-86.3* Lymphs-9.7* Monos-3.3 Eos-0.4 Baso-0.4 [**2176-12-12**] 09:45PM BLOOD PT-12.4 PTT-28.0 INR(PT)-1.0 [**2176-12-12**] 09:45PM BLOOD Glucose-110* UreaN-10 Creat-0.7 Na-136 K-3.7 Cl-101 HCO3-25 AnGap-14 [**2176-12-13**] 07:40AM BLOOD ALT-18 AST-24 CK(CPK)-106 AlkPhos-73 TotBili-0.4 [**2176-12-12**] 09:45PM BLOOD cTropnT-<0.01 [**2176-12-12**] 09:45PM BLOOD Cholest-223* [**2176-12-13**] 07:40AM BLOOD Calcium-9.1 Phos-2.3* Mg-1.9 Cholest-241* [**2176-12-13**] 07:40AM BLOOD %HbA1c-5.7 eAG-117 [**2176-12-12**] 09:45PM BLOOD Triglyc-54 HDL-82 CHOL/HD-2.7 LDLcalc-130* [**2176-12-13**] 07:40AM BLOOD TSH-3.4 [**2176-12-12**] 09:45PM BLOOD ASA-6.9 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2176-12-14**] 01:37AM BLOOD Type-ART FiO2-95 pO2-81* pCO2-38 pH-7.46* calTCO2-28 Base XS-2 AADO2-562 REQ O2-92 Intubat-NOT INTUBA [**2176-12-14**] 01:34PM BLOOD Lactate-1.3 [**2176-12-14**] 01:34PM BLOOD O2 Sat-92 [**2176-12-12**] 10:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008 [**2176-12-12**] 10:30PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2176-12-12**] 10:30PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2 [**2176-12-12**] 10:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG MRSA SCREEN (Final [**2176-12-17**]): No MRSA isolated. CT Head (OSH) Hypodensity in PCA distribution, not involving brainstem, but whole of left occipital pole, through inferior temporal lobe and left hippocampus to temporal pole. ECG [**2176-12-12**]: Sinus rhythm. Left axis deviation consistent with left anterior fascicular block. QRS axis minus 45 degrees. First degree A-V delay. Delayed R wave transition in the anterior precordial leads, may be due to left anterior fascicular block but cannot exclude anteroseptal wall myocardial infarction, age indeterminate. Clinical correlation is suggested. Possible left ventricular hypertrophy. Non-specific inferior and lateral ST-T wave changes. No previous tracing available for comparison. CTA Neck [**2176-12-13**]: IMPRESSION: 1. Left occipital infarct. 2. Narrowing of the left PCA P2 bifurcation segment. Atheromatous disease involving the left proximal vertebral artery. 3. Small low density right thyroid nodule measuring about 8mm. Clinical and TFT evaluation advised prior to US. TTE [**2176-12-14**]: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is an abnormal systolic flow contour at rest, but no left ventricular outflow obstruction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. Significant aortic stenosis is present (not quantified). Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. IMPRESSION: Small LV cavity size with moderate symmetric LVH and hyperdynamic LV systolic function. Abnormal LVOT systolic flow contour without frank obstruction. Probable diastolic dysfunction. Calcified mitral and aortic valve with at least mild aortic stenosis, moderate aortic regurgitation and mild mitral regurgitation. No cardiac source of embolism seen. CTA Chest [**2176-12-14**]: IMPRESSION: 1. No pulmonary embolism. 2. Enlarged thoracic aorta as described. No aortic dissection. 3. Liver hypodensities, too small to characterize. 4. Bibasilar atelectasis with trace left effusion. Abdominal X-ray [**2176-12-15**]: There is no evidence of obstruction or ileus. There is increased fecal material throughout the colon. There are degenerative changes in the thoracic and lumbar spine. TTE [**2176-12-16**]: After intravenous injection of agitated saline, there is prompt (within one beat) and prominent appearance of saline contrast in the left heart c/w a right-to-left shunt across the interatrial septum. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. Significant aortic regurgitation is present, but cannot be quantified. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2176-12-14**], a right-to-left shunt, likely at the atrial level is now identified. Video swallow [**2176-12-16**]: IMPRESSION: No aspiration. Moderate amount of gastroesophageal reflux. Barium swallow [**2176-12-16**]: IMPRESSION: Ineffective primary peristalsis. Minimal reflux seen. Possible small hiatal hernia. No evidence of stricture. Duplex ultrasound of lower extremities: IMPRESSION: No evidence of deep vein thrombosis in either leg. Brief Hospital Course: Active problems during admission were neurologic (secondary to left posterior cerebral artery infarction), paroxysmal hypoxic respiratory failure, hypertension, along with other issues listed below. Stroke Mrs. [**Known lastname 23081**] presented initially with lightheadedness, confusion and headache followed by dragging of right foot and insensible speech. CT head at OSH showed left occipital hypodensity extending into left temporal region. She was seen by neurology service who recommended CTA head and neck which showed narrowing of the left PCA P2 bifurcation segment and atheromatous disease involving the left proximal vertebral artery. She was kept on aspirin and statin. BP was allowed to autoregulate with goal SBP 140-180. MI was ruled out with cardiac enzymes. She also had TTE with bubble study that showed a right to left shunt. Ultrasound of both lower extremities did not reveal thrombus. In view of the alternative explanation for this presentation offered by vertebral disease and the high prevalence of septal defects in the general population, without evidence of a source and only in the presence of no other explanation would this be invoked as causal. Aspirin was changed to Aggrenox prior to discharge given dyspepsia and superiority in secondary prevention. Hypoxic Respiratory Failure On the day following admission, desaturation to the 80s was noted and Mrs. [**Known lastname 23081**] was transferred to the ICU for close monitoring (being transferred back to the floor subsequently) Most likely positional as patient's O2 saturations apparently rose quickly after sitting up. CTA was negative for PE. She had no evidence of CHF on CXR or exam. TTE showed probable diastolic dysfunction but preserved EF. On [**2176-12-15**], she desaturated to 80%'s and had to be put on a non-rebreather briefly. Oxygen saturations remained in high 90%'s on room air for remainder of hospital stay. A bubble study was performed. Atrial Septal Defect Bubble study was consistent with atrial septal defect but it was felt that her stroke was more likely attributable to vertebral disease than paradoxical emboli. Cardiology thought that this was a possible underlying cause of desaturation, but felt that this was unlikely given the paroxysmal nature of her desaturations that were more frequent during sleep. This will need to be followed in rehabilitation, but as an inpatient, such events did not occur later in the admission. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who saw her during this admission, will see her as an outpatient for further evaluation. Again, we do not attribute her stroke to this defect. Thyroid Nodule Of note, CTA also revealed a small low density right thyroid nodule measuring about 8 mm. She should get TFT's prior to ultrasound and this should be followed as an outpatient. Hypertension Pt remained hypertensive, reaching systolic 200's. Per neuro, BP was allowed to autoregulate with goal BP 140-180 systolic. She was controlled with hydralazine for SBP above 180's. Lisinopril was restarted at 5 mg, resulting in improved control. Blood pressure is best lowered gradually in this context, with uptitration of ACEI most desirable. Chest Pain In the ICU, she had episodes of chest pain often precipitated by food intake. EKG remained unchanged from prior. Cardiac enzymes were negative. She was put on a Nitro gtt at one point as she was hypertensive to systolic 190's. She was kept on full dose aspirin. Given negative cardiac work-up and relation to food intake intake, GI was consulted. Dyspepsia KUB was unremarkable. GI recommended barium esophagram which showed no strictures but did show ineffective primary peristalsis, minimal reflux, and possible small hiatal hernia. GI recommended that pt have outpatient GI appointment if symptoms continue. If symptoms continue by the time of this appointment, GI will consider EGD to rule out esophagitis. Bradycardia Pt had a few episodes of bradycardia precipitated by po intake which were attributed to increased vagal tone in the context of dyspepsia. Ativan Adverse Reaction We noted that even taking her home dose of Ativan resulted in marked sedation. We would suggest avoiding benzodiazepines. Leg Cramps Not an active problem during admission. Medications on Admission: Lisinopril one tab (dose unknown) PO daily Lorazepam 0.5-1mg PO daily PRN insomnia, anxiety Quinine PRN leg cramps Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Can stop when ambulating frequently. 4. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for rash . 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as needed for GERD. 9. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO DAILY (Daily) for 4 days: After four days, increase to [**Hospital1 **]. 10. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day): Do not start until four days of once daily dosing is completed. 11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Primary Stroke - ischemic, left posterior cerebral artery Atrial septal defect Vertebral stenosis Secondary Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). At baseline she has been more independent, but this is our present recommendation. She has complete right visual field loss and memory impairment. She cannot typically encode new memories at present, particularly when these are episodic or linguistic. Discharge Instructions: You came to the hospital after having a stroke. This was of the back part of your brain and involves brain areas important for your right visual field (left occipital lobe), along with a brain region important for memory formation (left hippocampus). This has occurred in the context of narrowing of a blood vessel that supplies these regions (vertebral artery). We adjusted your medications to include an antiplatelet [**Doctor Last Name 360**], Aggrenox. Now that you are medically [**Last Name (un) 2677**], we feel that you will now benefit from rehabilitation, where you will adapt to the changes that have occurred as a result of this stroke. Please attend follow-up listed below. Please continue to take your medications as directed. Followup Instructions: Please follow-up in stroke clinic. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2177-1-17**] 10:30 Please follow-up with Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2177-1-9**] at 13:00. [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital1 18**] [**Hospital Ward Name 5074**]. Please follow-up with Gastroenterology if your dyspepsia continues: [**Last Name (LF) 2643**], [**First Name3 (LF) **] B Office Phone: ([**Telephone/Fax (1) 2306**] Office Location: LMOB 8E Department: GI, Medicine Organization: [**Hospital1 18**] Please see your primary care doctor (we have not made an appointment, because you will be at rehabilitation) as soon as you are discharged from rehabilitation. [**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 5294**]. If your primary care doctor would like you to see a cardiologist again, you could make an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 69**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

17063, 17208

11384, 15690

289, 296

17374, 17374

5980, 5980

18573, 19785

2398, 2457

15856, 17040

17229, 17353

15716, 15833

17808, 18550

2472, 3055

1525, 1924

212, 251

324, 1506

4049, 5961

5994, 11361

17389, 17784

3079, 3079

1946, 2162

2178, 2382

31,662

196,790

31443

Discharge summary

report

Admission Date: [**2102-8-7**] Discharge Date: [**2102-9-7**] Date of Birth: [**2021-2-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: sternal drainage Major Surgical or Invasive Procedure: sternal wound debridement and VAC, sternal flaps [**8-16**] History of Present Illness: 81 yo M s/p CABG/AVR/tracheostomy [**6-17**], discharge to rehab [**7-11**], return to ED with sternal drainage, new requirement for intermittent ventilatory support. Past Medical History: Hypertension Hyperlipidemia Prior CVA ([**2083**]) Known 6 mm L MCA aneurysm Mild aortic stenosis chronic renal insufficiency - baseline creatinine 1.9 Acute on chronic systolic heart failure Social History: The patient has been married for 61 years and lives with his wife and daughter. [**Name (NI) **] smoked previously, but quit ~ 50 years ago. He drinks 2 beers rarely. There is no family history of premature coronary artery disease or sudden death; he had one brother who died of complications surrounding an MI in his 60s. Family History: The patient has been married for 61 years and lives with his wife and daughter. [**Name (NI) **] smoked previously, but quit ~ 50 years ago. He drinks 2 beers rarely. There is no family history of premature coronary artery disease or sudden death; he had one brother who died of complications surrounding an MI in his 60s. Physical Exam: NAD, on trach collar some increased work of breathing Chest with paradoxical movement, superior MSI open ~3cm with yellow base, Remainder of incision erythematous and fluctuent. Distal incision with serosanguinous drainage. Abdomen soft/NT. PEG tube. Extrem 2+ edema, SVG harvest incisions healing Pertinent Results: [**2102-9-6**] 12:58AM BLOOD WBC-12.1* RBC-2.92* Hgb-8.3* Hct-25.5* MCV-87 MCH-28.4 MCHC-32.5 RDW-16.7* Plt Ct-242 [**2102-9-7**] 02:36AM BLOOD WBC-10.6 RBC-2.76* Hgb-7.8* Hct-23.9* MCV-86 MCH-28.3 MCHC-32.8 RDW-17.2* Plt Ct-230 [**2102-9-7**] 02:36AM BLOOD Plt Ct-230 [**2102-9-7**] 02:36AM BLOOD PT-14.2* PTT-30.3 INR(PT)-1.3* [**2102-9-7**] 02:36AM BLOOD Glucose-134* UreaN-45* Creat-3.8* Na-136 K-3.5 Cl-100 HCO3-31 AnGap-9 [**2102-9-6**] 12:58AM BLOOD Glucose-126* UreaN-56* Creat-4.4* Na-137 K-4.0 Cl-101 HCO3-30 AnGap-10 [**2102-9-5**] 12:57AM BLOOD Glucose-133* UreaN-37* Creat-3.5* Na-138 K-4.3 Cl-101 HCO3-30 AnGap-11 [**2102-9-4**] 02:44AM BLOOD Glucose-102 UreaN-49* Creat-4.2* Na-137 K-4.6 Cl-100 HCO3-30 AnGap-12 [**2102-8-7**] 04:30PM BLOOD Glucose-138* UreaN-55* Creat-2.3* Na-139 K-4.5 Cl-96 HCO3-35* AnGap-13 [**2102-8-18**] 06:39AM BLOOD ALT-10 AST-17 AlkPhos-94 Amylase-13 TotBili-0.4 CHEST (SINGLE VIEW) IN O.R. [**2102-9-1**] 1:21 PM ONE VIEW CHEST: A single fluoroscopic spot intraoperative radiograph was obtained. A right tunneled dialysis catheter begins outside the field of view and extends into the distal SVC. The tracheostomy has not changed in position. IMPRESSION: Right tunneled dialysis catheter with tip in the distal SVC. CHEST (PORTABLE AP) [**2102-8-29**] 9:22 AM FINDINGS: AP single view of the chest obtained with patient in supine position is analyzed in direct comparison with a similar preceding study obtained [**2102-8-28**]. Position of tracheal cannula is unchanged. The previously described parenchymal densities in the apical areas of both upper lobes have further progressed and so is the evidence of pleural effusions bilaterally apparently layering posteriorly but reaching also the apical area [**2102-8-7**] 04:30PM BLOOD WBC-15.8*# RBC-3.29* Hgb-9.7* Hct-29.3* MCV-89 MCH-29.7 MCHC-33.2 RDW-16.7* Plt Ct-223 [**2102-8-7**] 04:30PM BLOOD Plt Ct-223 [**2102-8-8**] 12:09AM BLOOD PT-76.5* PTT-42.4* INR(PT)-10.0* TISSUE (Final [**2102-8-11**]): STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Trimethoprim/Sulfa sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ENTEROBACTER CLOACAE. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ENTEROBACTER CLOACAE | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 0.25 S MEROPENEM------------- <=0.25 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R PIPERACILLIN---------- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- S <=1 S ANAEROBIC CULTURE (Final [**2102-8-12**]): NO ANAEROBES ISOLATED. Brief Hospital Course: Mr. [**Known lastname **] was admitted to cardiac surgery. He received vitamin K and FFP for an INR of 10. He was given amiodarone for rapid afib. He was started on meropenum and vancomycin. He was then taken to the operating room where he underwent sternal debridement and VAC dressing placement. He was transferred to the ICU in stable condition on propofol. He remained sedated and paralyzed. He was started on tube feeds. His paralytics were dc'd on POD #2. He was taken back to the operating room on [**8-11**] by plastic surgery for further debridement and vac replacement. His vac was again changed on [**8-14**]. Blood cultures grew MRSA. He remained on vanco. He underwent TEE for MRSA bacteremia, no vegetations were identified. He was taken back to the operating room by plastic surgery on [**8-16**] where he underwent further debridement and irrigation as well as bilateral pectoralis myofascial advancement flaps. He was seen by infectious diseases and he finished courses of vancomycin and meropenum. Renal counsult was called for borderline oliguria, increasing creatinine and volume overload, and acute on chronic renal failure. Renal u/s showed No evidence of hydronephrosis in either kidney. He was started a lasix drip, however required dialysis within the next few days. He underwent tunnelled catheter placement on [**2102-8-31**]. He continued with intermittent hemodialysis. He was stable for discharge to rehab on [**2102-9-7**]. He continues to require ventilatory support. Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed. 9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed. 10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation [**Hospital1 **] (2 times a day). 14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: sternal wound infection s/p AVR(#25Pericardial)CABGx3(SVG-LAD,SVG-OM,SVG-Ramus)[**6-22**] HTN,^chol,CVA,AS,CRI(1.9),6 mm L MCA aneurysm Discharge Condition: Stable. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. No lotions, creams or powders to incisions. Followup Instructions: Dr. [**Last Name (STitle) **] after discharge from rehab Dr. [**Last Name (STitle) 5686**] after discharge from rehab [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2102-9-7**]

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icd9cm

[ [ [] ] ]

[ "96.6", "77.61", "86.74", "96.71", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

8611, 8690

5731, 7232

335, 397

8870, 8880

1822, 5708

9090, 9329

1165, 1489

7255, 8588

8711, 8849

8904, 9067

1504, 1803

279, 297

425, 593

615, 808

824, 1149

66,796

126,892

45262

Discharge summary

report

Admission Date: [**2118-9-15**] Discharge Date: [**2118-9-18**] Date of Birth: [**2049-6-9**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: dyspnea and hypotension Major Surgical or Invasive Procedure: Chest tube endobronchial biopsy History of Present Illness: This is a 69 year old female patient, former smoker, h/o RCC s/p nephrectomy in [**2106**], and DCIS s/p right mastectomy and reconstruction in [**2115**] who originally presented to [**Hospital **] [**Hospital1 2519**] on [**2118-9-14**] with worsening DOE and cough and is now being admitted to the ICU with hypotension in the setting of a large PTX during a pleuracentesis today. . Current course begins with her DOE starting about 1 month ago and a mild cough that started a few weeks ago. At the time her husband had a URI and she thought she had caught his infection. She continued to have dyspnea on exertion (never at rest). No chest pain with exertion. No fevers, chills or night sweats. No orthopnea or PND. She also notes that about 3 weeks ago she significantly lost her appetite. . Yesterday she decided to go to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for further evaluation (of note she is in between PCPs). At the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] a CXR there showed a large left pleural effusion. She was referred to [**Hospital1 18**] for a pulmonology consult and thoracentesis. She subsequently got a thoracentesis by IP earlier today. 2L of fluid removed. Post-procedure CT showed large left PTX (40-50%) and concern for an endobronchial lesion. She was subsequently sent to the ED for chest tube placement. . On arrival to the ED, initial vitals were 98.2 110 137/79 20 98% RA. A chest tube was placed by ED. She received several doses of IV dilaudid. She was going to be admitted to the floor when she all of a sudden felt light-headed and diaphoretic. No chest pain or worsening of her SOB at that time. Her family asked that they check her BP and it was 52/47. She was given 2L and her blood pressures went back up to the low 100s. Her symptoms quickly resolved and she appeared well looking throughout the rest of her ED course. Her BPs however remained somewhat labile and so it was decided to send her to the ICU instead of the floor. No fevers. Received total of 2L. Chest tube with 250cc serosangenous fluid. VS prior to transfer were 105/58 23 98%. . On arrival to the MICU she appears well and is breathing comfortably on room air and surrounded by her family. Past Medical History: RCC s/p nephrectomy [**2106**] DCIS s/p right mastectomy and breast reconstruction [**2115**] with silicone implant HTN Hyperlipidemia chronic renal insufficiency s/p hysterectomy (still has both ovaries) s/p cervical fusion Social History: She lives with her husband of 48 years and has a large supportive family locally. Occupation retired RN, worked in [**Location (un) 86**] VNA. Smoking history smoked on/off for many years, unable to quatify total amount. Denies alcohol. Family History: None pertinent to this hospitalization Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 102/60 Hr 70 RR 19 975 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, 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: decreasedbreath sound at left lung base. chest tube on left side hooked to suction draining serosanguinous fluid Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred DISCHARGE PHYSICAL EXAM Vitals: T 97.4 BP 117/67 P 79 RR 18 O2 sat 94% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, 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: decreased breath sound at left lung base (unchanged from yesterday). chest tube on left on water seal Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred . Pertinent Results: ADMISSION LABS [**2118-9-15**] 05:45PM BLOOD WBC-22.4* RBC-5.25 Hgb-15.0 Hct-46.3 MCV-88 MCH-28.6 MCHC-32.4 RDW-13.0 Plt Ct-600* [**2118-9-15**] 05:45PM BLOOD Neuts-87.6* Lymphs-8.1* Monos-3.1 Eos-0.6 Baso-0.5 [**2118-9-15**] 05:45PM BLOOD Plt Ct-600* [**2118-9-15**] 05:45PM BLOOD Glucose-95 UreaN-35* Creat-1.6* Na-138 K-4.5 Cl-99 HCO3-24 AnGap-20 Relevant Studies Pleural Fluid Studies [**2118-9-15**] 03:25PM PLEURAL WBC-400* RBC-280* Polys-16* Lymphs-17* Monos-0 Meso-4* Macro-50* Other-13* [**2118-9-15**] 03:25PM PLEURAL TotProt-5.5 Glucose-128 LD(LDH)-124 Albumin-3.4 Cholest- GRAM STAIN (Final [**2118-9-15**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2118-9-18**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes, and lymphocytes. [**2118-9-17**] 11:39 am BRONCHIAL WASHINGS Site: LOWER LOBE LT LOWER LOBE. GRAM STAIN (Final [**2118-9-17**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Preliminary): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. FUNGAL CULTURE (Preliminary): [**2118-9-17**] 11:39 am BRONCHIAL WASHINGS Site: LOBE LOWER LOBE. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Preliminary): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. This is only a PRELIMINARY result. If ruling out tuberculosis, you must wait for confirmation by concentrated smear. IMAGING: [**2118-9-15**] CXR FINDINGS: Single portable view of the chest compared to previous exam from earlier same day at 6:32 p.m. There has been interval placement of a left-sided chest tube seen projecting over left lung base, side port within the thoracic cavity. Overlying subcutaneous gas is identified. Pneumothorax seen at the lower chest on prior has resolved. There is still subtle lucency adjacent to the AP window suggesting persistent pneumothorax, although no discrete pleural line is identified. Right lung remains clear. Cardiomediastinal silhouette is stable as are the osseous structures. IMPRESSION: Interval placement of left-sided chest tube with decrease in size of pneumothorax which may persist medially. [**2118-9-18**] CXR Comparison is made with the prior study performed four hours earlier. Left chest tube has been removed. There is no evident pneumothorax. Cardiomediastinal contours and left lower collapse are unchanged. Right lower lobe atelectasis is stable. CT CHEST: 1. The patient has prior history of breast cancer and renal cell carcinoma. Thoracocentesis was done today for left pleural effusion. There is a pneumothorax that measures up to 3 cm. Left upper lobe opacities are compatible with re-expansion edema. Residual left pleural effusion is small. 2. Left lower lobe is completely collapsed by an endobronchial lesion. Bronchoscopy is suggested. 3. Few less than 4-mm soft tissue lung nodules are seen in right lung. There is also one dominant ground glass opacity in right upper lobe measuring 9 mm. These nodules will have to be followed up in three months and they are indeterminate. Brief Hospital Course: Ms. [**Known lastname 1617**] is a 69F with a h/o RCC (s/p nephrectomy in [**2106**]) and DCIS (s/p right mastectomy and reconstruction in [**2115**]) who originally presented to [**Hospital **] [**Hospital3 4107**] on [**2118-9-14**] with dyspnea and was found to have a new pleural effusion of unclear etiology. She was admitted to the MICU for hypotension after a large volume thoracentesis complicated by pneumothorax. #. Hypotension: The patient was noted to have SBPs in the 50s on presentation to the ED. The hypotensive [**Location (un) 1131**] most likely a false [**Location (un) 1131**], given repeats were higher in the ED. Symptoms of lightheadedness resolved with fluids and patient remained asymptomatic overnight and during the remainder of the hospital course. #. Pneumothorax: A result of her procedure. The patient had a chest tube placed in the ED which was put to suction -20mmHg. Interventional pulm provided recommendations regarding chest tube management during the hospital course. The chest tube was initially hooked to suction -20mmHg on hospital day 1 and 2. Repeat CXR showed millimetric left apical lateral pneumothorax without evidence of tension of the pneumohthorax. The chest tube was then hooked to water seal on hospital day 3. Repeat CXR showed a small pneumothorax with near complete resolution. On hospital day 4 the chest tube was clamped for 2 hours and follow up CXR showed an unchanged tiny left apical pneumothorax. The chest tube was subsequently removed and final CXR showed no evident pneumothorax. # Pleural Effusion, presumed malignant: The patient pleural fluid studies are consistent with an exudative process by Light's criteria. There was initial concern for a malignant effusion given history of RCC and DCIS. She could also have a new lung cancer given smoking history and possible endobronchial lesion seen on CT. Cytology was ultimately negative for malignant cells. # Endobronchial lesion-The patient was found to have an endobronchial lesion on CT chest, with concern for possible metastatis in the setting of previous RCC and breast CA. or a possible primary lung malignancy given patient's smoking history. The patient underwent an endobronchial biopsy for further evaluation of the lesion and BAL washings were sent. She will follow up with Dr. [**Last Name (STitle) **] in THORACIC MULTI-SPECIALTY to for follow up the biopsy results. - Biopsy results pending, but her IP, consistent with malignancy. She has close follow up with IP to discuss these findings Chronic Issues Hyperlipidemia: continue home lipitor Transitional Issues -follow up endobronchial biopsy results and BAL washings -follow up with IP Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Atorvastatin 20 mg PO DAILY Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth 6Qh Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis-Pneumothroax Secondary Diagnosis- endobronchial lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 1617**], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the hospital because you had a partially collapsed lung (pneumothorax). You had a chest tube placed which helped the lung re-expand. You were also noted to have a lesion in the lung which was biopsied by interventional pulmonary. The results of this test are still pending; you can follow up with your pulmonologists to discuss the results at your upcoming appointment (see below). Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2118-9-22**] at 3:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "33.27", "33.91", "34.04", "32.24" ]

icd9pcs

[ [ [] ] ]

11016, 11022

7968, 10654

328, 362

11139, 11139

4551, 5311

11823, 12136

3168, 3208

10833, 10993

11043, 11118

10680, 10810

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5877, 5933

265, 290

390, 2648

5347, 5836

11154, 11266

2670, 2897

2913, 3152

46,034

191,925

37604

Discharge summary

report

Admission Date: [**2170-11-14**] Discharge Date: [**2170-11-18**] Date of Birth: [**2126-12-25**] Sex: M Service: MEDICINE Allergies: Penicillins / Vancomycin Attending:[**First Name3 (LF) 4393**] Chief Complaint: L rectus sheath hematoma Major Surgical or Invasive Procedure: Paracentesis [**11-16**] History of Present Illness: The patient is a 43M with EtOH cirrhosis on liver transplant list p/w Hct 15.7, and an 11 cm left rectus sheath hematoma with CTA showing no extravasation, 8mm aneurysm L inf epigastric a. branch. Past Medical History: - HTN - cholelithiasis - gout - depression - C. diff colitis - mild pulmonary artery systolic hypertension-mean PA pressure 28 - incarcerated umbilical hernia s/p repair [**2-/2170**] c/b subcutaneous hematoma and wound dehiscence . Social History: Lives alone, divorced x2, has three children. Denies tobacco or other IV drug use. Last drink was [**2168-7-28**]. Not sexually active, has never had sex with men. No recent travel. No sick contacts. Family History: No history of liver disease or GI cancer Physical Exam: GEN: WD, WN in NAD HEENT: NCAT, EOMI, anicteric CV: RRR, +S1S2 w no M/R/G PULM: CTA B/L w no W/R/R, normal excursion, no respiratory distress BACK: no vertebral tenderness, no CVAT ABD: soft, NT, ND, no mass, no hernia PELVIS: deferred EXT: WWP, no CCE, no tenderness, 2+ B radial/DP/PT NEURO: strength intact/symmetric, sensation intact/symmetric DERM: no rashes/lesions/ulcers PSYCH: normal judgment/insight, normal memory, normal mood/affect Vitals: 97.1, 132/79, 94, 18, 99% RA GENERAL - NAD, comfortable HEENT - EOMI, mild scleral icterus, MMM, OP clear, no LAD NECK - supple, no thyromegaly, no JVD LUNGS - CTAHEART - RRR, no MRG, nl S1-S2 ABDOMEN - Distended abdomen, soft, NABS EXTREMITIES - 3+ pitting edema b/l LE, 2+ DPs SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, asterixis present Mental status: alert, oriented x3, somewhat confused, recalls [**12-28**] objects after 5 min, can count backwards by serial 7s Pertinent Results: Labs on Admission: [**2170-11-14**] 09:17PM WBC-3.6* RBC-3.13* HGB-10.5* HCT-28.6* MCV-91 MCH-33.4* MCHC-36.5* RDW-24.4* [**2170-11-14**] 09:17PM PLT COUNT-32* [**2170-11-14**] 09:17PM PT-18.0* PTT-34.2 INR(PT)-1.7* [**2170-11-14**] 04:09PM GLUCOSE-124* UREA N-34* CREAT-1.1 SODIUM-128* POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-25 ANION GAP-13 [**2170-11-14**] 04:09PM WBC-3.8* RBC-2.83* HGB-10.1* HCT-27.1* MCV-96 MCH-35.8* MCHC-37.4* RDW-23.7* [**2170-11-14**] 04:09PM PLT COUNT-38* [**2170-11-14**] 04:09PM FIBRINOGE-165* [**2170-11-18**] 08:55AM BLOOD WBC-5.2 RBC-3.84* Hgb-12.8* Hct-37.4* MCV-97 MCH-33.3* MCHC-34.2 RDW-24.0* Plt Ct-27* [**2170-11-18**] 08:55AM BLOOD Plt Ct-27* [**2170-11-18**] 08:55AM BLOOD PT-32.6* PTT-40.6* INR(PT)-3.2* [**2170-11-18**] 08:55AM BLOOD Glucose-85 UreaN-28* Creat-1.3* Na-129* K-4.4 Cl-93* HCO3-31 AnGap-9 Labs on Discharge: [**2170-11-18**] 08:55AM BLOOD WBC-5.2 RBC-3.84* Hgb-12.8* Hct-37.4* MCV-97 MCH-33.3* MCHC-34.2 RDW-24.0* Plt Ct-27* [**2170-11-18**] 08:55AM BLOOD PT-32.6* PTT-40.6* INR(PT)-3.2* [**2170-11-18**] 08:55AM BLOOD Glucose-85 UreaN-28* Creat-1.3* Na-129* K-4.4 Cl-93* HCO3-31 AnGap-9 [**2170-11-18**] 08:55AM BLOOD ALT-22 AST-37 AlkPhos-147* TotBili-17.8* [**2170-11-18**] 08:55AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.1 Mg-1.8 Brief Hospital Course: [**Hospital 2947**] Hospital Course:The patient was admitted to the West 3 surgery service on [**2170-11-14**] and with anemia and rectus sheath hematoma. Neuro: Post-operatively, the patient received Dilaudid IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Pulmonary toilet including incentive spirometry and early ambulation were encouraged. The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His/Her diet was advanced when appropriate, which was tolerated well. Patient passed flatus on PODX and had a BM on PODX. He/She was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#1. Intake and output were closely monitored. ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cephalexin on POD#2. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#3, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. [**Hospital **] Hospital Course: Patient was transfered to the medical service on the day of discharge for hyponatremia and [**Last Name (un) **]. #. Elevated Creatinine: Over the past month the baseline creatinine has ranged 1.1 - 1.3 over the last month. On admission the patient creatinine was 1.2 and improved with volume. Without volume the patient's creatinine trended back up to 1.3 from 0.8 yesterday. GFR today is not far off baseline and likely represents a relative intravascular volume depletion in setting of diuretic use. Patient was given albumin 75 Grams IV and discharged with follow up in two days for repeat lytes and urine studies with Dr. [**Last Name (STitle) **]. Patient was also asked to stop Lasix/Aldactone for two days. #. Hyponatremia: Unclear if tolvaptan has been given daily during hospitalization. Sodium of 127 not far from baseline. Patients MS is normal. Patient to continue Tolvaptan and follow up with electrolytes in two days time. Medications on Admission: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. ciprofloxacin 250 mg PO Q24H 3. Vitamin D2 Sig: 50,000 units once a week. 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. 6. lactulose 10 gram/15 mL Syrup 30 ML PO three times a day. 7. lidocaine 5 %(700 mg/patch) Adhesive Patch daily 8. omeprazole 20 mg Capsule po daily 9. oxycodone 5 mg Tablet 1-2 Tablets PO twice prn pain 10. rifaximin 550 mg Tablet PO BID 11. spironolactone 100 mg Tablet daily 12. tolvaptan 30 mg Tablet daily 13. zolpidem 5 mg Tablet qhs prn insomnia 14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit PO bid 15. magnesium oxide 400 mg PO tid prn cramps 16. multivitamin daily 17. simethicone 80 mg Tablet 0.5-1 Tablet, po qid prn bloating Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for pain: do not drive or drink alcohol with medication. 9. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 11. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 12. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO three times a day as needed for cramps. 13. multivitamin Tablet Sig: One (1) Tablet PO once a day. 14. simethicone 80 mg Tablet Sig: 0.5-1 Tablet PO four times a day as needed for gas. 15. tolvaptan 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. Outpatient Lab Work Pleae obtain lab work on [**2170-11-21**]. Please check CBC, CMP, Urine sodium, Urine Urea Nitrogen, Urine Creatinine, Urinalysis. Discharge Disposition: Home Discharge Diagnosis: Primary: Rectus Sheath Bleed Anemia Acute Renal Failure Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 84380**], It was a pleasure caring for you at [**Hospital1 18**] while you were admitted with bleeding into your rectus sheath. You were initially monitored in the intensive care unit and given blood transfusions. Your blood counts stabilized. Prior to discharge you were found to have a rise in your creatinine (a measure of kidney function) slightly above your baseline. We felt this was secondary to dehydration and ask you to hold your diuretics (lasix/spironolactone)for two days and have lab tests done on Wednesday prior to seeing Dr. [**Last Name (STitle) **] in clinic on that day. The following changes were made to your medications: --STOP Lasix (until Dr. [**Last Name (STitle) **] instructs you to restart) --STOP Spironolactone (until Dr. [**Last Name (STitle) **] instructs you to restart) Please call on Tuesday to arrange follow up in Dr.[**Name (NI) 37751**] clinic on Wednesday [**2170-11-21**]. Followup Instructions: Please contact the transplant clinic on Tuesday [**2170-11-21**] at [**Telephone/Fax (1) 673**] to confirm and appointment with Dr. [**Last Name (STitle) **] on Wednesday [**2170-11-21**]. . Department: TRANSPLANT When: WEDNESDAY [**2170-11-28**] at 11:00 AM With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

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icd9cm

[ [ [] ] ]

[ "38.97", "38.91", "54.91", "88.47" ]

icd9pcs

[ [ [] ] ]

8311, 8317

3466, 3486

313, 340

8430, 8430

2141, 2146

9545, 10111

1059, 1102

6803, 8288

8338, 8409

5956, 6780

4989, 5930

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249, 275

3018, 3443

368, 566

2160, 2999

8445, 8557

588, 823

840, 1043

18,254

180,531

47965

Discharge summary

report

Admission Date: [**2195-2-27**] Discharge Date: [**2195-3-3**] Date of Birth: [**2134-9-9**] Sex: F Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 2145**] Chief Complaint: Black tarry stools Major Surgical or Invasive Procedure: EGD s/p epinephrine injection and clipping History of Present Illness: Ms. [**Known lastname 101213**] is a 60-year-old female with a h/o ESRD on hemodialysis and hypertension presenting with 2 days of melena and coffee-ground emesis. Patient reports four days prior to admission she began to feel fatigued and a decreased appetite. Two days prior to admission, she reports black stools after hemodialysis (3-4 episodes) as well as three episodes of vomiting with a small amount of dark-red blood. She was evaluated at an OSH and discharged home (no labs were drawn). On the day of admission, patient had a recurrence of black, tarry stools and immediately went to [**Hospital1 18**] ED. Patient did not report hematemesis on the day of admission. . In the ED, vitals signs were stable. NG lavage could not be performed because the patient did not tolerate the procedure. Hct was initialy 16.7 in the ED. She was transfused 2units PRBCs. GI consult scheduled an EGD immediately and she was tranferred to the MICU. She denied a history of NSAIDS, EtOH, previous GI bleeding, and she has never had an EGD or c-scope. ROS was positive for mild peri-umbilical abdominal pain, mild dysphagia to pills in last several months-weeks, increasing fatigue recently, and depression. . Patient was hemodynamically stable when tranferred to the MICU, hct at 21.9. She had a bedside EGD, was placed on PPI [**Hospital1 **], and had [**Hospital1 **] hct checks. EGD was revealing for bleeding ulcers that were clipped and cauterized (see full report below). Oxygen saturation dropped post-procedure and patient was hyperventilating, CXR revealed left left lower lobe collapse. Prior to arriving to the floor, patient underwent hemodialysis and was tranferred to medicine. Past Medical History: 1. IgA nephropathy in [**2169**] - hemodialysis dependant since [**2193**]. 2. S/p renal transplant in [**2173**], acute on chronic rejection in [**1-25**], now ESRD on hemodialysis. Has left permacath placed several months ago. 3. Hypertension 4. Depression 5. s/p rheumatic fever in childhood 6. h/o seizure in [**5-26**] [**2-21**] HTN per pt, has not been on anti-seizure meds in many months (without further seizures). Social History: Lives alone in [**Location (un) 686**] with no family in the area. No health insurance recently. Works at a part-time coffee shop manager. She reports prior distant h/o tobacco (quit 23yrs ago, [**1-21**] PPDx20yrs) and illicit drug use (marijuana & cocaine), seldomly drinks EtOH. Has had difficulties with insurance in the past. Family History: - Mother with lung cancer, died at age 64. - Many aunts/uncles with cancer. - Sister with breast cancer, survived. - No family h/o renal problems. Physical Exam: VITALS: T 98.4, HR 98, BP 178/80 99 100%RA GENERAL: Awake, alert, oriented x3 with flat affect in moderate distress complaining of headache. HEENT: PERRL, EOMI, MMM with clear OP. SKIN: No rashes, jaundice, petechiae. CHEST: Lungs clear to auscultation on upper lung fields. Moderate aeration. Decreased breath sounds on lower lung fields. CV: Regular rhythm, tachycardic, 2/6 systolic murmur best heard at upper sternal border with radiation to right carotid. ABDOMEN: Normal bowel sounds, slightly hard abdominal muscles, no distension, no tenderness, scar from prior transplant on right. RECTAL: Guaiac positive stool in ED. EXTREM: No clubbing, cynosis, edema. Warm. No peripheral edema. NEURO: AAOx3. CN II-XII grossly intact. Pertinent Results: LABS at admission: [**2195-2-27**] 09:30AM PT-13.4 PTT-23.8 INR(PT)-1.1 [**2195-2-27**] 09:30AM PLT COUNT-214 [**2195-2-27**] 09:30AM NEUTS-66.0 LYMPHS-29.0 MONOS-3.8 EOS-1.0 BASOS-0.3 [**2195-2-27**] 09:30AM WBC-4.9 RBC-1.65*# HGB-5.5*# HCT-16.7*# MCV-101*# MCH-33.4*# MCHC-33.0 RDW-18.0* [**2195-2-27**] 09:30AM CALCIUM-9.2 PHOSPHATE-5.8* MAGNESIUM-1.9 [**2195-2-27**] 09:30AM estGFR-Using this [**2195-2-27**] 09:30AM GLUCOSE-103 UREA N-99* CREAT-6.0*# SODIUM-140 POTASSIUM-6.0* CHLORIDE-96 TOTAL CO2-28 ANION GAP-22* [**2195-2-27**] 09:49AM HGB-5.6* calcHCT-17 [**2195-2-27**] 11:39AM K+-4.4 [**2195-2-27**] 03:57PM PLT COUNT-170 [**2195-2-27**] 03:57PM WBC-4.9 RBC-2.31*# HGB-7.5*# HCT-21.9*# MCV-95 MCH-32.3* MCHC-34.1 RDW-17.1* [**2195-2-27**] 03:57PM CALCIUM-9.3 PHOSPHATE-6.0* MAGNESIUM-1.9 [**2195-2-27**] 03:57PM GLUCOSE-89 UREA N-101* CREAT-6.4* SODIUM-141 POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-20 [**2195-2-27**] 05:48PM VoidSpec-UNLABELED [**2195-2-27**] 05:48PM VoidSpec-UNLABELED [**2195-2-27**] 10:24PM HCT-21.3* [**2195-2-27**] 10:24PM POTASSIUM-4.8 .... IMAGING: CHEST (PORTABLE AP) Study Date of [**2195-2-27**] 6:48 PM The mediastinum is shifted to the left, which in combination with new left retrocardiac opacity is consistent with left lower lobe collapse. Also partial collapse of the left upper lobe is present obscuring the aortic arch. The right lung areation is preserved. There is interval improvement of pulmonary edema and decrease in bilateral pleural effusions. . ECG Study Date of [**2195-2-27**] 8:26:06 AM Sinus rhythm. Left ventricular hypertrophy with repolarization change. Compared to the previous tracing of [**2194-7-31**] no change. . CHEST (PORTABLE AP) Study Date of [**2195-2-28**] 3:55 AM REASON FOR EXAMINATION: Followup of a patient with left lower lobe bronchus impaction. Portable AP chest radiograph compared to the previous study obtained on [**2195-2-27**] at 7:13. The mediastinum currently is positioned more centrally with partial but significant improvement of left lower lobe collapse. Still present left retrocardiac opacities consistent with partial atelectasis as well as there is opacity in the left upper lobe consistent with non-resolving atelectasis. There is no appreciable failure. Small bilateral pleural effusions are present. . ECG Study Date of [**2195-2-28**] 10:48:58 AM Sinus rhythm. Left ventricular hypertrophy. Compared to the previous tracing no change. Brief Hospital Course: 60-year-old female with a h/o ESRD [**2-21**] IgA nephropathy, HD-dependent, anemia, and hypertension presenting from the MICU with upper GI bleed [**2-21**] bleeding duodenal ulcer s/p clipping and cauterization. . # Upper GI bleed [**2-21**] bleeding ulcer: Patient presented with both melena and intermittent hematemesis x2 days consistent with a clinical picture of an upper GI bleed. Her hematocrit at admission was 16. Patient received 4units of PRBCs and remained hemodynamically stable. EGD was revealing for esophagitis, non-bleeding gastric ulcer, and a large bleeding vessel in the duodenal bulb, which was clipped and cauterized. Per GI recommendations, she was on an IV PPI infusion x72hrs. Several days into her hospital stay, the patient had gastroccult-positive emesis x1 episode. She then tolerated her renal diet well and did not have any more vomiting episodes. H. pylori antibody test returned negative. Patient had no bowel movements as an inpatient. She will be taking a PPI [**Hospital1 **] x1 month, and daily thereafter. She has a follow-up EGD on [**4-24**] with GI. As part of outpatient health maintenance, she has never had a colonoscopy. She was asked to discuss this with her PCP. . # Acute blood loss anemia: Patient had a hematocrit of 16.7 at admission, [**2-21**] UGIB. She was transfused 4units PRBCs and IVF. Patient's hematocrit continued to rise and she was discharged with a stable hematocrit at 27.4 . # ESRD - Patient has a h/o IgA nephropathy in [**2169**], and a renal transplant in [**2173**]. She suffered transplant rejection in [**2193**] and has since then been receiving hemodialysis TID/[**Year (4 digits) 20515**] in [**Location (un) **]. She reports good adherence to hemodialysis outpatient treatments. She had hemodialysis x2 while inpatient, and her blood pressure dropped after each treatment to an SBP in the 150s. While she was inpatient, renal followed her and recommended the addition of Calcium Acetate 667mg TID/with meals given high phosphate levels. . # Depression - Per patient, she reported depression to MICU and to medicine team. She states that since the beginning of HD in [**2193**], she's noticed worsening mood over recent months. She reports it also has to do with the lack of a strong social support - her sister lives in [**Country 26467**] and other family members are in [**Location (un) **]. She admits to suicidal ideations in the last couple of months (with an overdose of labetalol). She denies homicidal ideations. She keeps a $20 [**Doctor First Name **] on her at home in case if she ever felt actively suicidal, she would get a taxi to the emergency room. She was treated with anti-depressants in the past but they caused restless leg syndrome. Given the concern for suicidal ideation, she was monitored with a sitter while inpatient. She was seen by psychiatry and social work. Psychiatry reported patient does have chronic depression with passive suicidal ideation. They felt that she was of no imminent risk to self but does have mood disorders and needs outpatient follow-up. She was cleared for discharge and a follow-up appointment was made with psychiatry urgent care. Social work will be setting up longer term referral to a therapist. . # HTN - At home patient is on labetalol 200mg QID and lisinopril 40mg daily to control her elevated blood pressure. She reports a h/o seizures in the past due to severe hypertension. In the MICU, her blood pressure kept rising and was only moderately controlled with hydralazine. In the setting of a GI bleed, her hypertensive regimen was held. However, after her first inpatient hemodialysis and upon transfer to the floor, her blood pressure rose dramatically (SBPs 180-190s) and she was given 10mg IV hydralazine to a minimum effect, she also reported a severe headache and nausea. Labetalol 200mg QID was re-started with a stable hematocrit at 27.5, and her symptoms resolved and blood pressure dropped to SBPs 140s. Lisinopril was also restarted and only had a minimum effect on the blood pressure. Labetalol dosage was increased to 400mg QID. Her blood pressures continued to stay with SBPs in the 170-180s. It is unclear what her baseline blood pressure on medications is at home. She received IV metoprolol for acute control. Refractory high BP could be [**2-21**] increases in intravascular fluid after multiple tranfusions. After 2nd inpatient hemodialysis patient's blood pressure dropped to 150/79. Patient was discharged on an increased regimen of labetalol. Per renal, a possible future medication that might be beneficial for this patient would be a CCB, such as amlodipine. . # Headache: Patient reports h/o HA 2-3x per week. She does not have a h/o migranes. No hearing or visual disturbances, but they are associated with nausea. Since arrival to the floor, she had several severe headaches that woke her up. She reports that she usually experiences headaches near the end of her dialysis treatment, and both headaches s/p dialysis treatment were similar in character. However, there were other headaches that were not associated with acute elevations in BP or hemodialysis treatments. She was managed with morphine for pain control. . # Left lower lobe lung collapse: After patient had EGD procedure in the MICU, her oxygen saturation dropped and she began to hyperventilate. 1st CXR revealed LLL collapse, 2nd CXR revealed resolving LLL collapse and LUL non-resolving atelectasis. While inpatient she had good oxygen saturation (95-100% on RA), did incentive spirometry x10/hr, and ambulated. Clinically, she was much improved at discharge. . # Dysphagia: Patient reported dyspaghia for the last several months-weeks. Per EGD report, this could be [**2-21**] esophageal ring. Patient has a scheduled endoscopy within the next 8 weeks for the follow-up of the ulcers and this could also be addressed at this point. Also, she should continue on a PPI indefinitely (see above). Medications on Admission: 1. asa 81mg daily 2. labetalol 400mg tid 3. lisinopril 40mg qd 4. sevalamer 1600mg tid Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). Disp:*240 Tablet(s)* Refills:*2* 5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: please start Rx after finishing Rx for pantoprazole 40 mg twice a day for 1 month. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Bleeding duodenal ulcer Non-bleeding gastric ulcer Esophagitis s/p LLL lung collapse Secondary diagnosis: Hypertension Depression with passive suicidal ideation ESRD on dialysis Discharge Condition: Good, BPs improved, other VSS, ambulating without difficulty, no further SI. Discharge Instructions: You were admitted with a bleeding duodenal ulcer and had an endoscopy where the gastroenterologists were able to stop the bleeding. As a result of the bleeding, you had several units of blood transfused. You were also continued on dialysis and your blood pressure medication was increased for better control of your blood pressure. The following changes have been made to your medications: 1) You are being started on a proton pump inhibitor called pantoprazole. You will need to take a 40 mg pill twice a day for one month. After that, you will take one pill once a day. 2) Your blood pressure medication labetalol was increased to 400 mg four times a day. 3) You were started on calcium acetate which will need to be taken 3 times a day with meals. This is to help decrease the amount of phosphate in your blood. Please call your physician if you experience any of the following: recurrence of foul smelling black stools, bright red blood in your vomit or stools, lightheadedness, chest pain, shortness of breath, and worsening abdominal pain. Followup Instructions: You have the following appointments: 1) Psychiatry Urgent Care on Friday [**2194-3-6**], 2:30 pm with Dr. [**Last Name (STitle) 10166**]. Please report to the [**Hospital Unit Name **], [**Location (un) **]. The [**Hospital Unit Name **] is located on the [**Hospital Ward Name 516**] at [**Location (un) **]. You can call [**Telephone/Fax (1) 14439**] 2) Please continue to keep all outpt HD appts. 3) [**4-24**] arrive at 8:30am for a 9:30 am repeat endoscopy with Dr. [**First Name4 (NamePattern1) 2795**] [**Last Name (NamePattern1) 908**]. Please go to [**Location (un) **] of the [**Hospital Ward Name 121**] building on the [**Hospital Ward Name 517**]. Please call [**Telephone/Fax (1) **] if this date is a problem. Please do not eat or drink after midnight on the morning of the procedure. 4) Please call your PCP [**Last Name (NamePattern4) **]. [**Known firstname **] [**First Name5 (NamePattern1) 5969**] [**Last Name (NamePattern1) 101209**] at [**Telephone/Fax (1) 101214**] to reestablish primary care. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

[ "285.1", "532.00", "V62.84", "530.19", "V45.1", "518.0", "531.90", "585.6", "403.91", "311" ]

icd9cm

[ [ [] ] ]

[ "44.43", "39.95" ]

icd9pcs

[ [ [] ] ]

13224, 13230

6289, 12220

286, 331

13472, 13551

3774, 6266

14647, 15768

2857, 3006

12362, 13201

13251, 13251

12246, 12339

13575, 14624

3021, 3755

228, 248

359, 2046

13377, 13451

13270, 13356

2068, 2493

2509, 2841

54,602

166,648

47692

Discharge summary

report

Admission Date: [**2162-8-15**] Discharge Date: [**2162-8-24**] Date of Birth: [**2084-1-10**] Sex: M Service: MEDICINE Allergies: Iodine Containing Agents Classifier / Nitroglycerin / Codeine / Shellfish Derived Attending:[**First Name3 (LF) 12**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Pt is a 78 yo M with PMH of Stabe IV NSCLC who presented to the ED with SOB. Pt is chronically SOB at baseline but noted progressive SOB over last 1-2 weeks. Also with worsening fatigue, letharyg, anorexia and poor PO intake. Denies fevers, chills, vomiting or diarrhea. Day of admission, pt was acutely SOB while at rest. He called EMS who noted pts sats to be 89% on RA. SOB was associated with some CP. . In the ED, VS: T97.8 HR 126 BP 191/87 RR 35 99NRB. He was moving air bilaterally but with diffuse wheezes. Labs notable for WBC count of 15.5. CXR was concerning for pulmonary edema. He was given lasix 200mg IV x 1 and started on positive pressure ventilation. He received ceftriaxone/azithro and nebs for possible pneumonia and transferred to the ICU for further management. On ROS: Denies CP, pleuritic pain. Admits to [**7-12**] abdominal pain associated with constipation. Daughter reports progressive hoarseness of voice. . On arrival to MICU, pt on noninvasive ventilation. Reports improvement in SOB. Denies CP. Asking to take morning meds. Clarifies with spanish interpreter that he is DNR/DNI with good understanding of CODE discussion. . On arrival to the floor, he complains of continued SOB, however much improved from prior. He also complains of L chest pain lasting only a few seconds, only with cough/respiration, it is located under his left nipple, and located in an area as large as his finger. Denies palpitations, nausea, vomitting, diarrhea, constipation, wheeze, fevers, chills. Does report slight increase in his chronic cough. Past Medical History: 1. NSCLC - Stage IA NSCLCA status post LUL wedge resection [**2156**] - Stage IB NSCLCA status post RUL wedge resection [**2159**] - Recurrent Stage IV NSCLCA [**9-9**] 2. COPD on 2L NC at home 3. hypertension 4. hypercholesterolemia 5. gastritis 6. pulmonary hypertension 7. h/o colon polyps 8. benign prostatic hypertrophy -?t/p ?TURP 9. osteoarthritis 10. s/p bilateral knee replacements [**2157**], [**2158**] 11. s/p hernia repair 12. s/p thyroidectomy for what is reported as a Hurthle cell carcinoma of the thyroid - ?[**2145**] Social History: Originally from [**Country 5976**] Lives independently in an apartment downstairs from his daughter and her family Previously worked as maintenance supervisor and painter at [**Hospital1 18**] Tob: 60 pack-year history; started at 10yrs, smoked 1ppd until 58yrs; from [**2139**]-[**2146**] smoked cigars and/or pipe EtOH: none Illicits none Family History: No history of lung or other malignancy Mother d. 86yrs Father d. at young age, killed in the army Two brothers - one had asthma and has passed away. The other had a benign lung mass removed. Physical Exam: VS: T98.7 BP 142/80 RR 24 HR 93 97% 35% facemask GEN: Sitting up in bed, tachypneic but able to speak full sentences HEENT: EOMI PERRL NECK: Supple CHEST: Diffuse wheezes and rhonchi CV: Tachycardic, no murmurs ABD: Firm, distended, nontender; hypoactive BS EXT: no cyanosis or edema SKIN: no rashes NEURO: AAOx3, answering questions appropriately, no focal deficits; gait deferred Pertinent Results: Admission: GLUCOSE-115* UREA N-15 CREAT-1.1 SODIUM-137 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-28 ANION GAP-11 CK(CPK)-149 CK-MB-8 cTropnT-0.10* CK(CPK)-140 CK-MB-7 cTropnT-0.14* CK(CPK)-136 CK-MB-5 cTropnT-<0.01 CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-2.1 GLUCOSE-171* UREA N-14 CREAT-1.1 SODIUM-138 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 proBNP-1336* WBC-15.5*# RBC-4.18* HGB-12.7* HCT-39.4* MCV-94 MCH-30.4 MCHC-32.2 RDW-18.7* PLT COUNT-167# NEUTS-64 BANDS-4 LYMPHS-23 MONOS-6 EOS-2 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2162-8-15**] 04:35AM PT-13.3 PTT-26.4 INR(PT)-1.1 DISCHARGE: [**2162-8-24**] WBC-10.7 RBC-3.97* Hgb-11.8* Hct-36.9* MCV-93 MCH-29.7 MCHC-31.9 RDW-18.5* Plt Ct-443* Glucose-84 UreaN-20 Creat-1.0 Na-136 K-4.0 Cl-97 HCO3-33* AnGap-10 Calcium-9.0 Phos-4.9* Mg-2.2 ALT-213* AST-81* LD(LDH)-291* AlkPhos-75 TotBili-0.5 TSH-1.9 [**8-15**] PORTABLE CXR: IMPRESSION: Study limited due to motion. Airspace opacities bilaterally at the lung bases, which could be due to motion blur, however fluid overload /edema are strongly suspected. Pneumonia cannot be excluded. No evidence of pneumothorax. CTA Chest [**2162-8-17**]: 1. No sign of pulmonary embolus. 2. Slightly increasing right hilar mass and small increase in the mediastinal lymphadenopathy. Otherwise, no evidence of new metastatic disease. Brief Hospital Course: 78 yo M with PMH of NSCLC s/p wedge resection x 2, COPD on home O2, hypertension presents with acute onset SOB and worsening failure to thrive over 3 weeks. 1. SOB: Was thought to be primarily due to acute on chronic diastolic CHF with concominant COPD exacerbation. In the ICU, patient was given BIPAP with good response. Was started on emperic lovenox and abx, these were both discontinued once CTA chest confirmed no PE or no pneumonia. The patient improved significantly with diureses and standing nebs and steroid taper, however, patient eventually plateaud and continued to complain of SOB and wheezing. This was most likely secondary to excess fluid remaining. Patient had a small cardiac enzyme leak, likely demand related during his acute hypoxic and tachypnic episode. Cardiology saw the patient and recommended further diuresis. The patient was diuresed with good response in his symptoms. The patient still has room to go for diuresis (still has 1+ pitting pedal edema), and will need to continue high dose PO Lasix (120mg PO BID) for 7 days until titrated back down to a maintanaince regimen. 2. Hoarse voice/? Aspiration: Per daughter's report, coughing with food. S&S was obtained at bedside, which patient passed. Per S&S, if more concern, can attempt a video S&S. Started on regular diet and maintained aspiration precautions. This was not a significant issue. 3. NSCLC: He was receiving carboplatin and gemcitabine for third line palliative chemotherapy with signs of some response. Repeat CT scan did not show significant change in disease progression. Dr. [**Last Name (STitle) **], his oncologist, was made aware of pt's admission and will f/u with him as an outpatient to discuss continuing his chemo regimen. 4. COPD: Noted wheezes and rhonchi on exam on admission. Wheezes persisted on thought to be likely secondary to diastolic CHF. Placed on standing nebulizers and outpatient regimen. Patient was placed on a steroid taper. Pulmonology was consulted and recommended Spiriva, advair, and placing PRN albuterol and ipratropium. 5. HTN: continue ACE and bblocker for afterload reduction. Started Carvedolol for patient's heart failure. 6. Aminitis: Patient had a mild transaminitis, the slightly worsened but remained otherwise stable. Patient denied RUQ pain. Labs were not c/w obstructive etiology. Labs should be followed up by PCP, [**Name10 (NameIs) **] persistently elevated or worsened, may need further work-up. Patient is scheduled to see PCP in [**Month (only) 359**]. Also has just been scheduled for [**Hospital 191**] [**Hospital 1944**] clinic to check lytes and adjust lasix dose. 7. Hyperlipidemia: continue statin 8. Hypothyroidism: continue levothyroxine CODE: DNR/DNI (confirmed with patient and daughters in room through translator) CONTACT: [**Name (NI) 2759**] daughter Medications on Admission: albuterol neb q4hours prn shortness of breath atenolol 25mg daily Lipitor 10mg daily Celexa 20mg daily Robitussin DM TID prn cough Advair 250mcg-50mcg 1puff INH [**Hospital1 **] Atrovent neb q6hour prn shortness of breath Lasix 20mg daily levothyroxine 100mcg daily lisinopril 40mg daily lorazepam 0.5mg [**Hospital1 **] prn anxiety Zofran 8mg q8hr prn nausea Compazine 10mg q8hr prn nausea Spiriva 18mcg INH daily Ambien 5-10mg qhs prn sleeplessness aspirin 81mg daily Tylenol prn pain Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Citalopram 20 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). 4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 16. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: Take for 1 day. Last dose [**2162-8-25**]. . 18. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): Take this dose for 7 days, then titrate down once reaches dry-weight. . 19. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) Puff Inhalation twice a day. 20. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Puff Inhalation once a day. 21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 Puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 22. Atrovent 0.06 % Spray, Non-Aerosol Sig: 1-2 Puffs Nasal every six (6) hours as needed for shortness of breath or wheezing. 23. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for itching. 24. Hydrocortisone 1 % Cream Sig: One (1) Topical every twelve (12) hours as needed for Rash: apply to affected skin every 12 hours as needed for rash for erlotinib-induced rash. 25. Clindamycin Phosphate 1 % Gel Sig: One (1) Topical every twelve (12) hours as needed for Rash: apply to affected skin every 12 hours as needed for for rash for erlotinib-induced rash . Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Acute on chronic diastolic heart failure Secondary: Acute on chronic COPD exacerbation Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted to the hospital for shortness of breath and chest pain. Your blood oxygen levels were very low and you were admitted to the intensive care unit for positive air pressure ventilation to help you breath. Your respiratory failure was thought to be due acute diastolic heart failure, when your heart does not pump effectively. Your heart failure improved with lasix or water pills, which helped to get rid of the fluid in your lungs to help you breath. You need rehab to help regain some strength and will be discharged to a rehab facility. We have made some changes to your medications: STOP taking Atenolol 25mg by mouth once a day START taking Spironolactone 12.5mg by mouth once a day START taking Prednisone 10mg by mouth once a day for 1 day START taking Carvedolol 6.25mg by mouth twice a day START taking Furosemide (Lasix) 120mg by mouth twice a day. Your doctors [**Name5 (PTitle) **] change the dosage after 1 week to maintain your fluid status. Please return to the emergency department for chest pain, shortness of breath, or high fevers, or any other symptoms that are concerning to you. Followup Instructions: You have an appointment with Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2162-8-23**] 8:30 You have an appointment with Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2162-9-9**] 9:50 You have an appointment with Provider: [**Name10 (NameIs) **] [**Doctor Last Name 94622**]/DR [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2162-9-17**] 5:20 Completed by:[**2162-8-24**]

[ "535.50", "300.00", "V43.65", "V45.76", "491.21", "V15.82", "V87.41", "716.90", "V12.72", "428.33", "162.8", "V46.2", "783.7", "272.4", "244.0", "428.0", "416.8", "402.91", "V10.87" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10850, 10920

4852, 7683

344, 351

11060, 11080

3492, 4829

12247, 12804

2881, 3074

8221, 10827

10941, 11039

7709, 8198

11104, 11678

3089, 3473

11707, 12224

301, 306

379, 1945

1967, 2505

2521, 2865

78,100

155,629

35799

Discharge summary

report

Admission Date: [**2143-9-22**] Discharge Date: [**2143-9-30**] Date of Birth: [**2078-2-10**] Sex: M Service: MEDICINE Allergies: Pravachol / Levaquin / Bactrim / Zyvox Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: sub-acute mental status change Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 65 yo M recently discharged [**2143-9-18**] after being hospitalized for decompensated HF and for milrinone titration, with ischemic cardiomyopathy (EF 15%), congestive cirrhosis, BiV ICD, s/p CABG [**2115**] & [**2127**], s/p VT ablation, h/o CVA, s/p right CEA, who presents with sub-acute mental status change in the setting of a fever to 101.6, GNR bacteremia, and euvolemia. . According to his wife, he was discharged last Wednesday feeling lethargic and not having regular BMs, but was otherwise his usual self until Saturday morning. The day of discharge he had 1 bowel; the night prior to discharge, his lactulose was downtitrated because it was causing bloating and gas; he was discharged on Lactulose 45ml [**Hospital1 **]. He had no bowel movements Thursday or Friday on this regimen, then on Saturday he had diarrhea in the evening, received 60ml more of lactulose from his wife, and then had another bout of diarrhea, followed by more lactulose. . Sunday morning, he presented to [**Hospital3 **], where he continued to have diarrhea. He also spiked a temperature to 101.6F. He underwent CT-Head imaging, which upon review on admission was unrevealing for any acute intracranial processes - final read pending. He also had a CXR that was stable compared to studies prior to discharge. Blood cultures were drawn and grew out GNRs. He was transferred to [**Hospital1 18**] for further management, and admitted to the CCU after initially presenting in unstable condition to [**Hospital Ward Name 121**] 3. . Initial vitals in the CCU were: Temp = 99.8, HR = 96, BP 104/66, RR 24, Sat 99% on 50% Venti face mask. ABG at that time was: pH = 7.50, pCO2 = 33, pO2 = 142, HCO3 = 27. He was awake but unresponsive to verbal commands. . Review of systems was limited, but conversation with his wife was essentially unrevealing - no chest pain, dyspnea on exertion more in excess of his baseline, no paroxysmal nocturnal dyspnea, no orthopnea, ankle edema, palpitations, or syncope/presyncope. No myalgias, joint pains, cough, hemoptysis, black stools or red stools. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -AF Fib formerly on coumadin, but recently stopped by Dr. [**First Name (STitle) 437**] [**Name (STitle) 81422**] ischemic cardiomyopathy with LVEF of 15% -CABG: s/p CABG: [**2115**] and again in [**2127**] -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: status post biventricular pacer ICD ([**2127**]) status post VT ablation x 3 ([**2137**], [**2130**], ?) 3. OTHER PAST MEDICAL HISTORY: Congestive Hepatopathy Gout Hypothyroidism Cerebrovascular accident ([**2127**]) with no residual neuro deficits s/p Carotid endarterectomy, right, in [**2127**] Appendiceal perforation with colostomy Social History: He is married with 3 children. He is a retired business man. -Tobacco history: He does not smoke, but has a history of pipe smoking, quit in [**2127**]. -ETOH: He previously drank 1 glass a wine per week, but no longer does. He never drank more than 1-2 drinks per day. -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. His father developed a CVA at age 88 and also had lung cancer. His mother is alive and well at [**Age over 90 **] years of age. Physical Exam: VS: As above GENERAL: Chronically ill appearing. NAD. Not responsive to verbal commands. HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP exam equivocal in the setting of known TR CARDIAC: PMI displaced latrally. Holosystolic I-II/VI murmur loudest at the LLSB. RR, normal S1, S2. No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Hepatomegaly -> + Asterixes. EXTREMITIES: 1+ pitting edema up to mid tibia bilaterally. SKIN: Right arm skin lesion at the site of the PICC adhesive PULSES: PT Pertinent Results: [**2143-9-22**] 10:33PM GLUCOSE-135* UREA N-112* CREAT-3.6*# SODIUM-135 POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-26 ANION GAP-20 [**2143-9-22**] 10:33PM ALT(SGPT)-21 AST(SGOT)-32 CK(CPK)-14* ALK PHOS-257* TOT BILI-2.4* [**2143-9-22**] 10:33PM CK-MB-2 cTropnT-0.02* proBNP-5167* [**2143-9-22**] 10:33PM ALBUMIN-3.5 CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-2.4 [**2143-9-22**] 10:33PM WBC-12.3*# RBC-3.31* HGB-10.1* HCT-31.0* MCV-94 MCH-30.7 MCHC-32.7 RDW-18.9* [**2143-9-22**] 10:33PM NEUTS-97* BANDS-0 LYMPHS-2* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2143-9-22**] 10:33PM PLT COUNT-110* [**2143-9-22**] 10:33PM PT-23.0* PTT-36.8* INR(PT)-2.2* [**2143-9-22**] 09:58PM TYPE-ART PO2-142* PCO2-33* PH-7.50* TOTAL CO2-27 BASE XS-3 [**2143-9-22**] 09:58PM LACTATE-3.6* . Brief Hospital Course: The patient is a 65 yo M recently discharged [**2143-9-18**] after being hospitalized for decompensated HF and for milrinone titration, with ischemic cardiomyopathy (EF 15%), congestive cirrhosis, BiV ICD, s/p CABG [**2115**] & [**2127**], s/p VT ablation, h/o CVA, s/p right CEA, who presents with sub-acute mental status change in the setting of a fever to 101.6, GNR bacteremia, and euvolemia. . # Altered mental status: This was thought to be multifactorial, due to both hepatic encephalopathy and a GNR bacteremia found on blood culture. Of note, an OSH Head CT was unrevealing for intracranial processes. His mental status improved with treatment of these two etiologies. His encephalopathy was thought to be due to congestive hepatopathy secondary to CHF. The patient was treated with Rifaximin and Lactulose and had appropriate diarrhea. Bacteremia was treated with a course of Zosyn and Cefepime; Patient was discharged on Cefepime to finish course. . # Systolic HF: Patient was initially kept even but gently diuresed towards the end of his hospital course with Lasix gtt, Metolazone, Eplerenone. He was discharged on metolazone and torsemide. His PICC was replaced and Milrinone was continued. . # Acute on Chronic Kidney Injury: Cr at baseline 2.2, elevated during admission likely secondary to diuresis Max 3.4. 3.3 on discharge. . # Arrythmias: s/p VT ablation. Patient was continued on Quinine Sulfate and Dofetilide. . # CAD: No ischemic changes on EKG. Patient was continued on ASA, Metoprolol. . # Gout: Patient continued on Prednisone and Allopurinol. . # Hypothyroid: Patient continued on Levothyroxine. Medications on Admission: aspirin 81 DAILY metoprolol succinate 25 mg Daily eplerenone 25 mg DAILY metolazone 2.5 mg DAILY torsemide 60 mg DAILY Milrinone 0.25 mcg/kg/min continuous quinine sulfate 324 mg QHS dofetilide 125 mcg [**Hospital1 **] . lactulose 10 gram/15 mL 45 ML PO BID, titrated to 3 BMs daily rifaximin 550 mg [**Hospital1 **] prednisone 5 mg DAILY allopurinol 100 mg DAILY . alprazolam 0.25 mg QHS tramadol 50 mg Q6H PRN Pain levothyroxine 50 mcg DAILY Vitamin C Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*3* 3. metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. quinine sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. lactulose 10 gram/15 mL Syrup Sig: 15-60 MLs PO TID (3 times a day) as needed for hepatic encephalopathy: Must be given three times a day, titrate to 3 BM's per day. 8. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Gout. 10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for gout. 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for pain. 12. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. cefepime 1 gram Recon Soln Sig: One (1) bag Intravenous once a day: Last day [**2143-10-7**]. Disp:*7 bags* Refills:*0* 15. milrinone 1 mg/mL Solution Sig: 0.25 mcg/kg/min Intravenous continuous: Please compound to 400 mcg/ml. Weight [**9-30**] is 75.7 kg. . Disp:*30 bags* Refills:*2* 16. sodium chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ml Injection prn for PICC flush: PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. Disp:*60 syringes* Refills:*2* 17. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 18. Outpatient Lab Work Please check Chem-7, CBC and INR on [**2143-10-2**] and call results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP or Dr. [**First Name (STitle) 437**] at [**Telephone/Fax (1) 62**]. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: ... Bacteremia Encephalopathy Acute on Chronic Systolic Congestive Heart 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: ... You were admitted to the hospital because you were confused at home and had a fever. In the hospital, we found that you had bacteria in your blood that was likely due to the PICC line that had been recently placed. We removed that PICC line and placed a new one and treated you with antibiotics. You will need to continue antibiotics for one more week. We think that some of your confusion at home was due to this infection but also that some of it was due to encephalopathy from your liver disease. This improved with lactulose which is a very important medication for you to take 3 times a day. Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. We are have made the following changes to your medications: 1. Discontinued aprazolam and epleronone 2. Decreased Tramadol to twice daily as needed for pain 3. Started Famotidine 20 mg daily for heartburn/indigestion . Please call Dr. [**First Name (STitle) 437**] for daily weight increase of more than 3 pounds in 1 day or 5 pounds in 3 days. Followup Instructions: ... Please go to the following appointments: Provider: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2143-10-14**] 9:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2143-10-14**] 9:20 Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2143-11-27**] 11:00 . Department: CARDIAC SERVICES When: THURSDAY [**2143-10-3**] at 2:00 PM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "97.49", "38.93" ]

icd9pcs

[ [ [] ] ]

9609, 9661

5445, 5854

338, 344

9786, 9790

4619, 5422

11075, 11932

3547, 3790

7575, 9586

9682, 9765

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268, 300

372, 2510

9805, 9942

3017, 3220

2532, 2598

3236, 3531

15,340

197,445

13664+56476

Discharge summary

report+addendum

Admission Date: [**2187-2-3**] Discharge Date: [**2187-2-6**] Date of Birth: [**2111-9-19**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 75 year-old male with an extensive history of coronary artery disease status post coronary artery bypass graft times two, congestive heart failure, history of V fibrillation arrest in [**2185**], status post an ICD who was transferred from [**Hospital3 38285**] after presenting complaining of being shocked multiple times by his ICD. The patient has multiple medical problems, but was in his usual state of health on home O2 until earlier in [**Month (only) **] when he had an episode of shortness of breath followed by fatigue and fever. At that time he was admitted to [**Location (un) **] [**Location (un) 1459**] where he spent one week for pneumonia and atrial fibrillation. Subsequently he was found to have an atrial thrombus so he was not cardioverted. In subsequent weeks the patient had increased O2 requirement, increased nebulizer use and lower extremity edema as well as fatigue and was found to have decompensated congestive heart failure. Lasix was increased and Zaroxolyn started on [**1-16**]. The patient slowly improved with loss of about 20 pounds and Zaroxolyn was discontinued. Over the past several nights the patient has had increased shortness of breath with increased abdominal girth, increased weight, increased lower extremity edema, plus paroxysmal nocturnal dyspnea. He experienced multiple ICD shocks culminating in six or seven shocks the night prior to admission. The patient began to feel more increased shortness of breath on the morning of admission and called 911 and was taken to [**Hospital3 **]. There the patient's ICD was interrogated and showed multiple episodes of ventricular tachycardia, one episode of V fibrillation with 18 shocks since [**1-19**]. He was started on a Lidocaine drip and transferred to [**Hospital1 69**] where the Lidocaine drip was discontinued. The patient was started on Amiodarone and admitted to the Coronary Care Unit. PAST MEDICAL HISTORY: 1. Coronary artery disease. History of myocardial infarction in [**2171**]. Coronary artery bypass graft. V fibrillation arrest in [**2185**] and an ICD placed. 2. Lung cancer status post lobectomy with radiation therapy to the chest. 3. Chronic obstructive pulmonary disease on home O2 since [**2172**]. 4. Paroxysmal atrial fibrillation first in [**2182**] with pneumonia. 5. History of pneumonia times two. 6. Bladder cancer diagnosed in [**2177**] with spread to nodes. 7. Hypertension. 8. History of smoking. 9. Thrombocytopenia secondary to chemotherapy. 10. Anemia. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Lisinopril 5 a day. 2. Digoxin .25 once a day. 3. Coreg 6.25 twice a day. 4. Warfarin 3 mg four out of seven days and 1.5 mg three out of seven days. 5. Lasix 80 a day. 6. K-Ciel 20 a day. 7. Amiodarone 200 a day. 8. Procrit 40,000 units q week. 9. Iron. 10. Albuterol and Atrovent nebulizers b.i.d. 11. Sublingual nitroglycerin prn. SOCIAL HISTORY: He lives with his wife. Thirty plus pack year history of tobacco. No drugs. No alcohol. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 98.6. Blood pressure 155/58. Pulse 59. Respiratory rate 15. Satting 89% on 2 liters to 93% on 3 liters. General, obese, elderly male sitting upright, mildly tachypneic, in no acute distress, speaking in four to five word sentences. HEENT positive exophthalmos bilaterally. Anicteric sclera. Pale conjunctiva. Pupils are equal, round and reactive to light. Dry mucous membranes. Neck supple. JVD to the angle of the jaw. Cardiovascular positive LV heave, regular rate and rhythm. Normal S1 and S2. Positive S4. 3 out of 6 holosystolic murmur left sternal border going to the axilla. Lungs decreased breath sounds on the left, 2/3 up on the right crackles. No wheezes or rhonchi. Poor air movement throughout. Abdomen obese, soft, nontender, nondistended. There is a 5 by 5 firm nontender suprapubic mass. Extremities no clubbing, cyanosis, 1+ pitting edema bilaterally. Rectal normal tone. Guaiac negative. LABORATORY STUDIES: Electrocardiogram V paced with fusion beats, white blood cell count 8.9, hematocrit 31.3, platelets 134, sodium 136, potassium 3.5, BUN 22, creatinine 1.2, CK 32, troponin .04. Chest x-ray cardiomegaly with a left pleural effusion, questionable left lower lobe opacity versus atelectasis. HOSPITAL COURSE: 1. Cardiovascular: A: Rhythm, patient with recurrent ventricular tachycardia and one episode of V fibrillation with recurrent ICD firings. The patient was seen by EP to change the lower pace rate increasing it to 80 as well as programming the ATP therapy for ventricular tachycardia. The patient was loaded on Amiodarone. Digoxin was held. Warfarin was held for possible EP study. The patient was diuresed aggressively with intravenous Lasix and Zaroxolyn. It was felt that the patient's ventricular rhythms were likely secondary to decompensated heart failure rather then active ischemia. After the adjustment in the ICD and the Amiodarone load, the patient had no further events on telemetry. There was consideration of placing a [**Hospital1 **] V pacer. This decision was deferred during this hospital stay as the patient had no further events on telemetry and there was a question of patient's long term prognosis from his bladder cancer. The patient had an appointment set up to see Dr. [**Last Name (STitle) **] in clinic in two to three weeks. B: Ischemia, the patient was treated with aspirin and statin, enzymes were cycled and he ruled out for an myocardial infarction. An ace inhibitor and beta blocker were slowly titrated up. C: Pump, the patient was in decompensated heart failure, diuresed aggressively with Lasix. Echocardiogram was performed revealing an EF of 20 to 25% with 3+ mitral regurgitation, which was increased from his prior study. Wall motion abnormalities including inferior and inferolateral and apical akinesis as well as septal hypokinesis. His LA was moderately dilated and his left ventricular was moderately dilated. The patient was started on Coreg slowly titrated up as well as Captopril. Digoxin continued to be held at the time of this dictation. 2. Pulmonary: The patient with a history of chronic obstructive pulmonary disease as well as lung cancer and the decompensated congestive heart failure makes his hypoxia multifactorial in origin. The patient improved with diuresis as well as with nebulizer treatments. At the time of this dictation the patient was nearing baseline, however, was still deconditioned and requiring more O2 then in the weeks prior to the patient's recent illnesses according to his wife. [**Name (NI) **] continued on Serevent and Flovent, Atrovent and Albuterol nebulizers as well as Mucomyst nebulizers. 3. Hematology: The patient with a fluctuating hematocrit at the lowest point down to 26.7 with no clear evidence of bleeding. The patient was guaiac negative. He was continued on his Epogen as well as iron, folate and B-12 were checked, which were normal. He was transfused 1 unit of packed red blood cells with a goal of keeping his hematocrit greater then 28. The patient's Coumadin was held on admission with the possibility of [**Hospital1 **] V pacer. At the time of this dictation the decision regarding his further anticoagulation is pending on discussion with his oncologist and therefore understanding whether or not the [**Hospital1 **] V pacer is in his future. 4. Oncology: Patient with bladder cancer followed at [**Hospital3 7778**] by Dr. [**Last Name (STitle) 31394**]. At the time of this dictation attempts were being made to contact Dr. [**Last Name (STitle) 31394**] regarding the patient's overall prognosis as this will determine his need for placement of a [**Hospital1 **] V pacer. 5. Renal: The patient's creatinine bumped from 1.2 on admission to 1.5. This was felt likely to be secondary to diuresis. At this point the diuresis was slowed. 6. Psychiatric: Patient with multiple problems with sundowning as he had in the past. His wife stayed in the room, which helped some. He was treated with Zyprexa at bedtime. The remainder of this discharge summary including the remainder of the hospital course as well as discharge medications and follow up will be dictated at a later date in an addendum to the summary. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 13747**] MEDQUIST36 D: [**2187-2-6**] 12:16 T: [**2187-2-6**] 12:27 JOB#: [**Job Number 41205**] Name: [**Known lastname 7423**], [**Known firstname **] E Unit No: [**Numeric Identifier 7424**] Admission Date: [**2187-2-3**] Discharge Date: [**2187-2-10**] Date of Birth: [**2111-9-19**] Sex: M Service: ADDENDUM: The patient remained in house because of decompensated congestive heart failure. The congestive heart failure service was consulted and recommended him changing to intravenous diuretics from which he diuresed effectively. He was down to his dry weight, which was thought to be approximately 210 to 215 pounds. At that point it was thought because of his contraction alkalosis he should be changed from Metolazone to Diamox. This seemed to work effectively. His ace inhibitor was also titrated up to assist in diuresis. Of note, the patient was slightly somnolent during hospitalization. His Zyprexa was weaned and then discontinued which resulted in improvement of his mental status. He was restarted on his Coumadin for paroxysmal atrial fibrillation. His creatinine was 1.4 upon discharge. His baseline was 1.0. It had been stable at 1.4. It was thought this was secondary to the diuresis and would likely resolve with equilibration. His contraction alkalosis improved prior to discharge with his last bicarbonate being 36. He was starting standing potassium repletion and was discharged home with home physical therapy as well as VNA nursing with close follow-up of his magnesium, potassium and INR. MEDICATIONS ON DISCHARGE: 1. Lisinopril 7.5 mg p.o. once daily. 2. Acetazolamide 250 mg p.o. q12hours. 3. Lasix 60 mg p.o. twice a day. 4. Warfarin 1.5 mg p.o. once daily. This is to be alternated with 3 mg p.o. once daily. 5. Amiodarone 400 mg p.o. once daily. 6. Albuterol and Atrovent inhalers. 7. Carvedilol 6.25 mg p.o. twice a day. 8. Epogen 400 units subcutaneously q.week. 9. Flovent two puffs twice a day. 10. Aspirin 81 mg p.o. once daily. 11. Colace. 12. Iron 325 mg p.o. once daily. 13. Multivitamin. 14. Serevent inhaler. 15. Atorvastatin 10 mg p.o. once daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**], M.D. [**MD Number(1) 298**] Dictated By:[**Last Name (NamePattern4) 2694**] MEDQUIST36 D: [**2187-2-10**] 12:43 T: [**2187-2-10**] 13:59 JOB#: [**Job Number 7425**] cc:[**Numeric Identifier 7426**] [**Known firstname **] [**Known lastname **] [**Female First Name (un) 7427**] [**Location (un) 7428**], [**Numeric Identifier 7429**]

[ "424.0", "412", "496", "428.0", "285.9", "V45.81", "427.1", "427.31", "414.8" ]

icd9cm

[ [ [] ] ]

[ "89.59", "99.04" ]

icd9pcs

[ [ [] ] ]

10251, 11270

4521, 10225

2747, 3096

157, 2079

3241, 4503

2101, 2726

3113, 3226

7,223

129,670

19849+19850

Discharge summary

report+report

Admission Date: [**2154-10-9**] Discharge Date: [**2154-11-14**] Date of Birth: [**2109-7-17**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: scheduled surgery Major Surgical or Invasive Procedure: ileostomy reversal [**2154-10-9**] ileocolonic anastomosis resection and creation or end ileostomy [**1-2**] dehiscence [**2154-10-20**] vac placement for wound healing History of Present Illness: Mr. [**Known lastname 53636**] is a 45 year old male who presented to the transplant [**Last Name (un) 12003**] approximately two years ago with an acute arch dissection, which resulted in right renal, hepatic, and right colon ischemia. He was hospitalized for a lengthy period of time and quite critically ill, had an open abdomen during this time. He has since had multiple re-ops for both the chest and abdomen. Eventually he was able to under a right hemicolectomy and ileostomy with a long Hartmann's pouch. He has been recovering over the past two years and now presents for reversal of his long Hartmann's. Past Medical History: PSH J tube placement [**11-3**], Picc [**11-2**], trach 12/034, expl lap,rt. hemicolectomy w ileostomy, aortic arch repair, rt fem-lt fem pbg [**11-2**] PMH depression legally blind ATN CVA hx VRE / MRSA Social History: His highest level of education was 12th grade. He is a machine operator handling heavy equipment, mechanic. He is married with 2 kids. He does not smoke, he does not drink; however, he did admit to using cocaine. Family History: The patient was adopted so nothing much is known of his immediate family. He does have 1 daughter who is 14 and the son who is 7, and they are in good health. Physical Exam: Gen: NAD Lungs: CLA b/l CV: RRR, normal S1S2, + SEM ABD: soft, tender to deep palpation around the incisions Ext: no c/c/e Neurologic: AxOx3 Pertinent Results: [**2154-10-9**] 02:27PM BLOOD WBC-11.7* RBC-3.52* Hgb-11.6* Hct-34.1* MCV-97 MCH-32.9* MCHC-33.9 RDW-12.8 Plt Ct-241 [**2154-10-15**] 08:25AM BLOOD WBC-11.1* RBC-3.22* Hgb-10.4* Hct-30.7* MCV-95 MCH-32.2* MCHC-33.8 RDW-12.8 Plt Ct-314 [**2154-10-9**] 02:27PM BLOOD Plt Ct-241 [**2154-10-10**] 09:55AM BLOOD Glucose-87 UreaN-22* Creat-2.1* Na-144 K-5.1 Cl-112* HCO3-23 AnGap-14 [**2154-10-15**] 08:25AM BLOOD Glucose-114* UreaN-12 Creat-1.7* Na-142 K-3.7 Cl-108 HCO3-26 AnGap-12 Brief Hospital Course: TL is a 45 year old man with a complicated past medical history stemming from a Type A aortic dissection repair in [**11-2**] with resultant CVA, renal insufficiency, and ischemic bowel requiring a right hemicolectomy and end ileostomy. His ICU course was prolonged ICU but he survived and was discharged from the hospital. He returned on [**2154-10-9**] for ileostomy takedown and reconstitution of intestinal continuity. He underwent a laparoscopically assisted ileostomy takedown. The procedure was very difficult with extensive lysis of dense adhesions. A side-to-side stapled anastomosis was fashioned between the ileum and transverse colon using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] and TA stapler. The patient did well initially, passing flatus on POD #3. On POD 3, he tolerated clears and his Foley was discontinued. His diet was advanced to regular on POD 4. On POD 5, he had some diarrhea with several bloody stools. His hematocrit was stable at 30. His vital signs were all stable as well. On POD #5 he was started on Flagyl for empiric treatment of C. Diff because of diarrhea. On POD 6, the pt. began having diarrhea that became frankly bloody in the afternoon. Stool cultures and C diff tox were sent. The pt. continued on Flagyl and continued to have bloody bowel movements until POD 10. His aspirin, heparin, and plavix had been stopped and the pt. had received a bag of platelets, one unit of cryo, and one unit of PRBCs the day prior to the bleeding stopping. The hematochezia resolved but on POD #10 he developed a fever to 101 F. He had a persistent leukocytosis that had risen to 25K. The pt. was started on Vancomycin and Zosyn and made NPO for bowel rest. A CT scan was obtained with oral contrast demonstrating an anastomotic leak. The patient was taken back to the operating room on [**2154-10-20**] where an end ileostomy and long Hartmann??????s was fashioned. He was placed in the ICU post-operatively for hypotension and low urine output requiring central line placement and volume resuscitation. He was transferred out of the intensive care unit by POD #2. His incision became infected requiring opening the wound and a VAC dressing was applied. TPN was initiated however by POD #17/6 he was tolerating PO??????s and TPN was stopped. On POD #21/10 serosanguinous fluid was noted draining from the VAC and a fascial dehiscence was diagnosed. He is currently doing well with the wound VAC and is planned for discharge to rehab. Blood and stool cultures were negative including stool for c.diff sent on 3 separate occasions. A rectal swab was postivie on [**2154-10-21**] for MRSA. He was VRE positive noted on a prior admission. Aspirin and plavix were on hold up until discharge pending approval to restart per the attending Dr. [**First Name (STitle) **]. Follow up with Dr. [**First Name (STitle) **] should occur in 1 week post discharge. He will be discharged to [**Hospital **] Rehab in [**Location (un) 53637**], MA with wound vac changes every three days. PT/OT were requested. Labs on [**11-5**] as follows: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2154-11-5**] 04:43AM 11.4* 3.61* 11.3* 32.8* 91 31.2 34.3 14.6 624* BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2154-11-5**] 04:43AM 624* [**2154-11-5**] 04:43AM 14.2* 27.9 1.4 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2154-11-5**] 04:43AM 93 24* 1.5* 138 4.6 105 221 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2154-11-5**] 04:43AM 9.7 3.9 1.9 Medications on Admission: celexa, lipitor, labetolol, neurontin, plavix, catapres Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 6. Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold if sbp <110 . 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day: Fingerstick Q6hoursInsulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-50 mg/dL [**12-2**] amp D50 51-100 mg/dL 0 Units 101-150 mg/dL 2 Units 151-200 mg/dL 4 Units 201-250 mg/dL 6 Units 251-300 mg/dL 8 Units > 300 mg/dL Notify M.D. . Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: ileostomy reversal [**2154-10-9**] ileocolonic anastomosis resection and creation or end ileostomy [**1-2**] dehiscence [**2154-10-20**] vac placement for wound healing hypertension legally blind s/p cva [**11-2**] MRSA, rectal swab h/o VRE Discharge Condition: stable Discharge Instructions: call if fever (temperature of 101), chills, nausea, vomiting, diarrhea, abdominal distension or inability to have a bowel movement, any redness/pus or bleeding from incisions call [**Telephone/Fax (1) 673**] to schedule appointment with Dr. [**First Name (STitle) **] in 1 week may shower no heavy lifting no driving while taking pain medication Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2154-12-11**] 11:00 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2155-3-24**] 10:30 Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2155-3-24**] 11:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Call to schedule appointment in 1 week (week of [**11-12**]) Completed by:[**2154-11-5**] Admission Date: [**2154-10-9**] Discharge Date: [**2154-11-14**] Date of Birth: [**2109-7-17**] Sex: M Service: [**Last Name (un) **] ADDENDUM: The patient was admitted on [**2154-10-9**], and discharged on [**2154-11-14**]. The patient was not discharged on [**2154-11-5**], due to abdominal wound bleeding after vac was removed. The patient had started back on his aspirin and Plavix. He remained in the hospital until [**2154-11-14**]. He had the wound vac to suction. He was afebrile. His antibiotics were stopped on hospital day 35/24. His wound vac was removed. The wound had granulated in nicely. He did have some superficial bleeding at the wound bed that was treated with silver nitrite stick and the bleeding stopped. He was placed on normal saline wet to dry dressing change. The wound had granulated in quite a bit and still approximately 2 inches deep with slight visibility of sutures in the base of the wound. Surrounding skin around the wound on his abdomen was erythematous with a superficial sort of abrasion, contact dermatitis. On postoperative day 35/24 he experienced some hematuria. UA was sent off. He had greater than 20 RBCs and 3 to 5 white cells, epithelial cells were 0 to 2. Urine culture was sent that was contaminated. UA and C&S were repeated. Culture is pending at this date. RBCs remain 21 to 50. His hematuria resolved. An abdominal CT was done that demonstrated calcified stone within the left renal collecting system which had migrated since the prior examination. No stones were seen within the mid to distal ureters or within the bladder. There was interval improvement in the degree of ventral fat wall stranding and anterior abdominal defect had appeared improved in comparison to the prior study. He was encouraged to drink at least 2 liters of fluid. His vital signs are stable. He was afebrile. He was discharged home on normal saline wet to dry dressings. VNA was consulted for b.i.d dressing change. He was in stable condition ambulating, tolerating regular diet without any diarrhea. DISCHARGE MEDICATIONS: Discharge medications included: 1. Aspirin 325 mg PO once daily. 2. Celexa 20 mg PO once daily. 3. Clonidine patch one patch every Tuesday. 4. Plavix 75 mg PO once daily. 5. Hydralazine 10 mg PO q6 hours p.r.n. 6. His labetalol was 300 mg PO b.i.d. 7. Percocet 1 to 2 tabs PO q 4 to 6 hours. He was not on any antibiotics. LABORATORY DATA ON DISCHARGE: White blood cell count of 11.6, hematocrit 32.9, platelet count 374, PT 12.6, PTT 23.5, INR 1.1. Urinalysis revealed RBC count of 21 to 50, white blood cell count 3 to 5, 2 bacterias, no yeast and 0 to 2 epithelial cells, negative nitrite, and negative leukocytes. Sodium 139, potassium 4.5, chloride 105, bicarb 26, BUN 23, creatinine 1.5. He was instructed to schedule follow up visit in one week to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He was also scheduled to follow up with Dr. [**First Name (STitle) 3122**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1860**] as well as Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4229**], his urologist in 1 week to reevaluate the left renal calculus. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2154-11-14**] 17:16:59 T: [**2154-11-15**] 00:46:51 Job#: [**Job Number 53638**]

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Discharge summary

report

Admission Date: [**2169-11-19**] Discharge Date: [**2169-12-8**] Date of Birth: [**2095-7-11**] Sex: F Service: MEDICINE Allergies: Sulfasalazine / Salicylates Attending:[**Last Name (un) 7835**] Chief Complaint: Headache and neck pain Major Surgical or Invasive Procedure: [**2169-11-24**] left sided craniotomy for subdural hematoma evacuation History of Present Illness: This is a 74 year old woman who presented to [**Hospital1 **]-[**Location (un) 620**] on [**11-17**] with frontal headache and neck pain. She has a history of C4 fracture in [**2169-8-7**]. Since discharge she has had multiple episodes of fall and head injury although she was not evaluated for this. She has not experienced any change in vision, muscle weakness, loss of sensation or altered coordination. She was admitted to [**Hospital1 **]-[**Location (un) 620**]. During her admission, she experienced a fever to 102 and work up was started. Cultures were pending at the time of admission. A CT was performed which demonstrated subacute on chronic SDH. She was transfered to [**Hospital1 **] [**Location (un) 86**] for further work up. Past Medical History: Peptic ulcer disease Pernicious anemia, peripheral neuropathy Hypertension Hyperlipidemia Macular degeneration Hyperthyroidism Migraines Anxiety Heart murmur Infrarenal AAA S/p Partial gastrectomy with Bilroth 1 for PUD in [**2146**] S/p "Gastric aneurysm" repair in [**2157**] S/p appendectomy S/p total hysterectomy S/p cesarean section x2 S/p ventral hernia repair with mesh in [**2158**]. S/p C5-C6 fusion Social History: Divorced, Retired psychologist. Lives by herself. No tobacco. 4-5 drinks/week. Family History: Father with lung ca at 79. Mother with leukemia at 84. Physical Exam: On Admission: O: T: 101.3 HR 64 BP: 138 / 93 R 18 O2Sats 94 RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: EOMs Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-9**] 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, to 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. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-11**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: CT Head [**11-19**] Left sided acute on chronic SDH and Right chronic SDH [**2169-11-21**] EKG Baseline artifact. Low voltage in the limb leads. Probable sinus rhythm. Early R wave progression. Lateral precordial T wave inversions. Since the previous tracing of [**2169-8-31**] ST-T wave abnormalities may now be less prominent at a slower rate. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 132 98 452/473 66 -19 -24 [**2169-11-21**] CXR IMPRESSION: AP chest compared to [**2169-8-30**]: Mild interstitial pulmonary abnormality is new, and there is hazy opacification in the juxtahilar left mid and lower lung zones which could be due to pneumonia. Heart size is normal. There is no appreciable pleural effusion. [**2169-11-21**] CT CHEST / ABD / PELVIS CT OF THE CHEST WITH CONTRAST, FINDINGS: Current study is compared to prior exam of [**2168-9-20**]. There are scattered emphysematous changes involving both lung fields. Compared to the prior study, there are new diffuse ground-glass opacities involving both lung fields, predominantly on the left, however. There is also interval development of small lymph nodes within the AP window and in the lower paratracheal region, likely reactive. There are no focal masses identified, no pleural effusions seen. Extensive atherosclerotic disease of the aortic arch, origin of the great neck vessels and coronary artery calcification are again seen and unchanged. There is small adenopathy involving both axillae, also unchanged. No large pulmonary arterial filling defects. CT OF THE ABDOMEN WITH CONTRAST, FINDINGS: No change in the mild biliary prominence with diffuse biliary air suggesting a prior sphincterotomy. The patient apparently has also undergone surgery for probable reflux, though not stated within the history. The liver demonstrates no focal masses, the portal vein is patent. The pancreas shows no abnormalities. There is mild prominence of both adrenal glands, likely due to hyperplasia and unchanged compared to the prior exam. Both kidneys demonstrate scattered areas of cortical thinning, indicative of a prior infectious or inflammatory insult, but unchanged. There are also bilateral renal cysts and hypodensities, too small to characterize but all unchanged. There is no hydronephrosis, no definite nephrolithiasis on this contrast only study. The visualized loops of large and small bowel appear normal as does the spleen. There is no free fluid, no significant adenopathy. CT OF THE PELVIS WITH CONTRAST, FINDINGS: The infrarenal abdominal aorta measures a maximum of 3.6 cm and is unchanged. There is diffuse atherosclerotic disease which includes a high-grade stenosis involving the celiac axis. There is no evidence of bowel ischemia. There is extensive calcification involving the iliac vessels and marked calcification with high-grade stenosis involving the left common femoral artery, all findings are unchanged, however. There is no free fluid. There are surgical clips involving the anterior abdomen. The patient is status post hysterectomy. There are ill-defined areas of soft tissue density within the right lower quadrant in the region of the omentum or serosa. These are unchanged compared to the prior study. Some may be iatrogenic as the overlying soft tissue demonstrates some stranding and subcutaneous air indicative of injections. Stability would suggest this does not represent serosal or omental implantation resulting from any metastatic disease. Bone windows demonstrate significant degenerative change; however, there is no evidence of any suspicious bony lesions. Small grade 1 spondylolisthesis of L3 on L4. IMPRESSION: Compared to the exam of [**2168-9-20**]: 1. Interval development of ground-glass opacities involving both lung fields with adjacent reactive adenopathy within the mediastinum. Given history of multiple falls, aspiration should be considered. No definite focal pulmonary nodules or other pulmonary parenchymal pathology. 2. Extensive atherosclerotic disease including an infrarenal abdominal aortic aneurysm which is unchanged in size, celiac axis stenosis, high-grade stenosis involving the left common femoral artery. 3. Multiple other chronic changes including areas of renal cortical thinning, renal cysts, and other small renal areas too small to characterize but stable, prominence of both adrenal glands, degenerative changes involving the bony structures. 4. Some ill-defined areas of increased density involving the omentum or serosa within the right lower quadrant, these are likely post-inflammatory or postoperative in origin and unchanged compared to the prior study. Overall appearance is not that of serosal or omental implantation, especially in light of the one-year stability. [**2169-11-24**] Head CT: IMPRESSION: 1. No evidence of acute intracranial hemorrhage. No shift of midline structures. 2. Post-surgical changes from left frontoparietal evacuation of subdural hematoma with expected pneumocephalus. 3. Acute on chornic right frontal subudural hematoma, stable from [**2169-11-19**]. [**2169-11-25**] Head CT: IMPRESSION: 1. Stable post-surgical changes from evacuation of a left frontoparietal subdural hematoma. 2. Stable acute on chronic right frontal subdural hematoma with unchanged mass effect. 3. No evidence of subfalcine or transtentorial herniation. 4. No new intra- or extra-axial hemorrhage or evidence of acute large territorial infarction. [**2169-11-26**]: CT HEAD: FINDINGS: Again noted are post-surgical changes of left frontoparietal craniotomy and left subdural evacuation. There is pneumocephalus and residual subdural collection with mixed attenuation components layering along the left hemisphere. There is no significant shift of normally midline structures. There is no new hemorrhage. The ventricles and sulci remain prominent consistent with age-related involutional changes. There is no interval development of ventriculomegaly. There is no evidence of acute territorial infarct. Bilateral mastoid air cells are clear. Visualized paranasal sinuses are within normal limits. IMPRESSION: No significant interval change since [**2169-11-26**], at 11:46 a.m. Persistent mixed attenuation left subdural collection with pneumocephalus. No new acute intracranial hemorrhage. [**2169-11-27**] MRI brain 1. Leptomeningeal enhancement in the region of underlying left subdural hematoma, without enhancement of the hematoma wall, and without cerebral edema. There is no evidence of ischemia, infarction or brain edema. 2. Stable left frontal subdural hematoma with expected post-surgical changes. 3. No new intracranial hemorrhage [**2169-11-29**] RUQ U/S - 1. Pneumobilia, as previously seen. No focal liver lesion identified. 2. No evidence of biliary dilation. Status post cholecystectomy. 3. Bilateral pleural effusions. No intra-abdominal ascites [**2169-11-30**] CXR for PICC Right PICC terminates at approximately the junction of the superior vena cava and right atrium. Heart size is normal. Aorta is tortuous. Lungs are clear except for minimal patchy atelectasis at the bases. Note that the extreme left lung base laterally has been excluded from the radiograph and cannot be assessed [**2169-12-1**] CT head 1. No evidence of new hemorrhage or ventriculomegaly. 2. Post-surgical changes from left frontoparietal craniotomy and evacuation of subdural hematoma Brief Hospital Course: Ms. [**Known lastname **] was admitted to the neurosurgery service after she was transferred from OSH with bilateral subdural hematomas. Her cervical collar was cleared after negative CT C spine. Medicine was consulted for a fever workup. CT Chest was concerning for pneumonia dx given recent hospitalizations and fever without other source, antibiotics were started/ broad spectrum under their guidance. They asked the neurosurgery team to delay surgery till antibiotics were on board greater than 24 hours so her case was put off until the 18th. On [**11-24**], The patient was taken to the Operating Room for left sided craniotomy for subdural evacuation. The patient was given one unit PRBC in the OR from Hematocrit 27.4. The post transfusion hematocrit was 31.7. Intra operative there were ST depression that were worse than pre-operatively and Cardiac enzymes were sent x 3 sets: The first set was CE CK: 27 MB: 3 Trop-T: 0.03. second set 0.3, third set 0.3. Intraoperatively noted to have a collection suspicious for infection in the subarachnoid space and cultures were sent. Infectious Disease was called and it was recommended that until the final culture results are available continue vancomycin,ceftriaxone 2 gms q 12 and discontinue levofloxacin, and discontinue ceftazidime. The post operative exam was consistent with slight right pronator drift, strength 5/5, toes mute, pupils reactive, dressing clean, dry, and intact. The Post-operative head CT was consistent with expected post operative changes. Post-operatively the PTT was 48 and the patient was transfused with 2 of FFP. The patient was 2 liters positive after transfusions and given 20 IV Lasix with a goal to keep the patient fluid volume status even. The serum potassium, magnesium, and calcium were low and these were repleated intravenously. On [**11-25**] Liver Function Tests were sent and were stable. A Non Contrast Head CT was performed prior to am rounds which was stable. SUBQ Heparin was held due to slightly elevated PTT. On the morning of Sunday the 20th she was noted to be very aphasic. CT was without change. An EEG was placed and found to have epileptiform discharges arising from the right side of the central parietal region. She was given Ativan 0.5mg iv x 2 without effect. Neurology consultation was obtained and their recs followed. Her Keppra was increased and she was given a bolus as well. She received additional IVF after fever and low blood pressure. She responded well to this. Over the course of the night to the next morning her exam improved markedly. She was still having epileptiform discharges and another Keppra bolus of 500 mg was given. MRI imaging was obtained per Neuro recs on [**11-27**] and this showed some leptomeningeal enhancement, no new hemorrhage or infarct. Her Vanc level was 14.4. Social work spoke to family about interpersonal issues and potential abuse. SW involvement will be continued at rehab. EEG recording continued and her exam was stable on [**11-28**]. On [**11-29**], EEG was read as negative for seizure activity and EEG was discontinued. Her exam remains stable and she was transferred to the floor. PICC line was ordered for long term antibiotic treatment with vanc and ceftriaxone until 12/1 per ID recs. It was place in routine fashion. A PT/PTT studies were obtained which was elevated. Liver enzymes were obtained which showed elevated transaminase. Medicine and subsequently Hepatology were consulted and there recommended to obtain multiple blood studies and Vit k x 3 doses. Repeat coag studies showed improvement in INR. RUQ u/s obtained showed no acute hepatic issues. PICC line was placed and confirmed on [**11-30**]. CT head was stable on [**12-1**]. She was being screened for rehab. She was febrile on [**12-1**] to 102. Recent CXR and UA were not concerning for infection. A LENS and blood cultures were ordered on [**12-2**]. On [**12-4**] she was deemed to have no further neurosurgical needs and was transferred to the medicine service for work up of her leukocytosis, fevers, seizures and altered mental status. She was continued on vancomycin and cefepime and per reccomendations of the ID and neurology team underwent a lumbar puncture. CSF anlysis did not show evidence of acute infection. On [**12-5**] her WBC normalized and she remained afebrile. On [**12-6**] under the guidance from the ID team an in light of negative cultures her antibiotics were stopped. Her seizures were followed by the neurology team and these too resolved shortly following her transfer to medicine. She will be continued on Keppra and will follow up in the neurology clinic following discharge. Her AMS also resolved and a certain etiology was never fully ascertined. On the day of discharge she c/o of headache. A CT was performed that showed improvement overall and no acute pathologic abnormality. She was dischargd to rehab facility in stable condition. ================= TRANSITIONAL ISSUES # Follow up final culture results # Follow up outstandinf CSF viral PCR Medications on Admission: bupropion, divalproex, lasix, levothyroxine, ativan, paroxetine Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. divalproex 500 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. [**Month/Year (2) **] 8.6 mg Capsule Sig: One (1) Capsule PO once a day. 10. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Location (un) 6594**] and Rehabilitation Discharge Diagnosis: Bilateral subdural hematomas Fever unknown origin Seizures expressive aphasia postoperative anemia requiring transfusion Transaminitis Malnutrition Hyponatremia 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 sustaining a fall. You were found to have right and left sided subdural hematomas. The left one was removed surgically. After surgery you were noted to have difficulty getting your words out. This was found to be caused by seizure activity. You were treated with medication for this and seen by the Neurology service. General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate ([**Location (un) **]) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. . While you were here we changed your medications in the following ways: We STARTED you on: Multivitamin Potassium chloride [**Location (un) 10687**] Miralax Keppra We STOPPED your Buproprion Lorazepam . You should continue taking your other medications as prescribed. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????Please return to the office in [**7-16**] days(from your date of surgery [**2169-11-24**]) for removal of your staples and sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. Other appointments: Department: NEUROLOGY When: THURSDAY [**2169-12-14**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD [**Telephone/Fax (1) 3294**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "03.31", "01.31" ]

icd9pcs

[ [ [] ] ]

16555, 16625

10492, 15546

310, 384

16830, 16830

3110, 7858

18656, 19718

1704, 1761

15661, 16532

16646, 16809

15572, 15638

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8555, 10469

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16845, 16957

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25,049

180,379

10607+10648

Discharge summary

report+report

Admission Date: [**2140-2-9**] Discharge Date: [**2140-2-26**] Date of Birth: [**2078-1-6**] Sex: M Service: THORACIC SURGERY CHIEF COMPLAINT: Shortness of breath. HISTORY OF THE PRESENT ILLNESS: The patient is a 62-year-old diabetic male admitted to the [**Hospital1 18**] through the Emergency Department on [**2140-2-9**]. The patient's past medical history is significant for a laparoscopic cholecystectomy in [**2139-8-3**] with a postoperative course complicated by bile duct injury requiring Roux-en-Y reconstruction. Following the surgery, the patient also developed chronic pleural effusions, worse on the right requiring multiple thoracentesis. Early in [**2139**], the patient began to develop worsening dyspnea, fatigue, and malaise, and inability to achieve a complete breath. It was noted on workup that he had developed bilateral fibrothoraxes, particularly on the right. The patient's CAT scan also revealed mediastinal adenopathy as well as a ground glass appearance to both lungs of unclear etiology. The patient had been admitted to the [**Hospital1 18**] between [**2140-1-5**] and [**2140-1-8**] with a chief complaint of increased shortness of breath and was subsequently discharged to a rehabilitation facility. The patient had been home for one week when he developed increasing shortness of breath and was brought into the Emergency Department by his wife. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Hypertension. 3. Chronic leg pain. 4. Diabetic neuropathy. 5. Cataracts. 6. Chronic anemia. 7. Benign prostatic hypertrophy. 8. Prostatitis ([**2140-2-1**]). PAST SURGICAL HISTORY: 1. Laparoscopic cholecystectomy in [**2139-4-2**]. 2. Roux-en-Y hepatojejunostomy on [**2139-5-8**]. 3. Thoracentesis in [**2139-5-3**] and [**2139-6-2**]. 4. Left hip replacement in [**2138-10-3**], complicated by chronic left leg pain. 5. Left knee arthropathy. 6. Cardiac catheterization in [**2139-6-2**]. ADMISSION MEDICATIONS: 1. Ciprofloxacin. 2. Colace. 3. Epogen. 4. Actos. 5. Vitamin C. 6. Metformin. 7. Flomax. 8. Nexium. 9. Lisinopril. 10. Metoprolol. 11. Aspirin. ALLERGIES: Vicodin (hallucinations). SOCIAL HISTORY: The patient is a retired umpire for multiple sports. He is married and lives with his wife. [**Name (NI) **] has two children and five grandchildren. He has never smoked. FAMILY HISTORY: The patient's father died at the age 61 of COPD. The patient's mother died of breast cancer at age 88. One brother has had multiple strokes and two sisters are both healthy. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: On admission, the patient's temperature was 97, heart rate 76, blood pressure 129/70, breathing at 24, saturating 96%. General: The patient appeared to be in no distress. The physical examination was notable for bibasilar crackles, worse on the right than the left with an occasional wheeze. The patient's heart was regular and abdomen was benign. LABORATORY/RADIOLOGIC DATA: The patient's white count was 8.76, hematocrit 29.1, platelets 174,000. The patient's serum chemistries revealed a sodium of 142, potassium 4.7, chloride 102, bicarbonate 34, BUN 44, creatinine 1.6 as well as a blood glucose of 42. The patient had a blood gas drawn on arrival to the Emergency Department with a pH of 7.3, carbon dioxide of 71, and oxygen of 122. Subsequent arterial blood gases drawn an hour and a half and five hours after arrival in the Emergency Department continued to have a pH between 7.31 and 7.33 and serum carbon dioxide level of 63-67. Cardiac enzymes were drawn with troponins of 0.13, 0.14, and 0.12. HOSPITAL COURSE: The patient was admitted to the medical service on admission and workup initiated for possible congestive heart failure. Some consideration was given to admitting the patient to the Intensive Care Unit but given that the patient's mental status was at baseline with no evidence of distress as well as the fact that his elevated carbon dioxide level of ABG was probably chronic. The decision was made to admit the patient to the floor. Diuresis was initiated with Lasix. A Thoracic Surgery consultation was requested. The Thoracic Surgery Team was of the opinion that the patient had an entrapped right lung and that decortication may be of benefit. It was hoped that the decortication would improve the patient's respiratory function. The patient was also seen by the Pulmonary Service. The patient was started on BIPAP on the evening of [**2140-2-12**] in an attempt to improve his ventilation while asleep. The patient tolerated the BIPAP well and felt that he had improved sleep and energy with it. The patient was taken to surgery on [**2140-2-17**] and underwent decortication of his right lower, middle, and upper lobes as well as his diaphragm. The patient was difficult to intubate and was kept intubated over the night of postoperative day number zero for continued monitoring. The patient was on an epidural for pain control. We were unable to have the patient extubated on postoperative day number one secondary to apnea as well as suboptimal blood gases. The patient was extubated on postoperative day number two. On the evening of postoperative day number three, the patient was noted to be very lethargic, barely responding to voice, diaphoretic, and with decreasing oxygen saturations as well as heart rate. The patient ultimately require reintubation. Bronchoscopy was performed revealing a left main stem plug as well as plugs in the left upper and left lower lobes with thick copious whitish secretions. Repeat bronchoscopy was performed on postoperative day number four with minimal residual secretions noted. Please note that the patient's arterial blood gas on reintubation revealed a pH of 6.98 with a carbon dioxide level of 140 and oxygen of 178. Further bronchoscopy was performed on postoperative day number five revealing once again thick yellow secretions worse on the left than the right. The patient was started on Levaquin presumptively for pneumonia. The patient underwent tracheostomy on [**2140-2-22**]. The patient was returned to the Intensive Care Unit following performance of the tracheostomy. The patient did well following this. The patient's chest tubes were removed on [**2140-2-23**]. The patient underwent a swallowing evaluation on [**2140-2-24**]. With a Passy Muir valve, the patient was noted to aspirate during an evaluation the patient was noted to aspirate during evaluation with the recommendation to keep the patient strictly n.p.o. The patient was receiving tube feeds through a Dobbhoff nasogastric tube. The patient was weaned off the ventilator and placed on CPAP on [**2140-2-25**] as well as [**2140-2-26**]. The patient was tolerating this mode of ventilation for long periods. The patient was continued on Lasix diuresis. A rehabilitation screening was initiated. On [**2140-2-25**], the patient did have the complaint of some chest pain. An EKG was obtained which revealed no changes. However, the patient's pain did resolve with some sublingual nitroglycerin. A Cardiology consultation was requested. Please note that the patient had a cardiac catheterization in [**2139-6-2**] which revealed minimal left circumflex disease and with otherwise clear coronary arteries. Cardiac enzymes drawn revealed a troponin level of 0.07 decreasing to 0.06 and then 0.05. At this time, the patient's discharge is on hold pending the cardiology consult. An addendum to this discharge summary will be dictated following input from Cardiology. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Fibrothorax. 2. Diabetes mellitus. 3. Pneumonia. 4. Prostatitis. 5. Anemia. DISCHARGE MEDICATIONS: 1. Colace liquid 100 mg p.o. b.i.d. 2. Metoprolol 75 mg p.o. b.i.d. 3. Insulin by sliding scale. 4. Lasix 40 mg IV b.i.d. 5. Percocet elixir [**4-11**] milliliters p.o. q. four hours p.r.n. 6. Oxymetazoline one spray b.i.d. as needed. 7. Ibuprofen 400 mg q. eight hours p.r.n. 8. Levofloxacin 750 mg p.o. q.d. 9. Pepcid 20 mg p.o. b.i.d. 10. Ambien 5 mg p.o. q.h.s. p.r.n. 11. Nortriptyline 75 mg p.o. q.h.s. 12. Albuterol ipratropium four puffs inhaler q. six hours. 13. Saline nasal spray p.r.n. 14. Neutra-Phos one packet p.o. t.i.d. 15. Tylenol 325-650 mg p.o. q. four hours p.r.n. 16. Heparin 5,000 units subcutaneously t.i.d. 17. Aspirin 325 mg p.o. q.d. 18. Dorzolamide 2%/Timolol 0.5% eyedrops b.i.d. 19. Vitamin C 250 mg p.o. t.i.d. 20. Lexapro 10 mg p.o. q.d. 21. Tamsulosin 0.4 mg p.o. b.i.d. FOLLOW-UP: The patient is to follow-up with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] in one to two weeks following discharge. The patient is also to follow-up with his primary care physician as well as his pulmonologist within one to two weeks following discharge. The patient will need cardiac follow-up pending the recommendations of cardiology consultation team. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2140-2-26**] 02:37 T: [**2140-2-26**] 15:17 JOB#: [**Job Number 34871**] Admission Date: [**2140-2-9**] Discharge Date: [**2140-2-27**] Date of Birth: [**2078-1-6**] Sex: M Service: Thoracic Surgery ADDENDUM: Please refer to the previously dictated Discharge Summary covering the period of [**2140-2-9**] through [**2140-2-26**]. As previously stated, the patient was evaluated by Cardiology Service for his complaint of chest pain which had resolved with sublingual nitroglycerin in the absence of electrocardiogram changes. The patient had cardiac enzymes with his troponin trending down from 0.07 to 0.05. Of note, the patient also had a cardiac catheterization in [**2139-6-2**] which revealed minimal left circumflex disease with otherwise clear coronary arteries. The Cardiology Service did not believe the patient's chest pain to have been cardiac and noted that the patient had previously had elevated serum troponin levels throughout much of his hospitalization. The cause for the elevated serum troponin was unclear. The Cardiology Service recommended no further workup. DISCHARGE DISPOSITION: Plans for discharge were therefore finalized. The patient was to be transferred to a rehabilitation facility on [**2140-2-27**]. MEDICATIONS ON DISCHARGE: The patient's discharge medications were unchanged from those listed on his prior Discharge Summary except for the discontinuation of levofloxacin. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2140-2-27**] 09:49 T: [**2140-2-27**] 09:55 JOB#: [**Job Number 34942**]

[ "786.59", "250.60", "788.20", "357.2", "428.0", "486", "511.8", "601.9", "599.0" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.72", "34.51", "93.90", "33.24", "99.04", "96.6" ]

icd9pcs

[ [ [] ] ]

10292, 10423

2395, 2592

7748, 10268

7640, 7725

10450, 10864

3655, 7585

1992, 2185

1652, 1969

165, 1415

2607, 3637

1437, 1629

2202, 2377

7610, 7619

25,315

177,247

23129

Discharge summary

report

Admission Date: [**2199-2-2**] Discharge Date: [**2199-3-6**] Date of Birth: [**2127-9-21**] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 71 year old gentleman who was in his usual state of good health until 9:00 PM on the day of admission when he was eating dinner and developed the worse headache of his life. He went to [**Hospital **] Hospital where they found a subarachnoid hemorrhage. The patient denies nausea, vomiting, chest pain or shortness of breath. The headache is currently is [**3-28**]. PAST MEDICAL HISTORY: Hypertension and foot surgery in the past. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: Temperature was 98, blood pressure 137/100, respiratory rate 18, saturations 100 percent, heart rate 72. HEENT - Pupils equal, round and reactive to light, 2 down to 1.5. Extraocular movements were full. Lungs - Clear to auscultation bilaterally. Cardiovascular - Regular rate and rhythm. Abdomen - Soft, non-tender, positive bowel sounds. Extremities - No edema. Neurologic - Prefers eyes closed, awake, alert and oriented times three and following commands. Speech was fluent. Comprehension was intact. He had no drift. His smile was symmetric. His strength was [**5-23**] in all muscle groups. His reflexes were 2 plus throughout and his toes were downgoing and visual fields were full. He was admitted to the neurosurgical service in the ICU for q one hour neuro checks. He underwent an angiogram which showed a ruptured ACA aneurysm which he had coiled on [**2199-2-3**]. On [**2-4**] postoperatively being recovered in the ICU, he had several episodes of bradycardia down into the 40's and ventricular bigeminy. The bradycardia was felt to be related to vagal activity after his hemorrhage and was treated conservatively with telemetry. The patient was asymptomatic in terms of blood pressure problems. The patient had a repeat head CT on [**2199-2-4**] which showed no new hemorrhage. The ventricles were slightly smaller. The patient was extubated on [**2199-2-5**]. He had an echocardiogram which showed an ejection fraction of 55 percent, 1 plus AR and trivial MR. The patient had a head CT on [**2-5**] that was stable or improved from [**2-4**]. His neurologic status remained stable. The patient had a ventricular drain placed at the time of admission. On [**2199-2-8**] the patient had a repeat angiogram which showed a stable appearance of the aneurysm with moderate spasm in the right A1 segment. The patient's blood pressure was kept in the 150-190 range and CVP 8-10 range. The patient's ventricular drain was at 10 cm above the tragus. The patient was neurologically stable and intact. On [**2-7**] the patient had a chest x-ray which showed mild to moderate volume overload and the patient spiked to 102.9. He was continued cefazolin 1 gram IV q eight hours for ventricular drain prophylaxis and drain cultures showed 2 plus polys but no organisms from CSF sent on [**2-8**]. On [**2-6**] CSF showed 1 plus polys and no organisms. On [**2199-2-10**], the patient spiked to 103. Urinalysis was negative. CSF cultures continued to be negative. Blood cultures were pending. The chest x-ray showed resolving perihilar edema and new bibasilar opacities and right small pleural effusion. The patient also was hyponatremic and was having sodium checks every six hours. The patient was started ceftriaxone and vancomycin prophylactically and continued to have no positive cultures. On [**2199-2-13**], the patient had a CTA which again showed vasospasm of the right A1 segment of the anterior circulation. The patient's blood pressure continued to be kept in the 150-190 range. The patient's temperature resolved and all cultures were negative to date. Ceftriaxone and vancomycin were discontinued on [**2199-2-13**]. The patient was continued on cephazolin 1 gram IV q eight for drain prophylaxis. The chest x-ray showed no consolidation and less atelectasis on [**2199-2-13**]. The patient had his ventricular drain changed to a lumbar drain on [**2199-2-13**] and the drain was clamped. The patient was transferred to the Step-Down Unit on [**2199-2-17**]. The patient had the lumbar drain removed after a head CT showed a stable size of the ventricles with the ventricular drain clamped for 24 hours. On [**2199-2-20**] the patient had an LP and opening pressure was 22 and 30 cc of CSF was sent. The patient had serial LP's done to assess for high opening pressures with the last being on [**2199-2-26**] with an opening pressure of 21 and closing pressure of 9. The patient was then scheduled for a VP shunt placement, however, the patient's neurologic status remained stable and no VP shunt was placed. The patient remained neurologically intact and was followed by physical therapy and occupational therapy and found to be stable for discharge to home on [**2199-3-6**]. Medications at the time of discharge include Metoprolol 12.5 mg PO BID, Keppra 1,000 mg PO BID, lansoprazole 30 mg PO q day and insulin for sliding scale. The patient's condition was stable at the time of discharge. He will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2199-3-6**] 12:19:15 T: [**2199-3-6**] 14:01:50 Job#: [**Job Number 59535**]

[ "435.8", "401.9", "276.6", "518.0", "511.9", "426.13", "250.00", "305.1", "430", "276.1", "331.3" ]

icd9cm

[ [ [] ] ]

[ "38.93", "03.31", "96.6", "96.71", "00.17", "02.39", "39.72", "88.41" ]

icd9pcs

[ [ [] ] ]

674, 5450

163, 551

574, 651

70,912

178,834

41011

Discharge summary

report

Admission Date: [**2153-4-12**] Discharge Date: [**2153-4-19**] Date of Birth: [**2118-4-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1115**] Chief Complaint: Wegeners granulomatosis Major Surgical or Invasive Procedure: CT guided biopsy Chest tube placement and removal Kidney biopsy History of Present Illness: 34 y/o M with PMHx of DM I who was recently admitted [**Date range (3) 89453**] for work-up of anemia of unclear etiology. He was found to have a hematocrit of 18.9 at his PCP's office. During his admission he was noted to have eosinophilia, coagulopathy, infiltrates and an anterior mediastinal mass. He was seen by [**Location (un) 2274**] Hematology/Oncology, and [**Hospital1 18**] pulmonary and thoracic surgery. He received two units of PRBCs and Hct at discharge was 24.6. Haptoglobin was high. Bone marrow biopsy showed bone marrow suppression and iron deficiency. He was discharged with iron supplementation. His mediastinal mass felt to most likely be a thymoma, and would tie together all of his other findings including anemia, atypical pneumonia and recurrent sinus infections with eosinophilia and coagulopathy. Notably, germ cell marker HCG neg, AFP normal. He had a bronchoscopy with BAL which was negative for pathogens (some still pending) or eosinophilic predominance. He had an MRI of the chest which showed Round heterogeneous lesion in the anterior mediastinum measuring 5.4 x 3.9 x 4.7 cm without appreciable loss of signal intensity on out-of-phase imaging with mild enhancement. Findings are NOT consistent with thymic hyperplasia. Diagnostic considerations include thymoma versus lymphoma. Thoracic surgery decided no biopsy should be performed as risk of seeding the surrounding tissue if this is malignant. He was to follow up with them next week for further management. Incidentally during his work up, P-ANCA was preliminarily positive and thought to be paraneoplastic, but they were awaiting confirmatory results from [**Hospital1 2025**]. On [**2153-4-10**] the attg was notified from the [**Hospital1 2025**] lab that the patient was strongly positive for PR3-ANCA - which has prompted the current admission. Patient had labs drawn yesterday and notably his Hct was 20.1, wbc: 12.0 On the floor, patient denies complaints. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: DM Social History: Occasional EtOH. No tobacco or illicit drug use. Not currently sexually active. Has always used condoms in previous sexual relationships. No recent travel Family History: No family history of blood disorders. Lung cancer in his father Physical Exam: Vitals: 96 109/60 70 19 94% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, mild pallor Neck: supple, JVP not elevated, no LAD Lungs: Mild crackles at BL Bases, otherwise clear CV: tachycardic regular 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: Admission labs: [**2153-4-12**] 08:00PM BLOOD WBC-11.6* RBC-2.44* Hgb-6.6* Hct-19.8* MCV-81* MCH-27.1 MCHC-33.4 RDW-14.2 Plt Ct-440 [**2153-4-12**] 08:00PM BLOOD Neuts-76.3* Bands-0 Lymphs-9.3* Monos-3.8 Eos-10.3* Baso-0.3 [**2153-4-12**] 08:00PM BLOOD Hypochr-3+ Anisocy-OCCASIONAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ [**2153-4-12**] 08:00PM BLOOD Ret Man-4.8* [**2153-4-13**] 05:45AM BLOOD Glucose-176* UreaN-21* Creat-1.2 Na-137 K-4.9 Cl-102 HCO3-28 AnGap-12 [**2153-4-12**] 08:00PM BLOOD LD(LDH)-138 TotBili-0.4 [**2153-4-13**] 05:45AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.2 [**2153-4-12**] 08:00PM BLOOD Hapto-365* [**2153-4-13**] 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2153-4-13**] 05:45AM BLOOD HCV Ab-NEGATIVE UA Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [**4-13**] LG NEG TR NEG NEG NEG NEG 5.0 NEG MICROSCOPIC URINE RBC WBC Bacteri Yeast Epi [**2153-4-13**] 10:53 18* 4 FEW NONE 0 URINE CHEMISTRY Hours Creat TotProt Prot/Cr [**2153-4-13**] 10:53 RANDOM 63 38 0.6* Discharge labs: [**2153-4-19**] 05:56AM BLOOD WBC-14.4* RBC-2.94* Hgb-7.7* Hct-23.9* MCV-81* MCH-26.3* MCHC-32.4 RDW-13.7 Plt Ct-409 [**2153-4-19**] 05:56AM BLOOD Glucose-149* UreaN-29* Creat-1.1 Na-137 K-4.8 Cl-100 HCO3-30 AnGap-12 Pathology: [**2153-4-17**] Renal biopsy: DIAGNOSIS: Necrotizing extracapillary glomerulonephritis consistent with the ANCA-associated vasculitic syndrome (see note). NOTE: Sections reveal fragments of renal parenchyma containing approximately 33 glomeruli, one or two of which, depending on the level, are globally sclerotic. Glomerular necrotizing lesions are noted associated with mild extracapillary proliferation (very small crescent formation). Mild interstitial fibrosis and tubular atrophy are noted accompanied by chronic inflammation. Of interest is the medullary thick ascending limbs which show apoptotic/degenerative changes. Endocapillary proliferation is minimal. The small arteries/arterioles show mild fibrotic changes. Larger arteries show intimal fibroplasia.. Immunofluorescence studies reveal 4 to 8 glomeruli to be present depending on the level. There is no staining with IgG or IgM. Mesangial IgA (minimal), kappa light chain (trace), lambda light chain (minimal), and C1q (minimal) are seen. Trace C3 is noted in tubular basement membranes and vessels. In the fibrin preparations, there is considerable ([**1-14**]+) segmental staining. Albumin stains are non-contributory. Electron microscopy studies will be sent as an addendum. PAS and silver methenamine stains were done to evaluate basement membranes. Masson trichrome preparations were done to study fibrotic changes. Findings are those of a glomerulonephritis of the type associated with the ANCA vasculitic syndromes. The thick ascending limb changes have been reported as a result of drug toxicity (Am J Kidney Dis 31:[**2153**]). [**2153-4-13**] mediastinal mass cytology: IMPRESSION: Technically successful aspiration of a predominantly cystic anterior mediastinal mass. FNA, Anterior mediastinal mass: NON-DIAGNOSTIC Specimen consists of scattered macrophages. Note: Please also refer to flow cytometry report Imaging: [**2153-4-16**] CXR: Comparison chest radiographs dating between [**2153-4-4**] to [**2153-4-15**]. FINDINGS: Tiny left apical pneumothorax has decreased in size since the priorradiograph. Cardiomediastinal contours are unchanged. Bilateral patchy infrahilar opacities have slightly improved. Subtle ground-glass opacities are present and shown to better detail on recent CT scan. Brief Hospital Course: Mr. [**Known lastname 89454**] is a 34 year-old male with Type I DM and recent complicated history and hospitalizations for a mediastinal mass now thought to be a thymic cyst, vasculitis with DAH on BAL thought to be Wegeners granulomatosis (also with renal involvement confirmed on biopsy) whose course has been complicated by pneumothorax s/p chest tube placement and removal s/p high dose methylprednisolone and first dose of rituxan. Active issues: # Wegeners Granulomatosis: The patient has both pulmonary and renal manifestations of Wegeners. He was found to have a high titer positive for C-ANCA after extensive workup of iron deficiency anemia on prior hospitalization. He was treated with IV solumedrol 1gm X 3days then transitioned to prednisone 40 mg po bid. As he did have a mediastinal mass, the concern was that this may be lymphoma and steroids would partially treat, obscuring a diagnosis. A CT guided biopsy of the mass was performed on [**2153-4-13**] which revealed it was cystic in nature, not consistent with lymphoma. He will require prolonged steroid treatment so omeprazole, vit d, calcium and bactrim were added for ppx. Hepatitis serologies were negative and a PPD was negative on [**4-9**]. After renal biopsy confirmed acute changes consistent with Wegner's in the kidney, the rheumatology and renal consult teams conferred and decided to treat him with rituxan (instead of cytoxan) due to rituxan's more favorable side effect profile. He was given his first rituxan infusion on [**4-19**] without complication and will receive 3 more infusions over the next month. # Hyperglycemia/Type I diabetes: The patient had worsening control of blood sugars with high dose steroids. Despite uptitration of his insulin he remained hyperglycemic and was transferred to the ICU for one day for insulin gtt titration. His blood sugars decreased on increased lantus dosing (now at 35 qam and 30 qpm) and an increased humalog sliding scale. [**Last Name (un) **] had been consulted and educated the patient how to down titrate his lantus dose when his steroid dose changes. He will follow up with his endocrinologist. # Anterior mediastinal mass: Visualized on previous imaging. Appears to be thymic cyst based on fluid aspirated. Cytology was nondiagnostic showing only macrophages. Per discussion with heme/onc, we cannot definitively rule out lymphoma, but that they felt it is very unlikely to be lymphoma. He was treated with high-dose steroids without change in clinical status which makes it even more unlikely this is lymphoma. Their recommendation is to repeat an MRI of his chest in 3 months. He does not currently need heme/onc follow up as this is unlikely to be malignancy. # Anemia: Thought to be secondary to blood loss from likely DAH from Wegeners. His Hct dropped as low as 21, but then rose on its own and was 23 by discharge. He received one unit of PRBCs during this hospitalization and was maintained on iron and vit c supplementation. He should have a Hct check during follow up to ensure his anemia continues to improve. # Hemopneumothorax: Complication of mediastinal biopsy. The patient was found to be more hypoxic on [**2153-4-14**], tachycardic and with chest pain on the left. Exam was significant for hyperresonance. CXR revealed large hemopneumothorax with mild tension. Thoracic surgery was consulted and chest tube placed. The pneumothorax resolved within 24 hours and the chest tube was removed. Follow up CXR on [**4-16**] showed continued resolution. # Leukocytosis: Thought to be secondary to steroids. No clinical evidence of infection. Transition of care: - Patient needs repeat chest MRI in 3 months (early [**2153-7-13**]) for follow up of the mediastinal mass. - Patient will need continued titration of insulin dosing as his steroid dose changes. - Hct check to monitor anemia. - Follow up has been arranged with his PCP, [**Name10 (NameIs) 10368**], nephrologist, pulmonologist, and endocrinologist. Medications on Admission: 1. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous twice a day. 3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 4. Insulin Sliding Scale Please use attached Flowsheet for regimen Discharge Medications: 1. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO three times a day. 3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*1* 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. 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* 6. Lantus 100 unit/mL Solution Sig: 35 units in the morning and 30 units at bedtime lantus Subcutaneous . 7. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 9. Humalog 100 unit/mL Solution Sig: sliding scale humalog Subcutaneous four times a day: See attached sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Wegeners granulomatosis Thymic cyst Hemopneumothorax Secondary diagnoses: Diabetes Type I Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] for treatment of Wegeners Granulomatosis. You were started on high dose steroids and ultimately placed on 40 mg of prednisone twice daily. The rheumatologists decided to treat you adjunctively with rituxan as this [**Doctor Last Name 360**] has fewer sided effects then the mainline treatment for your condition. You will need 3 more doses of rituxan which the rheumatologists will arrange. You had a biopsy of the mass in your chest which was found to be a cyst. You suffered a complication of this procedure which was a pneumothorax (collapse of part of the lung). A chest tube was placed and then removed. Cytology from the biopsy was nondiagnostic. Hematology/oncology had evaluated you during your stay and felt that it was very unlikely that the mass in your chest was a lymphoma or other cancer, but this has not been definately ruled out. You will need a repeat chest imaging in 3 months to check for any change in the mass/cyst. We will communicate with your primary doctor so he is aware of the need for this repeat imaging. It is important that you avoid non-steroidal anti-inflammatory medications in the future (alleve, ibuprofen, ect). You can use tylenol as need for pain control. Otherwise discuss other pain medications with your primary doctor before using. MEDICATION CHANGES: INCREASE lantus to 35 units every morning and 30 units every evening USE NEW humalog sliding scale Glucose Mealtime Insulin Dose Bedtime Insulin Dose 71-79 mg/dL 0 Units 0 Units 80-119 mg/dL 12 Units 0 Units 120-159 mg/dL 14 Units 0 Units 160-199 mg/dL 17 Units 0 Units 200-239 mg/dL 20 Units 3 Units 240-279 mg/dL 24 Units 5 Units 280-319 mg/dL 28 Units 9 Units 320-359 mg/dL 32 Units 13 Units 360-400 mg/dL 36 Units 16 Units START Prednisone 40 mg twice daily START Calcium and Vit D START Bactrim daily START Omeprazole 20 mg daily Otherwise continue your outpatient medications as prescribed. An endocrinologist from [**Last Name (un) **] helped manage your blood sugars and recommends decreasing your lantus by 2 units each dose every time your prednisone dose decreases by 5 mg. You should also contact your endocrinologist when your prednisone dose changes. Followup Instructions: Multiple follow up appointments were made for you to follow up with your outpatient providers. It is important that you keep these appointments. Name: [**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] Location: [**Location (un) 2274**]-[**Location (un) 2277**] Rheumatology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] Appointment: Wednesday [**2153-4-25**] 3:50pm Name: [**Last Name (LF) 38584**],[**First Name3 (LF) **] P. Location: [**Hospital1 641**] Primary Care Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 3530**] Appointment: Friday [**2153-4-27**] 2:00pm Name: [**Last Name (LF) 6810**],[**Name8 (MD) 6811**] MD Location: [**Hospital1 641**] Endocrinology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] Appointment: Thursday [**2153-5-3**] 8:00am Name: [**Last Name (LF) 3112**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD Location: [**Hospital1 641**] Nephrology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] Appointment: Wednesday [**2153-5-9**] 3:40pm Name: [**Last Name (LF) 9303**], [**Name8 (MD) **] MD Location: [**Hospital1 641**] Pulmonary Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] Appointment: [**2153-7-4**] 8:40am Dr. [**Last Name (STitle) 9303**] is out of the office and this was the first appointment available. You should be called with a sooner appointment when he returns. If you don't hear from their office within a week, please call to check if your appointment has been moved. Completed by:[**2153-4-19**]

[ "446.4", "280.0", "254.8", "E849.7", "E879.8", "250.03", "584.9", "511.89", "998.11" ]

icd9cm

[ [ [] ] ]

[ "55.23", "34.25", "34.04" ]

icd9pcs

[ [ [] ] ]

12671, 12677

7256, 7695

328, 394

12838, 12838

3581, 3581

15497, 17393

2995, 3060

11686, 12648

12698, 12771

11280, 11663

12989, 14319

4707, 7233

3075, 3562

12792, 12817

2401, 2780

14339, 15474

265, 290

7710, 11254

422, 2382

3597, 4691

12853, 12965

2802, 2807

2823, 2979

3,791

190,749

22221

Discharge summary

report

Admission Date: [**2155-6-24**] Discharge Date: [**2155-7-15**] Date of Birth: [**2124-3-2**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Lumbar Puncture ERCP Thoracentesis History of Present Illness: 31year old woman without sig past medical history who presented [**2155-6-24**] on transfer from [**Hospital1 **] [**Location (un) 620**] with hypotension, presumed sepsis, ARDS, hyperbilirubinemia, now with facial palsy and generalized weakness. Three days prior to transfer, she had presented to OSH with lower abdominal pain, slight F. Whe was diagnosed with UTI by UA, given levofloxacin and discharged home. Upon arriving home, she developed fevers to 103, n/v, and diarrhea. She did not take the Abx. She returned to the ED two days later with worsening symptoms. RUQ u/s showed gallbladder wall thickening, but no cholecystitis. CT abd/pelvis at that time was normal. Patient became hypotensive to 70s and experienced respiratory failure with hypoxia (O2 desat to 80s). She was intubated and transferred to [**Hospital1 18**]. Past Medical History: Postpartum depression IUD placed 6 mos ago Social History: Native of [**University/College **]. lives here in US with her husband and 2 kids. Does not smoke. Rare EtOH. Mother and Father are here with her during her hospital stay, came from [**University/College **]. Physical Exam: VS:98.5 142/90 112 18 97RA Genl: ill appearing, HEENT: PEERL, EOMI, cornea injected bilaterally, mmm CV: rr no m PULM: ctab ABD: s, nt, nd EXT: trace edema NEUR: A&Ox3, CN II-XII intact with the exception of CN VII, motor exam significant for weak biceps to [**2-24**] and general difficulty walking, sensation grossly intact, reflexes symmetrical, cerebellar tests wnl Pertinent Results: SIGNIFICANT LABS: [**2155-7-11**] 03:04AM BLOOD WBC-11.8* RBC-3.93* Hgb-11.6* Hct-34.5* MCV-88 MCH-29.5 MCHC-33.6 RDW-14.9 Plt Ct-758* recent base Hct 24 [**2155-7-11**] 03:04AM BLOOD Neuts-63.3 Lymphs-28.1 Monos-5.6 Eos-1.7 Baso-1.3 [**2155-7-11**] 03:04AM BLOOD Plt Ct-758* [**2155-7-5**] 04:30AM BLOOD Fibrino-668*# [**2155-6-30**] 12:45PM BLOOD WBC-10.8 Lymph-8* Abs [**Last Name (un) **]-864 CD3%-79 Abs CD3-685 CD4%-62 Abs CD4-533 CD8%-16 Abs CD8-142* CD4/CD8-3.8* [**2155-6-26**] 04:43AM BLOOD Ret Aut-0.5* [**2155-7-11**] 03:04AM BLOOD Glucose-85 UreaN-14 Creat-0.4 Na-139 K-4.2 Cl-104 HCO3-23 AnGap-16 [**2155-7-7**] 04:32AM BLOOD ALT-32 AST-36 AlkPhos-437* TotBili-1.1 DirBili-0.6* IndBili-0.5 [**2155-7-2**] 03:48AM BLOOD ALT-36 AST-69* LD(LDH)-267* AlkPhos-101 TotBili-4.7* DirBili-3.3* IndBili-1.4 [**2155-7-6**] 04:21AM BLOOD GGT-384* [**2155-6-26**] 04:43AM BLOOD CK-MB-5 cTropnT-0.12* [**2155-6-25**] 03:57AM BLOOD CK-MB-8 cTropnT-0.12* [**2155-7-11**] 03:04AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.1 [**2155-7-9**] 05:35AM BLOOD Triglyc-365* [**2155-6-24**] 10:32PM BLOOD Cortsol-44.2* [**2155-7-8**] 08:10AM BLOOD Type-ART Temp-37.4 Rates-/28 Tidal V-530 O2-40 pO2-124* pCO2-42 pH-7.40 calHCO3-27 Base XS-1 Intubat-INTUBATED [**2155-7-7**] 06:09AM BLOOD freeCa-1.18 SIGNIFICANT STUDIES: *Swallow Eval [**2155-7-11**] RECOMMENDATIONS: Did not pass. Oral diet of honey thick liquids by tsp and pureed solids. Ice cubes are okay. Meds whole in puree. Agree with rec for neuro consult ASAP. *CXR [**2155-7-10**] Improving ARDS/pulmonary edema. *Pleural Fluid Cytology [**2155-7-4**] NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells, neutrophils, macrophages, lymphocytes and red blood cells. [**2155-7-3**] 05:22PM PLEURAL WBC-800* RBC-2050* Polys-84* Lymphs-4* Monos-5* Meso-7* [**2155-7-3**] 07:36PM PLEURAL TotProt-2.1 Glucose-93 LD(LDH)-298 Amylase-28 *Paracentesis [**2155-7-1**] Successful removal of 400 cc of clear yellow fluid from the left lower quadrant without complication. [**2155-7-1**] 04:57PM ASCITES WBC-263* RBC-2238* Polys-63* Lymphs-14* Monos-19* Eos-3* Basos-1* [**2155-7-1**] 04:57PM ASCITES TotPro-1.7 Glucose-97 LD(LDH)-99 Albumin-LESS THAN *CTA [**2155-6-29**] ARDS, R>L pleural effusion, no PE. *Bronchial Washings Cytology [**2155-6-30**] ATYPICAL. A few groups of atypical cells of undetermined origin and significance. *Echo [**2155-6-25**] LVEF 30% moderate global left ventricular hypokinesis 1+MR *ERCP [**2155-6-24**] No evidence of biliary ductal dilatation, filling defects, or strictures *Pelvic U/S [**2155-6-24**] Moderate amount of free fluid within the pelvis. No evidence of hydrosalpinx or tubo-ovarian abscess. EMG Study Date of [**2155-7-15**] Abnormal study. There is electrophysiologic evidence for severe, subacute bilateral facial neuropathies characterized by prominent axonal loss; the right side is slightly worse than the left. There is no evidence for a generalized polyneuropathy or polyradiculopathy to explain this patient's appendicular weakness (as would be seen in Guillain-[**Location (un) **] Syndrome). In addition, there is no definite evidence for a myopathic process to explain this weakness, although subtle myopathies may be difficult to identify on electrophysiologic study. Studies of neuromuscular transmission were not performed during this evaluation. Given the absence of a clear peripheral etiology for the patient's appendicular weakness, a central cause should be considered. MR HEAD W & W/O CONTRAST [**2155-7-12**] 12:16 PM Normal [**Month/Day/Year 4338**] of the brain with and without gadolinium. Brief Hospital Course: 31F with presumed sepsis due to pneumonia vs. urinary tract infection vs. IUD though all cultures negative developed ARDS requiring intubation. 1. Infection/sepis: At [**Hospital1 18**] [**Location (un) 620**], patient presented with fever/nausea/vomiting and had bibasilar infiltrates, abdominal pain and increased liver enzymes with bilirubin of 5.0. CT showed pericholic fluid and ?hydrosalpinx with IUD in place but was normotensive. On transfer, patient was intubated, hypotensive, on neosynephrine. Patient initially require blood pressure support with three pressors. However, patient was successfully fluid resuscitated to good blood pressure, pressors stopped and changed to levophed. Chest XRay consistent with ARDS. ERCP negative. Transvaginal ultrasound showed no hydrosalpinx, no tubovarian abscess, and some mild ovarian cysts, none dominant; there was free flowing fluid in the peritoneum and in [**Location (un) 6813**] pouch that did not appear purulent or bloody. Of note, echocardiogram revealed an ejection fraction of 30% of unclear etiology, although it was postulated due to postpartum cardiomyopathy. Per ID consultants, clinical picture may be consistent toxic shock syndrome, although toxin negative and no erythroderma. Clindamycin (d/c??????d [**6-29**]) was started for protein synthesis inhibition of toxin and Gr- covg, and oxacillin (d/c??????d [**6-29**]) for Gr+ coverage switched to vancomycin and piperacillin/tazo for better nosocomial coverage. Levofloxacin for legionella, atypical coverage. Flagyl for anaerobic and Clostridium difficile coverage in setting of diarrhea following antibiotics. IUD removed. As patient's hemodynamics improved, cultures continued to remain negative, and patient's clinical picture stabilized. Patient was weaned off pressors, and antibiotics were removed. Patient was transferred to the floor. Total microbiological workup revealed negative for: RPR, C diff, AFB, fungus, yeast, legionella, HIV, ASO, Stool studies negative for O/P, PCP, [**Name10 (NameIs) 57976**], RSV, cryptococcal antigen, gonorrhea, chlamydia, Hepatitis C Serology, Hantavirus, Aspergillus, HbS, anti-HepBS, anti-HepBc, [**Last Name (un) **], [**Last Name (un) **] IgM, Lyme, Babesiosis. 2. ARDS/hypoxia: Patient was ventilated with low tidal volumes to prevent volume trauma. Patient underwent broncheoalveolar lavage as well as thoracenteses which were both unrevealing, except for transudate in pleural fluid, which was otherwise negative for evidence of a source. ARDS gradually resolved, and patient was extubated without complications on [**2155-7-12**]. Patient's oxygen requirement remained stable for remaining hospital course. By the day of discharge, patient's respiratory symptoms had resolved completely. 3. Hyperbilirubinemia: No biliary pathology was identified by ERCP. Hyperbilirubinemia was therefore thought to be potentially due to sepsis, eg. Shock liver. 4. Bilateral Cranial Nerve VII Palsy: Following transfer to the floor, patient's only remaining issues were a bilateral cranial nerve VII palsy and generalized weakness. Of note, patient was not able to voluntarily close her eyes, close her lips, or smile. Therefore, patient was given lacrilube to protect her eyes, and speech and swallow consultants felt that patient should only have thickened liquids and pureed solids. Neurology consultants recommended a lumbar puncture, [**Date Range 4338**], thyroid studies, and EMG. Lumbar puncture and [**Date Range 4338**] were not revealing, although EMG was found to be abnormal although without a clear source. It was thought that the patient may have a paralysis secondary to the tape used to immobilize endotracheal tube during prolonged unit course. Over the course of the next two days on the floor, patient's facial weakness gradually improved. 5. Hyperthyroidism: At the end of the [**Hospital 228**] hospital course, patient's thyroid stimulating hormone was found to be low, and free thyroid hormone was elevated. This was correlated with her subjective feelings of tachycardia, tremor, and heat intolerance. Patient was treated with metoprolol for rate control with good effect. 6. Benzodiazepine withdrawal: Patient had been treated with fentanyl and versed for sedation while intubated in the unit, and following transfer from the floor, patient exhibited symptoms of benzodiazepine withdrawal including hypervigilance, tachycardia, and tremor. Patient responded well to benzodiazepines, and was placed on CIWA scale with chlordiazepoxide taper. As patient was continuing to have symptoms at the time of discharge, she was discharged with a chlordiazepoxide taper to be further managed by her primary care physician. At the time of discharge, all infectious workups had been negative, and patient's clinical issues had stabilized with only CNVII weakness, generalized weakness, and hyperthyroidism remaining. Patient was felt to be stable for discharge and to follow up with new primary care physician within two weeks of discharge as well as to follow up with infectious disease, neurology (for weakness and CNVII palsy), and endocrine (for hyperthyroidism). Medications on Admission: none Discharge Medications: 1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Disp:*1 tube* Refills:*2* 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Do not take if you feel light-headed or weak. Disp:*60 Tablet(s)* Refills:*2* 4. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:*1 * Refills:*2* 5. Chlordiazepoxide HCl 5 mg Capsule Sig: Two (2) Capsule PO twice a day for 3 days: Then take one cap twice a day for three days. Then take one cap once a day for three days. Then stop taking. Disp:*21 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Sepsis Acute Respiratory Distress Syndrome Bilateral Facial nerve palsy Hyperthyroidism Discharge Condition: Good Discharge Instructions: 1. Continue taking your medications as directed. 2. Follow up with the Endocrinologist for hyperthyroidism. 3. Follow up with your primary doctor, [**Doctor First Name 27656**] [**Doctor First Name **]. 4. Follow up with the Neurologist for your weakness. 5. You are scheduled for an [**Doctor First Name 4338**] of your neck to determine the source of your weakness. Please make sure to have it done. 6. Call your doctor ([**Telephone/Fax (1) 250**]) if you have fever, chills, shortness of breath, or worsening weakness, or come to the emergency room. 7. Continue to use the medications for your eyes as needed and cover them with moistened gauze when you sleep. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2155-7-22**] 1:30 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 540**], MD Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 8302**] Date/Time:[**2155-8-28**] 1:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 44382**] [**Name (STitle) **] Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2155-8-26**] 11:00 - Please call in advance to register. Provider: [**Name10 (NameIs) 4338**] Where: CC CLINICAL CENTER [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2155-7-17**] 8:30

[ "263.9", "482.9", "692.9", "038.8", "785.52", "995.91", "285.9", "518.82", "286.9" ]

icd9cm

[ [ [] ] ]

[ "33.24", "99.15", "03.31", "97.71", "70.0", "96.6", "99.04", "96.72", "34.91", "51.10" ]

icd9pcs

[ [ [] ] ]

11639, 11697

5588, 10767

315, 390

11829, 11835

1956, 5565

12549, 13334

10822, 11616

11718, 11808

10793, 10799

11859, 12526

1562, 1937

269, 277

418, 1254

1276, 1320

1336, 1547

8,195

167,541

19037

Discharge summary

report

Admission Date: [**2143-9-10**] Discharge Date: [**2143-9-19**] Service: HISTORY OF PRESENT ILLNESS: This is an 89-year-old gentleman, who has a history of known aortic stenosis. Was scheduled for aortic valve replacement with Dr. [**Last Name (STitle) 1537**] on [**9-13**], however, patient called Dr.[**Name (NI) 18056**] office, and stated he was having increasing shortness of breath. Patient was brought to [**Hospital1 69**] and admitted to the Cardiac Surgery service preoperatively for aortic valve replacement on [**9-10**]. PAST MEDICAL HISTORY: 1. Aortic stenosis. 2. Congestive heart failure. 3. Atrial fibrillation. 4. History of permanent pacemaker two months ago. 5. Status post colectomy for colon cancer. 6. Status post bilateral hip replacements. 7. Hard of hearing. 8. Osteoarthritis. PREOPERATIVE MEDICATIONS: 1. Lasix 40 mg p.o. q.d. 2. Lorazepam 1 mg p.o. q.i.d. 3. Digoxin 0.125 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone. Has a remote history of tobacco, quit 40 years ago. Admits to occasional EtOH. ADMISSION PHYSICAL EXAM: Pulse 82 with atrial flutter and V pacing, blood pressure 94/23, respiratory rate 20, and oxygen saturation on 3 liters was 95%. Physical exam was HEENT: Pupils are equal, round, and reactive to light with EOMI. Mucous membranes moist. Neck is supple. Lungs are clear to auscultation bilaterally. Heart is irregularly, irregular with a 3/6 systolic ejection murmur. Abdomen is soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly. Extremities are cool, no edema, and no varicosities. Carotids were 2+ with murmur radiating bilaterally. Chest x-ray showed left lower lobe collapse with effusion. HOSPITAL COURSE: The patient was taken to the operating room on [**9-11**] with Dr. [**Last Name (STitle) 1537**] for an aortic valve replacement with a #23 Bovine pericardial aortic valve. In the operating room, by transesophageal echocardiogram, it was noted the patient's ejection fraction was 35%. After cardiopulmonary bypass the ejection fraction improved to about 45%. Please see operative note for further details. The patient tolerated the procedure well. Transferred to the Intensive Care Unit in stable condition at low dosed dobutamine 2.5 mcg/kg/minute with adequate cardiac index and SPO2. Patient was weaned and extubated from mechanical ventilation on postoperative day #1 without difficulty. Patient required a Neo-Synephrine infusion on postoperative day #1 to maintain adequate systolic blood pressure. Patient's pulmonary artery catheter was removed on postoperative day #1 with adequate cardiac index. Patient's pacemaker was interrogated on postoperative day #1 by the Electrophysiology fellow, which shows that the pacemaker was functioning normally. Patient required 1 unit of blood transfusion on postoperative day #2 for a low hematocrit. Patient also received Lasix subsequently and on postoperative day #2, the patient was transferred from the Intensive Care Unit to the floor. Patient began working with Physical Therapy on postoperative day #2, and it was felt the patient could benefit from a stay at [**Hospital 3058**] rehab. Postoperative day #3 the patient began experiencing confusion and delirium. Patient's narcotic pain medicines were discontinued. Patient was started on Haldol with good result. Patient was restarted on digoxin per recommendation of Cardiology, and patient's diuretics were increased as patient continued to have lower extremity pitting edema. By postoperative day #5 and postoperative day #6, the patient's postoperative delirium and confusions have cleared. Patient continued on Haldol and this was decreased to Haldol at bedtime. Patient had been started on Lopressor and tolerated this well. Patient continued to ambulate with Physical Therapy and continued for aggressive diuretic treatment. On postoperative day #7, patient was started on an ACE inhibitor, which she tolerated well and on postoperative day #8, the patient was cleared for discharge to rehab. CONDITION ON DISCHARGE: Temperature max 98.1, pulse 66, atrial flutter with ventricular pacing, blood pressure 111/60, respiratory rate 18, on room air oxygen 97%. Patient is awake, alert, and oriented times three. Patient is hard of hearing, occasionally has difficulty understanding communicating. Denies any further hallucinations or confusion. Neurologically nonfocal. Heart: Irregularly, irregular, no rub, and no murmur. Lungs are clear to auscultation bilaterally. Decreased at the bilateral bases. Abdomen has positive bowel sounds, soft, nontender, nondistended, tolerating regular diet. Extremities are warm and well perfused. Lower extremities have 2+ pitting edema, and sternal incisions are clean and dry. Steri-Strips are intact. There is no erythema and no drainage. Derm stable. LABORATORY DATA: Hematocrit 33.8. Sodium 143, potassium 3.9, chloride 108, bicarb 28, BUN 23, creatinine 0.7, glucose 90. Patient had a PT and INR pending for today. Patient has a chest x-ray pending for today. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Zantac 150 mg p.o. b.i.d. 3. Enteric coated aspirin 81 mg p.o. q.d. 4. Tylenol 650 mg p.o. q.4h. prn. 5. Lopressor 12.5 mg p.o. b.i.d. 6. Dulcolax prn. 7. Digoxin 0.125 mg p.o. q.d. 8. Captopril 6.25 mg p.o. t.i.d. 9. Haldol 2.5 mg p.o. q.h.s. 10. Lasix 40 mg p.o. b.i.d. x2 weeks, thereafter, dose will be determined by patient's cardiologist, Dr. [**Last Name (STitle) **]. 11. Potassium chloride 40 mEq p.o. b.i.d. x2 weeks, thereafter dose will be adjusted by Dr. [**Last Name (STitle) **] with the Lasix. 12. Coumadin: Patient should have a daily dose of Coumadin which should be titrated for an INR of 1.5 to 2.0. DISCHARGE DIAGNOSES: 1. Aortic stenosis. 2. Status post aortic valve replacement. 3. Chronic atrial fibrillation. 4. Postoperative delirium and confusion. CONDITION ON DISCHARGE: The patient is to be discharged to rehab in stable condition. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [**Last Name (STitle) 1537**] in four weeks. The patient is to followup with Dr. [**Last Name (STitle) **] in two weeks. Patient is to followup with his primary care physician in four weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2143-9-19**] 09:44 T: [**2143-9-19**] 10:36 JOB#: [**Job Number 51991**]

[ "292.81", "427.31", "V10.05", "396.2", "398.91", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

5818, 5953

5143, 5797

1768, 4094

1120, 1750

846, 970

113, 549

6066, 6577

571, 820

987, 1104

5978, 6041

28,611

135,818

29186

Discharge summary

report

Admission Date: [**2123-3-8**] Discharge Date: [**2123-3-15**] Date of Birth: [**2056-4-30**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Ceftriaxone Attending:[**First Name3 (LF) 3984**] Chief Complaint: Seizure, respiratory failure Major Surgical or Invasive Procedure: Intubation with extubation, central line placement History of Present Illness: Ms. [**Known lastname 70206**] is a 66 y/o female with PMH of ESRD on HD, TTP, + HIT, and h/o CVA who presents after tonic clonic seizure witnessed at nursing facility at about 9:15 am (per neurology note). Patient was found by nursing staff at nursing facility with witnessed tonic clonic activity; no prior seizures. She received 2 mg ativan X 1 per nursing staff; EMS was called and the patient was intubated in the field for airway protection. On their arrival she was noted to have tonic clonic activity with deviation of eyes to the left. Oxygen sat prior to intubation noted to be 60-98%; fingerstick blood sugar 106. She was noted at that time to be bleeding from her mouth due to biting her tongue; she received 4 mg more ativan prior to arrival in ED and the seizure terminated one minute prior to arrival in the ED. In the ED, VS: T 99 HR 116, BP 130s-140s/80-100 RR 15 98%. She was given a dose of 1 g of vancomycin, and propofol for sedation. FFP, acyclovir, dilantin were ordered but not given in the ED. ROS was not obtainable as patient is intubated and sedated. Past Medical History: 1. s/p CVA ([**5-4**], with left facial drop) 2. HIT Ab + ([**2120**], s/p treatment with argatroban and Coumadin, PF4+ in [**4-5**]) 3. TTP (s/p plasmapheresis *10) 4. ESRD on HD (first HD, [**2121-9-5**], HD three days/week) 5. VRE septic thrombophlebitis in IJ ([**1-4**]) s/p linezolid) 6. C. difficile colitis with h/o failed flagyl 7. SLE (diagnosed [**2119**]) 8. HTN 9. ACD (baseline Hct from [**Date range (1) 70208**], 26---37) 10. Bowel and bladder incontinence 11. Peripheral vascular disease 12. Diverticulosis 13. Peptic ulcer disease 14. s/p Billroth II gastrectomy ([**2118**]) 15. Gout 16. ETOH abuse 17. Depression 18. s/p hysterectomy 19. h/o PE Social History: Pt worked as a nurse for [**Hospital6 70211**] in [**Location (un) 86**], but is currently retired. She came from [**Hospital1 **] prior to this admission. Her husband passed away 3 years ago. She has a son and two daughters, [**Name (NI) 24592**] and [**Name (NI) **]; daughter [**Name (NI) **] [**Last Name (NamePattern1) **] is her HCP. [**Name (NI) **] son lives locally with his wife, and they are supportive. She smoked for 8 years, [**1-31**] cigs/day, but quit ~40 years ago. She quit EtOH ~1 year ago, with previously heavy use. She denies illicit drug use. Pt states that she can obtain support from her relatives and friends. Family History: Non-contributory; daughter has scleroderma Physical Exam: (UPON TRANSFER OUT OF MICU) VS: wt 45 kg, T 98.1, BP 136/92, HR 107, RR 16, O2 98% on RA GEN: chronically ill appearing woman, alert, responds to voice commands, grinding teeth and with dysarthric speech, minimal comprehensible HEENT: right pupil with clouding, pupils minimally reactive b/l, no eye deviation noted LUNGS: clear to auscultation bilaterally CV: RRR, 2/6 systolic murmur at LUSB ABD: normoactive bowel sounds, minor facial grimace concerning for TTP, but pt cannot verbally verify EXTREM: no peripheral edema NEURO: Moves all extremities, but unable to assess strength, CN or sensation due to baseline mental status Pertinent Results: [**2123-3-8**] 10:55AM WBC-4.5 RBC-2.97* HGB-8.5* HCT-28.8* MCV-97 MCH-28.6 MCHC-29.4* RDW-18.3* [**2123-3-8**] 10:55AM NEUTS-66.2 BANDS-0 LYMPHS-23.6 MONOS-7.5 EOS-2.6 BASOS-0.1 HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2123-3-8**] 10:55AM GLUCOSE-82 UREA N-19 CREAT-4.4* SODIUM-140 POTASSIUM-5.8* CHLORIDE-100 TOTAL CO2-31 ANION GAP-15 [**2123-3-8**] 10:55AM CALCIUM-8.4 PHOSPHATE-3.6# MAGNESIUM-1.7 [**2123-3-8**] 06:48PM TYPE-ART RATES-/14 TIDAL VOL-500 PEEP-5 O2-50 PO2-237* PCO2-39 PH-7.54* TOTAL CO2-34* BASE XS-10 -ASSIST/CON [**2123-3-8**] 06:48PM LACTATE-1.2 [**2123-3-8**] 10:49PM ALBUMIN-2.5* [**2123-3-8**] 10:49PM ALT(SGPT)-6 AST(SGOT)-16 LD(LDH)-231 ALK PHOS-161* TOT BILI-0.4 CHEST (PORTABLE AP) Study Date of [**2123-3-13**] 3:37 PM A large bore catheter is present in the right IJ and terminates in the superior vena cava. Endotracheal tube has been placed and is in satisfactory position. Nasogastric tube terminates in the stomach. There is minimal atelectasis at the right lung base. The left lung appears grossly clear. MR HEAD W/O CONTRAST Study Date of [**2123-3-11**] 1:34 AM Limited study due to motion artifact. The ventricles have enlarged since [**2122-9-28**], and there is periventricular white matter hyperintensity raising a concern of hydrocephalus with transependymal resorption of CSF. CT ABDOMEN W/CONTRAST Study Date of [**2123-3-9**] 5:09 PM 1. No cause for the patient's fever is identified.ET tube should be retracted a little bit.This was subsequently discussed with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] by Dr [**First Name (STitle) **] [**Name (STitle) **].There is some atelectasis of the left lung and mild mucoid impaction. 2. Multiple hypodense kidney lesions which are too small to characterize. Stable left renal Angiomyolipoma. CT head: There is a new hypodense crescentic subdural along the convexity of the right frontoparietal vertix and adjacent to this, a lentiform hypodense epidural hematoma with maximal diameter approximately 1.9 cm. Associated with this, there is partial effacement of the right lateral ventricle and a 6 mm leftward subfalcine shift of normally midline structures. There is a smaller left frontal lentiform epidural hematoma with maximal dimension 7 mm, again hypodense. [**Doctor Last Name **]-white matter appears essentially preserved. There are perventricular white matter changes consistent with chronic micorvascular disease. Paranasal sinuses are clear, but there is partial opacification of the mastoid air cells bilaterally. There are degenerative changed of the mandibular head on the left- consider TMJ degeneration. IMPRESSION: 1. Subacute subdural and epidural hematomas with slight midline shift. 2. Opacification of the mastoid air cells probably reflect an infectious etiology. Portable TTE (Complete) Done [**2123-3-9**] at 11:26:31 AM The left atrium is elongated. Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect (clip #[**Clip Number (Radiology) **]), but this could not be confirmed on the basis of this study. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-30**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Good quality study. No vegetations seen. Normal global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Mildly dilated ascending aorta. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2123-2-2**], mitral regurgitation appears more prominent, although no vegetations/new structural heart abnormalities are seen to account for this. Brief Hospital Course: Patient initially admitted to the MICU. Review of her PMH revealed chronic subdurals. CT head revealed mass effect from the right sided epidural collection with partial effacement of the right lateral ventricle and a 6 mm leftward subfalcine shift of normally midline structures. [**Doctor Last Name **]-white matter appeared essentially preserved. LP was initially deferred for mass effect and admission INR was 2.2. Got Factor 9 and FFP to reverse coagulopathy. Neurosurgery was consulted and thought that the bleeds may have triggered seizures, thought NS intervention was not indicated given multiple comorbities and coagulopathy. ID was also consulted given concern that occult infection may be causing seizures. Evaluated for infection with blood (including mycolytic), urine culture and ultimately LP on [**3-12**] once patient was more medically stable. Work-up for infectious source thus far negative despite mildly low glucose in CSF. Was treated empirically with Acyclovir, Vancomycin, Bactrim and Caspofungin until [**2123-3-12**]. HSV culture still pending on transfer. Also had ophthamology consult for concern of candidal endophthalmitis given right corneal increased opacification. Consult concluded this was unlikely. She was additionally extubated [**2123-3-13**] without complication and has maintained adequate oxygen saturation during her MICU course. Renal has followed her throughout her course, and she continues to be dialyzed three times weekly. While in the ICU received a total of 7 units FFP and was transfused 2 units PRBC. Additionally, while in the MICU a family meeting was held concerning goals of care. Patient apparently has disliked HD for some time and appears unhappy and has limited ability to interact given her baseline mental status. Family decided to continued aggressive treatment for the time being. Upon transfer to the floor VSS at 97.8, 139/92, 96-106, 13-23 100%RA. There additionally was new concern for L arm swelling and UE ultrasound was obtained the day of transfer to evaluate for DVT. Preliminary read revealed nonocculsive clot in R subclavian and no thromboses on the left. She was also on po vancomycin taper for C. diff having failed Flagyl therapy. Primary team was also continuing to adjust dilantin dosing (corrected level is 30m which is a bit too high). She was previously on Coumadin for DVT and HIT positive with the plan to discuss these issues the following morning with Heme. The night of [**2123-3-15**], VS were checked at approximately 4:30 and patient was noted to be stable. Soon after, phlebotomy visited patient for AM lab draw and found her to be unresponsive. Code Blue was called and patient was asystolic on initial evaluation. Code was continued for 20-30 and patient was intubated during this, but she never regained a pulse. Patient expired [**2123-3-15**]. Medications on Admission: neutra-phos 1 pkt TID darbepoietin alfa 200 mcg once weekly mg oxide 400 mg daily reglan 5 mg tab TID MVI daily clonazepam 0.5 mg tid prn trazodone 12.5 mg daily prn agitation coumadin 3 mg daily zofran 4 mg q4h prn atarax 25 mg po q6h prn itching benadryl 25 mg po q6h prn itching tylenol 650 mg q6h prn bentropine 1 mg [**Hospital1 **] lopressor 25 mg [**Hospital1 **] amlodipine 2.5 mg once daily vitamin c 500 mg twice daily folate 1 mg daily protonix 40 mg daily K dur 20 meQ daily vitamin B complex daily vancomycin 125 mg PO q6h until [**3-10**], then q12h until [**3-17**] then daily until [**3-24**] then every other day until [**3-31**] then every 72h until [**4-7**] diet- pureed with thin liquids Discharge Medications: Patient expired [**2123-3-15**]. Discharge Disposition: Expired Discharge Diagnosis: Patient expired [**2123-3-15**]. Discharge Condition: Patient expired [**2123-3-15**]. Discharge Instructions: Patient expired [**2123-3-15**]. Followup Instructions: Patient expired [**2123-3-15**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "348.4", "710.0", "443.9", "432.1", "585.6", "403.91", "285.21", "V45.1", "446.6", "453.8", "274.9", "518.81", "345.10" ]

icd9cm

[ [ [] ] ]

[ "96.72", "39.95", "38.93", "03.31", "96.04" ]

icd9pcs

[ [ [] ] ]

11699, 11708

8029, 10881

317, 369

11785, 11820

3549, 5512

11902, 12064

2838, 2882

11641, 11676

11729, 11764

10907, 11618

11844, 11879

2897, 3530

249, 279

397, 1478

5521, 8006

1500, 2167

2183, 2822

2,337

140,546

30536

Discharge summary

report

Admission Date: [**2161-5-11**] Discharge Date: [**2161-5-15**] Service: MEDICINE Allergies: Penicillins / Tetracycline / Erythromycin Base Attending:[**First Name3 (LF) 6029**] Chief Complaint: Hypotension and hypoxia. Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a [**Age over 90 **] yo female with h/o PVD, dementia, GERD, HTN, h/o CVA and recent TIA, CAD, depression was found to be febrile to 101.2 and "generally uncomfortable" given tylenol and found to have O2 sat 86-89% on RA and 92 % on 2L and repeat T 102.2. She was brought to [**Hospital3 5365**] and CXR was performed which revealed a RUL PNA. She was tranferred to [**Hospital1 18**] for further management. She received levaquin, vancomycin and a chest CT was performed which revealed multifocal PNA. Bedside ultrasound revealed small pericardial effusion. She was also found to be hypotensive with SBPs 90s. She was given 1 liter NS in the ED with no imporvement. It was noted that her HCT was 24.8 down from 32 11 day prior per PCP. [**Name10 (NameIs) **] was guiac negative in the ED and there were no reports of bleeding on history. Of note she was recently started on aggrenox for possible TIA while on plavix. Her plavix was d/c'd. On admission to the MICU, she denied CP, SOB, Abd pain, BRBPR. Past Medical History: HTN CAD no known h/o of MI or stents CRI Dementia Depression GERD Wound MRSA Right sided mastectomy CVA with recent TIS while on plavix PVD Social History: Lives in [**Location 391**] [**Hospital **] nursing home with husband. They both have a legal guardian. Recently moved here from [**Location (un) **]. Family History: NC Physical Exam: General: Elderly female awakens to voice, oriented to person only Vitals: T 96.3 HR 78 BP 107/53 O2 sats 100% 2 L NC HEENT: MM dry CV: RRR, no m/g/r Pulmonary: isolated wheezes in RUL and occasional wheezes on left Abd: NABS, soft. NT/ND, no organamegaly EXT: no edema, 3 venous stasis ulcers on the tibial surface of LLE, minimal surrounding erythema, slightly moist purulent areas, minimally painful to touch, warm, 1+ DP pulses. Chronic venous stasis b/l LE. Neuro: oriented to person only. Moves all 4 extremities. Not able to fully participate in neuro exam Pertinent Results: CXR: 1) Enlarged cardiac sillhoutte with small bilateral effusions and mild congestive heart failure. Per discussion with the ordering resident, a pericardial effusion was seen on bedside ultrasound. 2) Right upper lung zone consolidation, likely pneumonia, less likely asymmetric edema. . CT chest: 1. Multifocal consolidation and peribronchial opacity in a dependent distribution, right greater than left, which likely represents multifocal pneumonia and is likely secondary to aspiration in the setting of a hiatal hernia. Multiple mediastinal nodes measuring up to 1.2 cm are likely reactive in nature. 2. Small-to-moderate pericardial effusion containing simple fluid. 3. Smooth septal thickening and bilateral, right greater than left, small pleural effusions, which likely represents mild CHF/hydrostatic edema. 4. Left adrenal mass, which does not meet the noncontrast CT criteria for adrenal adenoma. In the setting of mastectomy and likely history of cancer, this may represent a metastatic focus and if no prior studies are available for comparison, this could be further evaluated with triphasic CT or MRI. 5. Moderate height loss of the T11 vertebral body with replacement of the normal architecture by hypoattenuating lesion, which likely represents a hemangioma, however, with the history of malignancy, a metastatic focus cannot be ruled out. This is of unknown chronicity without priors and if no prior studies are available for comparison, this may be further evaluated with MR. 6. Abnormal opacity posterior to the left main stem bronchus of unclear etiology. While this may represent another focus of infection, a neoplastic mass cannot be excluded. Therefore, repeat CT with IV contrast is recommended after a course of treatment (i.e. four weeks). Above noted tracheal secretions can also be reevaluated at that time. . EKG: NSR, rate 77, nl axis, borderline first degree AV bloock, no ST T wave changes Brief Hospital Course: [**Age over 90 **] yo female with h/o dementia, CAD, HTN and CVA presenting with hypoxia and hypotension if multifocal PNA on chest CT and 7 point HCT drop . # Hypotension: Likely combination of dehydration, ? sepsis in addition to anemia, although no obvious source of acute blood loss. She was only given 1 liter of IVF and therefore was likely not adequately fluid resuscitated. After transfusing two units PRBCs and starting antibiotics, blood pressure stabilized; did not require pressors. Have restarted antihypertensives for BP control. . # Hypoxia: She was satting 100 % on 2 L on arrival to the ICU and appeared comfortable with a few wheezes in RUL. Likely [**3-13**] to PNA. She has minimal cough but is likely dry and may have increase cough with fluid resusitation. - Levaquin + flagyl for likely aspiration PNA (10 day course = through [**5-21**]) - Speech and swallow recommended ground solids and nectar liquids with 1:1 supervision for meals . # Fever: Likely [**3-13**] to PNA/aspiration event. She has been afebrile here. Also must consider RLE cellulitis as possible source but does not appear acutely infected - F/u blood cultures--NGTD - repeat urine culture negative; <100,000 colonies presumptive Strep bovis may have been contaminant - Wound care per wound nurse recommendations . # Elevated CE's: No evidence of ischemia on EKG and no CP. Trop trended down to 0.02. CK continues to trend up, but index unremarkable. ? elevated CK [**3-13**] to in setting of possible fall or ? medication effect. Unlilkely cardiac, but would only get medical management given age and overall poor status. Back on aggrenox, beta blocker, ACE inhibitor. . # Dementia: Oriented x1. This seems to be her baseline per her PCP [**Name Initial (PRE) **] Continue [**Name9 (PRE) 72519**] . # Depression/agitaion: continue celexa, seroquel and remeron monitoring closely for sedation and will hold [**Name9 (PRE) 25419**] for now . # Hypertension: Held lisniopril and metoprolol in the setting of hypotension and restarted yesterday. Will need to titrate if BP remains elevated. . #h/o CVA: re-started aggrenox . # Left mainstem bronchus and adrenal lesion: Radiology recommends repeat CT with contrast in 4 weeks; given advanced age and DNR/DNI status, will defer to outpatient PCP . #FEN: -ground solids and thickened liquids per S & S -per PCP [**Name Initial (PRE) 72520**]'t eat when away from husband . # Access: PIV # CODE: DNR/DNI confirmed with HCP # Dispo: Will discuss with CM to arrange return to NH Medications on Admission: TYlenol PRN MVI Citaopram 20 mg PO QD Lisinopril 20 mg PO QD Zinc 220 mg POQD Colace 100 mg PO BID Metoprolol 50 mg PO BID Vit C 500 mg [**Hospital1 **] Seroquel 37.5 mg PO Q9PM [**Name (NI) 10687**] PRN MOM PRN [**Name (NI) **] 50 mg PO Q6H PRN Seroquel 5 mg PO Q 5 PM Aggrenox i tab PO BID Prilosec 20 mg PO QD Remeron 30 mg Po QHS Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: through [**5-21**] to complete total 10 days for aspiration pna. 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days: through [**5-21**] to complete 10 days for aspiration pna. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. [**Month (only) 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Quetiapine 25 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 11. Galantamine 4 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**6-18**] MLs PO Q6H (every 6 hours) as needed for cough. 17. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: aspiration pneumonia, dementia, CVA and recent TIA, hypertension, h/o right sided mastectomy for breast cancer Discharge Condition: stable Discharge Instructions: Take all meals sitting up with supervision to reduce the risk of aspiration. . We increased lisinopril to 40mg daily for HTN. Followup Instructions: With Dr [**Last Name (STitle) 72521**] as needed. [**Telephone/Fax (1) 72522**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**]

[ "585.9", "799.02", "V10.3", "507.0", "403.90", "276.51", "707.13", "530.81", "294.8", "285.9" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

8721, 8801

4245, 6760

279, 285

8956, 8965

2283, 4222

9139, 9314

1680, 1684

7144, 8698

8822, 8935

6786, 7121

8989, 9116

1699, 2264

215, 241

313, 1333

1355, 1496

1512, 1664

1,569

108,540

13462

Discharge summary

report

Admission Date: [**2178-1-10**] Discharge Date: [**2178-2-5**] Date of Birth: [**2106-8-2**] Sex: F Service: MEDICINE Allergies: Aspirin / Heparin Agents / Morphine / Tylenol Attending:[**First Name3 (LF) 3556**] Chief Complaint: Hypotension at HD Major Surgical or Invasive Procedure: None History of Present Illness: 71 F with DM, cirrhosis [**3-7**] NASH and acetaminophen toxicity, h/o gastric angioectasia (GAVE/watermelon stomach) with GIB, ESRD on HD MWF, diastolic CHF, HIT, seizure dx on [**Month/Day (2) 13401**], admitted on [**1-11**] to the ICU for low hematocrit and hypotension. She went to HD on [**1-11**] where she was found to be hypotensive in the 70's and 80's systolic. Of note, ED documentation indicates that she may have received the wrong antihypertensive prior to dialysis. Patient does not recall what medications she may have received, and only vaguely recalls the events surrounding her dialysis. She had a recent hospitalization from [**Date range (1) 40795**] for fall complicated by tib/fib fracture, altered mental status (with contributions from UTI, hepatic encephalopathy, and hypercapnea from narcotic use), ESBL enterobacter UTI, and heme positive stools. In the ED, her BP was 86/p, HR 70, RR 16, Sat 100%RA. She was given 1L fluid, one unit of packed red cells, and platelets. She was guaiac positive. Blood cultures were drawn and stool was sent for C-diff. Inferior ST changes were concerning for ongoing ischemia, and she was transferred to the MICU. In ICU, patient was given 2 unit PRBC's and 1 unit of platelets. Her BP improved thereafter and Hct stabilized. She was then transferred to the floor for management. Past Medical History: Recent history includes multiple admissions in [**5-7**], and [**9-10**] for confusion in the setting of lactulose noncompliance, and in [**12-11**] for hypotension. In [**5-11**], she was diagnosed with GIB from gastric angioectasias/watermelon stomach. She was also found to have a portal vein thrombosis on ultrasound but was not anticoagulated for h/o GAVE, GIB, HIT. OTHER PAST MEDICAL HISTORY: - Portal vein thrombosis [**5-11**] but not anticoagulated for h/o GAVE, GIB, HIT - Type 2 diabetes. - End-stage renal disease, on hemodialysis M/W/F - Cirrhosis [**3-7**] NASH and acetaminophen toxicity. - Gastric angioectasia with h/o GI bleeding in 4/[**2177**]. - Diastolic CHF. EF>55% by echocardiogram in 7/[**2176**]. She has a prlonged mitral deceleration time and moderate MR. - ?right sided pleural effusion: diagnosed on U/S [**11/2176**], CXR showed a small effusion - stayed stable in subsequent imaging. - Heparin-induced thrombocytopenia, Ab+ in 1/[**2176**]. - History of seizure disorder, on [**Year (4 digits) 13401**]. - History of infection in the left knee. - History of MRSA and Clostridium difficile. - History of gram-positive rod bacteremia in 4/[**2177**]. - Status post ORIF of the left distal femur fracture 12/[**2175**]. Social History: She was recently discharged [**2178-1-8**] to [**Location (un) **] Manor in [**Location (un) **]. Her daughter is involved in her care. The patient currently denies alcohol use, tobacco use, and illicit drugs. Family History: Noncontributory. Physical Exam: On transfer to the floor... VITALS: Tm 97, Tc 95.9, Hr 73, BP 120/51, RR 14, 97%RA GENERAL: Comfortable, in no acute distress. [**Location (un) 4459**]: Sclerae icteric, OP clear, MMM, EOMI HEART: [**4-9**] holosystolic murmur, radiating to the axilla, audible across precordium. LUNGS: Mild crackles at left based, decreased on right, clear anteriorly ABDOMEN: Extremely Obese, soft, + bowel sounds. Cannot assess hepatosplenomegaly given body habitus. 2+ dependent edema. EXTREMITIES: 2+ edema bilaterally, 2+ DP pulses, LUE AV fistula with palpable thrill NEURO: A&O x 3, +mild asterixis, tremor. Pertinent Results: [**2178-1-10**] 05:00PM WBC-2.2* RBC-2.00* HGB-6.9* HCT-21.3* MCV-107* MCH-34.5* MCHC-32.4 RDW-21.5* [**2178-1-10**] 05:00PM NEUTS-61.6 LYMPHS-29.7 MONOS-5.6 EOS-2.9 BASOS-0.1 [**2178-1-10**] 05:00PM GLUCOSE-125* UREA N-17 CREAT-2.2*# SODIUM-144 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-30 ANION GAP-11 [**2178-1-9**] 04:45PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.7 [**2178-1-10**] 05:12PM LACTATE-3.0* [**2178-1-10**] 05:00PM CK-MB-NotDone cTropnT-<0.01 BLOOD CULTURES: [**1-13**] enterococcus and coag neg staph; [**1-15**] w/ GNR Urine cx 12/ll: mixed bacterial flora [**Last Name (un) **] U/S [**1-14**]: no e/o ascites but pleural effusion noted CXR [**1-15**]: stable right-sided pleural effusion Brief Hospital Course: 71 yo h/o gastric angioectasia (GAVE/watermelon stomach) with chronic GIB, type 2 diabetes, ESRD on HD (MWF), diastolic CHF, HIT, seizure dx on [**Month/Year (2) 13401**], admitted with hypotension and anemia in setting of chronic GIB and polymicrobial (proteus, enterococcus, coag neg staph) cultures from PICC line and AV fistula. #) BACTEREMIA: Patient w/baseline low blood pressures in 80s/90s likely [**3-7**] ESLD and generalized low systemic vascular resistence. Cortisol stim from [**1-20**]: 10.1->15.6. Patient also with PICC cultures growing pansensitive ENTEROCOCCUS FAECALIS and coag negative staph [**1-12**], CORYNEBACTERIUM SPECIES [**1-13**], PROTEUS MIRABILIS [**1-14**], and GNRs [**1-14**], [**1-16**], and VANC resistant ENTEROCOCCUS FAECIUM. Surveillance cultures since [**1-17**] has NGTD until [**Female First Name (un) **] on [**1-25**]. CT scan without clear abdominal source. Other source could be GI fistula (no fluid collection per US). TTE negative for vegetations and no TEE obtained as pt was not a surgical candidate given comorbidities. Antibiotics were planned for full four week course. ID followed her during her stay, and in the days preceeding her death, she was on a four drug pathogen-specific regimen. Despite these treatments, Ms. [**Known lastname 32662**] continued to have progressively poor hemodynamic stabily, until, despite pressors, her blood pressure declined causing cardiopulmonary arrest. #) Hypotension: Likely [**3-7**] to sepsis and low SVR due to ESLD. Required pressor support throughout her stay. Many family discussion were held, and, given her poor prognosis, it was decided that pressor support would not be escalated. Thus, despite these treatments, Ms. [**Known lastname 32662**] continued to have progressively poor hemodynamic stabily, until, despite pressors, her blood pressure declined causing cardiopulmonary arrest. #) Cirrhosis secondary to NASH/acetaminophen. Hepatologist Dr. [**Last Name (STitle) **]. Liver disease was end-stage upon admission. Total Bili and INR were monitor and continued to increase during her stay. Associated illnesses included coagulopathy, thrombocytopenia, hypotension and chronic GI bleed. Per Liver consult obtained while inpatient, she was not a transplant candidate. She was continued on rifaximin, ursodiol, and lactulose. Nadolol was held given hypotension. . #) Anemia/GI bleed. Has known chronic GI bleed from GAVE as well as insufficient erythropoeitin in setting of ESRD. Transfused for Hct less than 21. #) Thrombocytopenia. Chronic, most likely from splenomegaly and ESLD with poor thrombopoetin levels. Also has h/o HIT so heparin products were avoided. Transfused for platelets of < 10K for spontaneous bleed. #) ESRD on HD. Upon admission was requiring dialysis three times weekly, but becamed too hypotensive to tolerate HD. Per Renal, CVVH would be the next step, but this is not indicated given patient's continued hypotension and poor prognosis. #) Type 2 Diabetes: Well controlled while inpatient with insulin sliding scale and QID glucose monitoring. #) Diastolic CHF. Extravascular hypervolemia but continued to need pressor support to maintain adequate blood pressure. Thus, diuretics were held while inpatient. #) Seizure disorder. No observed seizures while in patient. Continued on [**Last Name (STitle) 13401**] at home dose. #) s/p L tib-fib fracture: First noted [**2177-12-17**] upon follow-up appointment with orthopedics s/p ORIF. Admitted with external brace. Orthopedics followied while inpatient and determined no additional interventions were required. Despite these treatments, Ms. [**Known lastname 32662**] continued to have progressively poor hemodynamic stabily, until, despite pressors, her blood pressure declined causing cardiopulmonary arrest. Medications on Admission: Pantoprazole 40mg Q12H Sevelamer 800mg TID with meals Urosdiol 300mg [**Hospital1 **] Rifaximin 400mg TID Levetiracetam 500mg daily Lactulose 30mL PO QID Propranolol 10mg [**Hospital1 **] Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Primary: Sepsis Secondary: ESLD, ESRD, Diastolic CHF, chronic anemia Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

[ [ [] ] ]

[ "99.05", "39.95", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

8705, 8714

4615, 8425

322, 328

8826, 8836

3875, 4592

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8860, 8870

3255, 3856

265, 284

356, 1704

2127, 2979

2995, 3206

19,066

173,701

45829

Discharge summary

report

Admission Date: [**2161-4-22**] Discharge Date: [**2161-5-1**] Service: MEDICINE Allergies: Aspirin / Phenobarbital / Meperidine / Penicillins / Codeine / Levofloxacin Attending:[**First Name3 (LF) 898**] Chief Complaint: cough Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] yo woman who presented to [**Hospital1 18**] on [**2161-4-22**] with cough and decreased mental status. In the ED, she had an episode of emesis, found to be hypertensive, hypoxic to 60s, diuresised, given Levofloxacin, and started on nitro drip. Of note, CXR in ED was without pneumonia though subsequent to the episode of emesis, CXR's with opacity. On arrival to the MICU pt was hypotensive and bradycardic, resolution on hypotension with titration off of the nitro drip. . In the MICU pt was diagnosed with aspiration pneumonia and treated with levofloxacin and flagyl. On her second night in the MICU she had an episode of staring consistent with seizure activity. Neurology was consulted, felt that episode was likely seizure and recommended discontinuing Levofloxacin and flagyl which decrease seizure threshold, titrating up [**Name (NI) **] (pt on this at home), and prn ativan for future spells. Since that episode there was no further seizure. . In review of medical history leading up to admission, pt hospitalized at [**Hospital1 18**] in [**3-2**] with shortness of breath but no evidence of pneumonia or CHF and was discharged to rehab. She was diagnosed with a UTI at rehab and completed a course of treatment. On [**2161-4-10**], she was discharged from rehab to home. Several days prior to admission, the patient noted dysuria and her VNA checked a UA that, by report, was consistent with a UTI as well. As a result, the patient's PCP placed her on Cipro for which she received one dose prior to presentation. On day of admission her niece noted that the patient overnight had increased coughing and ?shortness of breath. The niece was afraid she might have aspirated (she had not been eating at the time). The patient denied any chest pain. She did, however, develop a productive-sounding cough with no sputum. Of note, the niece noted that the patient also may have had difficulty swallowing full tablets recently. . On the day of admission, the patient then complained of nausea with mild, diffuse abdominal pain. She had no fevers or chills at home. One of her home health aides had been sick but did not come to work recently (1 week ago). . In addition, the patient's niece notes that she has had a change in her mental status on the day prior to presentation. At baseline, she is interactive with a microphone and headset (hard of hearing) but today, her mental status is depressed and she is not very interactive. . Currently pt complains only of cough. Denies fever, chest pain, abdominal pain. [**Name8 (MD) **] RN in ICU no diarhea, pt had wone BM in past 24 hours. Past Medical History: 1. S/P right cerebellar infarct 2. Macular degeneration resulting in legal blindness 3. Hypertension 4. Osteoarthritis 5. History of chorioretinitis 6. Diastolic heart failure. Echo [**10/2160**] with normal EF, E/A ratio 0.4. 7. S/P appendectomy complicated by peritonitis and urosepsis 8. H/O seizures- "Staring spells" complicated by fall in [**7-28**]. 9. RLQ Ventral Hernia seen on CT [**9-29**] 10. Presbyacusis with severe hearing impairment 11. Right bundle branch block 12. Ventral hernia. 13. ? Squamous cell cancer on face s/p excision 14. Duodenitis, gastritis 15. Appendectomy as child. Social History: The patient is a retired [**Hospital1 18**] nursing. She previously worked in the [**Hospital Ward Name 121**] building. She currently lives in a two-family house in [**Location 1268**] with her niece living upstairs. She does not cook nor independently cleans and bathes herself. She receives assistance from a home health aide who visits 3 times a week and she also has an assistant who stays with her from [**9-29**] pm. She is otherwise monitored by her niece by a baby monitor. She denies tobacco, alcohol, and drug use. She ambulates with a walker at baseline. She only recently got out of rehab 10 days ago. She has been admitted to the hospital several times in the last few months. Her niece works in the department of medicine at [**Hospital1 18**]. . Family History: Mother deceased from MI. Father died secondary to influenza infection. Physical Exam: Tc = 98.0 P= 80 BP= 125/45 RR=18 O2=100%RA . Gen: speaking easily HEENT:PERRLA, bilateral erythematous macules on face s/p excision of malignant skin disease Heart: Regularly irregular rhythm, Grade II/VI holosystolic murmur Lungs: Rhonchi in mid lung fields, mild crackles at bases Abdomen: Ventral hernia - reducible. discomfort on deep palpation of LLQ, active bowel sounds. No rebound/guarding/hepatosplenomegaly Ext: No C/C/E, +2 d. pedis bilaterally Neuro: awake and alert but could not cooperate due to difficulty hearing, mae Pertinent Results: Micro: UA negative, all cultures negative . Results/Images: . CXR: right peri-hilar opacity . KUB ([**4-22**]): no obstruction . Echo [**2160-11-5**]: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF> 55%). Regional left ventricular wall motion is normal. 2. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. . EKG: Rate 101, sinus tachycardia. RBBB with normal axis. No acute ST/TW changes. . RUQ ultrasound: no CBD dilation, nl liver Brief Hospital Course: Impression: [**Age over 90 **] yo F with h/o prior stroke, HTN, CHF EF > 55%, admitted with ?chf, aspiration pneumonia, change in mental status, now all resolving. . 1. Hypoxia: multifactorial. Aspiration right middle lobe PNA and possible flash PE were likely culprits. She was initially treated with levofloxacin and flagyl but given seizure activity (see below), this was changed to IV clindamycin. Patient clinically improved on this medication and was changed to PO augmentin several days prior to her discharge. Her last day of augmentin (to complete a 14 day total antibiotic course is [**2161-5-4**]). Of note, DFA was negative for influenza. Sputum culture was also unrevealing. At the time of discharge, patient is on low flow oxygen with daily improvement. Sputum production has lessened. . 2. aspiration: treated for pneumonia as above. Had speech and swallow evaluation twice during hospitalization and was felt safe for thin liquids. GERD thought to be a large component of her aspiration so high dose PPI with lansoprazole liquid [**Hospital1 **] was started. Scopolamine patch also helped secretions somewhat. She was on aspiration precautions with head of bed at >30 degrees at all times. Speech pathology recommended crushing all meds. . 2. Leukocytosis. Nausea, vomiting, abdominal pain initially in ED were nonspecific. KUB did not show obstruction. LFTs were unrevealing. RUS did not show any evidence of acute cholangitis. PNA remains most likely etiology. Resolved. . 3. Low UO - Patient was found to have low UO at the start of her admission. Ulytes showed FeNa 0.4%, Osm 516, she was given IVF boluses and her output improved. No active issues upon discharge. . 4. Absence seizure - patient has h/o of seizures that appears to have previously occured in a setting of her stroke, appears to have had an episode AM on [**4-23**] -> ativan 0.5 IV x 1, appears to have stopped the spell. Neurology service was consulted and recommended switching levoquin to other antibiotics. Her [**Month/Year (2) 74959**] was also increased to 300 mg PO BID. EEG [**4-24**]- showed only mild encephalopathy and no epileptiform features. Levaquin was added to her allergy list since it seemed to lower her seizure threshold. . 5. CHF, EF >55% : no evidence of vol overload on exam. given 80 mg Iv lasix in ED with good UO. Patient appears to be dry after the lasix with low UO. She received several IVF boluses while in the unit and tolerated themm well. Patient UO improved and she was restarted on her home dose of Lasix 20 mg QD as she appeared euvolemic. . 6. HTN: HTN urgency while in ED [**2-26**] aggitation. Also did not recieve home meds today. Patient was subsequently started on nitro gtt and became hypotensive. She was controlled with her home dose of Lopressor 12.5 mg PO BID and imdur 30. Imdur was stopped since this cannot be crushed. BP's stable off this medication. . 7. Mental status : ddx infection vs medication related, less likely new stroke or repetitive seizure. Patient was easily reoriented and remained at her baseline once the ativan given in ED wore off. She did have an episode of unresponsiveness in ICU that was attributed to complex partial seizure that resolved with 0.5 mg ativan x 1. At time of discharge, patient's mental status continues to improve. She is alert, oriented x 3 and conversant, appropriate. She is very hard of hearing. . 8. hard of hearing: uses microphone/headphones to chat. . 10. Code - The patient has a signed DNR form. Her HCP is formally her son but is being transferred by his attorney to include his wife, [**Name (NI) **], as well. Her number is [**Telephone/Fax (1) 97617**]. She works at [**Hospital1 18**] and can be reached during the day at [**Numeric Identifier 97618**]. Medications on Admission: Aspirin 81 mg PO QD Oxcarbazepine 150 mg PO BID Lopressor 12.5 mg PO BID Imdur 30 mg PO QD Lasix 20 mg PO QD Prevacid Trazadone 25 mg PO QHS prn Kdur 20 meq PO QD Cipro x 1 ([**4-21**]) Colace . Medications in MICU: . Metronidazole 500 tid Pantoprazole 40 qd Metoprolol 12.5 [**Hospital1 **] Heparin 500u tid Isosorbide mononitrate 30 qd Furosemide 20 qd Ceftriaxone 1 gm IV q12 Oxycarbazepine 300 mg po bid Discharge Medications: 1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) units Injection TID (3 times a day). 4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a day). 7. Oxcarbazepine 300 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 9. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 10. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 7 days: for candidal infection of groin. . 11. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 12. Trazodone 50 mg Tablet [**Hospital1 **]: [**1-26**] Tablet PO once a day as needed for insomnia. 13. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for Reconstitution [**Month/Day (2) **]: Five Hundred (500) mg PO Q12H (every 12 hours) for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: aspiration pneumonia resolved somnolence abscence seizure Discharge Condition: stable Discharge Instructions: Take all medications as directed. Followup Instructions: Follow up with your primary care doctor within one week of discharge from rehab. Completed by:[**2161-5-1**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11222, 11295

5536, 9296

287, 293

11397, 11406

5001, 5513

11488, 11599

4358, 4431

9755, 11199

11316, 11376

9322, 9732

11430, 11465

4446, 4982

242, 249

321, 2935

2957, 3559

3575, 4342

60,987

116,954

41810

Discharge summary

report

Admission Date: [**2103-8-13**] Discharge Date: [**2103-8-30**] Date of Birth: [**2021-11-16**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: fluent perseverative speech, confusion Major Surgical or Invasive Procedure: Intubation [**2103-8-13**] ([**Hospital6 302**]) History of Present Illness: [**Known firstname **] [**Initial (NamePattern1) **] [**Known lastname 7710**] is an 81-year-old man with history of HTN, HLD, prostate [**Hospital 4699**] transferred from OSH for seizure. History is obtained via chart review as patient is intubated. He was at physical therapy this AM for his left shoulder when he became confused, repetitive, and could not follow commands. This started at 09:40. When asked his name, he would respond, "[**Last Name (un) 46536**], my name," and would move all extremities on his own and speech was clear although he remained "confused." He was taken via EMS to [**Hospital3 **] ED and en route he had a seizure lasting 45-60 seconds and then was thought to be post-ictal afterwards. His FS was 90 and was thought to be in afib with a possible run of vtac per EMS while en route. Upon arrival to [**Hospital3 **] ED, T 96.7 P 80 RR 16 BP 140/67 100% on NRB. He was noted to be non-verbal, un-arousable, and unresponsive, with gaze to the right. After arrival he had another witnessed seizure in the ED, possibly lasting 30 seconds. He received a total of 4 mg ativan, 1 g dilantin, and then was intubated receiving etomidate, succinylcholine and propofol. A CT head prior to transfer was unrevealing. BP was transiently up to 216/99 P 119 prior to transfer. Per his PCP (Dr. [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) 90800**]) he has no history of seizure, stroke, or CNS infections and is a bright and independent person at baseline. Per EMS note he may have had a similar episode last month and was seen at [**Hospital6 302**] for that. Past Medical History: [] Cardiovascular - HTN, HLD [] Oncologic - Prostate CA (treated > 10 years ago) Social History: Lives with wife. Family History: Not known Physical Exam: At admission: Gen; lying in bed, intubated HEENT; NC/AT, ETT in place CV: RRR, II/VI SEM Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Skin; multiple ecchymoses on arms Neuro; MS; (off propofol x5 minutes) eyes closed but grimaces and briefly opens eyes to noxious. Does not follow any commands or attempt to speak. CN; eyes conjugate in midposition, pupils 3mm and minimally reactive. does not blink to threat. brisk corneals b/l. face obscured by ETT. + gag. Motor; normal bulk, increased tone in legs b/l. spontaneously moves arms and briskly withdraws all extremities to noxious stimuli. Reflexes; 1+ and symmetric at biceps, brachioradialis, and patellars. Toes upgoing b/l. __________________________________________________________ At discharge: Pertinent Results: [**8-13**] EEG - IMPRESSION: This extended routine video EEG telemetry captured no pushbutton activations. Automated and routine sampling captured several brief runs of sharp and slow wave discharges but no clinical correlate. The interictal period showed one every 1-1.5 second periodic epileptiform discharges over the left hemisphere. The background otherwise showed a well-organized posterior predominant rhythm on the right and generalized delta and theta frequency slowing over the left hemispheric leads. [**8-13**] CXR - IMPRESSION: Endotracheal tube ends approximately 5 cm above the carina. Given low lung volumes, bibasilar opacities likely represent atelectasis, although pneumonia cannot be excluded. [**8-14**] EEG - IMPRESSION: This is an abnormal continuous ICU video EEG telemetry due to a few brief electrographic seizures with no clinical correlation all occurring between 9:00 and 10:00 a.m. The interictal period showed one every 1-1.5 second periodic lateralized epileptiform discharges (PLEDs) over the left hemisphere. The background otherwise showed a well- organized posterior predominant rhythm on the right and generalized delta and theta frequency slowing over the left hemispheric leads. These findings are consistent with an epileptogenic focus in the left hemisphere related to an underlying structural lesion. The EEG was improved compared to previous day's recording as the electrographic seizures were shorter and less frequent. [**8-14**] MRI Brain c/s contrast - IMPRESSION: 1. T2 hypointense focus in the posterior aspect of the left thalamus with slowed diffusion and mild contrast enhancement, most likely representing a subacute infarct. With regard to enhancement, a followup study should be scheduled in four to six weeks to definitely rule out underlying mass such as lymphoma. 2. Evidence of global cerebral volume loss as well as sequela of chronic small vessel ischemic disease. [**8-16**] MRI/MRA/MR [**Month/Year (2) **] - BRAIN MRI: There are now new acute infarcts identified in the left posterior temporal and occipital regions since the previous study. The previously seen left thalamic infarct has evolved. There are no definite new infarcts identified in the right cerebral hemisphere. Previously noted changes of small vessel disease and brain atrophy are seen. There is no midline shift. There is no evidence of abnormal parenchymal, vascular, or meningeal enhancement seen. The MR [**First Name (Titles) 15758**] [**Last Name (Titles) 4059**] increase in time to peak in the left occipital lobe, corresponding to the region of infarct. No definite decreased blood volume is appreciated. Subtle increase in the time to peak is identified in the right occipital lobe. IMPRESSION: 1. Acute infarcts are now seen in the left posterior temporal and occipital lobes. No definite new infarcts are seen in the right cerebral hemisphere. 2. No enhancing brain lesions or mass effect is seen. Otherwise, the MRI of the brain is not changed since the previous study. 3. Increased time to peak is identified in the left posterior temporal and occipital lobes corresponding to the infarcts seen and could indicate ischemia. Subtle increased time to peak is identified in the right occipital lobe which could indicate ischemia in the right occipital region. However, no definite new infarct is seen in this region. MRA HEAD: The head MRA [**Last Name (Titles) 4059**] normal flow signal in the arteries of anterior and posterior circulation without stenosis or occlusion. IMPRESSION: Normal MRA of the Head. [**8-16**] EEG IMPRESSION: This is an abnormal continuous ICU video EEG telemetry due to two electrographic seizures in the right hemisphere maximum at T4 and P4 correlating with no clinical correlation on video. Also there were periodic lateralized epileptiform discharges (PLEDs) over the left hemisphere. The background otherwise was markedly suppressed and slow over both hemispheres occasionally reaching low amplitude theta frequency intermixed with delta. These findings are consistent with independent epileptogenic foci in both hemispheres likely related to underlying structural lesions. After 21:00, a burst suppression of background was seen related to midazolam administration. Compared to prior day's EEG, there were fewer and shorter electrographic seizures. [**8-17**] TTE w/bubble study The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler; single bubble contrast injection negative for right to left shunt at atrial level. No late contrast is seen in the left heart (suggesting absence of intrapulmonary shunting). 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 normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2 cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. If clinically indicated, a transesophageal echocardiographic examination is recommended. IMPRESSION: Suboptimal image quality. No obvious intracardiac mass or shunt. However, due to the technically suboptimal nature of this study, a cardiac source of embolus cannot be excluded. If clinically indicated, a transesophageal echocardiogram (with or without bubble study) is recommended to exclude cardiac source of embolus. [**8-17**] Carotid Duplex Series Impression: Right ICA with stenosis 40-59%. Left ICA with stenosis 60-69%. Antegrade bilateral vertebral artery flow. [**8-17**] EEG [**Known lastname **],[**Known firstname **] [**Medical Record Number 90801**] M 81 [**2021-11-16**] Neurophysiology Report EEG Study Date of [**2103-8-17**] OBJECT: ROE, EKG, VIDEO, [**8-17**] TO [**2103-8-18**]. REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] FINDINGS: ABNORMALITY #1: The background is markedly abnormal. It shows, for the vast majority of the record, that the two hemispheres appear to be working relatively independently of each other. Over the left hemisphere, there is a fairly persistent pseudoperiodic spike and wave and sharp slow wave discharge broadly present across the left posterior quadrant maximum in the region of the occipital pole. These discharges occur every two to four seconds and interposed between them is a period of marked electrical suppression. The bursts, themselves, in addition to having an epileptiform transient have frontal central irregular theta and suppression of electrical activity except for the spike wave discharge posteriorly. The right hemisphere has similar pseudoperiodic bursting but no clearly identified epileptiform transients. The periods vary from two to six seconds in duration and appear to be occurring relatively independently of the activity on the left. There is also marked suppression of electrical activity in the posterior quadrant on the right when the bursts themselves occur. At about 2:30 in the morning, the amplitude of the background bursts seem to increase slightly and there appeared to be more frequent synchronization between the two hemispheres. SLEEP: No cycling of sleep activity was identified. PUSHBUTTONS: There were no pushbuttons. SEIZURE DETECTIONS: Did not detect any sustained events. AUTOMATED INTERICTAL FILES: Almost all of the occipital sharp discharges from the left were detected. CARDIAC MONITOR: Shows a regular rhythm. IMPRESSION: This EEG gives evidence for an extremely severe diffuse encephalopathy that, curiously, appears independently in the two hemispheres. The right hemisphere appears to be a burst and burst suppressive pattern with no clear epileptic features. The left is a similar pattern seen with a different periodicity to the right and with an occipitally predominant broadly based epileptiform discharge seen with most of the bursts. There were no sustained seizures and most of the effect in the burst and burst suppressive pattern may very well reflect the effects of systemic medication. [**8-18**] UE US - IMPRESSION: Left distal cephalic venous thrombosis. [**8-18**] EEG IMPRESSION: This EEG continues to show a severe diffuse encephalopathy. In comparison to the previous 24 hours, most of this record was synchronous over the two hemispheres and there was little epileptiform activity from the left after 22:00 and, overall, it appears to be a slight improvement to the record. The pattern is still most in keeping with drug effect. [**8-19**] EEG IMPRESSION: This tracing still shows a fairly significant diffuse encephalopathy although the suppressive bursts appear to be somewhat shorter, particularly near the end of the record, on the morning of the 15th. On the morning of the 14th, there was one brief electrographic seizure from the right central temporal region that was not associated with a clinical accompaniment. [**8-20**] EEG IMPRESSION: This EEG did not capture any electrical evidence for sustained seizure discharges. A few isolated left occipital discharges were still seen but they occur very infrequently. The tracing is still compatible with a moderate to moderately severe diffuse encephalopathy with a bursting pattern of electrical activity and suppressive bursts. No clear laterality, except for the occipital discharges, was noted. [**8-21**] EEG IMPRESSION: This EEG gives evidence still for a moderately severe diffuse encephalopathy with suppressive bursts and intervening activity that appears more normal than on previous studies but still shows leftsided slowing, particularly over the more posterior aspects of the left hemisphere admixed with interictal sharp and epileptic spike discharges relatively infrequently in the left occipital pole. It should be noted that there was one brief electrographic seizure discharge from the right temporal central region lasting about 30+ seconds that appeared to be without any electrographic correlate. [**8-22**] EEG IMPRESSION: This EEG gives evidence for both encephalopathic as well as multifocal abnormalities. The encephalopathic features are loss of normal background and suppressive bursts. The epileptiform activity was seen in the left occipital pole and right mid-temporal and there appears to be fairly discrete right lateral temporal slow wave abnormality suggestive of additional structural pathology in that region. [**8-22**] NCHCT - IMPRESSION: 1. No evidence of hemorrhage, mass effect or shift in normally midline structures. 2. Evolution of known left parieto-occipital infarction, compared to previous studies. 3. Poorly-defined hypodensities in the superficial aspect of the right posterior occipital lobe; additional infarction (presumably, embolic) at this site is not excluded. [**8-23**] EEG IMPRESSION: This 24-hour recording shows a fairly persistent posterior left temporal slow wave focus suggestive of a subcortical structural lesion. The left occipital relatively rare epileptiform transients seem to increase significantly throughout the course of the record, both in their frequency of occurrence as well as their distribution. No sustained seizures, however, were identified and the background continues to be a diffusely abnormal encephalopathic pattern. Brief Hospital Course: 81 yo M h/o HTN, HL, prostate CA p/w perseverative and fluent speech disturbance and two convulsive seizures with post-ictal lethargy and confusion and left hemisphere seizure activity, likely secondary to a subacute posterior thalamic ischemic stroke. [] Status Epilepticus - At the OSH, he was given 4 mg of lorazepam, 1000 mg of phenytoin, was intubated at the outside hospital, and was sedated with Propofol. Phenytoin was switched to Fosphenytoin at transfer, and he was given an additional 500 mg IV since his Phenytoin was subtherapeutic. He had evidence of 20 second runs suggesting left hemisphere seizure activity and PLEDS despite the second loading dose. Valproate sodium was added for further seizure suppression. He was initially treated empirically for HSV encephalitis, but his LP cell counts were not suggestive of infection and his HSV PCR was negative. His MRI revealed a subacute left posterior thalamic ischemic stroke which may correlate with an antecedent event three weeks prior to admission when he was noted to be confused with right arm symptoms (described as pain at that time). He was started on aspirin and continued on his home medications for hypertension. A second [**Doctor Last Name 360**], valproate sodium, was added for further suppression as he was continuing to have frequent PLEDs. His Propofol was then weaned for possible extubation but he remained quite lethargic. Overnight on [**8-15**], he had electroencephalographic seizures affecting the right hemisphere as well as report of nonrhythmic arm and leg movements. We opted to switch from Propofol to Midazolam (as the patient was requiring IVF boluses to maintain blood pressure) and uptitrate for burst suppression. Concerned for new lesions, we obtained a repeat MRI with MRA and MR [**Month/Year (2) **] to identify a seizure focus (MR Spectroscopy was not readily available due to requirements to transfer the patient to another campus for which the patient was not stable enough). While the patient's Midazolam was being uptitrated, he had one 60 second right hemisphere electroencephalographic seizure at 20 mg/hr overnight on [**8-16**], but seizures where suppressed at 25 mg/hr. He had additional electroencephalographic evidence of seizures on [**8-17**], so Levetiracetam 500 q12h was started as a third antiseizure [**Doctor Last Name 360**]. He did not have any more EEG evidence of seizures over [**8-18**] and [**8-19**] but did on [**8-20**]; Epilepsy recommended to wean off the Midalazom infusion and Valproate Sodium. He was successfully weaned from the Midazolam infusion with gradually returning background activity, and we started simplifying his antiseizure regimen under close observation in the ICU. He was maintained on Fosphenytoin and Levetiracetam. His EEG gradually showed more return of background activity but continued to show sharp discharges from the left occipital lobe. His clinical exam very slowly recovered, first with brainstem reflexes and subsequently increased motor response to noxious stimuli and then eye opening. However, he never recovered the ability to attend to the examiner or follow commands. [] Acute Subacute Ischemic stroke - His initial MRI revealed a subacute stroke, likely affecting the left posterior choroidal artery. We suspected this event was likely the result of small vessel disease (hypertension), but artery-to-artery and cardioaortoembolic etiologies are also possible. As this event was subacute, he was started on an antiplatelet and kept normotensive. However, in light of the additional seizure activity, we pursued further imaging with a repeat MRI which revealed an acute ischemic infarction of the left occipital and temporal lobes, possibly the event that triggered the initial series of seizures. This was more strongly suggestive of artery-to-artery or [**Last Name (LF) 90802**], [**First Name3 (LF) **] we pursued a carotid/vertebral artery ultrasound and TTE. We increased his aspirin from 81mg to 325mg and kept him normotensive. Given the distribution of strokes suggesting an embolic source and normal vessel imaging with a report of AFib en route to the OSH, he will likely need anticoagulation for stroke prevention; he has a CHADS of 4. He started him on a Heparin GTT. [] Klebsiella pneumonia - On [**8-21**], the patient had two episodes of O2 desaturations in the setting of fever. He was found to have 4+ GNR which were identified as pan-sensitive Klebsiella. He was treated with Cefepime 2gm q12h initially, but his antibiotics were broadened to Cefepime, Vancomycin and Tobramycin due to worsening of his infection with increased leukocytosis. [] Acute Kidney Injury/Acute Tubular Necrosis - The patient's renal function worsening from [**Date range (1) 90803**] (peak of 2) in the setting of relative hypotension in the setting of his pulmonary infection requiring pressors and fluid boluses. His renal US was negative for obstruction or hydronephrosis and his FE Urea was most consistent with ATN, likely from hypoperfusion. His fluid status was monitored closely and his blood pressure stabilized. His antihypertensives were held. His renal function improved back to Cr 1.3 and he required further diuresis but continued to show signs of [**Last Name (un) **] (to Cr 3.1) whenever diuresis was pursued. He had anasarca and significant volume overload including pulmonary congestion which did not permit downtitration of his ventilator settings, yet his kidneys would not tolerate pharmacologic diuresis. [] Liver Dysfunction - The patient has a noted mild coagulopathy and synthetic dysfunction (low albumin), likely contributing to his third-spacing and peripheral edema. His wife agreed that as a young man it is likely that he had consumed excess amounts of alcohol, and he most recently was still drinking [**2-8**] glasses of hard liquor at a time. This baseline liver dysfunction has likely contributed to both his volume overload as well as his prolonged sedation from Midazolam. [] Goals of Care - Several discussions with the wife [**Name (NI) 17301**], [**First Name3 (LF) **] [**Name (NI) **], and other family members were held which revealed hope regarding the patient's prognosis but also understanding of the severity of his illnesses. In discussions with the family on [**8-29**], it was found that he actually had a living will which indicated that he would want to be DNR/DNI. The family came to the hospital on [**8-30**] and decided to make the patient DNR/DNI with goals of care directed toward Comfort Measures Only. He was extubated and placed on a morphine infusion for pain and air hunger. He passed away on [**2103-8-30**] at 3:30 PM of hypoxic respiratory failure. His family was notified and declined autopsy. Medications on Admission: -tricor 145 mg daily -zocor 80 -lisinopril 20 daily -folate 1 mg [**Hospital1 **] -norvasc 5 mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Seizures, Status Epilepticus Subacute ischemic stroke Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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Discharge summary

report

Admission Date: [**2118-8-14**] Discharge Date: [**2118-9-7**] Date of Birth: [**2054-3-21**] Sex: M Service: MEDICINE Allergies: Iodine / Nafcillin Attending:[**First Name3 (LF) 4393**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Insertion of temporary dialysis catheter x 2 Dialysis Diagnostic paracentesis History of Present Illness: Mr. [**Known lastname 15131**] is a 64year old male with hepatic sarcoidosis and NASH cirrhosis complicated by refractory ascites, LE edema, esophageal varices, s/p TIPS placement in [**Month (only) **] who initially presented to [**Hospital1 18**] with altered mental status. The patient was well compensated until about 1 year prior when he had a series of medical complications including a broken humerus c/b staph infection, interstitial nephritis, nephrectomy for benign renal cyst, and recent left hip fracture after another fall. The patient underwent hip surgery at the end of [**Month (only) **] in [**State 108**] and has spent the last month at [**Hospital1 9494**] Rehab. According to MD note from rehab, the patient's wife thought that he looked more sluggish on day of admission compared to the last few days. Patient denies this. The patient is on lactulose after TIPS procedure and had 4 BMs on Friday, [**1-10**] on Saturday, 2 BMs Sunday. An ammonia level was checked and found to be 160. The patient was brought in to [**Hospital1 18**] for further evaluation of hepatic encephalopathy. While in the ED, diagnostic paracentesis reviewed a WBC in 500s though on 8%PMN and patient was started on CTX. While on the floor, patient received 100g of albumin for SBP treatment. Expediated transplant work-up was also started. On day of transfer he was noted to be dyspneic and was hypoxic to low 90s on RA. He was given nebulizer treatments without improvement. EKG showed ?lateral ST changes with elevated troponin to 0.48. Patient was given aspirin and monitored telemetry. CXR revealed pulmonary edema and patient was given IV lasix 40mg. With no response, pt was given lasix IV 80mg and foley catheter was placed. He had total of 125cc UOP. Given ongoing respiratory distress, patient was transferred to MICU for closer monitoring. Past Medical History: 1) Decompensated cirrhosis [**2-10**] NASH/hepatic sarcoidosis ---last EGD was done at an OSH last year (no report), previous EGD @ [**Hospital1 18**] [**12/2114**] noted three cords of grade 1 esophageal varices. ---refractory ascites requiring serial paracentesis 2) Sarcoidosis dx [**2106**] and this diagnosis was based on hilar lymphadenopathy, raised ACE level, raised calcium and a mediastinal lymph node biopsy that showed granulomatous change. 3) Renal mass s/p left total nephrectomy [**12/2111**] (pathology noted that overall, the morphologic and immunophenotypic findings are consistent with a reactive lymphoid infiltrate.) 4) Elevated BMI. 5) Hyperlipidemia. 6) IDDM 7) Hypertension 8) CAD 9) nephrolithiasis s/p appy s/p lithortipsy s/p tonsilectomy s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] eye surgery Social History: -Tobacco history: None -ETOH: None -Illicit drugs: None -works at CPA -married w/ two adult children Family History: -father w/ DM Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, 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: diffusely wheezing Abdomen: soft, non-tender, mildly distended, obese, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAOx3, mild asterixis Pertinent Results: ============== ADMISSION LABS ============== [**2118-8-14**] 08:30PM BLOOD WBC-11.3* RBC-3.58* Hgb-11.6* Hct-37.4* MCV-105* MCH-32.5* MCHC-31.1 RDW-19.3* Plt Ct-332 [**2118-8-14**] 08:30PM BLOOD Neuts-72* Bands-2 Lymphs-8* Monos-9 Eos-3 Baso-0 Atyps-0 Metas-5* Myelos-1* [**2118-8-14**] 08:30PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-2+ Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Target-2+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 23262**] [**2118-8-14**] 08:55PM BLOOD PT-15.3* PTT-44.5* INR(PT)-1.4* [**2118-8-14**] 08:30PM BLOOD Glucose-89 UreaN-57* Creat-2.0* Na-136 K-3.6 Cl-101 HCO3-23 AnGap-16 [**2118-8-14**] 08:30PM BLOOD ALT-24 AST-47* AlkPhos-211* TotBili-4.0* [**2118-8-14**] 08:30PM BLOOD Lipase-76* [**2118-8-14**] 08:30PM BLOOD cTropnT-0.13* [**2118-8-14**] 08:30PM BLOOD Albumin-2.6* Calcium-10.3 Phos-3.1 Mg-2.6 [**2118-8-14**] 10:47PM BLOOD Lactate-1.7 [**2118-8-14**] 09:45PM ASCITES WBC-550* RBC-4350* Polys-8* Lymphs-1* Monos-0 Mesothe-1* Macroph-90* =============== BLEEDING LABS =============== [**2118-8-28**] 04:52AM BLOOD Ret Man-2.5* [**2118-8-30**] 06:30PM BLOOD Fibrino-160* [**2118-8-29**] 12:00PM BLOOD Hapto-<5* ============ ABG ============ [**2118-8-16**] 11:50PM BLOOD Type-ART pO2-73* pCO2-37 pH-7.43 calTCO2-25 Base [**2118-8-17**] 03:24AM BLOOD Type-ART pO2-68* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 [**2118-8-22**] 09:20AM BLOOD Type-ART pO2-75* pCO2-48* pH-7.28* calTCO2-24 Base XS--4 [**2118-8-22**] 01:24PM BLOOD Type-ART pO2-60* pCO2-46* pH-7.30* calTCO2-24 Base XS--3 [**2118-8-22**] 10:46PM BLOOD Type-ART pO2-59* pCO2-42 pH-7.38 calTCO2-26 Base XS-0 [**2118-8-23**] 12:07PM BLOOD Type-ART pO2-61* pCO2-44 pH-7.42 calTCO2-30 Base XS-3 =========== URINE LABS =========== [**2118-8-15**] 06:06PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2118-8-15**] 06:06PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2118-8-15**] 06:06PM URINE RBC-0 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 [**2118-8-15**] 06:06PM URINE CastGr-1* CastHy-3* [**2118-8-31**] 12:50PM URINE Color-AMB Appear-Cloudy Sp [**Last Name (un) **]-1.015 [**2118-8-31**] 12:50PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2118-8-31**] 12:50PM URINE RBC->182* WBC->182* Bacteri-MANY Yeast-MOD Epi-0 [**2118-8-27**] 02:37AM URINE CastHy-4* [**2118-8-20**] 04:22PM URINE Eos-NEGATIVE [**2118-8-20**] 09:30AM URINE Hours-RANDOM UreaN-323 Creat-106 Na-19 K-29 Cl-39 [**2118-8-20**] 09:30AM URINE Osmolal-325 ============== DISCHARGE LABS ============== [**2118-9-6**] 04:32AM BLOOD WBC-16.6* RBC-2.29* Hgb-7.3* Hct-23.2* MCV-101* MCH-31.9 MCHC-31.5 RDW-20.7* Plt Ct-133* [**2118-8-31**] 06:12AM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+ [**2118-9-6**] 04:32AM BLOOD PT-18.1* INR(PT)-1.7* [**2118-9-6**] 04:32AM BLOOD Glucose-181* UreaN-35* Creat-3.8*# Na-134 K-4.3 Cl-99 HCO3-28 AnGap-11 [**2118-9-6**] 04:32AM BLOOD ALT-24 AST-62* CK(CPK)-287 AlkPhos-134* TotBili-5.0* [**2118-8-17**] 04:00AM BLOOD CK-MB-29* MB Indx-20.3* cTropnT-0.62* proBNP-4513* [**2118-9-6**] 04:32AM BLOOD Calcium-8.5 Phos-4.6* Mg-2.2 ============== IMAGING ============== Coronary Cath [**2118-8-18**]: COMMENTS: FINAL DIAGNOSIS: 1. One vessel coronary artery disease with old, mid total occlusion of the LAD which has no break and is well collateralized. 2. Moderately severe pulmonary hypertension. . TTE [**2118-8-17**]: IMPRESSION: Normal biventricular cavity sizes with preserved regional and excellent global biventricular systolic function. Mild pulmonary artery hypertension. . CXR [**2118-8-17**]: Moderately severe diffuse infiltrative pulmonary abnormality has improved since [**8-16**], after worsening over the preceding two days. The interval change is probably resolving hydrostatic edema. Azygous distension persists indicating elevated central venous pressure or volume, and indicates a potential for further diuresis. Heart is top normal size. Pleural effusions are minimal, if any. . Anal Warts Biopsy: Anus, biopsy (A-B): Low grade squamous intraepithelial lesion (condyloma acuminatum). . CXR [**2118-8-20**]: FINDINGS: The heart continues to be mildly enlarged with bilateral alveolar infiltrates, upper lobe greater than lower lobe. The pulmonary vessels are ill-defined. A few Kerley B lines are seen. There are no definite effusions. It is unclear if this is due to pulmonary edema or underlying infection CXR [**2118-8-26**]: 1. Alveolar and interstitial pulmonary edema is still severe. It is slightly improved in the left upper lobe. 2. Left highly comminute humeral fracture is only partially included in this exam. Duplex U/S [**8-29**]: IMPRESSION: No deep vein thrombosis in left lower extremity. CT Pelvis/Leg [**8-30**]: (Wet Read) Large hematoma in the anterior compartment of the left thigh approximatley 12 x 5.5 x 15 cm. Small left knee effusion. Subacute periprosthetic fracture of the left hip CARIAC CATH [**8-30**]: Time Site Hgb (gm/dL) Sat (%) 11:08 AM PA 7.80 82 11:14 AM ART 7.80 99 11:18 AM RA 7.80 79 11:21 AM SVC 7.80 83 Cardiac Output Results [**8-30**]: Phase Fick C.O.(l/min) C.I. (l/min /m2) Baseline 14.35 6.72 Hemodynamic Measurements (mmHg) Baseline Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR RV 30 3 83 PCW 7 9 9 83 PA 30 8 17 83 RA 3 7 5 85 [**8-31**] CXR: FINDINGS: In comparison with the study of [**8-29**], there has been some decrease in the still substantial diffuse bilateral pulmonary opacifications. Hemidiaphragms are now more sharply seen. It is unclear whether a more erect position of the patient may account for the apparent improvement in the hazy opacification at the bases. ============ MICROBIOLOGY ============ [**8-14**] Peritoneal Cx: No growth [**8-14**] BCx: No growth [**8-27**] Urine: [**Numeric Identifier 961**]-100,000 Yeast [**8-30**] BCx: No growth [**8-30**] C diff negative [**8-31**] Urine: >100,000Yeast Brief Hospital Course: 64 yo male with h/o of hepatic sarcoidosis and NASH cirrhosis complicated by refractory ascites s/p TIPS, LE edema, esophageal varices initially admitted for hepatic encephalopathy with course complicated by [**Last Name (un) **], pulmonary edema, and demand ischema, now called out of the ICU after being transferred for acute Hct drop (s/p endoscopy showing portal gastropathy but no bleed on EGD); found to have L thigh hematoma. MICU [**Location (un) 2452**] course [**2025-8-25**] On [**8-27**], pt began to experience multiple melanotic stools and his hematocrit dropped from 34 to 25. Despite being transfused a unit of pRBC his HCT remained at 25. He was transferred back to the MICU on [**8-28**] for concern of ongoing upper GI bleed. In the MICU he was started on a PPI drip. He underwent an EGD on [**8-28**] which showed portal gastropathy but nothing to intervene upon. He was transfused more pRBC and had a PICC line placed for access. He was hemodynamically stable throughout his bleeding episode and was stable to be transferred back to the ET team. # Cirrhosis: Patient with Grade 1 varices with ascites. He has had intermittent encephalopathy throughout his admission. He presented with SBP and was treated and transitioned to PO ciprofloxacin for prophylaxis. He was being worked up for liver transplant, but his transplant status was post-poned until his acute status resolved. He was put on dialysis as a bridge to liver transplant initially, however he decided he wanted to pursue hospice care after multiple discussion regarding goals of care. Patient was made CMO on [**9-6**]. SW set pt and family up with inpatient hospice status. Pt expired on CMO early [**2118-9-7**]. # Anemia with acute hematocrit drop 2/2 L thigh hematoma - Patient with down trending hematocrit and melanotic stools, intially concerning for variceal bleed. [**2114**] EGD did show varices. He went to the MICU where no bleed was seen on EGD. Back on the floor, he was seen to have a left leg hematoma and dependent pitting edema, and CT confirmed large internal thigh bleeding. Vascular Surgery and Orthopedic Surgery had been consulted and did not feel there was anything to intervene on. Patient was given blood as needed. CK's were trended to ensure no compartment syndrome, as well as neurovascular checks frequently being done. His old left hip fracture appears well healed. His increased pain was managed with oxycodone. # [**Last Name (un) **] on CKD: Patient had Cr increase to 5.2 from b/l in the low to mid 2 range. Because of this, and fluid overload that was uncorrectable with diuretics, he was started on dialysis. Initially, his [**Last Name (un) **] was thought likely from volume overload and venous congestion. His urine sediment had no casts, so ATN unlikely. His urine eos were negative. Per renal, pre-renal vs HRS as FeNa is <1%. He received midodrine octreotide (5/100) without any improvement so it was stopped. He stopped his dialysis when he decided to become CMO. # Deconditioning: Patient walking with assist at [**Hospital1 9494**] Rehab Center. In hospital, he continued to deteriorate, in spite of interventions. Prior to being considered for transplant, patient was going to have to improve his functional status. There was concern that his L thigh hematoma would set pt back much further. Pt thus opted for CMO per above. # Hepatic Encephalopathy: presented with report of more lethargy per wife. [**Name (NI) **] is s/p TIPS, which can precipitate encephalopathy. He was on lactulose at rehab, with 2-4 BMs per day. A Ox2-3 throughout his hospital stay. Lactulose was titrated to prevent encephalopathy and Rifaxamin continued. # Leukocytosis- Patient's WBC peaked at 24, then slowly started down-trending. He had no infectious source seen (BCx, UCx, CXR). He had a couple dirty UA's but only thing that was found on his cultures were yeast, thought to be colonization from his previous foley catheter. It was thought that this was a leukemoid reaction from his thigh bleed. Diagnostic para considered but very small pocket of ascites so it was deferred. # Type II NSTEMI (Demand ischemia) - MB peaked at 29. TTE without hypokinesis, excellent function with elevated TR gradient. Initially, cath showed diffusely elevated pressures (per above). Old LAD occlusion, no acute changes. Repeat Cath on [**8-30**] showed much improved filling pressures after extensive diuresis. On metop, which was subsequently discontinued in setting of acute bleed. Continued atorvastatin. D/c'ed ASA due to acute bleed. # Hypoxia - Flash pulmonary edema and increased cardiac filling pressures resolving with dialysis. Pt was started on dialysis on [**8-22**]. Has lost 11kg since start of dialysis. Continued o2 supplementation prn. Nebulizer tx prn. Fluid restrictions: 500cc in. D/c'ed 5mg Metolazone and 160mg IV lasix when started on HD # S/p Hip and Shoulder [**Name (NI) 23263**] Pt was in rehab for shoulder and hip fx. Hip was activity as tolerated in rehab. Shoulder was being moved to prevent any difficulties with healing. # Elevated blood pressures - Started B-blocker in the setting of demand ischemia. DCd pt's hydralazine to allow for more room for beta blocker to be increased. Currently with SBP in the low 100s. Increased BP could be responsible for initial insult. Held B-blockers in setting of acute bleed. # Thrombocytopenia: Patient with decreased platelets since [**8-27**], which subsequently improved. # DM2: Patient initially allowed on insulin pump. However, deemed unsafe to use. Was then put on Lantus and SSI per Joslins recommendations. Transitional Issues: # DNR/DNI, CMO # Pt expired [**2118-9-7**] while CMO. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Aspirin 81 mg PO DAILY 2. Amlodipine 10 mg PO DAILY 3. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Target glucose: 80-180 4. Omeprazole 40 mg PO DAILY 5. Tricor *NF* (fenofibrate nanocrystallized) 145 mg Oral DAILY 6. [**Last Name (un) 390**] Forte *NF* (ursodiol) 500 mg Oral [**Hospital1 **] 7. Lactulose 45 mL PO TID 8. Ferrous Sulfate 325 mg PO BID 9. FoLIC Acid 1 mg PO DAILY 10. darbepoetin alfa in polysorbat *NF* 100 mcg/mL Injection QSUNDAY 11. Ascorbic Acid 500 mg PO DAILY 12. Nephrocaps 1 CAP PO DAILY 13. Zinc Sulfate 220 mg PO DAILY 14. Rifaximin 550 mg PO BID 15. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 16. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 17. HydrALAzine 10 mg PO Q8H 18. Miconazole Powder 2% 1 Appl TP QID:PRN butt rash Discharge Disposition: Expired Discharge Diagnosis: Primary diagnoses: Cirrhosis ESRD Acute L thigh hematoma Discharge Condition: Expired [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**] Completed by:[**2118-9-7**]

[ "585.6", "416.8", "578.9", "403.91", "V49.83", "250.03", "599.0", "998.12", "411.89", "V58.67", "285.1", "567.23", "584.9", "414.01", "135", "569.0", "V45.11", "572.2", "571.5", "518.4", "789.59", "275.42", "078.11", "287.5", "572.3" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "49.23", "37.21", "88.56", "38.97", "45.16", "54.91" ]

icd9pcs

[ [ [] ] ]

16586, 16595

9959, 15559

286, 365

16696, 16841

3763, 7066

3247, 3262

16616, 16675

15661, 16563

7083, 9936

3302, 3744

15580, 15635

239, 248

393, 2245

2267, 3112

3128, 3231

21,442

121,250

54180+54181+59584

Discharge summary

report+report+addendum

Admission Date: [**2129-1-8**] Discharge Date: [**2129-1-14**] Service: CHIEF COMPLAINT: Status post fall with left hip pain. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old gentleman with a history of coronary artery disease (status post coronary artery bypass graft), with aortic valve replacement in [**2113**], with known paroxysmal atrial fibrillation, and reactive airway disease who has a history of falls. The patient presents status post a mechanical fall at home with subsequent left leg pain and deformity. The patient was assessed and stabilized in the Emergency Department and was subsequently brought to the operating room for an open reduction/internal fixation of his left intertrochanteric fracture on [**1-9**]. The patient was subsequently difficult to wean from sedation and remained intubated in the Postanesthesia Care Unit following surgery. The patient had received metizoline and Fentanyl intraoperatively and 10 mg of morphine postoperatively. In the Postanesthesia Care Unit, the patient's blood pressure decreased to a systolic blood pressure of 78, and he spiked a fever to 101.7 degrees Fahrenheit. In addition, decreased urine output was noted. A phenylephrine drip was started, and the patient was transferred to the Intensive Care Unit where he subsequently was extubated. His blood pressure returned to baseline without pressors, and his mental status improved. In the Medical Intensive Care Unit, the patient had improved oxygenation, having adequate oxygen saturations on oxygen via nasal cannula at 3 liters to 4 liters. He required multiple normal saline boluses to maintain his urine output at greater than 20 cc per hour. He did have an episode of paroxysmal atrial fibrillation on [**1-9**] and required one unit of packed red blood cells for a hematocrit of less than 28. The patient remained disoriented, at baseline. He complained of mild nausea. No chest pain. No shortness of breath. He noted pain at his left hip which was worse with movement. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post coronary artery bypass grafting and aortic valve replacement with a Porcine valve in [**2123**]. 2. Benign prostatic hypertrophy; status post transurethral resection of prostate. 3. Paroxysmal atrial fibrillation. 4. Anemia secondary to iron deficiency anemia and chronic gastrointestinal bleeds. 5. Hypothyroidism. 6. Congestive heart failure (with a prior transthoracic echocardiogram in [**2113-3-20**] with normal left ventricular systolic function with mitral regurgitation noted). 7. Reactive airway disease. 8. Recurrent mechanical falls; status post right hip fracture with open reduction/internal fixation and fracture of the ramus. 9. Decreased hearing. 10. Cataract surgery. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Lasix 20 mg by mouth once per day. 2. Singulair 10 mg by mouth once per day. 3. Protonix 40 mg by mouth once per day. 4. Albuterol 2 puffs inhaled four times per day. 5. Levoxyl 37.5 mcg by mouth once per day. 6. Detrol 1.5 mcg by mouth every day. SOCIAL HISTORY: The patient is retired. He lives with his wife. [**Name (NI) **] has a 24-hour care taker. He has a remote history of tobacco abuse. Rare ethanol use. PHYSICAL EXAMINATION ON PRESENTATION: On general physical examination, the patient was a frail and elderly gentleman who was disoriented. He was in no acute distress. Vital signs on transfer from the Medical Intensive Care Unit revealed the patient's temperature was 98.2 degrees Fahrenheit, his heart rate was 100, his blood pressure was 108/60, his respiratory rate was 20, and his pulse oximetry was 92% on 4 liters. Head, eyes, ears, nose, and throat examination revealed extraocular muscles were intact. The pupils were equal, round, and reactive to light. The mucous membranes were moist. The oropharynx was clear. The neck was supple. No lymphadenopathy. No jugular venous distention appreciated. Lung examination revealed a poor effort. Decreased breath sounds throughout and course at the bases. Mild end-expiratory wheezes. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. The abdomen was soft, mildly distended, and mild tenderness on the right. Positive bowel sounds. No masses. Extremity examination revealed 1+ edema at the ankles (right greater than left). Left hip with tenderness and swelling. Neurologic examination revealed cranial nerves II through XII were grossly intact. The patient was disoriented to time and place. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data on admission revealed the patient's white blood cell count was 11.5 and his hematocrit was 35.3. Differential on the white blood cell count revealed 69.8% neutrophils, 23.3% lymphocytes, 4.2% monocytes, 2.1% eosinophils, and 0.6% basophils. The patient's INR was 1.2, his prothrombin time was 13.7, and his partial thromboplastin time was 32.6. Electrolytes revealed the patient's sodium was 142, potassium was 3.5, chloride was 103, bicarbonate was 31, blood urea nitrogen was 30, creatinine was 1.1, and blood glucose was 164. The patient's albumin was 3.4. His calcium was 8.4, his phosphate was 3.4, and his magnesium was 2.5. His creatine kinase was 30. His CK/MB was 2. His troponin was less than 0.01. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram on admission revealed atrial fibrillation at a rate of 83 beats per minute, normal axis, normal intervals, poor R wave progression, and nonspecific ST-T wave changes in the inferior and lateral leads. No acute ischemic changes. A chest x-ray on admission revealed mild congestive heart failure with a small right pleural effusion. Left hip films revealed an intertrochanteric fracture of the left proximal femur was seen. ASSESSMENT AND PLAN: The patient is a [**Age over 90 **]-year-old gentleman with coronary artery disease (status post coronary artery bypass graft and aortic valve replacement) with known paroxysmal atrial fibrillation and a history of falls who presented with a left femur intertrochanteric fracture after a mechanical fall at home. The patient required open reduction/internal fixation of his left femur and subsequent Medical Intensive Care Unit stay. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. ORTHOPAEDIC ISSUES: The patient was status post left femur open reduction/internal fixation. The Orthopaedic team continued to follow and manage the operative wound. The patient was advanced to left lower extremity touchdown weightbearing status. A Physical Therapy consultation was ordered to facilitate rehabilitation. Per the Orthopaedic team recommendations, the goal INR was set at 1.5 to 2. The patient's left leg wound remained clean, dry, and intact (per the Orthopaedic team). He continued to have good distal perfusion and sensation in his left lower extremity. He was to follow up with Dr. [**Last Name (STitle) 12528**] (his orthopaedic surgeon) as an outpatient two weeks following the surgery. Tylenol was continued for pain management. 2. CARDIOVASCULAR ISSUES: A perioperative beta blocker was initiated prior to the patient going to surgery. This beta blocker was continued throughout the [**Hospital 228**] hospital stay and was continued at the time of discharge. The patient did have an episode of hypotension while in the Postanesthesia Care Unit after surgery. A phenylephrine drip was started. Upon transfer to the Medical Intensive Care Unit, the patient was weaned from the phenylephrine drip, and his blood pressure returned to his baseline with intravenous fluids. The patient did rule out for a myocardial infarction during his hospitalization. During the [**Hospital 228**] Medical Intensive Care Unit stay, and for two days subsequent, the patient was noted to have low marginal urine output. Fluid boluses were given to maintain his urine output. The patient had presented in atrial fibrillation and had recurrence of atrial fibrillation during his one day stay int he Medical Intensive Care Unit. Subsequently, the patient was noted to be in a normal sinus rhythm. 3. HEMATOLOGIC ISSUES: The patient required two units of packed red blood cells perioperatively. He received an additional unit of blood during his Medical Intensive Care Unit stay on [**1-9**] and another unit on [**1-12**] for a hematocrit of less than 28. His anemia was thought to be related to intraoperative bleeding and postoperative changes due to femur repair. There was no evidence of significant bleeding at the left femur site (per the Orthopaedic team assessment). There was no hematoma formation. With regard to the patient's anticoagulation, the patient did initially receive Coumadin 5 mg by mouth while in the Medical Intensive Care Unit. His INR became markedly elevated above 5. Coumadin was held for the remainder of his hospital stay, and his INR trended down toward the goal of 1.5 to 2. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] will follow his anticoagulation status during his stay at rehabilitation and subsequently. 4. INFECTIOUS DISEASE ISSUES: The patient had a fever to 101.7 degrees Fahrenheit postoperatively. He had no obvious signs of infection after surgery, and the patient was continued on cefazolin intravenously q.8h. for approximately three days (per Orthopaedic Surgery recommendations). The patient remained afebrile and stable. Urine cultures and blood cultures showed no growth. A chest x-ray showed no infiltrate. A urinalysis was negative. His white blood cell count trended downward throughout his hospital stay. 5. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient required intravenous fluids to maintain his urine output at greater than 20 cc to 30 cc per hour. He was continued on a cardiac-prudent, 2-gram sodium, and ground diet (per the recommendations of the Speech and Swallow Service who evaluated him on [**1-12**]). The patient required repletion of his potassium several times during his hospital stay. 6. RESPIRATORY ISSUES: The patient required 4 liters of oxygen through nasal cannula at the time of transfer from the Medical Intensive Care Unit. He remained on 4 liters for the next days. He was intermittently wheezing during this time and did require albuterol nebulizer treatments on several occasions. The patient was eventually weaned to room air where he did have adequate oxygen saturations in the low 90s. 7. PROPHYLAXIS ISSUES: The patient was continued on a proton pump inhibitor and anticoagulation throughout his hospital stay. 8. CODE STATUS ISSUES: The patient remained do not resuscitate/do not intubate throughout his hospital stay. DISCHARGE DISPOSITION: The patient was to be transferred to [**Hospital3 **] for rehabilitation. CONDITION AT DISCHARGE: The patient was hemodynamically stable, afebrile, tolerating touchdown weightbearing status of his left femur. The patient remained disoriented to time and place (as is his baseline). DISCHARGE STATUS: The patient was transferred to rehabilitation extended care facility. DISCHARGE DIAGNOSES: 1. Left intertrochanteric femur fracture. 2. Congestive heart failure. 3. Anemia. 4. Coronary artery disease. 5. Paroxysmal atrial fibrillation. 6. Hypothyroidism. 7. Reactive airway disease. MEDICATIONS ON DISCHARGE: 1. Tylenol 325-mg tablets one to two tablets by mouth q.4-6h. as needed (for pain). 2. Metoprolol 25 mg by mouth twice per day (hold for a systolic blood pressure of less than 100 or a heart rate of less 60). 3. Levothyroxine 25 mcg by mouth every day. 4. Albuterol nebulizer inhaled q.6h. as needed (for shortness of breath). 5. Albuterol meter-dosed inhaler 1 to 2 puffs inhaled q.4-6h. as needed (for shortness of breath or wheezing). 6. Docusate sodium 100 mg by mouth twice per day. 7. Montelukast 10 mg by mouth once per day. 8. Pantoprazole 40 mg by mouth once per day. 9. Warfarin 1 mg by mouth at hour of sleep (to be started n [**1-13**] with INR monitoring daily and dose adjustment by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] or in house physician; with a goal INR of 1.5 to 2). 10. Lasix 20 mg by mouth once per day as needed (for weight gain of greater than 2 kilograms or as instructed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**]). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to be followed by [**Hospital3 **] by his primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] (telephone number [**Telephone/Fax (1) 608**]). Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] will manage the patient's anticoagulation and Coumadin dose adjustments during his stay at [**Hospital3 **]. 2. The patient was instructed to keep his appointment with Dr. [**Last Name (STitle) 12528**] (his orthopaedic surgeon) on [**1-24**] at 9:45 in the morning to follow up on his left femur fracture. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**] Dictated By:[**Last Name (NamePattern1) 1615**] MEDQUIST36 D: [**2129-1-13**] 07:58 T: [**2129-1-13**] 08:17 JOB#: [**Job Number 50741**] Admission Date: [**2129-1-8**] Discharge Date: [**2129-1-14**] Service: Medicine HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old male with a history of coronary artery disease, status post coronary artery bypass graft in [**2113**] with an aortic valve replacement, paroxysmal atrial fibrillation and reactive airway disease who has a history of falls who presented status post fall with left leg pain. In the Emergency Department he had a negative head computerized tomography scan and was found to have fracture of his left femur, intertrochanteric fracture. HOSPITAL COURSE: On [**1-9**], the patient was brought to the Operating Room for open reduction and internal fixation of this fracture. Subsequently the patient was difficult to wean from sedation and remained intubated. The patient had received Midazolam and Fentanyl intraoperatively and 10 mg of Morphine postoperatively. In the Post Anesthesia Care Unit the patient became hypotense with an systolic blood pressure down to 78 and had spiked a fever to 101.7. He was also noted to have a decreased urinary output. A Phenylephrine drip was started. The patient was transferred to the Medicine Intensive Care Unit and subsequently had been extubated. Intravenous pressors were discontinued and his mental status improved. In addition, the patient's oxygenation improved to adequate oxygen saturation on oxygen nasal cannula 3 to 4 liters. He required multiple normal saline boluses to maintain his urine output greater than 20 cc/hr. He did have an episode of atrial fibrillation on [**1-9**]. On presentation to the medical service, the patient complained of mild nausea, no chest pain, no shortness of breath, no dizziness. He notes pain of his left leg with movement. He is disoriented and is generally a poor historian. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass grafting and aortic valve replacement with porcine valve, [**2113**]; 2. Benign prostatic hypertrophy, status post transurethral resection of prostate; 3. Paroxysmal atrial fibrillation; 4. Anemia due to iron deficiency with chronic gastrointestinal bleed; 5. Hypothyroidism; 6. Question of congestive heart failure, left transthoracic echocardiogram in [**2113-3-20**] with normal left ventricular systolic function and mitral regurgitation noted; 7. Reactive airway disease; 8. Recurrent mechanical falls with prior right hip fracture with open reduction and internal fixation; 8. Fracture of the ramus; 9. Decreased hearing; 10. Cataract surgery. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Lasix 20 mg p.o. q.d.; Singulair 10 mg p.o. q.d.; Protonix 40 mg p.o. q.d.; Albuterol 2 puffs inhaled q.i.d., Levoxyl 37.5 mcg p.o. q.d.; Detrol 1.5 mg p.o. q.d. SOCIAL HISTORY: The patient is retired and lives with his wife. [**Name (NI) **] has a 24 hour caretaker. [**Name (NI) **] has a remote tobacco abuse history and rare ethyl alcohol consumption. PHYSICAL EXAMINATION ON ADMISSION: Elderly frail male in no acute distress. Vital signs revealed temperature 98.2, heartrate 100, blood pressure 108/60, respiratory rate 20, pulse oximetry 92% on 4 liters. Head, eyes, ears, nose and throat, extraocular movements intact, pupils equal, round and reactive to light, moist mucosal membranes, oropharynx clear. Neck, supple, no lymphadenopathy and no jugulovenous distension. Lungs, poor effort, decreased bowel sounds throughout, coarse at the bases, mild end-expiratory wheezes. Heart regular rate and rhythm. Normal S1 and S2. Abdomen soft, mildly distended, mild tenderness at the right. Positive bowel sounds. No masses. Extremities, 1+ edema at the ankles, right greater than left. Left hip with tenderness. Neurologic, cranial nerves II through XII grossly intact. Disoriented to time and place. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**] Dictated By:[**Last Name (NamePattern1) 1615**] MEDQUIST36 D: [**2129-1-13**] 07:08 T: [**2129-1-13**] 07:34 JOB#: [**Job Number 111049**] Name: [**Known lastname 18222**], [**Known firstname **] Unit No: [**Numeric Identifier 18223**] Admission Date: [**2129-1-8**] Discharge Date: [**2129-1-14**] Date of Birth: [**2029-6-23**] Sex: M Service: ADDENDUM: The patient remained in the hospital from [**2129-1-13**], to [**2129-1-14**], due to concerns about his respiratory status requiring oxygen intermittently yesterday with intermittent Albuterol nebulizer treatments and Atrovent nebulizer treatments. The a.m. of [**2129-1-14**], the patient was back to adequate oxygen saturation in room air. Due to concerns about lower extremity edema, left side greater than right, on [**2129-1-13**], a lower extremity ultrasound was done which did rule out deep vein thrombosis. The patient was cleared for discharge by covering physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Please see prior discharge summary for discharge diagnoses and discharge recommendations. MEDICATIONS ON DISCHARGE: 1. Pantoprazole 40 mg p.o. once daily. 2. Montelukast 10 mg p.o. once daily. 3. Fluticasone two puffs inhaled twice a day. 4. Albuterol meter dose inhaler two puffs inhaled four times a day as needed for shortness of breath or wheezing. 5. Docusate Sodium 100 mg p.o. twice a day. 6. Senna tablets one tablet p.o. twice a day as needed for constipation. 7. Levothyroxine 25 mcg p.o. once daily. 8. Metoprolol Tartrate 50 mg one half tablet p.o. twice a day, hold for systolic blood pressure less than 100, heart rate less than 60. 9. Albuterol Sulfate 0.083% solution one nebulizer inhaled q4-6hours p.r.n. shortness of breath or wheezing. 10. Acetaminophen 325 mg p.o. one to two tablets q4-6hours as needed for pain. 11. Coumadin 1 mg p.o. once daily. Please have INR drawn each day and have on call medical doctor adjust dose for goal INR of 1.5 to 2.0. 12. Lasix 20 mg p.o. once daily p.r.n. weight gain greater than two kilograms or as instructed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. 13. Ipratropium Bromide 0.02% solution one nebulizer inhaled q6hours p.r.n. shortness of breath or wheezing. CONDITION ON DISCHARGE: Stable tolerating full diet with oxygen saturation within acceptable limits in room air, hemodynamically stable and afebrile. The patient was cleared for transfer to [**Hospital3 643**] today. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 872**] Dictated By:[**Last Name (NamePattern1) 8843**] MEDQUIST36 D: [**2129-1-14**] 10:41 T: [**2129-1-15**] 15:56 JOB#: [**Job Number 18224**]

[ "427.31", "285.1", "428.0", "518.81", "998.11", "458.29", "998.0", "V42.2", "820.21" ]

icd9cm

[ [ [] ] ]

[ "79.35", "96.71" ]

icd9pcs

[ [ [] ] ]

10846, 10931

11243, 11443

18590, 19735

16077, 16240

14044, 15266

12535, 13524

6419, 10822

10946, 11222

101, 139

13553, 14025

16474, 18564

15289, 16050

16257, 16459

19760, 20225

747

130,986

5517+55680

Discharge summary

report+addendum

Admission Date: [**2147-3-7**] Discharge Date: [**2147-3-7**] Date of Birth: [**2063-3-10**] Sex: M Service: MEDICINE Allergies: Amlodipine Attending:[**First Name3 (LF) 3556**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: Expired History of Present Illness: (per OMR and the patient's family as he is unable to give history due to AMS): 83 yo male with DM, COPD, h/o MSSA PNA, CHF (multiple recent hospitalizations for decompensated CHF), AVR with restenosis (valve area 1.2 in [**Month (only) **]), recent admission for new Afib and symptomatic NSVT (no intervention but BB uptitrated), found to have worsening O2 status at his rehab. Patient's daughter went to visit him at reham yesterday and his 02 was 'in the low 80s' on oxygen and he was coughing (non-productive). They decided to try to increase his 02 and wait overnight to see if there was improvement, was given morphine sulfate x3 but had no improvement so family brought him to [**Hospital1 18**]. Patient's family notes that he seems more aggitated and uncomfortable today but otherwise similar mental status with poor short term memory, waxing/[**Doctor Last Name 688**] mental status. . On review of OMR notes, he has had multiple hospitalizations over last few months for CHF and pneumonia. He was admitted in [**9-21**] with L/R sided HF, readmitted in [**11-21**] with weight gain, SOB, found to be in acute heart failure complicated by new onset afib at which point he was started on coumadin. TTE at that time showed EF 45-55%, aortic valve area 1.2, severe [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], 3+ tricuspid regurg, 2+ pulmonic regurg. mild diffuse hypokinesis and mild depression of contractility of L/R ventricle. Admitted again [**2146-12-31**] and intubated for acute respiratory decompensation [**2-14**] CHF, also treated for MSSA pneumonia. Admitted [**1-27**] for NSVT and new Afib, treated with increasing dose of BB. Patient has also recently worked up for altered mental status thought most likely [**2-14**] toxic metabolic. . In the ED, initial vs were: 97.9 60 118/45 17 98 on. Labs notable for a WBC count of 13.9, HCT 34.4, Cr. 1.7 and troponin 0.10. BNP pending. Lactate 1.0., INr 3.3. abg: Ph7.27 pCO2 76 pO2 78 HCO3 36. CXR with large right pleural effusion. Patient was given Vanco 1g IV, Levofloxacin 750mg, Ceftriaxone, and Methyprednisone 125. He was then given aspirin 600 PR. Cards was consulted who said it is likely demand due to a large pleural effusion with someone with known coronary artery disease. They did not look at the EKGs. EKG showed v1 and v2 ST depressions, 1-2 mm. Vitals currently: 61 120/41 98% on Bipap [**5-17**] 40%. DNR/DNI confirmed with patient and his family in the ED. . On the floor, the patient is wearing bipap and appears to be working hard to breath. He reports feeling like he can't breathe. His family (3 daughters, one of whom is his HCP) report that he appears uncomfortable and again report that the patient wants to be DNR/DNI. . Dr. [**Last Name (STitle) 665**], his PCP came in and a family meeting was held with Dr. [**Last Name (STitle) **], the MICU resident and the patient's 3 daughters. The family was updated on the patient's situation and his low likelihood of recovery without intubation (and very low likelihood of cure regardless). All three sisters were in agreement that the patient was clear that he did not want to be intubated, they felt that intubation and CPR would cause him more suffering and felt comfortable with keeping the patient DNR/DNI. Plan was to try lasix, antibiotics and Bipap to see if it was possible to improve the patient's respiratory status but to also make the patient comfortable with morphine even if this decreased his respirations. The sisters requested a catholic priest for the patient as well as some time to update their other 5 siblings. . Review of systems(per family): (+) Per HPI (-) Denies fever, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies nausea, vomiting, diarrhea, Denies rashes or skin changes. Past Medical History: 1. Multiple admissions since [**Month (only) **] with respiratory decompensation, pneumonia, congestive heart failure. Previously admitted to [**Hospital 38**] [**Hospital **] Hospital on [**2146-12-31**] then [**2147-1-21**]. 2. Diabetes mellitus, insulin dependent. 3. Chronic renal disease, stage III. 4. Cardiomyopathy and congestive heart failure. 5. History of CABG times 2. 6. Aortic valve replacement [**2140**]. 7. Chronic venous stasis with cellulitis. 8. Hyperlipidemia. 9. Hypertension. 10. Morbid obesity. 11. Depression. 12. GERD. 13. Diabetic polyneuropathy. 14. Afib 15. NSVT Social History: The patient lives alone. Has some elderly services but dependent on daughter who visits every day. They note that he is not always compliant with his medications. Widowed. Has eight children who are very supportive. Goes to senior center every day. Quit smoking > 30 years ago. Rare EtOH. Used to work in commercial insulation. Family History: Mother had heart disease. Physical Exam: Tmax: 36.1 ??????C (97 ??????F) Tcurrent: 36.1 ??????C (97 ??????F) HR: 60 (60 - 66) bpm BP: 119/42(61) {94/34(55) - 120/56(61)} mmHg RR: 20 (17 - 24) insp/min SpO2: 94% Heart rhythm: AF (Atrial Fibrillation General Appearance: Overweight / Obese, increased WOB Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: with BIPAP on Cardiovascular: lound mechanical click, no audible murmur Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: Crackles : on left, Wheezes : mild expiratory on left, Diminished: right side 2/3 up anteriorly) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+, dusky venous stasis changes bilaterally, no warmth Skin: Not assessed, No(t) Rash: Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: Admission labs: [**2147-3-7**] 10:50AM BLOOD WBC-13.9* RBC-3.78* Hgb-10.2* Hct-34.4* MCV-91 MCH-26.9* MCHC-29.6* RDW-17.8* Plt Ct-213 [**2147-3-7**] 10:50AM BLOOD Neuts-85.6* Lymphs-10.0* Monos-3.7 Eos-0.6 Baso-0.1 [**2147-3-7**] 10:50AM BLOOD PT-33.1* PTT-38.1* INR(PT)-3.3* [**2147-3-7**] 10:50AM BLOOD Glucose-75 UreaN-53* Creat-1.7* Na-145 K-5.1 Cl-104 HCO3-38* AnGap-8 [**2147-3-7**] 10:50AM BLOOD CK(CPK)-20* [**2147-3-7**] 10:50AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 22275**]* [**2147-3-7**] 10:50AM BLOOD cTropnT-0.10* [**2147-3-7**] 10:50AM BLOOD Calcium-9.7 Phos-4.8*# Mg-2.4 [**2147-3-7**] 11:46AM BLOOD Type-ART pO2-78* pCO2-76* pH-7.27* calTCO2-36* Base XS-4 Intubat-NOT INTUBA [**2147-3-7**] 10:54AM BLOOD Lactate-1.0 Brief Hospital Course: As per HPI, a family meeting was held with the patient's family, the MICU attending, and the patient's primary care physician, [**Name10 (NameIs) 4120**] goals of care. He DNR/DNI status was affirmed. [**Hospital **] medical strategies such as diuresis, antibiotics, and positive pressure ventilation masks were pursued. The patient, however, did not tolerate the BiPAP mask and was clearly uncomfortable, despite morphine boluses. Further discussions were held with the family, and the patient was transitioned to comfort measures only status. He was placed on a morphine drip with PRN ativan available. He passed away peacefully with his family at his side, shortly thereafter. Medications on Admission: Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-14**] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Lantus 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous in the mornings. Insulin Regular Human 100 unit/mL Cartridge Sig: dose depends on glucose finger stick Injection daily. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Name: [**Known lastname 3725**],[**Known firstname **] Unit No: [**Numeric Identifier 3726**] Admission Date: [**2147-3-7**] Discharge Date: [**2147-3-7**] Date of Birth: [**2063-3-10**] Sex: M Service: MEDICINE Allergies: Amlodipine Attending:[**First Name3 (LF) 3727**] Addendum: Discharge diagnoses include: Primary: Hypoxic respiratory failure Secondary: Diabetes mellitus, insulin dependent Chronic renal disease, stage III Cardiomyopathy and congestive heart failure Coronary artery disease status-post coronary artery bypass grafting Chronic venous stasis with cellulitis Hyperlipidemia Hypertension Morbid obesity Gastroesophageal reflux disease Atrial fibrillation Discharge Disposition: Expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3728**] MD, [**MD Number(3) 3729**] Completed by:[**2147-4-6**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10046, 10212

6979, 7660

290, 300

9085, 9095

6210, 6210

9151, 10023

5171, 5199

8992, 9001

9054, 9064

7686, 8969

9119, 9128

5214, 6191

230, 252

328, 4193

6226, 6956

4215, 4809

4825, 5155

27,388

136,985

34644

Discharge summary

report

Admission Date: [**2182-8-24**] Discharge Date: [**2182-8-30**] Date of Birth: [**2102-3-9**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2745**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Colonoscopy [**2182-8-28**] History of Present Illness: 80M w/ MMP including dementia, CAD, chronic Afib, CHF, CRI, and diverticulosis, who initially presented to OSH with BRBPR. At [**Hospital **] Hospital, where he had an additional 2 episodes of BRBPR. BP was 70/palp and NG lavage was reportedly negative, so he was transfused 4 units PRBCs and 2 units FFP, and given Vitamin K and 2.5 L NS. Hct was 34 at [**Name (NI) **] (unclear when this was in relation to transfusions). He had a CT to evaluate his endovascular AAA repair, which was intact. He was transferred to [**Hospital1 18**] ED on [**2182-8-25**] where SBPs were stable in 90s, HR 80s. Given Protonix 40mg IV. GI and surgery were consulted and he was dmitted to the MICU for further care. . In the MICU, received 5 units pRBC with last transfusion yesterday AM. Hct has remained stable x24h. Colonoscopy today with left and right diverticulosis but no active bleeding. Has mild O2 requirement thought to be [**2-9**] CHF from multiple transfusions. Not on ASA or plavix at baseline, unable to contact PCP as to why, and not on coumadin for Afib [**2-9**] falls. Given stability, transferred to the floor. Currently feels well. States no new issues. No CP/SOB. No N/V. No further episodes of BRBPR . Past Medical History: - dementia - CAD s/p CABG [**2173**], cardiac stents x2 - chronic atrial fibrillation (not on coumadin [**2-9**] falls) - congestive heart failure - h/o tachy-brady syndrome s/p pacemaker - s/p endovascular AAA repair - hypertension - hyperlipidemia - chronic renal insufficiency (Cr 2.0) - h/o GI bleeds - diverticulosis - prostate ca s/p prostatectomy - osteoarthritis - gout - s/p knee replacement - incisional hernia repair - h/o Staph aureus infection - h/o interstitial nephritis Social History: Resident at [**Hospital3 **] facility. 4 daughters, 2 nearby and 2 in NH. +Tobacco hx, denies EtOH. Family History: Father w/ leukemia, mother w/ CVA. Physical Exam: Vital: afebrile, 110/63, HR 87, RR 26, 99%RA Gen: well appearing in NAD HEENT: NCAT. no pallor, no icterus. MMM. OP clear Neck: Supple, no JVD, no LAD Pulm: CTA bilat. bilateral basilar rales Cor: s1s2 irreg irreg. no murmur. hx sternum removed. Abd: obese, soft. nt/nd Ext: R hand markedly swollen, TTP ulna. No pain on axial loading. TTP along MCP joints/DIP joints. No BLE edema. DP 2+ Bilat Neuro: AAOx4. MAE. no gross deficits. Pertinent Results: [**2182-8-24**] 10:30PM BLOOD WBC-7.7 RBC-3.38* Hgb-9.9* Hct-30.5* MCV-90 MCH-29.3 MCHC-32.5 RDW-15.6* Plt Ct-123* [**2182-8-25**] 02:12AM BLOOD WBC-7.1 RBC-3.33* Hgb-9.5* Hct-30.0* MCV-90 MCH-28.6 MCHC-31.8 RDW-15.3 Plt Ct-103* [**2182-8-25**] 06:15AM BLOOD Hct-27.4* [**2182-8-26**] 03:20AM BLOOD WBC-8.4 RBC-3.49* Hgb-10.1* Hct-30.3* MCV-87 MCH-29.1 MCHC-33.5 RDW-16.5* Plt Ct-108* [**2182-8-27**] 03:33AM BLOOD WBC-7.4 RBC-3.36* Hgb-9.9* Hct-29.1* MCV-87 MCH-29.6 MCHC-34.1 RDW-16.6* Plt Ct-108* [**2182-8-28**] 03:50AM BLOOD WBC-9.6 RBC-3.56* Hgb-10.5* Hct-31.4* MCV-88 MCH-29.5 MCHC-33.5 RDW-16.0* Plt Ct-115* [**2182-8-29**] 06:10AM BLOOD WBC-9.0 RBC-3.49* Hgb-10.1* Hct-31.4* MCV-90 MCH-28.9 MCHC-32.3 RDW-15.8* Plt Ct-138* [**2182-8-30**] 06:10AM BLOOD WBC-9.2 RBC-3.53* Hgb-10.0* Hct-31.3* MCV-89 MCH-28.3 MCHC-31.9 RDW-15.8* Plt Ct-175 [**2182-8-24**] 10:30PM BLOOD PT-16.2* PTT-34.2 INR(PT)-1.4* [**2182-8-25**] 02:12AM BLOOD PT-15.4* PTT-30.5 INR(PT)-1.4* [**2182-8-26**] 03:20AM BLOOD PT-14.2* PTT-28.4 INR(PT)-1.2* [**2182-8-26**] 05:25PM BLOOD PT-13.8* PTT-27.5 INR(PT)-1.2* [**2182-8-26**] 11:14PM BLOOD PT-13.9* PTT-28.2 INR(PT)-1.2* [**2182-8-27**] 03:33AM BLOOD PT-14.2* PTT-28.5 INR(PT)-1.2* [**2182-8-30**] 06:10AM BLOOD PT-14.1* PTT-30.8 INR(PT)-1.2* [**2182-8-24**] 10:30PM BLOOD UreaN-39* Creat-1.8* [**2182-8-25**] 02:12AM BLOOD Glucose-118* UreaN-39* Creat-1.9* Na-145 K-4.3 Cl-115* HCO3-23 AnGap-11 [**2182-8-25**] 10:08PM BLOOD Glucose-127* UreaN-38* Creat-2.0* Na-142 K-4.0 Cl-112* HCO3-24 AnGap-10 [**2182-8-26**] 03:20AM BLOOD Glucose-104 UreaN-37* Creat-2.1* Na-143 K-3.9 Cl-112* HCO3-25 AnGap-10 [**2182-8-26**] 05:25PM BLOOD K-3.9 [**2182-8-27**] 03:33AM BLOOD Glucose-121* UreaN-28* Creat-1.7* Na-144 K-3.8 Cl-111* HCO3-24 AnGap-13 [**2182-8-28**] 03:50AM BLOOD Glucose-139* UreaN-25* Creat-1.7* Na-144 K-4.4 Cl-111* HCO3-23 AnGap-14 [**2182-8-30**] 06:10AM BLOOD Glucose-114* UreaN-35* Creat-1.8* Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 [**2182-8-24**] 10:30PM BLOOD ALT-12 AST-14 LD(LDH)-141 CK(CPK)-47 AlkPhos-64 Amylase-33 TotBili-1.7* [**2182-8-25**] 02:12AM BLOOD ALT-10 AST-13 LD(LDH)-166 CK(CPK)-52 AlkPhos-65 Amylase-37 TotBili-1.9* [**2182-8-24**] 10:35PM BLOOD cTropnT-0.01 [**2182-8-25**] 02:12AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2182-8-29**] 06:10AM BLOOD calTIBC-177* Ferritn-366 TRF-136* [**2182-8-24**] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2182-8-25**] 06:30AM BLOOD Type-[**Last Name (un) **] pH-7.24* Comment-GREEN TOP [**2182-8-25**] 07:02AM BLOOD Type-ART Temp-36.4 Rates-/30 O2 Flow-2 pO2-69* pCO2-41 pH-7.33* calTCO2-23 Base XS--4 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2182-8-28**] 04:13AM BLOOD Type-[**Last Name (un) **] pH-7.33* Comment-GREEN TOP [**2182-8-25**] 06:30AM BLOOD freeCa-1.19 [**2182-8-28**] 04:13AM BLOOD freeCa-1.00* [**8-28**] Colonoscopy: Findings: Protruding Lesions A single pedunculated 10 mm non-bleeding polyp of benign appearance was found in the sigmoid-descending colon at 40cm. Given recent history of bleeding no polypectomy was performed. Small non-bleeding grade 1 internal hemorrhoids were noted. Excavated Lesions Multiple non-bleeding diverticula were seen in the sigmoid colon, descending colon and ascending colon. No fresh or old blood was seen in the entire colon. Impression: Left and Right colon diverticulosis Polyp in sigmoid-descending colon Grade 1 internal hemorrhoids Otherwise normal colonoscopy to cecum Recommendations: No polypectomy performed because of recent significant bleeding. Follow-up full colonoscopy at 3 months for elective polypectomy - patient has been scheduled for [**11-26**] at [**Hospital1 18**].. Brief Hospital Course: Studies: Colonoscopy: Diverticulosis. Pedunculated polyp. No polypectomy. No active bleeding. Grade 1 hemorrhoids. Will have f/u colonoscopy on [**2182-11-26**] for polypectomy. ECG - A-fib @ 72bpm, LAD, nl intervals, +Qs in III,aVF, TWF diffusely, poor R-wave progression, no prior for comparison . CXR ([**8-24**]) - mild cardiomegaly, retrocardiac opacity (atelectasis vs. infection), normal pulmonary vascularity, small left pleural effusion . OSH CT-scan ([**8-24**]) - (prelim) aortobiiliac stent in place, no periaortic hematoma; cholelithiasis and suspected CBD stone w/o e/o cholecystitis; diverticulosis w/o diverticulitis; suspected nonobstructing right renal calculus. . Hospital Course: . 80-M s/ MMP incl dementia, CAD, chronic Afib, CHF, CRI, and diverticulosis, p/w multiple episodes of BRBPR with dropping Hct and HD instability manifesting as hypotension. Now s/p 4units PRBCs, 2units FFP, Vit K, 3.5L NS, with continued drop in Hct to 30. . #. GI bleeding - Pt p/w BRBPR w/ dropping Hct and hypotension. NG lavage at OSH reportedly negative. CT to eval AAA s/p endovascular repair reportedly negative. GI scoped [**2182-8-28**]. Results above. On PPI [**Hospital1 **]. Anti-hypertensives were held initially given hypotension and patient was given gentle hydration given CHF history. Patient remained hemodynamically stable throughout the remainder of his hospital course and was transferred to the medical floor in stable condition. He had no further episodes of bleeding and his HCT remained stable until discharge. . #. Coagulopathy - Pt w/ INR 1.4 on admit, after receiving 2units FFP and Vit K at OSH. Unclear reason for elevated INR (?nutritional) but came down slowly throughout admission. His final INR on discharge was 1.2 . # CAD - Pt w/ h/o CAD s/p CABG [**2173**], cardiac stents x2, unclear [**Name2 (NI) 79461**]. Most recent TTE done in [**2178**] per PCP who state EF 45%, last persantine study [**2181**] with EF 55%, patient not currentyl on ASA or plavix, has been very stable recently from CV perspective. Patient has hx sternal infection, s/p sternal resection. Restarted on home metoprolol without complications. Quinapril was held due to low blood pressures and will continue to be held until seen in outpt follow-up. . # Chronic atrial-fibrillation - Pt's ECG afib, rate-controlled w/BB but not on any anti-coagulation. Also w/pacemaker in place. Monitored on tele without events. Restarted on metoprolol with good HR control. . # Congestive heart failure - Pt maintained on BB and ACE-I at home. On exam, with rales e/o fluid overload. Given lasix 20mg IV overnight upon transfer from MICU [**8-28**] with diuresis of 2000cc. No further lasix given. EF per above. . # AAA s/p endovascular repair - Pt had CT at OSH to eval endovascular repair of AAA, which was negative, no leak. . #. Hypertension - Home medications include quinapril and metop. Restarted on metoprolol but held quinapril until outpt follow-up. . #. Hyperlipidemia - continued on statin . #. Chronic renal insufficiency - Baseline Cr per PCP 1.9-2, on admit was 1.8, currently at baseline through hospital admission, no changes or interventions done. . #. Depression: continued on sertraline . #. Dementia: Cont Namenda and galantamine . #. FEN: Cardiac diet, replete lytes PRN . #. Access: Multiple large-bore PIVs (16g x2, 18g x1, 20g x1) . #. PPx: pneumoboots, IV PPI [**Hospital1 **], no SQ Hep given during hospitalization. . #. Code - FULL CODE (presumed) . #. Communication - [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) **] (h)[**Telephone/Fax (1) 79462**], (c)[**Telephone/Fax (1) 79463**]; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (h)[**Telephone/Fax (1) 79464**] #. Dispo - to rehab on discharge. Medications on Admission: Protonix 40mg qd quinapril 10mg qd Namenda 10mg qd Metoprolol XL 25mg [**Hospital1 **] Razadyne 4mg [**Hospital1 **] Sertraline 50mg qd Simvastatin 80mg qd Tylenol prn Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Galantamine 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] Center Discharge Diagnosis: Lower gastrointestinal bleed. Discharge Condition: Stable Discharge Instructions: You were admitted initially to [**First Name8 (NamePattern2) **] [**Hospital **] hospital because of gastrointestinal bleeding manifested as bright red blood from your rectum. Your blood pressure was low when you were evaluated and you were given blood transfusions and stabilized for transfer to [**Hospital1 **]. Upon admission to [**Hospital 61**] Hospital you were given more blood transfusions and were evaluated by both the Surgical consult service as well as the Gastrointestinal consult service. The Gastrointestinal doctors did [**Name5 (PTitle) **] a colonoscopy as well as an upper endoscopy. The colonoscopy showed that you have some internal hemorrhoids as well diverticula, which are small outpouching in your colon. There was also a polyp seen in your colon but no source of the bleeding was identified. You were observed in the Medical ICU after this procedure and had no further episodes of bleeding and your blood counts remained stable. You were transferred out of the ICU and onto a regular floor where you progressed well without any further issues. All of your labs remained normal and you were deemed stable and ready for discharge. During your hospitalization you were discontinued on your quinapril. You will remain off of this medication until your follow-up appointment with Dr. [**Last Name (STitle) 30176**]. Call your primary doctor or return to the Emergency Department if you have any persistent fevers, any further episodes of red blood from your rectum or in your stool, an black stools, chest pain, difficulty breathing.

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icd9cm

[ [ [] ] ]

[ "45.23", "99.04" ]

icd9pcs

[ [ [] ] ]

11030, 11079

6441, 7127

280, 310

11153, 11162

2713, 6418

2196, 2233

10442, 11007

11100, 11132

10249, 10419

7144, 10223

11186, 12753

2248, 2694

232, 242

338, 1553

1575, 2062

2078, 2180

12,634

151,821

47310

Discharge summary

report

Admission Date: [**2183-1-15**] Discharge Date: [**2183-2-5**] Date of Birth: [**2119-12-4**] Sex: F Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 63-year-old female patient with a history of atrial fibrillation, hypertension, diabetes mellitus, severe mitral regurgitation, significant history of asthma with two recent hospital admissions to [**Hospital6 1760**] for asthmatic exacerbation. She was also admitted to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] through [**2182-12-14**] with severe mitral regurgitation and rapid atrial fibrillation. Heart catheterization was performed on [**2182-12-16**], which revealed left ventricular ejection fraction of 68%, single-vessel coronary artery disease, questionable degree of mitral regurgitation, and moderate pulmonary hypertension. The patient subsequently had a retroperitoneal hematoma requiring blood transfusion after cardiac catheterization. The patient also had some prerenal azotemia which resolved during that hospitalization. The patient was subsequently discharged home with a plan to be readmitted early in [**Month (only) 404**] for mitral valve replacement with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]. On the day of admission, [**2183-1-15**], however, the patient was admitted with chest pain and palpitations which was of fairly significant onset. The patient had been on Amiodarone at that time. When EMS responded, she was found to have a heart rate in the 130s, blood pressure 220 systolic. She was given Aspirin and Nitroglycerin with relief of her symptoms. She was also treated with intravenous Lopressor at that time. The patient was admitted to the Medicine Service. PAST MEDICAL HISTORY: Type II diabetes mellitus, atrial fibrillation, hypertension, chronic renal insufficiency with a baseline creatinine of 1.5-2.0, granulomatous hepatitis, reactive airway disease with significant history of asthma, 3+ mitral regurgitation, moderate pulmonary hypertension, status post 6 U blood transfusion for a retroperitoneal bleed/hematoma status post cardiac catheterization, prerenal azotemia, hematuria, partial small bowel ileus, history of monoclonal gammopathy, status post total abdominal hysterectomy for fibroids, history of hypercholesterolemia. MEDICATIONS ON ADMISSION: Amiodarone 400 mg p.o. q.d., Diltiazem SR 180 mg p.o. b.i.d., Univasc 30 mg p.o. q.d., Hydrochlorothiazide 25 mg p.o. q.d., Premarin 0.625 mg p.o. Q.d., Glyburide 10 mg p.o. b.i.d., Avandia 2 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Colace b.i.d., Coumadin 2.5 mg p.o. q.d., Asthmacort metered dose inhaler, Albuterol metered dose inhaler, Prednisone 10 mg p.o. q.d. PHYSICAL EXAMINATION: General: On admission, exam revealed the patient to be in no acute distress. Neck: Supple. No jugular venous distention. HEENT: Unremarkable. Lungs: Clear to auscultation bilaterally. Cardiovascular: Irregularly, irregular rhythm with a grade 2/6 systolic murmur. Abdomen: Soft, nontender, nondistended. Positive bowel sounds. Extremities: Without edema. There were 2+ palpable dorsalis pedis pulses bilaterally. Neurological: Alert and oriented times three. Nonfocal exam. LABORATORY DATA: On admission white blood cell count was 21.9; potassium 3.9, creatinine 1.5; the rest of the admission laboratories were unremarkable; her INR upon admission was 3.0, and she was on Coumadin. HOSPITAL COURSE: The patient was admitted to the Medicine Service. Her Heparin was discontinued with the anticipation of her needing to go to the Operating Room for her cardiac surgery, and she was placed on intravenous Heparin drip. An Endocrinology consult was obtained on the day of admission. It was their impression that the patient had thyrotoxicosis, although mild. It was their recommendation to rate control the patient with beta-blocker as needed and to discontinue the Amiodarone. The Amiodarone was subsequently discontinued on [**2183-1-16**]. On [**2183-1-17**], the patient was taken to the Operating Room by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3876**] where she underwent a mitral valve replacement with a St. [**Male First Name (un) 1525**] mechanical mitral valve, #29 mm, as well as left-sided maze procedure. She also had removal of left atrial appendage. Postoperatively she was transported from the Operating Room to the Cardiac Surgery Recovery Unit on epinephrine drip. She was also on Levophed. Both the epinephrine and Levophed were weaned off readily. She remained on Insulin drip and some Nitroglycerin, as well as some Propofol for sedation, and low-dose Dopamine drip for labile blood pressure. On postoperative day #1, the patient was seen by the Renal Medicine Service for increasing creatinine. It was their recommendation to let the patient stay with a higher blood pressure for better renal profusion and to follow the patient's potassium closely. The patient was weaned from the mechanical ventilator and extubated on postoperative day #1. On postoperative day #2, the patient remained in the Intensive Care Unit requiring Insulin drip still for blood sugar which was not adequately controlled. She remained on low-dose Dopamine as well. Amiodarone was resumed on postoperative day #2 due to continued problems with atrial fibrillation. On postoperative day #3, the patient was weaned off all vasoactive drips, and he remained hemodynamically stable and was transferred out of the Intensive Care Unit to the Telemetry Floor. Cardiology Electrophysiology Service had been following the patient, and they recommended to discontinue the Amiodarone due to her preoperative problems with thyrotoxicosis. The patient had some intermittent problems with nausea over the next couple of days. The patient required pulmonary toilet and bronchodilators, however, remained essentially stable. The patient had some difficulties with rapid atrial tachycardiac arrhythmias, and the Electrophysiology Service thought that she may at some point require an AB nodal ablation with permanent pacemaker placement, and Coumadin was discontinued on [**1-21**] for that reason. Over the next 24-48 hours, from [**1-23**] to [**1-24**], the patient had continuing problems with worsening shortness of breath. On [**1-24**], 6 p.m., the patient was transferred back to the Intensive Care Unit due to worsening shortness of breath. She had bibasilar crackles, some hypertension to 150s to 170s systolic. The patient had been on a non-rebreather mask at that point. Her respiratory rate was in the 30s. Over the course of the next three days in the Intensive Care Unit, she had been started on broad-spectrum antibiotics and aggressively worked with diuresis and pulmonary toilet; however, on the morning of [**1-28**], the patient required reintubation for increasing shortness of breath and fatigue, at which point she was sedated to tolerate mechanical ventilation. Subsequent sputum gram stain grew out gram-negative rods; however, the culture was consistent with oropharyngeal flora and budding yeast and no definitive organisms. A Pulmonary Medicine consultation was obtained on [**2183-1-29**]. It was their thought that the patient may have been experiencing postpericardiotomy syndrome with questionable exacerbation of her reactive airway disease. For this reason, it was their recommendation to increase her steroids. She had been on her baseline of Prednisone 10 mg per day at this time. The patient also upon admission to the Intensive Care Unit had a significant pleural effusion drained of approximately 700 cc. On [**2183-1-30**], the patient had significantly improved from a respiratory standpoint after being on stress dose steroids for about 48 hours, and she was extubated on [**1-30**], and significant improvement in her pulmonary status was evident at that time. The patient continued to do well hemodynamically. She was begun on oral medication and nutrition which she tolerated well. On [**2183-2-1**], the patient was transferred out of the Intensive Care Unit to the Telemetry Floor once again. Over the next few days, she had been restarted on her Coumadin. Her INR had increased nicely to the 2.1 to 2.5 range. She remained hemodynamically stable. She began to progress with some ambulation, however was still extremely unsteady with her gait and unable to ambulate independently. The Renal Medicine Service signed off on her care since this was no longer an active issue. The patient remained hemodynamically stable and was ready to be discharged to her rehabilitation facility today, [**2183-2-5**], postoperative day #19. CONDITION ON DISCHARGE: Temperature 99.1??????, pulse 104, in atrial fibrillation, respiratory rate 20, blood pressure 145/68, room air oxygen saturation 93%, discharge weight 56 kg, which is actually somewhat below her preoperative weight of 58.2. Most recent laboratory values include a prothrombin time of 17.4, with an INR of 2.1, sodium 137, potassium 3.9, chloride 93, CO2 38, BUN 31, creatinine 1.6, fasting glucose 68; white blood cell count 15.8, which is stable, hematocrit 29.1, platelet count 293,000. Physical exam revealed the patient to be neurologically alert with no apparent deficit. Coronary exam is irregular, rate, and rhythm. No murmurs or rubs noted. Positive valve click audible. The patient's lungs are essentially clear to auscultation bilaterally with the exception of minimal fine bibasilar crackles. Her abdomen is somewhat distended, although it is soft with positive bowel sounds. The patient stated that she had a bowel movement today. She has had intermittent episodes of complaints of nausea. Her sternum is stable. Her Steri-Strips are clean, dry, and intact over her incision. Her extremities are warm and well perfused with palpable pulses bilaterally. There is some superficial skin breakdown in the sacral area which is reddened and healing over. DISCHARGE MEDICATIONS: Coumadin 4 mg on [**2-5**] and [**2-6**], the patient is to have a prothrombin time checked at that point in time to determine ongoing doses, her target INR should be 3.0-3.5 to anticoagulate her for mechanical mitral valve, Catapres TTS patch 0.1 mg transdermaly q.week, Lipitor 10 mg p.o. q.h.s., Levofloxacin 250 mg p.o. q.d. x 5 more days to complete a course for presumed tracheal bronchitis, Peri-Colace 1 p.o. b.i.d., Protonix 40 mg p.o. q.d., Enteric Coated Aspirin 325 mg p.o. q.d., Beclovent metered dose inhaler 2 puffs b.i.d., Albuterol metered dose inhaler 2 puffs q.4 hours, Premarin 0.625 mg p.o. q.d., Amaril 2 mg p.o. q.a.m., Prednisone 10 mg p.o. q.d., Reglan 10 mg p.o. q.8 hours, Diltiazem SR 180 mg p.o. b.i.d., Percocet 5/325 1 p.o. q.4 hours p.r.n. pain, sliding regular Insulin coverage in addition before meals and at bed time for blood sugar of 150-200 3 U subcue regular Insulin, 201-250 6 U, 251-300 9 U, 301-350 12 U. FOLLOW-UP: The patient should follow-up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6955**] upon discharge from the rehabilitation facility to reestablish her plan for diabetes management, she is on less oral hypoglycemics at this time because her nutritional status and eating and nausea has not quite become stable. The patient is also to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3876**] upon discharge from the rehabilitation facility. The patient should follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from the Electrophysiology Service upon discharge from the rehabilitation facility. The patient is discharged in stable condition. DISCHARGE DIAGNOSIS: Mitral regurgitation status post mitral valve replacement. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2183-2-5**] 10:38 T: [**2183-2-5**] 10:40 JOB#: [**Job Number 11678**]

[ "584.5", "429.4", "250.02", "242.90", "427.31", "518.5", "424.0", "486", "428.0" ]

icd9cm

[ [ [] ] ]

[ "37.99", "96.04", "96.71", "35.24", "39.61", "34.04" ]

icd9pcs

[ [ [] ] ]

10020, 11770

11792, 12101

2370, 2736

3479, 8695

2759, 3461

183, 1760

1783, 2343

8720, 9996

21,685

146,584

1549

Discharge summary

report

Admission Date: [**2179-4-30**] Discharge Date: [**2179-5-1**] Date of Birth: [**2112-11-30**] Sex: F Service: NEUROLOGY Allergies: Aspirin Attending:[**First Name3 (LF) 5018**] Chief Complaint: SDH Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: The patient is a 66yo R-handed woman with depression, HTN, recently diagnosed PE, treated with coumadin, who was transferred from OSH after massive SDH. This afternoon, she fell around 15.10, withou LOC. She hit her head and had a hematoma on her head. She was fine intitially, but around 16.30 she became lethargic and was complaining of nausea and headache. Her husband drove her to OSH. GCS 13; BP 197/47. In the CT scan she decompensated and her pupils were inequal (2L, 5R). She was intubated in CT and her BP dropped. CT showed large SDH, with significant midline shift (1.5cm). At OSH she received FFP and vit K. She was med-flighted here for neurosurgical intervention. Coags at OSH were pending upon transfer. During [**Location (un) **], she coded (cardiac arrest). She was given atropine and epinephrine and her pulse was found back. She was started on dopa gtt and her SBP initially were 60-70. In the ED at [**Hospital1 18**], she received factor 9 complex. Neurosurgery was consulted and based on exam (no response) and scan with extensive, the changes of her surviving this were deemed <5%. After discussion with the family, it was decided not to proceed with surgery. A repeat CT head showed, further increased hemorrhage, with more extensive shift, increasing size of L lat vent and complete subfalcine herniation. In addition, tonsilar herniation was present (no IVth vent present). ROS: -unable Past Medical History: -PE diagnosed last week, started on coumadin -HTN -spinal stenosis -bipolar disease -CRI Allergic to Aspirin Social History: lives with husband; about to retire (next week); 4 children, 3 still alive. No alc, tob. Walks with cane at baseline. Family History: -n.c. Physical Exam: VITALS: T HR BP RR sO2 GEN: intubated HEENT: neck collar LUNGS: vented bs HEART: Regular rate and rhythm, normal S1 and S2 ABDOMEN: soft, nontender, nondistended EXTREMITIES: ++edema MENTAL STATUS: Non-responsive; eyes half open. No response to any cues. CRANIAL NERVES: II: Pupils blown bilaterally III, IV, VI: No VOR V: No corneals VII: No droop VIII: - IX: no gag XII: - [**Doctor First Name 81**]: - MOTOR SYSTEM: Normal bulk and tone flaccid. No response to noxious. No posturing or spon movements. REFLEXES: DTR absent Toes: mute bilaterally SENSORY SYSTEM: no response to noxious COORDINATION: deferred GAIT: deferred Pertinent Results: LABS and IMAGING: PT: 150 PTT: 111.7 INR: >22.8 pH7.28 pCO227 pO2445 HCO313 BaseXS-12 Na:140 K:3.6 Cl:115 TCO2:13 Glu:156 Lactate:5.9 [**Doctor First Name **]: 35 Lip: Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative WBC12.9 PLT49 Hct33.3 CT Head W/O Contrast Large right subdural hematoma, acute on subacute, with 1.8 cm midline shift,subfalcine herniation, and uncal herniation. Brief Hospital Course: The patient is a 66yo R-handed woman with depression, HTN, recently diagnosed PE, treated with coumadin, who was transferred from OSH after massive SDH with signs of herniation followed by cardiac arrest. Upon arrival to the ED, GCS was 3 and she required pressors. Neuro-exam showed blown pupils, absent corneals, no VOR and no response to noxious. No movements could be elicited. CT head showed progression of herniation, now also including tonsillar herniation. Neurosurg deemed changes for survival to very low and family decided not to proceed with surgery. Labs, especially coags, abnormal. Based on exam and scan, prognosis is extremely poor. This was discussed with family, including her husband [**Name (NI) **] [**Name (NI) 9035**]. Medical options such as hyperventilation and mannitol were discussed, but the family declined given the grim prognosis. Pt had expressed to her husband during her PE that she would not like to remain on life support in case that ever would happen. It was decided to call in a priest and proceed with [**Name (NI) 9036**] measures only. Given recent intubation and use of atropine, formal brain dead exam not valid. Patient was admitted to Neuro ICU (attending Dr. [**Last Name (STitle) **]. Patient was then extubated with husband's wish and placed on [**Last Name (STitle) **] measures only. Patient became bradycardic, apneic. Passed away at [**2179-5-1**] 2:30AM. The case was reported to Medical Examiner Dr. [**Last Name (STitle) 9037**] (Officer Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9038**]) and case was accepted due to trauma and <24h hospital time death. Post mortem exam will be performed on [**2179-5-1**]. Family was informed and agreed for ME exam. Above all reported to Admission Office. Medications on Admission: -coumadin -bupropion -depakote -ranitidine -levoxyl -atenolol -spiriva -fluoxetine -omeprazole -tramadol PRN Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Subdural Hematoma Brain Herniation Discharge Condition: Expired. Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2179-5-1**]

[ "585.6", "852.21", "296.80", "724.00", "E849.0", "403.91", "348.4", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5100, 5109

3137, 4912

274, 300

5188, 5199

2710, 3114

5251, 5400

2034, 2041

5072, 5077

5130, 5167

4938, 5049

5223, 5228

2056, 2241

230, 236

328, 1749

2330, 2691

2256, 2314

1771, 1882

1898, 2018

19,533

104,095

57642

Discharge summary

addendum

Name: [**Known lastname 11946**],[**Known firstname 732**] Unit No: [**Numeric Identifier 11947**] Admission Date: [**2108-6-20**] Discharge Date: [**2108-7-3**] Date of Birth: [**2039-7-6**] Sex: F Service: SURGERY Allergies: Bactrim / Cogentin Attending:[**First Name3 (LF) 9036**] Addendum: Patient discharged on [**2108-6-29**] to [**Hospital 1238**] rehab facility. Chief Complaint: s/p post colonic perforation w/ ileostomy Major Surgical or Invasive Procedure: [**2108-6-21**] Exploratory lap, Ileostomy take down w/ ileo-transverse colostomy History of Present Illness: 68 yo female with schizoaffective disorder and diabetes insipidus, probably from lithium use. She suffered a perforated colon approximately 6 months ago due to C- difficile colitis incidentally found at her operation for gross peritonitis was an ileal carcinoid which was resected and had positive nodal metastases. She has been intolerant of her ileostomy due to food and electrolyte issues and has been in the hospital for renal failure on two occasions on the medicine service despite trying her best to manage her fluid intake herself. She also has extensive skin excoriation and dermatitis problems due to her ileostomy. She is, therefore, electively brought in for ileostomy reversal. Past Medical History: carcinoid syndrome, ARF/CRF, hypoNa, hypoMag, hypothyroid, UTI ([**5-31**]), PNA ([**3-31**]), psoriasis, elevated transaminases (resolved), mental retardation, schizoaffective d/o, r elbow hemarthrosis PSHx: ileosotomy [**11-29**] Social History: Previously resided in group home Family History: Noncontributory Physical Exam: VS: Temp 99, HR 114, BP 130/86, Resp 18, SaO2, 98% on RA. Neuro: Pleasant, MR CVS: normal S1, S2, RRR Pulm: CTA b/l Abd: Soft, NT, ostomy intact, psoriasis Ext: good peripheral pulses, no edema Pertinent Results: [**2108-6-20**] 08:00PM GLUCOSE-128* UREA N-15 CREAT-1.7* SODIUM-140 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14 [**2108-6-20**] 08:00PM CALCIUM-9.1 PHOSPHATE-5.1* MAGNESIUM-1.4* [**2108-6-20**] 08:00PM WBC-7.2 RBC-3.55*# HGB-11.6*# HCT-31.7* MCV-89 MCH-32.7* MCHC-36.6*# RDW-15.8* [**2108-6-20**] 08:00PM PLT COUNT-377 [**2108-6-20**] 08:00PM PT-15.9* PTT-27.6 INR(PT)-1.4* CHEST (PRE-OP PA & LAT) Reason: S/P ILEOSTOMY; DIABETES INSIPIDIS; SCHIZO-AFFECTIVE DISORDER [**Hospital 5**] MEDICAL CONDITION: 68 year old woman here for reversal of ileostomy and ileocolic anastamosis REASON FOR THIS EXAMINATION: pre-op INDICATION: 68-year-old woman here for reversal of ileostomy and ileocolic anastomosis. Preop. COMPARISON: [**2108-2-29**]. FINDINGS: Since prior exam, the right PICC line has been removed. The cardiac silhouette, mediastinal and hilar contours are stable. The lungs are clear. No evidence of pneumothorax. The aorta is mildly tortuous. IMPRESSION: No evidence of acute cardiopulmonary process. Brief Hospital Course: She was admitted to the Surgical Service and taken to the operating room for exploratory lap, ileostomy takedown with ileo-transverse colostomy on [**6-21**]. There were no intraoperative complications. Postoperatively she has done fairly well, her diet was advanced slowly; she is having bowel movements. She was started on Imodium and Metamucil to help minimize frequent stools. Her ileostomy site is being packed with moist to dry dressing changes [**Hospital1 **]; her staples will remain in place until next week when she follows up with Dr. [**Last Name (STitle) **]. Her medications were changed from intravenous to oral, she is tolerating these without difficulty; appetite is good. Her fluids and electrolytes have been monitored closely and repleted accordingly. Her most recent sodium on [**6-28**] was 145. The wound ostomy nurse specialists were consulted because of dermatitis issues; Nystatin cream was recommended to these areas. Miconazole powder is being used to her perineal region. Medications on Admission: tincture of opium, mag oxide, oscal, medroline, vitD, levothyroxine, zyprexa, heparin, folate, tylenol, Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 2. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for breakthrough agitation. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): hold for HR <60; SBP <110. 7. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-27**] Tablet, Delayed Release (E.C.)s PO twice a day as needed for constipation. 12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 15. Metamucil Powder Sig: One (1) TBSP PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 4356**] - [**Location (un) 164**] Discharge Diagnosis: Ileostomy takedown Secondary diagnosis: Diabetes Insipidus Discharge Condition: Stable Discharge Instructions: Please call your primary care physician or go to the nearest ER if you experience any pain uncontrollable on your medications, blood in your stool, temperature greater than 101.5, increased diarrhea, nausea/vomiting, or any other symptoms that are concerning to you. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in Surgery Clinic in [**12-27**] weeks, call [**Telephone/Fax (1) 11871**] for an appointment. [**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**] Completed by:[**2108-6-29**]

[ "253.5", "295.70", "244.9", "E939.8", "319", "696.1", "V55.2", "V10.09" ]

icd9cm

[ [ [] ] ]

[ "46.51" ]

icd9pcs

[ [ [] ] ]

5555, 5628

2964, 3969

528, 612

5732, 5741

1904, 2394

6056, 6359

1658, 1675

4125, 5532

5649, 5669

3995, 4100

5765, 6033

1690, 1885

447, 490

2534, 2941

2430, 2505

640, 1336

5690, 5711

1358, 1592

1608, 1642

17,608

131,111

46992

Discharge summary

report

Admission Date: [**2198-11-29**] Discharge Date: [**2198-12-10**] Date of Birth: [**2124-4-26**] Sex: F Service: CHIEF COMPLAINT: Elective colonoscopy. HISTORY OF PRESENT ILLNESS: The patient is a 74 year old female with a history of hypertension, hypercholesterolemia and rheumatic heart disease with mitral regurgitation who presented for colonoscopy and was found to be in atrial fibrillation. Patient complained of mild dizziness and weakness at this time. She had no other symptoms prior to admission. She had some shortness of breath over the summer which was treated with Lasix. Patient stated she had one episode of congestive heart failure approximately 10 years ago at which time she was started on digoxin. She has had no changes in her dose subsequently because she had no complaints of chest pain, orthopnea, paroxysmal nocturnal dyspnea or edema. Patient underwent colonoscopy and had an episode of respiratory distress during the procedure. Therefore, it was terminated abruptly and patient was sent back to the floor. The night of the colonoscopy patient complained of respiratory distress which was unrelieved with oxygen escalation or with Lasix. She had no chest pain at this time and she has normal sinus rhythm on EKG. However, given her respiratory status, it was required that patient be intubated and she was transferred to the CCU for further management. PAST MEDICAL HISTORY: Significant for hypertension, congestive heart failure, mitral regurgitation, rheumatic heart disease with a history of endocarditis in [**2161**]. Patient also had breast cancer and is status post lumpectomy in [**2194**] and radiation therapy. She has a history of hypothyroidism status post partial thyroidectomy. Hypercholesterolemia. Total abdominal hysterectomy in [**2174**]. Right cataract removed recently. MEDICATIONS ON ADMISSION: Included Cardura 30 b.i.d., digoxin 250 mcg p.o. q.d., KCl 20 mEq b.i.d., Lasix 20 mg p.o. b.i.d., Lipitor 10 mg p.o. q.d., Levoxyl 75 mcg p.o. q.d., tamoxifen 10 mg p.o. q.d., Fosamax 70 mg p.o. q.week. ALLERGIES: Penicillin gives her a rash. FAMILY HISTORY: CAD. Father died at 70 from MI. Mother died at 84 from MI. SOCIAL HISTORY: The patient does not smoke or drink. She does not work outside the home. She has an extended family which she spends a great deal of time with. PHYSICAL EXAMINATION: On admission to the CCU temperature was 99.7, heart rate 75, blood pressure 117/64, respirations 18, sating 84% with an endotracheal tube in place with volume assisted breathing with tidal volume of 600. Patient's respiratory rate was 24 at that time. Minute ventilation was 4.5. General appearance: tired appearing, well nourished female in no apparent distress. HEENT: pupils equally round and reactive to light and accommodation. Sclerae were anicteric. Neck: no JVD, no carotid bruits. Cardiac: regular rate and rhythm, systolic murmur radiating from the apex to the axilla. Pulmonary: crackles diffusely bilaterally. Good breath sounds with ventilation. Abdomen: positive bowel sounds, soft, distended. Extremities had no cyanosis, clubbing or edema. Right groin line in place. Skin pale and warm. LABORATORY DATA: Labs at this time included white count of 10.6, hemoglobin 12.0, hematocrit 34.5, platelets 261. Electrolyte panel showed sodium of 139, potassium 4.0, chloride 105, bicarbonate 22, BUN 30 up from 23, creatinine 1.6 up from 1.4. Calcium was 7.9, phosphate 4.8, magnesium 1.8. Patient also had a digoxin level which came back as 1.1. She had an EKG on [**2198-11-30**], which showed a humped P wave, inverted Ts in 1, 2 and aVL and signs of left ventricular hypertrophy. There were no Q waves at this time. Patient also had colonoscopy done which showed a polyp at 25 cm in the sigmoid colon. The colonoscopy was terminated prior to removal of this polyp secondary to patient's respiratory distress. Chest x-ray showed asymmetric pulmonary edema with right greater than left diffuse infiltrate. ABG showed pH of 7.20, PCO2 54, PO2 58, bicarbonate 22. Lactate level at this time was 5.9. HOSPITAL COURSE: Given the above, patient was transferred to the CCU and was maintained on ventilation between [**2198-12-1**] and [**2198-12-5**]. She was diuresed aggressively with Lasix as tolerated to remove some of the fluid that may have contributed to her respiratory distress. Patient was also put on Neo-Synephrine for pressure support at this time. She was started on antibiotics, Levaquin 250 mg p.o. q.d. initially, for increased creatinine level and subsequently switched to 500 mg p.o. q.d. as her creatinine improved. Patient was weaned off the ventilator with these measures and subsequently was able to sat approximately 99% in room air. Otherwise her cardiac issues in terms of her pump, Lasix dose was increased as tolerated. Patient's digoxin dose was discontinued. Cardura was discontinued. She was switched from pressure support with Neo-Synephrine to other p.o. medications including lisinopril 20 mg p.o. q.d., Imdur 60 mg p.o. q.d., Lasix 100 mg p.o. b.i.d. with additional doses as needed. In terms of her rhythm, patient had an irregular heart rate with occasional episodes of atrial fibrillation and other supraventricular tachycardias. Otherwise she also maintained normal sinus rhythm for the most part. She was not anticoagulated given her history of heme positive stools secondary to the polyp and hematocrit decrease after admission. Otherwise she was rate controlled without any medications. In terms of her ischemia, enzymes were cycled and were shown to be negative. Patient was continued on Lipitor and aspirin was started subsequently at 81 mg p.o. q.d Patient's LFTs were within normal limits. Cholesterol panel was unremarkable. Otherwise in terms of GI issues, patient will have repeat colonoscopy as an outpatient. She had heme positive stools while in-house, but no significant GI bleed was noted. In terms of hematology/oncology, patient was continued on tamoxifen. In terms of endocrine issues, patient was found to be hypothyroid with TSH level of 2.2 in-house. Therefore, she was continued on her present Levoxyl dose. Musculoskeletal: patient will be continued on Fosamax on discharge. Prophylaxis: patient was on subcutaneous heparin and Protonix 40 mg p.o. q.d. After patient was weaned off the ventilator, she began to improve quickly and her expected date of discharge is [**2198-12-10**]. She will follow up in cardiology clinic at [**Telephone/Fax (1) 10316**] in two to three weeks and an appointment will be set up for her. Otherwise after approval and cardiac clearance in clinic, she can follow up with Dr. [**Last Name (STitle) 1940**] in the GI Department for colonoscopy. The clinic telephone number is [**Telephone/Fax (1) 1983**]. Patient will be started on Coumadin shortly given that her stools have converted to heme negative and that the GI Department feels she is stable to be anticoagulated despite the polyp. Therefore, she must have frequent INR checks after discharge to a rehab facility. In conclusion, patient will be discharged in stable condition to a skilled nursing facility. DISCHARGE MEDICATIONS: 1. Lisinopril 20 mg p.o. q.d. 2. Imdur 60 mg p.o. q.d. 3. Protonix 40 mg p.o. q.d. 4. Kaopectate 30 ml p.r.n. 5. Lasix 100 mg p.o. b.i.d. 6. Ambien 5 mg p.r.n. 7. Levaquin 500 mg p.o. q.d. until [**2198-12-15**]. 8. Aspirin 81 mg p.o. q.d. 9. Levoxyl 75 mcg p.o. q.d. 10. Tamoxifen 10 mg p.o. q.d. 11. Lipitor 10 mg p.o. q.d. 12. Tylenol 325 to 650 mg p.o. p.r.n. 13. Coumadin 2 mg p.o. q.h.s. DISCHARGE DIAGNOSES: 1. Septic shock secondary to aspiration pneumonia. 2. Congestive heart failure exacerbation. 3. Mitral regurgitation 3+. 4. Hypertension. 5. Rheumatic heart disease. 6. Hypercholesterolemia in the past. 7. History of breast cancer. 8. Hypothyroidism. 9. Status post cataract surgery. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**] Dictated By:[**Doctor Last Name 10182**] MEDQUIST36 D: [**2198-12-7**] 13:09 T: [**2198-12-7**] 13:32 JOB#: [**Job Number 99651**]

[ "401.9", "272.0", "507.0", "997.3", "427.31", "394.1", "785.59", "V10.3", "398.91" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "45.23", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

2146, 2208

7657, 8227

7232, 7636

1882, 2129

4142, 7209

2395, 4124

151, 174

203, 1413

1436, 1855

2225, 2372

29,215

108,838

31928

Discharge summary

report

Admission Date: [**2112-9-3**] Discharge Date: [**2112-9-12**] Date of Birth: [**2033-4-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: hypotension,respiratory failure,IMI Major Surgical or Invasive Procedure: emergency CABG x3/[**First Name3 (LF) **] with IABP [**2112-9-3**] (29mm [**Company 1543**] Mosaic Porcine valve, LIMA to LAD, SVG to OM, SVG to PDA) History of Present Illness: 79 yo male admitted from OSH with hypotension, respiratory failure and IMI. Arrived already intubated with IABP in place for acute MR. [**First Name (Titles) **] [**Last Name (Titles) 74846**] to [**Hospital **] Hosp. on [**9-1**] with angina and acute MI. Cath there revealed ramus 90%, RCA 95%, 80% PDA, and 3 bare metal stents were placed in the RCA. Dopamine drip started for hypotension at that time. Recurrent angina the next day led to a repeat cath and echo showed severe MR. [**Name13 (STitle) **] also was shocked 4 times for VTach. Transferred to [**Hospital1 18**] with IABP for further management and surgery. Past Medical History: HTN IMI rheumatoid arthritis prostate Ca [**2095**] bladder Ca [**2101**] Social History: retired and lives with wife no tobacco use occ. ETOH no recr. drugs Family History: non-contributory Physical Exam: 84/65 HR 111 RR 14 ventilated, intubated and sedated IABP in place left femoral anicteric, PERRL, EOMI, OP unremarkable neck supple, no JVD appreciated [**2-16**] holosystolic murmur coarse BS, bibasilar rales soft, NT, ND, no HSM or abd. bruits bil. art. and venous sheaths in place no carotid bruits bil. DPs/PTs dopplerable Pertinent Results: [**2112-9-12**] 06:15AM BLOOD WBC-11.9* RBC-3.52* Hgb-10.5* Hct-30.3* MCV-86 MCH-29.8 MCHC-34.7 RDW-15.0 Plt Ct-223 [**2112-9-8**] 05:50AM BLOOD PT-13.6* PTT-44.9* INR(PT)-1.2* [**2112-9-12**] 06:15AM BLOOD Plt Ct-223 [**2112-9-12**] 06:15AM BLOOD UreaN-14 Creat-0.8 K-4.9 [**2112-9-10**] 05:10AM BLOOD Glucose-75 UreaN-24* Creat-0.7 Na-135 K-4.7 Cl-100 HCO3-26 AnGap-14 [**2112-9-3**] 03:48PM BLOOD ALT-31 AST-126* LD(LDH)-573* CK(CPK)-846* AlkPhos-49 TotBili-0.7 [**2112-9-7**] 04:10AM BLOOD Mg-2.2 Cardiology Report ECHO Study Date of [**2112-9-3**] PATIENT/TEST INFORMATION: Indication: cabg,[**Date Range **] Status: Inpatient Date/Time: [**2112-9-3**] at 21:09 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW-1: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%) Aorta - Ascending: *3.6 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: *3.2 cm (nl <= 2.5 cm) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; lateral apex - hypo; apex - hypo; remaining LV segments contract normally. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Torn mitral chordae. Severe (4+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions: Pre-CPB: The patient is in extremis, with IABP well-positioned, on high-dose inotropes, very low cardiac output. No spontaneous echo contrast is seen in the left atrial appendage. The LV septum, infero-septal and antero-septal walls contract normally. The anterior, inferior and lateral walls are hypokinetic. . There is mild global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Torn mitral chordae are present. Severe (4+) mitral regurgitation is seen. Flow is directed anteriorly. There appears to be a rupture of the antero-lateral papillary muscle. There is no pericardial effusion. Post-CPB: Patient is on epinephrine and milrinone. RV systolic fxn is preserved. LV EF = 30-35%. Mild improvement of anterior wall. There is a well-seated and functioning mitral valve prosthesis. No leak, no MR, no AI. Aorta intact. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2112-9-3**] 23:06. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 74847**]) RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2112-9-9**] 7:22 PM CHEST (PA & LAT) Reason: r/o eff, inf [**Hospital 93**] MEDICAL CONDITION: 79 year old man with REASON FOR THIS EXAMINATION: r/o eff, inf CHEST PA LATERAL HISTORY: Evaluate for effusion or infiltrate. FINDINGS: Frontal and lateral views of the chest compared to prior study [**2112-9-6**]. Post-surgical changes of median sternotomy are again noted. Right internal jugular Swan-Ganz catheter has been removed. Bilateral pleural effusions persist. There is also bibasilar airspace density, likely atelectasis in the post-operative setting. There is no pneumothorax. Bony structures are unchanged. IMPRESSION: Small bilateral pleural effusions and associated bibasilar airspace opacity, likely atelectasis. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**] Brief Hospital Course: Admitted [**9-3**] and seen by cardiology. Continued on dopamine drip with IABP in cardiogenic shock and referred to Dr. [**Last Name (STitle) **] for urgent surgery after echo showed 4+ MR. [**First Name (Titles) **] [**Last Name (Titles) **]/cabg x3 that evening and transferred to the CVICU in fair condition on titrated epinephrine, milrinone, and insulin drips.IABP removed.Extubated on POD #2 and transferred to the floor on POD #4 to begin increasing his activity level.Chest tubes and pacing wires removed without incident. He was gently diuresed toward his preoperative wieght and continued amiodarone for postop Afib.Continued to make good progress and was cleared for discharge to home with services on POD #9. Pt. to make all followup appts. as per discharge instructions. Medications on Admission: meds on transfer: amiodarone drip heparin drip dopamine drip plavix ASA omeprazole tylenol zocor plaquenil atenolol enalapril meds at home: plaquenil atenolol 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Community VNA, [**Location (un) 8545**] Discharge Diagnosis: MR/CAD s/p emergency [**Location (un) **]/CABG x3 with IABP acute IMI RCA stents HTN RA prostate Ca/bladder Ca postop Afib Discharge Condition: Good. Discharge Instructions: SHOWER DAILY and pat incisions dry no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, or drainage Followup Instructions: see Dr. [**Last Name (STitle) **] in [**12-15**] weeks see Dr. [**Last Name (STitle) 2232**] in [**1-16**] weeks see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2112-9-13**]

[ "429.6", "410.41", "428.0", "428.20", "599.0", "424.0", "V10.46", "427.31", "785.51", "414.01", "788.5", "V10.51", "401.9", "997.1", "285.9", "V45.82", "998.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "97.44", "35.23", "96.71", "36.12", "88.72", "39.61", "89.60", "36.15" ]

icd9pcs

[ [ [] ] ]

9067, 9137

6760, 7546

355, 509

9306, 9314

1749, 2306

9572, 9791

1359, 1377

7756, 9044

5885, 5906

9158, 9285

7572, 7572

9338, 9549

2332, 5663

1392, 1730

280, 317

5935, 6737

537, 1161

5697, 5848

1183, 1258

1274, 1343

7590, 7733

29,305

191,380

53583

Discharge summary

report

Admission Date: [**2103-10-15**] Discharge Date: [**2103-10-22**] Date of Birth: [**2037-3-8**] Sex: F Service: MEDICINE Allergies: Bactrim / Tetracyclines / Erythromycin Base / Optiray 350 Attending:[**First Name3 (LF) 4052**] Chief Complaint: CC: Abdominal pain & diarrhea Major Surgical or Invasive Procedure: TPA for acute stroke History of Present Illness: Ms. [**Known lastname 110101**] is a 66yo female with PMH significant for CAD, atrial fibrillation, HTN, and ? Sjogren's, who presents with abdominal pain and diarrhea. Per patient, her symptoms first began back in early [**Month (only) **]. At that time she felt tired and bloated. Her PCP thought she had a bacterial infection in her abdomen and started her on Augmentin x 2 weeks. Her pain improved but as a result of the antibiotics she developed a yeast infection and was given Diflucan. 2 weeks later, she was also started on Protonix, which she states was very helpful. Since her insurance required pre-approval for the Protonix, she was switched to Prilosec which was not as helpful. In addition her Protonix, Celebrex was changed to Ibuprofen which further worsened her symptoms. She is not taking celebrex again. She also admits to nausea, which she has had for years. . Starting about 1 week prior to admission, she notes an episode of increased pain and bloating. She experienced some urgency and noted a dark bowel movement with increased [**Last Name (un) **]. This bowel movement also had some blood and mucus mixed with the stool. These loose BMs resolved over the day and she returned to regular BMs until the day prior to presentation. She again noted urgency and abdominal pain followed by a loose stool mixed with blood. This diarrhea continued for two more BMs while in the emergency room. She denies any fevers, chest pain, SOB, dizziness, or recent travel. She states that her son-in-law had a stomach virus last week. She has not had a colonoscopy or endoscopy. . ROS: positive for whats noted above. Denies fevers / chestpain / shortness of breath / vomiting / dysuria. Positive for chronic fatigue, noted since the start of these symptoms as well as a chronic stable fatigue / decreased exercise tolerance that has occured for years. She also notes that she has experienced mechanical falls for her lifetime that has been worked up by multiple physicians. She also noted dry mouth and decreased tear production that is currently being workup by her PCP for Sjogrens syndrome. Past Medical History: 1)?Sjogrens syndrome-being worked up by PCP 2)Spinal stenosis 3)Hypothyroidism 4)Type 2 DM 5)CAD 6)Atrial fibrillation 7)Hypertension 8)Mitral valve regurgitation 9)Neuropathy 10)s/p R TKR 11)s/p R cataract and retinal surgery [**07**])Arthritis 13)Asthma 14)Acne Social History: Denies tobaco, alcohol, or IVDA. Family History: No history of gastrointestinal diseases in her family. Physical Exam: vitals T98.7 BP132/76 HR 80 RR 20 O2 sat 97% on RA Gen: Pleasant female, lying in bed, NAD HEENT: NC AT, PERRLA, EOMI, mouth dry, clear OP NECK: No LAD, no thyromegaly Heart: RRR, no m,r,g Lungs: CTAB, no crackles Abdomen: NABS, soft, obese, diffusely tender to palpation, no guarding or rebound. No masses were able to be palpated. Extremities: no c/c/e, 2+ DP pulses Rectal: guiac positive (per ED) Pertinent Results: [**2103-10-15**] 05:00AM GLUCOSE-139* UREA N-15 CREAT-1.0 SODIUM-142 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-26 ANION GAP-14 [**2103-10-15**] 05:00AM CK(CPK)-373* [**2103-10-15**] 05:00AM CK-MB-7 cTropnT-<0.01 [**2103-10-15**] 05:00AM WBC-8.0 RBC-4.17* HGB-13.0 HCT-37.1 MCV-89 MCH-31.2 MCHC-35.1* RDW-13.2 [**2103-10-15**] 05:00AM NEUTS-72.3* LYMPHS-20.5 MONOS-5.7 EOS-0.7 BASOS-0.8 [**2103-10-15**] 05:00AM PLT COUNT-171 [**2103-10-15**] 05:19AM LACTATE-2.0 . Studies: Chest Xray: UPRIGHT AND LATERAL CHEST: Allowing for differences in inspiration, the cardiomediastinal silhouette is not significantly changed. Pulmonary vascularity is normal. Lungs are clear and there is no pleural effusion or pneumothorax. Thoracic spondylosis is observed. IMPRESSION: No acute cardiopulmonary process. . CT ABD/PELVIS IMPRESSION: 1. Fluid filled colon with mild prominence of the bowel wall. Findings may correlate with resolving colitis. 2. Sigmoid diverticulosis without acute diverticulitis. 3. 3 mm pulmonary nodule requires one-year followup if there are significant risk factors (i.e., history of smoking or history of known malignancy). If there are no such risk factors, no followup is required. . ABD U/S from [**2103-6-26**] ABDOMINAL ULTRASOUND: The liver parenchyma is unremarkable without evidence of focal mass. No intrahepatic ductal dilatation is identified and the common bile duct is normal measuring approximately 7 mm. Portal vein is patent with normal hepatopetal flow. Patient is noted to be status post cholecystectomy. Limited examination of the pancreatic head and body appears unremarkable. A small 2 x 0.5 x 1.8 cm peripancreatic lymph node is identified. The aorta is of normal caliber throughout and the spleen is noted to be slightly prominent but within normal limits measuring approximately 13.5 cm. The right kidney measures approximately 10.6 cm and the left kidney measures approximately 10.9 cm. There is no evidence of hydronephrosis or renal calculi bilaterally. No free fluid is noted within the abdominal quadrant. IMPRESSION: Unremarkable abdominal ultrasound. No cause for pain identified. Brief Hospital Course: 66 year old women who presents with chronic abd pain / bloating and possible acute process causing recent diarrhea . #Stroke: On the night of admission, the patient noted the acute onset of headache and left sided weakness. A code stroke was called and the patient was evaluted by the neurology team. CT scan of the head did not show any acute event and neurosurgery thought a bleed was very unlikely. She refused an MRI at the time. She was give IV TPA by the neurologists and transfered to the NICU. She did well in the ICU and most of her deficits resolved. She has some minimal residual weakness on the left side and a small left facial droop. It is believed that the event represents a thromboembolic event, likely from her Atrial fibrillation. After discussing with the patient and her PCP she was started on coumidin with IV heparin during the transition. She tolerated the coumidin well. She will follow up with the neurology stroke clinic. . #ABD pain / Diarrhea: No clear source of the abdmoninal pain was discovered. The patient may have been recovering from an acute infectious etiology at the time of admission as seen on the CT scan. GI saw the patient while she was in the hospital and deferred further evaluation until she was an outpatient because of her acute neurological event. She was started on a lactose free diet in the hospital and given Senna and Colace. She will follow up with GI as an outpatient. . #AFib: Patient was continued digoxin. Metoprolol for rate control. Due to the thromboembolic event, she was started on coumidin in house. She will be followed by her PCPs to monitor her INR. They would like a more concervative goal of 2.0-2.5. . #HTN: Continued metoprolol. Decreased dose to 25 [**Hospital1 **]. Can be titrated as needed as an outpatient. . #Type 2 DM: Held orals in house. Will keep on home regimin as outpatient. . #Hypothyroidism: continue levothyroxine Medications on Admission: Glipizide 5mg PO QAM Digitek 0.25mg PO daily Lasix 40mg PO daily Celebrex 200mg PO daily Metoprolol 50mg PO daily ASA 81mg PO QHS Levoxyl 25 micrograms PO daily Vitamin D Prilosec 40mg PO daily Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed. 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [**Hospital1 **] (2 times a day). 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Celebrex 100 mg Capsule Sig: One (1) Capsule PO twice a day. 13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 15. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: please take in evening. Disp:*30 Tablet(s)* Refills:*0* 17. Outpatient Lab Work Please check PT, PTT, INR on [**2103-10-23**] and fax results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 4647**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Stroke Atrial Fibrillation Diabetes Abdominal Pain Asthma Discharge Condition: Stable, abdominal pain improved, neurologically stable without additional events. Discharge Instructions: You were seen in the hospital for abdominal pain. We started you on new medications and your abdominal pain improved. You will see the GI physicians as an outpatient to follow up. . While you were in the hospital you had an acute thromboembolic stroke. You were seen by the neurologists and given a medication called TPA for your stroke. While in the hospital you were also started on a new medication called coumadin to help prevent future [**Doctor Last Name 6056**]. Your primary care physician will need to check blood levels to follow this medication. Please discuss with your primary care physician if they would like you to continue taking Aspirin and Coumidin together. . A few changes were made to you medications. Please discuss all of these medications with your primary care physician: [**Name10 (NameIs) 110102**] was decreased to 20mg daily -Metoprolol was decreased to 25mg twice daily -Coumadin 4mg daily was added to your medications. -To help with your stomach you can take simethicone as needed for gas, colace can be taken twice daily to soften stools, and Senna can be taken once or twice daily as needed for constiptation. These medications can be purchased at the drug store without a Rx . Please either call your primary care physician or return to the emergency room if you develop any new weakness, new sensory loss, difficulty speaking, a change in vision, new headache, bleeding, chest pain, shortness of breath, increased abdominal pain or other symptoms of concern to you. Followup Instructions: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 608**] to make a follow up appointment in [**12-12**] weeks. Please call her and discuss when you will need to have your blood checked to follow your coumadin. . Please call ([**Telephone/Fax (1) 2528**] to make an appointment with Dr. [**Last Name (STitle) **] in the Neurology [**Hospital 4038**] Clinic. They will need to see you in 4 weeks. . Please follow up with the GI physicians. Provider: [**Name10 (NameIs) **] WEST,ROOM THREE GI ROOMS Date/Time:[**2103-11-15**] 9:00 Provider: [**Name10 (NameIs) **] PROCEDURES FELLOW Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2103-11-15**] 9:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2103-11-23**] 1:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**] Completed by:[**2103-10-23**]

[ "250.00", "V43.65", "493.90", "009.0", "427.31", "244.9", "424.0", "434.11", "710.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

9309, 9367

5540, 7466

349, 372

9469, 9553

3365, 5517

11112, 12084

2870, 2926

7711, 9286

9388, 9448

7492, 7688

9577, 11089

2941, 3346

280, 311

400, 2515

2537, 2803

2819, 2853

70,872

186,292

5873

Discharge summary

report

Admission Date: [**2169-3-1**] Discharge Date: [**2169-3-7**] Date of Birth: [**2094-3-27**] Sex: F Service: MEDICINE Allergies: Morphine / Codeine Attending:[**First Name3 (LF) 759**] Chief Complaint: Right leg cellulitis. Major Surgical or Invasive Procedure: None. History of Present Illness: Briefly, Ms. [**Known lastname 23227**] is a 74 yoF with a history of HTN and & hypothyroidism, who presented to the ED this morning with rigors. Ten days ago she fell and lacerated her RLE; she was treated initially with Keflex 500 mg TID x 10 days by the ED at [**Hospital6 33**] where she also had stitches done (tetanus booster was also given). On [**2-28**] she was seen at [**Company 191**] for removal of the stitches and was noted to have some drainage from the wound; she was switched to Bactrim DS 1 tab [**Hospital1 **]. This morning, she awoke febrile, with worsening erythema, and with rigors. . In the ED, VS were T 102.1, BP 134/73, HR 104, RR 22, 97% on RA. Labs were notable for a leukocytosis of 12,000, a lactate of 3.3, and an elevated BUN to 27. A UA, and CXR were negative for any other infectious sources, and films of the ankle were negative for any signs of osteomyelitis. The patient was given 1L of NS and 1g of vancomycin. . On the floor, she remained febrile; HR 110; BP 90-110's. She was given 2 L NS. She was transferred to the MICU briefly for observation with borderline BP and elevated lactate. On arrival, she was c/o her chronic back and neck pain as well as nausea. She denied SOB, CP, abd pain. Past Medical History: Hypertension Hypothyroidism Osteoarthritis Chronic back pain Peripheral neuropathy Social History: The patient lives independently in [**Location (un) 38**], with no home care needs. She is widowed, and has her children nearby for support. She has never smoked, and drinks ETOH rarely. Family History: Noncontributory. Physical Exam: VS on arrival to the MICU: 102.1, 116, 171/55, 19, 96% on 3LNC GENERAL: Flushed, appears somewhat uncomfortable in bed in terms of moving around and being restless (c/o back & [**Last Name (un) 23228**] pain; no resp distress); speaking in full sentences HEENT: MM dry. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. Neck Supple, No LAD, No thyromegaly. CARDIAC: Tachycardic with soft [**3-17**] murmur at L second intercostal space, non-radiating. No gallops. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: Right lower extremity (tibia) with 2cm escar, and ~5-6cm of surrounding erythema (marked by pen). No edema, or purulent drainage after attempts to express; recent suture removal. NEURO: AA, Ox3, CNII-XII in tact, strength 5/5 throughout PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Labs at Admission: [**2169-3-1**] 09:45AM BLOOD WBC-12.0* RBC-4.80 Hgb-14.2 Hct-40.1 MCV-84 MCH-29.6 MCHC-35.4* RDW-13.9 Plt Ct-212 [**2169-3-1**] 09:45AM BLOOD Neuts-88.1* Lymphs-6.9* Monos-3.6 Eos-1.0 Baso-0.4 [**2169-3-1**] 09:45AM BLOOD Glucose-107* UreaN-27* Creat-1.0 Na-136 K-3.9 Cl-96 HCO3-27 AnGap-17 [**2169-3-3**] 05:30AM BLOOD Calcium-8.8 Phos-1.6*# Mg-1.8 [**2169-3-3**] 05:30AM BLOOD CRP-222.0* [**2169-3-1**] 09:45AM BLOOD TSH-3.0 [**2169-3-3**] 05:30AM BLOOD ESR-25* . Labs at Discharge: [**2169-3-7**] 05:35AM BLOOD WBC-9.2 RBC-4.08* Hgb-11.6* Hct-34.1* MCV-84 MCH-28.5 MCHC-34.1 RDW-14.2 Plt Ct-253 [**2169-3-7**] 05:35AM BLOOD Glucose-87 UreaN-17 Creat-0.8 Na-139 K-3.7 Cl-98 HCO3-32 AnGap-13 [**2169-3-4**] 01:02PM BLOOD LD(LDH)-311* [**2169-3-7**] 05:35AM BLOOD ALT-59* AST-55* AlkPhos-89 TotBili-0.6 [**2169-3-6**] 05:10AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8 . Lactate: [**2169-3-1**] 09:56AM BLOOD Lactate-3.3* [**2169-3-1**] 03:14PM BLOOD Glucose-99 Lactate-3.4* Na-133* K-4.2 Cl-96* [**2169-3-2**] 01:29AM BLOOD Lactate-2.9* [**2169-3-2**] 06:27PM BLOOD Lactate-1.2 . Micro Data: [**2169-3-4**] BLOOD CULTURE negative [**2169-3-4**] BLOOD CULTURE negative [**2169-3-2**] BLOOD CULTURE negative [**2169-3-2**] URINE CULTURE negative [**2169-3-2**] BLOOD CULTURE negative [**2169-3-1**] URINE CULTURE negative [**2169-3-1**] BLOOD CULTURE negative [**2169-3-1**] BLOOD CULTURE negative . Studies: . Chest PA and LAT ([**3-3**]): Since [**2169-2-9**], bibasilar opacities increased, likely atelectasis, very less likely bibasilar pneumonia. Incidentally, an azygos lobe is present, a normal variant. Bilateral upper lobe opacities are likely artifactual, due to a different technique. There is no pleural effusion. The cardiomediastinal silhouette and hilar contours are normal. . TTE ([**3-2**]): The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. No significant valvular abnormalities. No vegetations identified. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. . Right Leg MRI ([**3-5**]): (dictated report) No evidence of osteomyelitis or soft tissue abscess. . Bilateral Lower Extremity Doppler Ultrasound ([**3-6**]): 1. No left or right lower extremity DVT. 2. [**Hospital Ward Name 4675**] cyst on the right, as described on MRI of the calf, [**2169-3-6**]. Brief Hospital Course: A 74 year-old woman presenting with clear signs of a systemic infection, including fevers, leukocytosis, tachycardia, and elevated lactate. Likely source is right leg cellulitis. . 1. Infection, cellulitis. At admission, she had significant pain and erythema at the site of the right leg laceration. Her systemic symptoms were felt to be due to inflammatory response from the cellulitis. She was admitted to the MICU overnight for monitoring given concern of SIRS (tachycardia, tachypnea, lactic acidosis), and started empirically on IV vancomycin. The next morning she returned to the medicine floors with stable vitals and resolved acidosis. The area of cellulitis had also decreased substantially in size. She continued to have intermittent episodes of chills, with fevers up to 101, on the vancomycin. Blood cultures were repeatedly drawn, and these all returned negative (including cultures taken from the ED). Urine cultures were also negative. She underwent transthoracic echo for concern of endocarditis. This showed normal ejection fraction with no valvular vegetations. Once therapeutic on the vanco, her fever curve began down-trending, although she continued to have occasional episodes of chills. She underwent right leg MRI which showed no evidence of osteomyelitis. She also had lower extremity dopplers that were negative for DVT. Liver enzymes were checked for concern of alcalculous cholecystitis; these were mildly elevated but consistent with her baseline transaminitis, likely from NAFLD. After five days of vancomycin, with no positive culture data, we switched her to oral Linezolid to complete a fourteen day course. At time of discharge, she has not had fevers in over 24 hours. Her last recorded fever was 100.0. She had a markedly elevated CRP (222) during this admission, and it is felt her fevers and chills are due to a prolonged inflammatory response to the cellulitis. Symptomatically she feels improved, and her cellulitis is resolving. . 2. Hypertension. Her atenolol-chlorthalidone was held at admission due to hypotension in the setting of possible sepsis. Once stable on the floors, her antihypertensive was restarted without complication. . 3. Hypothyroidism. We continued her home levothyroxine. . 4. Chronic Pain/neuropathy. We continued her home pain regimen, which includes gabapentin, lidocaine patch, tolmetin and cyclobenzaprine prn. . 5. Gastrointestinal reflux disease. We continued her home proton pump inhibitor. . 6. Chronic bronchitis. We continued her home albuterol. . She was kept on a normal diet. Subcutaneous heparin, then pneumoboots, were used for venous thrombosis prophylaxis. Her code status is DNI, but okay to resuscitate. This was confirmed with patient and daughter during this admission. Medications on Admission: ALBUTEROL inhaler prn ATENOLOL-CHLORTHALIDONE 100 mg-25 mg daily ATIVAN 1mg qhs prn CYCLOBENZAPRINE 10mg daily prn GABAPENTIN 100mg TID LEVOTHYROXINE 50mcg daily LIDOCAINE PATCH prn STEROID TAPER? PRILOSEC 20MG daily TOLMETIN 400 mg [**Hospital1 **] ASPIRIN 81mg daily MELATONIN 1mg qhs Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Capsule, Delayed Release(E.C.)(s) 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:*18 Tablet(s)* Refills:*0* 9. Atenolol-Chlorthalidone 100-25 mg Tablet Sig: One (1) Tablet PO once a day. 10. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 11. Tolmetin 400 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain. 12. Melatonin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Right leg cellulitis . Secondary Diagnoses Hypertension Hypothyroidism Osteoarthritis Chronic back pain Peripheral neuropathy Discharge Condition: Vital signs stable. Afebrile. Discharge Instructions: You were hospitalized for treatment of right leg cellulitis. We treated the infection with intravenous vancomycin. You received five full days of vancomycin. We would like you to complete a fourteen day course total, so please take nine more days of Linezolid, which is the oral equivalent of vancomycin. . During the admission, we were trying to localize a source for infection that could explain the fevers. We took images of the heart that did not show evidence of valvular infection. We did an MRI of the right leg that did not show evidence of bone infection. We did ultrasounds of the legs that did not show any venous clots. We also checked six blood cultures and two urine cultures. All of these returned negative. We believe that the chills and fevers are likely due to cellulitis, and the cellulitis has improved significantly on antibiotics. . We have made the following changes to your medicines: 1. We have started Linezolid. This should be taken for nine additional days (18 doses) at a dose of 600 mg twice daily. . Please note your follow-up appointments below. . Please call your doctor or return to the emergency room if you have fever or other symptoms that are concerning to you. Followup Instructions: 1. Please follow-up in primary care clinic on [**Last Name (LF) 2974**], [**3-10**] with [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**] to have your wound checked. The appointment has already been scheduled: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2169-3-10**] 11:40. . 2. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2169-6-19**] Completed by:[**2169-3-7**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10185, 10191

5979, 8735

298, 306

10379, 10411

2885, 3370

11659, 12205

1894, 1912

9072, 10162

10212, 10358

8761, 9049

10435, 11636

1927, 2866

237, 260

3389, 5956

334, 1568

1590, 1674

1690, 1878

2,113

168,729

47912

Discharge summary

report

Admission Date: [**2187-4-9**] Discharge Date: [**2187-4-17**] Service: MEDICINE Allergies: Codeine / Demerol / Phenergan / Penicillins Attending:[**First Name3 (LF) 9240**] Chief Complaint: CC: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: HPI: [**Age over 90 **] yo female, h/o CHF, severe MR, CRI, p/w acute SOB from rehab. Pt was discharged on [**4-2**] (diagnosed and rxed for bronchitis, diuresed). She was recently here on [**4-8**] in the [**Hospital1 18**] ED for SOB, diagnosed with bronchitis, and discharged on azithromycin. She went to [**Hospital1 599**] for <24 hours and woke up 4am with acute SOB, nausea, dizziness. She denies f/c/cough. Denies increasing LE edema or weight gain. Denies palpitations. She was brought to the ED where she was found to be hypoxic (RA sats in 80s) with HR up to 140s (afib). Pt states she is usually in SR. She was given abx, steroids, nebs, and lasix 20 mg IV (CXR c/w volume overload, BNP elevated, and EKG showed afib with rate 128, ST depr V3-6, II, F -- change from baseline). She improved with the lasix (also radiographic improvement). Her SBP was transiently in the 90s but quickly improved. She was admitted to the ICU given tachycardia and hypoxia. . Currently, she states that her breathing is improved, but she still has some SOB, especially when talking for long periods. She states that at her baseline, she is functional (lives at home, uses cane if necessary). Denies f/c/urinary symptoms. Denies weight gain or LE edema. Past Medical History: 1. Paroxsymal atrial fibrillation on coumadin 2. Congestive heart failure with EF 55-60% 3. Severe mitral regurgitation 4. Peripheral vestibulopathy diagnosed by neurology on recent admission 5. Labyrinthitis at age 39, several recurrences later 6. Upper gastrointestinal bleed secondary to peptic ulcer in [**2182**], per patient has had negative colonoscopy, endoscopy and capsule endoscopy 7. Osteoporosis with compression fractures, recently started on Forteo by endocrine 8. Spinal stenosis 9. Hypothyroidism 10. Glaucoma 11. Anemia with baseline hematocrit low 30s, per pt has had negative colonoscopy, endoscopy and capsule endoscopy 12. Chronic renal insufficiency with baseline 1.5 Social History: Retired Social workder. Lives alone at home. Gets Meals-On-Wheels and on weekends has high school students help at home and do food shopping for her. Walks with a walker. Remote tobacco with 1-2 cig/day for ten years in the [**2140**] and rare EtOH. States that her "primary objective at this point is to be in the community for as long as possible." Family History: Brother with [**Name2 (NI) 499**] cancer. Physical Exam: PE: VS: 97.6 115/58 101 17 97% 4L Gen: pleasant female, A&Ox3, speaking in complete sentences, NAD HEENT: OP dry Neck: JVD to mid neck at 30 degrees Lungs: scant crackles at bases CV: 3/6 SEM heard LLSB (and throughout), irreg irreg s1/s2, no r/g Abd: soft, nt/nd, nabs Extr: no c/c/e, 1+ PT/DP bilat Neuro: grossly intact, moving all 4 extremities, CN II-XII intact Pertinent Results: [**2187-4-9**] 04:51PM CK(CPK)-70 [**2187-4-9**] 04:51PM CK-MB-4 cTropnT-0.03* [**2187-4-9**] 04:51PM OSMOLAL-292 [**2187-4-9**] 08:00AM POTASSIUM-3.4 [**2187-4-9**] 08:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2187-4-9**] 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2187-4-9**] 06:30AM TYPE-ART PO2-72* PCO2-29* PH-7.43 TOTAL CO2-20* BASE XS--3 [**2187-4-9**] 05:58AM GLUCOSE-112* UREA N-40* CREAT-1.7* SODIUM-135 POTASSIUM-5.9* CHLORIDE-101 TOTAL CO2-21* ANION GAP-19 [**2187-4-9**] 05:58AM CK(CPK)-84 [**2187-4-9**] 05:58AM CK-MB-NotDone cTropnT-<0.01 proBNP-6240* [**2187-4-9**] 05:58AM WBC-15.9* RBC-3.36* HGB-10.3* HCT-31.6* MCV-94 MCH-30.8 MCHC-32.7 RDW-13.5 [**2187-4-9**] 05:58AM NEUTS-85.1* BANDS-0 LYMPHS-10.4* MONOS-3.6 EOS-0.6 BASOS-0.3 [**2187-4-9**] 05:58AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2187-4-9**] 05:58AM PLT SMR-NORMAL PLT COUNT-418 [**2187-4-9**] 05:58AM PT-15.3* PTT-26.0 INR(PT)-1.4* [**2187-4-9**] 05:58AM D-DIMER-[**2115**]* [**2187-4-9**] 05:57AM LACTATE-1.5 [**2187-4-8**] 02:16PM K+-4.2 [**2187-4-8**] 12:20PM GLUCOSE-89 UREA N-40* CREAT-1.7* SODIUM-134 POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-22 ANION GAP-16 [**2187-4-8**] 12:20PM estGFR-Using this [**2187-4-8**] 12:20PM CK(CPK)-61 [**2187-4-8**] 12:20PM CK-MB-NotDone cTropnT-<0.01 [**2187-4-8**] 12:20PM WBC-11.5* RBC-3.11* HGB-9.8* HCT-28.1* MCV-90 MCH-31.5 MCHC-34.9 RDW-13.7 [**2187-4-8**] 12:20PM NEUTS-82.2* LYMPHS-12.6* MONOS-4.7 EOS-0.4 BASOS-0.1 [**2187-4-8**] 12:20PM PLT COUNT-355 [**2187-4-8**] 12:20PM PT-16.6* PTT-29.3 INR(PT)-1.5* . CXR: Improving pulmonary edema with a decrease in the size of the now tiny bilateral pleural effusions. Multiple chronic compression deformities of the thoracic vertebral bodies. . pCXR: Mild pulmonary edema has improved since [**4-9**]. Top normal heart size is stable. Pleural effusion has decreased or resolved. No pneumothorax. Brief Hospital Course: 1. SOB: On arrival to the [**Hospital Unit Name 153**], had signs of volume overload on CXR (and elevated BNP). Oxygenation much improved after diuresis. In the ED, she also got steroids/nebs and abx for ?bronchitis. History seems more consistent with flash pulmonary edema, in the setting of afib with RVR. She may have bronchitis (no definite inflitrate on CXR) that could have been the inciting event for afib. Doubt cardiac etiology/ischemia. Ruled out for MI. Rate controlled with verapamil and amiodarone. Follow up with cardiologist. . 2. Afib with RVR: Controlled with verapamil and amio. Cont. coumadin. Follow up with Dr. [**Last Name (STitle) **]. . 3. CHF: preserved EF but severe MR (so likely overestimated EF). Not usually on lasix, so it is likely in setting of afib/rvr. Diuresed gently with 20 mg po lasix, to complete a week of this at rehab. Started low dose ACEI. . 4. Anemia: hct at baseline, slightly lower today but has been this low in the past. Guaiac stools. . 5. CRI: At baseline 1.5-1.7. . 6. PPX: coumadin Medications on Admission: tylenol prn azithro 500mg (start [**4-8**]) finished 7d levoflox [**4-9**] coumadin 1 mg daily isosorbide 30 mg daily amiodarone 100mg qhs levothyroxine 50 mcg daily zantac 150 mg daily latanoprost gtt qhs both eyes calcium/D 500mg [**Hospital1 **] Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please check INR [**4-18**] or [**4-19**]. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 9. Multivitamin,Tx-Minerals Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Bimatoprost 0.03 % Drops Sig: One (1) gtt Ophthalmic QHS (once a day (at bedtime)). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 13. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 17. Outpatient Lab Work Please check INR [**4-18**] or [**4-19**] to adjust coumadin dose t rehab for goal INR [**3-3**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: primary: congestive heart failure, left side atrial fibrillation with rapid ventricular response secondary: chronic renal insufficiency Discharge Condition: good: stable on room air, rate controlled Discharge Instructions: Please call your doctor or go to the emergency room if you experience temperature > 101, shortness of breath, chest pain, dizziness, or other concerning symptoms. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 mL Followup Instructions: Please call to schedule follow-up with Dr. [**Last Name (STitle) 172**] [**Name (STitle) 766**] [**2187-4-23**] at 1:30pm. Call if you have questions. Phone: [**Telephone/Fax (1) 133**] Please call to schedule follow-up with Dr. [**Last Name (STitle) **] within 1 week. Phone: ([**Telephone/Fax (1) 11230**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8079, 8164

5214, 6252

274, 281

8345, 8389

3103, 5191

8728, 9041

2656, 2699

6551, 8056

8185, 8324

6278, 6528

8413, 8705

2714, 3084

211, 236

309, 1557

1579, 2272

2288, 2640

7,107

153,012

8875+8876

Discharge summary

report+report

Admission Date: [**2145-6-30**] Discharge Date: [**2145-7-9**] Date of Birth: [**2067-11-11**] Sex: F Service: MED CHIEF COMPLAINT: Fever and dyspnea. HISTORY OF PRESENT ILLNESS: This is a 77-year-old female with a history of chronic obstructive pulmonary disease, obstructive sleep apnea on CPAP, on home O2 with a baseline of 93 percent on two liters, with a history of bronchiectasis and two recent admissions for methicillin resistant Staphylococcus aureus pneumonia in [**3-/2145**] and [**4-/2145**] requiring Medical Intensive Care Unit stays complicated by hypotension requiring pressors and acute renal failure, prerenal and ATN who was at home in her usual state of health until last night when she was noted to have acute shortness of breath and needed to increase her home O2 from chronic two liters to five liters. She also had fevers and chills. She had a mild cough with mild yellow phlegm production. No nausea, vomiting, abdominal pain, chest pain, diarrhea or melena. In the Emergency Room, she had a temperature of 101.6. O2 saturation was 88 percent on room air to 95 percent on 50 percent face mask. She was started on vancomycin and levofloxacin and given Lasix 20 mg intravenously. PAST MEDICAL HISTORY: History of methicillin resistant Staphylococcus aureus in her sputum following hernia repair and again in [**3-/2145**] with documented pneumonia. Obstructive sleep apnea on CPAP at 8-10 cm of water. Chronic obstructive pulmonary disease and emphysema on chronic home oxygen 2-4 liters nasal cannula. Bronchiectasis. Pulmonary hypertension. Acute respiratory failure in [**3-/2144**] and again in [**3-/2145**] secondary to poor p.o. intake. Diastolic congestive heart failure with an ejection fraction greater than 55 percent in 03/[**2145**]. Coronary artery disease. Hypertension. Dysphagia with motility study in [**1-/2144**] showing no esophageal contraction. Symptomatic bradycardia status post VDD pacer in 11/[**2143**]. Gastroesophageal reflux disease. Status post hernia repair. Status post appendectomy. Status post total abdominal hysterectomy. Status post back surgery. Status post right total hip. Chronic lower back pain. ALLERGIES: Penicillin, codeine and Bactrim which cause rash. SOCIAL HISTORY: A thirty pack year tobacco use, quit fifteen years ago. Rare alcohol use. Lives with her 75-year-old cousin. [**Name (NI) **] refused rehabilitation in the past and has visiting nurses q weekly. FAMILY HISTORY: The patient has a father and brother with chronic obstructive pulmonary disease. Father died of pneumonia. Mother died of coronary artery disease. Sister with breast cancer. MEDICATIONS ON ADMISSION: 1. Cardia-XT 250 mg p.o. q day. 2. Lipitor 20 mg p.o. q day. 3. Lasix 20 mg p.o. q day. 4. Neurontin 600 mg p.o. b.i.d. 5. Vitamin D 400 IU. 6. Vitamin C. 7. Quinine sulfate 325 mg p.o. q day. 8. MS Contin 15 mg p.o. q p.m. 9. Home O2. 10. CPAP at 8 cm. 11. Fluticasone four puffs b.i.d. 12. Salmeterol one puff q twelve hours. 13. Combivent nebulizers as needed. PHYSICAL EXAMINATION: Vital signs: 101.6 temperature, blood pressure 116/97, heart rate 72, respiratory rate 18, saturation of 88 percent on room air and 94 percent on 50 percent face mask. In general, an elderly female in no apparent distress, obese. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Oropharynx clear. Moist mucous membranes. Neck: Jugular venous distension approximately 8 cm. Lungs: Rhonchi two-thirds up right lung, left rhonchi at bases, no wheezing. Cardiovascular: Regular rate and rhythm, normal S1, S2. No murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended, positive bowel sounds, obese, no hepatosplenomegaly, multiple healed scars. 1+ edema bilaterally. Neurological: Alert and fluent in speech, moves four extremities. LABORATORY DATA: White blood cell count 19.1 with 69 percent polycytes, 12 percent bands, 12 percent lymphocytes, three percent monocytes, hematocrit 29.9, potassium 3.1, creatinine 1.0 with a baseline of 0.8-0.9, INR 1.4, CK 92, troponin less than 0.01, lactate 1.5. Urinalysis: 21-50 white blood cells, [**4-2**] epis, contaminated. Chest x-ray: Mild congestive heart failure and a question of a left lower lobe retrocardiac opacity. Electrocardiogram: Atrially paced at 72, normal axis, right bundle branch block, occasional premature ventricular contractions, T-inverted on V1 and V6 with no changes since [**2145-4-29**]. Pulmonary function tests in [**1-/2145**]: FEV1 over FVC 90 percent, FVC 81 percent, FEV1 of 82 percent, PLC 79 percent. Mild obstructive and restrictive disease. Echocardiogram in [**3-/2145**]: Ejection fraction greater than 55 percent, dilated left ventricle and right ventricle, [**1-29**]+ mitral regurgitation, moderate pulmonary hypertension. HOSPITAL COURSE: The patient's shortness of breath was multifactorial. Initial concern was congestive heart failure given the chest x-ray, as well as pulmonary examination, as well as blossoming pneumonia. Other diagnoses included a history of bronchiectasis, worsening pulmonary hypertension, chronic obstructive pulmonary disease flair and obstructive sleep apnea. When the patient was admitted, overnight during her first hospitalization stay, she had an increase in her oxygen requirement and pleuritic chest pain. Chest x-ray was performed which showed a white out of the left lung. The patient received aggressive chest physical therapy and suctioning by Respiratory and subsequently transferred to the Intensive Care Unit where the patient received aggressive chest physical therapy, Mucomyst and guaifenesin with clearing of her secretions and improvement of her oxygenation from four liters to her baseline of two liters. It was likely due to worsening pneumonia. Her sputum culture returned and was positive for methicillin resistant Staphylococcus aureus. The patient continued to be treated on vancomycin when she was transferred to the floor after being in the [**Hospital Unit Name 153**] for a total of 2.5 days. Her levofloxacin was discontinued at this time. She had a stable course where she was afebrile. Blood cultures were negative to date. On [**2145-7-7**], the patient had increasing hypoxia with a stable heart rate. She had no clinical evidence of deep venous thrombosis with Homans sign that she was not tachycardiac. A repeat chest x-ray was performed, which showed increasing questioned left pleural effusion. The patient had an attempted blind tap without ultrasound guidance, which was unsuccessful. A chest CT was performed, which showed no pleural effusion, however, but continued consolidation of the left lower lobe and lingula region. The Pulmonary team was consulted in the management of this patient. Given the fact that she had multiple etiologies and underlying pulmonary disease, it was assumed that this was just progression of her methicillin resistant Staphylococcus aureus pneumonia, which required significant chest physical therapy. The patient underwent a bronchoscopy on [**2145-7-8**], which showed mucoid impaction within the right lower lobe, left lower lobe and the lingular region. No evidence of endobronchial lesion. The patient should have aggressive chest physical therapy and is currently being screened for rehabilitation for possible transfer today given her recurrent mucous plugging as the source of her hypoxia. Pneumonia: The patient presented with methicillin resistant Staphylococcus aureus pneumonia from the left lower lobe opacity in her chest which was confirmed by chest CT. The patient was initially given vancomycin and levofloxacin, but sputum was growing methicillin resistant Staphylococcus aureus, so levofloxacin was discontinued. The patient continued on vancomycin. She should receive a remainder of a fourteen day course per the Pulmonary team. Question of long- term antibiotics was brought up by the primary pulmonologist, [**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 2146**], M.D., who is likely leaving. The patient should follow-up for further evaluation with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 30899**], M.D., who is the attending in the Intensive Care Unit and took care of this patient. A sputum culture repeat was contaminated. She had stable temperature curve for the remainder of her hospital course with blood cultures that were negative to date. Congestive heart failure: The patient has a history of diastolic dysfunction with a normal ejection fraction. Chest x-ray initially showed congestive heart failure on admission. She was given a one time dose of Lasix with improvement of her hypoxia. Her home regimen of Lasix was increased from 20 mg to 40 mg p.o. q day. Hypertension: The patient was stable on Cardia and we increased her Lasix dose. She had no episodes of hypotension or hypertension during the hospitalization. Hypercholesterolemia: We continued with her Lipitor without event. Gastroesophageal reflux disease: The patient continued on Protonix. Anemia: The patient had no evidence of guaiac positive stools, but her hematocrit initially was down to 25.2, likely due to blood draws while she was in the Intensive Care Unit. She received a unit of packed red blood cells followed by 20 mg of intravenous Lasix with significant improvement and stable hematocrit. She had no evidence of gastrointestinal bleeding. Renal: The patient had no evidence of acute renal failure and with improved p.o. intake, her creatinine was at baseline. Fluids, electrolytes and nutrition: The patient was on a low sodium diet given her history of congestive heart failure. Prophylaxis: The patient was maintained on Protonix and subcutaneous heparin. Chronic low back pain: The patient had no acute flares of her back pain. She was maintained on her home dosage of OxyContin. FINAL DIAGNOSES: Methicillin resistant Staphylococcus aureus pneumonia. Chronic obstructive pulmonary disease. Obstructive sleep apnea on CPAP. Bronchiectasis. Pulmonary hypertension. Diastolic congestive heart failure with acute exacerbation. Hypertension. Gastroesophageal reflux disease. Chronic low back pain. RECOMMENDED FOLLOW-UP: Primary care: Please call [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD at [**Telephone/Fax (1) 133**] to schedule a follow-up appointment within two weeks and inform her of your recent hospitalization. Pulmonary: Please call [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. at [**Telephone/Fax (1) 30900**] to schedule a follow-up appointment within two weeks. [**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 2146**], M.D. has left the practice at the [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. Room Four Pain Management Center [**2145-7-22**] at 3:00 p.m. Ophthalmology, [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D., on [**2145-7-24**] at 9:45 a.m., phone number [**Telephone/Fax (1) 30901**]. Cardiology: [**Hospital Ward Name 23**] Center, phone number [**Telephone/Fax (1) 2207**], [**2145-9-8**] at 9:00 a.m. CONDITION ON DISCHARGE: Afebrile times six days, stable heart rate and blood pressure, baseline oxygen at 94 percent on two liters, no shortness of breath or chest pain. DISCHARGE MEDICATIONS: 1. Diltiazem HCL 240 mg sustained release, one capsule p.o. q day. 2. Atorvastatin 20 mg, one tablet p.o. q day. 3. Lasix 40 mg, one tablet p.o. q day. 4. Gabapentin 300 mg, two capsules p.o. b.i.d. 5. Quinine sulfate 325 mg p.o. q h.s. 6. OxyContin one tablet p.o. q p.m. 7. Vitamin E 400 units, one tablet p.o. q day. 8. Vitamin D 400 units, one tablet p.o. q day. 9. Vitamin C 500 capsule, one capsule p.o. q day. 10. Home oxygen titrated to greater than 93 percent O2 saturations, usually two liters. 11. CPAP 8 cm. 12. Fluticasone 110 mcg, four puffs inhaled b.i.d. 13. Salmeterol Diskus, one inhalation b.i.d. 14. Albuterol, one nebulizer inhaled q six hours as needed for wheezing. 15. Combivent, 1-2 puffs inhaled q six hours as needed for wheezing. 16. Colace 100 mg p.o. b.i.d. 17. Mucomyst 20 percent solution, 1-10 cc nebulizer q 4- 6 hours as needed for shortness of breath or wheezing. 18. Subcutaneous heparin 5,000 units, one injection subcutaneously q 12 hours. 19. Ipratropium bromide nebulizer solution, one inhalation q six hours as needed for wheezing. 20. Vancomycin 750 mg intravenously q 12 hours times two weeks. Start date is [**2145-7-6**]. 21. Heparin lock flush 10 cc. 22. Protonix 40 mg, one tablet p.o. q day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2364**], [**MD Number(1) 2365**] Dictated By:[**Last Name (NamePattern1) 12481**] MEDQUIST36 D: [**2145-7-9**] 10:52:07 T: [**2145-7-9**] 12:34:16 Job#: [**Job Number **] Admission Date: [**2145-6-30**] Discharge Date: [**2145-7-20**] Date of Birth: [**2067-11-11**] Sex: F Service: MED ADDENDUM: Please see the previously dictated discharge summary dated [**2145-7-9**] for prior hospital course. HOSPITAL COURSE (CONTINUED): 1. SHORTNESS OF BREATH: The patient continued to have worsening hypoxia during her hospital stay. She was found to have further lung collapse of the left lobe on chest x- ray, after initial aggressive chest PT and initial bronchoscopy on [**7-8**]. We consulted pulmonology for the further evaluation of this patient, and she underwent a repeat bronchoscopy on [**7-14**], with suctioning of large amounts of sputum and mucoid impaction. BAL was sent for further diagnosis, and grew out oral flora. She was maintained on her vancomycin, and she received a total course of 3 weeks in house. After consultation with the ID team, they felt that 3 weeks was appropriate treatment for her MRSA pneumonia. She had marked reexpansion of her left lower lobe after the second bronchoscopy, and she was maintained on an Acapella valve as per pulmonary recommendations. She continued to receive daily chest PT and Mucomyst nebs q 6 h. The patient continued to refuse pulmonary rehab and; therefore, initial dispo planning was that the patient should have outpatient VNA and follow for chest PT, physical therapy, as well as nebulizer treatment. The patient had marked stabilization of her oxygen back to her baseline of 2 liters with a range of 93-95 percent during her post bronchoscopy course, and she was felt to be back to her baseline. She will likely need further aggressive chest PT at home, Mucomyst nebs, Acapella valve continued use, as well as ambulation. 1. CHF: She was maintained on IV Lasix at 40 mg po qd, and she continued to be negative everyday for the remainder of her hospital stay. She was afebrile for the remainder of her hospital course. She had no acute exacerbation of her CHF. As per the remainder of her issues, including hypertension, hypercholesterolemia and GERD, these remained stable on the current regimen that she was on previously. CONDITION: Stable heart rate and blood pressure. Afebrile through the remainder of her hospital course. BAL was growing only an oral flora. RECOMMENDED FOLLOW-UP: Primary Care: Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], phone number [**Telephone/Fax (1) 133**], to schedule a follow-up appointment within 2 weeks to inform her of your recent hospitalization. Pulmonary: Pulmonary breathing tests, [**Hospital Ward Name 23**] Center, [**Telephone/Fax (1) 30902**], on [**2145-8-21**] a 11:45. A visit with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital Ward Name 23**] Center, [**Telephone/Fax (1) 5091**], also on [**2145-8-21**] afterwards. [**Apartment Address(1) **] Pain Management, [**2145-7-22**] at 3:00 pm. [**Year (4 digits) **] [**Doctor Last Name **] for ophthalmology, [**Telephone/Fax (1) 30903**], on [**2145-8-23**] at 9:45 am. Cardiology, [**Hospital Ward Name 23**] Center Cardiac Services, [**Telephone/Fax (1) 2207**], on [**2145-9-8**] at 9:00 am. DISCHARGE MEDICATIONS: 1. Diltiazem 240 mg SR 1 capsule po qd. 2. Atorvastatin calcium 20 mg 1 tablet po qd. 3. Lasix 40 mg 1 tablet po qd. 4. Gabapentin 300 mg 2 capsules po bid. 5. Quinine sulfate 325 mg 1 capsule po q hs. 6. Morphine sulfate SR 15 mg 1 tablet po q pm. 7. Vitamin E 400 U 1 tablet po qd. 8. Vitamin D 400 U 1 capsule po qd. 9. Vitamin C 500 mg capsules SR 1 capsule po qd. 10.Home oxygen titrate to greater than 93 percent O2 sats, usually on 2 liters. 11.CPAP at 8 cm. 12.Fluticasone propionate. 13.Flovent 4 puffs inhaled [**Hospital1 **]. 14.Salmeterol discus 1 inhalation q 12 h. 15.Albuterol nebulizer 1 nebulizer inhalation q 6 h prn wheezing. 16.Combivent 1-2 puffs inhaled q 6 h prn wheezing. 17.Colace 100 mg 1 capsule po bid. 18.Mucomyst 20 percent solution 1-10 mm nebulizer q 4-6 h prn shortness of breath or wheezing. 19.Subcu heparin 1 injection q 12 h. 20.Ipratropium bromide 1 nebulizer inhalation q 6 h prn wheezing. 21.Protonix 40 mg 1 tab po qd. 22.KCL 20 mEq 1 capsule po qd. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5825**] Dictated By:[**Last Name (NamePattern1) 12481**] MEDQUIST36 D: [**2145-7-20**] 11:42:06 T: [**2145-7-20**] 12:08:37 Job#: [**Job Number 30904**]

[ "518.0", "424.0", "428.33", "780.57", "482.41", "280.0", "416.8", "428.0", "494.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "33.24" ]

icd9pcs

[ [ [] ] ]

2502, 2677

16285, 17546

2703, 3089

4911, 9934

9952, 11211

3112, 4893

154, 174

203, 1230

1253, 2272

2289, 2485

11236, 11383

2,635

169,533

30229

Discharge summary

report

Admission Date: [**2168-4-22**] Discharge Date: [**2168-7-7**] Date of Birth: [**2115-6-4**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Yellow Dye Attending:[**First Name3 (LF) 974**] Chief Complaint: EC Abdominal Fistula/Sepsis Major Surgical or Invasive Procedure: Open Tracheostomy History of Present Illness: 52F s/p TAH on [**4-6**] for leiomyoma c/b bowel perforation, s/p exp lap with small bowel resection and primary anastomosis on [**4-12**], c/b abd wall fluid collection which was drained but is now draining bilious fluid c/b development of sepsis and pleural effusion w/ respiratory distress s/p intubation. Transferred from OSH intubated for further evaluation/treatment Past Medical History: PMH: Depression Ulcerative Colitis Leiomyosarcoma PSH: TAH-BSO SB Rsxn Physical Exam: Admission PE-[**2168-4-22**] 98 119/69 16(mv) 97% (60% FiO2) Intubated/sedated RRR, no m/r/g CTAB s/nt/nd; (+)bs(hypoactive) Pertinent Results: Admission Labs ------------------ [**2168-4-22**] 04:42PM BLOOD WBC-14.2* RBC-3.10* Hgb-9.2* Hct-26.8* MCV-86 MCH-29.6 MCHC-34.3 RDW-14.9 Plt Ct-249 [**2168-4-22**] 08:14PM BLOOD Neuts-88.4* Bands-0 Lymphs-7.3* Monos-3.1 Eos-1.0 Baso-0.2 [**2168-4-22**] 08:14PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2168-4-22**] 04:42PM BLOOD PT-15.4* PTT-36.0* INR(PT)-1.4* [**2168-4-22**] 04:42PM BLOOD Glucose-150* UreaN-33* Creat-1.0 Na-136 K-3.7 Cl-104 HCO3-21* AnGap-15 [**2168-4-22**] 04:42PM BLOOD ALT-14 AST-20 CK(CPK)-30 AlkPhos-124* Amylase-17 TotBili-1.3 [**2168-4-22**] 04:42PM BLOOD Albumin-2.0* Calcium-6.9* Phos-3.6 Mg-2.3 [**2168-4-25**] 03:04AM BLOOD calTIBC-87* Folate-7.4 Ferritn-379* TRF-67* Discharge Labs ----------------- [**2168-7-6**] 04:25AM BLOOD WBC-6.3 RBC-2.70* Hgb-8.9* Hct-26.6* MCV-98 MCH-32.9* MCHC-33.4 RDW-18.0* Plt Ct-329 [**2168-7-6**] 04:25AM BLOOD Glucose-102 UreaN-19 Creat-0.4 Na-137 K-4.4 Cl-104 HCO3-27 AnGap-10 [**2168-6-19**] 04:31AM BLOOD ALT-49* AST-45* LD(LDH)-121 AlkPhos-543* Amylase-60 TotBili-2.6* [**2168-6-19**] 04:31AM BLOOD Lipase-57 [**2168-7-6**] 04:25AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.2 [**2168-7-3**] 04:07AM BLOOD calTIBC-202* Ferritn-709* TRF-155* CT Scan ----------- PROCEDURE: 1. Tracheostomy. 2. Examination under anesthesia. ANESTHESIA: General via endotracheal tube. INDICATIONS: This is a 52-year-old woman who has been admitted to the [**Hospital1 69**] with symptoms and complications of an enterocutaneous fistula. She has been ventilator dependent now for over 2 weeks without signs of being able to wean. She is scheduled for an elective tracheostomy. Additionally, she was noted to have to stool coming from her vagina, so we performed an exam under anesthesia. PROCEDURE DESCRIPTION: After informed consent was obtained from the patient's husband, the patient was sedated and brought to the operating room. She was in the supine position and placed in stirrups. An exam under anesthesia was conducted using a speculum. We had noticed enteric contents consistent with stool emanating from the apex of the vagina. We were unable to intubate this tract with a sterile Q-Tip. Next, the patient was placed in the supine position with her arms at her side. Her neck was slightly extended. She was prepped and draped in the usual sterile fashion. A transverse incision was made roughly 3 cm above the jugular notch. Skin was divided sharply and soft tissue was divided using electrocautery. We divided through to the level of the platysma using electrocautery. Next, the hyoid and sternothyroid muscles were identified. We spread between these muscles to expose the trachea. The thyroid gland itself was retracted cranially. This exposed the uppermost rings of cartilage of the trachea. The third tracheal ring was identified and divided sharply. A trapdoor incision was made along the membranous portions above and below. Next, a 2-0 Vicryl stay suture was placed on the ring immediately superior to our incision. Then 2 Prolene sutures were placed laterally as safety sutures as well. The endotracheal tube was withdrawn under direct vision and a #8 Portex nonfenestrated tracheostomy tube was placed. This went easily in without difficulty. The balloon was inflated and the patient was ventilated without difficulty. Skin was approximated using 2 interrupted 4-0 nylon sutures on each side of the tracheostomy. The patient tolerated the procedure well and was transported to the intensive care unit in stable condition. Dr. [**Last Name (STitle) **], the attending surgeon of record, was present throughout the duration of the entire procedure. Brief Hospital Course: [**Known firstname **] [**Known lastname **] was trasferred to [**Hospital1 18**] on [**2168-4-22**] and was admitted to the surgery service under the care of Dr. [**Last Name (STitle) **]. She was taken to the ICU intubated and sedated on Levophed drip. An arterial and PICC line were placed. Linezolid, Zosyn, Flagyl, and Capsofungin were started for empiric coverage. A VAC dressing was placed at the open abdominal wound. A CT scan of the abdomen/pelvis showed extravasation of oral contrast, adjacent to the surgical sutures, presumably at the site of prior small bowel injury, concerning for persistent bowel perforation and leak; diffuse complex ascites and stranding, with multiple scattered foci of free air, consistent with peritonitis. In several areas the fluid is beginning to organize into early abscesses; two enterocutaneous fistulas, one over the wound in the lower pelvis, the second near the umbilicus, both draining oral contrast; and bibasilar consolidation and pleural effusions. At HD 2 the WBC count was 11.2, down from 13.7. Levophed was weaned. At HD 3 a drain was inserted into the labial wound. At HD 4 she was extubated but desaturated later in the day due to pulmonary edema with (+)response to lasix. TPN was started. CT chest was negative for PE - showed B/L pleural effusions and pulmonary edema. She remained extubated with CPAP/NIV. At HD 7 she was reintubated for respiratory distress. CT head was completed for AMS and was negative. She was febrile and with decreased urine output. WBC count 19.4. Repeat CT of abdomen/pelvis showed no obvioius undrained fluid collections. Lower lung fields in scan showed evidence of ARDS. RUQ ultrasound showed distended but otherwise normal gallbladder. At HD 9 renal was consulted for oliguric acute renal failure. At HD 12 she remained intubated/sedated with VAC dressings. She was afebrile and hemodynamically stable off pressors. Urine output had increased. BUN/Creat remained elevated at 110/3.3. Yeast sepsis was identified via sputum/blood/line tip cultures. At HD 15 she had episodes of complete heart block requiring CPR/atropine. Cardiology was consulted and temporary pacing wires were placed. At HD 17 the pacer was functioning appropriately. Urine output was WNL; BUN 60; Creat 1.8. At HD 20 all abx were discontinued except Caspofungin. She was febrile to 101.2. WBC was increased. Cultures were sent. At HD 22 she underwent open tracheostomy. At HD 33 Liver was consulted for continued elevated LFTs and felt that she most likely suffered from [**Female First Name (un) **] infection in liver combined with long-term TPN. Infectious disease was consulted given continued yeast line sepsis. Fluconazole was started in place of caspogungin. At this point she was on Zosyn and Linezolid for (+)VRE and E. Coli UTI. TEE was negative for endocarditis. Opthamology exam was negative for endoophthalmitis. At HD 35 the pacing wires were discontinued. Swallowing study was passed and her diet was slowly advanced. She remained on TPN. At HD 42 a SBFT was performed which showed enterovaginal and enterocutaneous fistulae. At HD 45 she underwent a barium enema which showed an unremarkable J pouch, and enterocutaneous and enterovaginal fistulae. At HD 46 a guide wire was placed for feeding tube via the fistula site, but could not be positioned due to remaining contrast from prior studies. Enemas were given to clear the contrast. After clearing of the contrast there was successful placement of two 12-French Wills-[**Doctor Last Name 12433**] jejunostomy catheters with tips in the distal and proximal jejunum (relative to the enterocutaneous fistula). Tube feedings were then initiated. At HD 48 she had an episode of asystole and was transferred to the ICU. A pacer was not placed due to continued candidemia based on (+) blood and IV tip cultures on [**5-30**]. At HD 51 a CT scan was performed which was negative for infectious foci of candidemia. Debate reigned regarding placement of permanent vs temporary pacer vs SVC reconstruction. ID recommended two weeks of negative blood cultures prior to intervention. At HD 62 she underwent a fustulogram which showed dye flowing to rectum with (+) enterovaginal fistula seen; alos reflux of contrast into b/l ureters concerning for enterovescicular fistula. She had been without asystolic events since admission to the ICU. She was transferred back to the floor. By [**2168-7-7**] she had progressed well. She had no more episodes of asystole or bradycardia. She was afebrile and ambulating independently. Serial blood cultures were negative. It was decided not to perform any intervention in regards to the SVC thrombus. Cardiology did not recommend pacemaker placement. She was discharged home in good condition, tolerating a clear liquid diet and supplemented with tube feeds and cycled TPN. The fistula was pouched. She was to follow up with Dr. [**Last Name (STitle) **]. Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Tube Feeding Tubefeeding: Replete w/fiber 3/4 strength at 65ml/hr. Please flush tube with 30ml water twice daily. [**Month (only) 116**] substitute Promote with Fiber. Discharge Disposition: Home With Service Facility: [**Hospital 6136**] homecare Discharge Diagnosis: Sepsis Enterocutaneous Fistula Enterovaginal Fistula SVC Thrombus Malnutrition Discharge Condition: Stable Discharge Instructions: Please return or contact for: * Fever (>101 F or chills) * Nausea, vomiting, diarrhea * Abdominal pain * Increased redness or breakdown of wound sites * Chest pain, shortness of breath, dizziness Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **]. You may contact the clinic for any questions or concerns by calling [**Telephone/Fax (1) 2359**]. Completed by:[**2168-7-7**]

[ "453.2", "996.62", "427.5", "038.9", "596.1", "426.0", "261", "V10.42", "998.59", "569.81", "567.22", "453.8", "511.9", "995.92", "556.9", "619.1", "789.5", "599.0", "112.5" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "38.93", "00.14", "93.59", "37.78", "99.15", "96.72", "99.04", "88.14", "93.90", "88.72", "46.39", "31.1" ]

icd9pcs

[ [ [] ] ]

9968, 10027

4722, 9655

318, 337

10150, 10159

998, 4699

10404, 10585

9678, 9945

10048, 10129

10183, 10381

849, 979

251, 280

365, 739

761, 834

10,314

127,175

2351

Discharge summary

report

Admission Date: [**2150-2-12**] Discharge Date: [**2150-2-15**] Service: HISTORY OF PRESENT ILLNESS: This is a 78-year-old male with a history of having been on Coumadin for several months prior to admission. He was seen in the Emergency Room one day prior to admission, status post a fall, and was treated for right upper extremity injuries and subsequently discharge home in stable condition at that time with an INR of 1.3. However, he returned on the [**2-12**] with a history of reported decreased alertness as noted by family and was taken urgently for a head CT scan which showed a large right subdural hematoma. A Neurosurgery consultation was obtained at that time, and the patient was taken emergently to the operating room for drainage of the subdural hematoma. PAST MEDICAL HISTORY: (His previous medical history is reported to have included) 1. Atrial fibrillation (for which he was on the Coumadin). 2. History of hypertension. 3. History of chronic obstructive pulmonary disease. 4. History of type 2 diabetes mellitus. 5. History of hematochromatosis. 6. History of renal stones. 7. History of anemia. 8. History of peptic ulcer disease. 9. History of sleep apnea. MEDICATIONS ON ADMISSION: Medications at the time of admission were uncertain due to the patient's comatose status. His only known medication was the Coumadin. ALLERGIES: Allergic history reaction was unknown. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient was nonresponsive to verbal or painful stimuli. He has positive corneas bilaterally, and the right pupil was round at 6 mm. Left pupil was round and 3 mm but reactive to 2 mm. There was no withdrawal of the bilateral upper extremities to painful stimuli, and there was sluggish withdrawal in the bilateral lower extremities with painful stimuli. Toes were bilateral upgoing. Hoffmann was negative bilaterally. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory findings at the time of admission showed a PTT of 27.1, a PT of 13.9, and an INR of 1.3. A hematocrit of 27.1, white blood cell count of 18.9, and a platelet count of 154. RADIOLOGY/IMAGING: A head CT at the time of admission showed a large right-sided subdural hematoma. HOSPITAL COURSE: He was taken emergently to the operating room for evacuation of the hematoma. Subsequent to this, the patient was taken to the trauma Intensive Care Unit at approximately 9:15 p.m. after drainage of the hematoma. However, at 11:15 p.m., the patient was noted to have bilateral fixed and dilated pupils. A STAT CT scan of the head was again performed which demonstrated reaccumulation of a right-sided subdural, primarily over the high frontal parietal convexity measuring approximately 25% of the preoperative size of the subdural. Notably, however, there was relatively satisfactory evacuation of the low temporal clot, and there was still air present in the subdural space from the earlier craniotomy that evening. There was also a new right temporal intercerebral hematoma and intraventricular hemorrhage. There was also right-sided massive hemispheric brain swelling with a 3-cm midline shift, a trapped contralateral ventricle, and diffuse of the [**Doctor Last Name 352**]/white differentiation consistent with infarction or ischemic brain injury. On examination at that time, the pupils were 8 mm and fixed. There was trace corneas bilaterally and trace cough, but no withdrawal or motor response in all four extremities to noxious stimuli. The INR remained 1.3. He had been given 2 units of fresh frozen plasma. The platelets were 85,000. Dr. [**Last Name (STitle) 1327**] had a long discussion with the patient's wife, daughter, and extended family, as well as a conversation with the daughter in [**Name (NI) 622**] who is reportedly an Intensive Care Unit nurse. The family understood the magnitude of the situation and the gravity of the patient's condition. Yet, at that time, they elected to continue with full aggressive therapy. The patient's neurologic condition continued to deteriorate to the point where the patient was completely unresponsive on [**2150-2-14**], with no evidence of withdrawal of any extremities to painful stimuli. Pupils remained fixed and dilated, and serial brain death examinations showed the patient to have met all criteria for brain death, and the family was so informed. The family understood the magnitude and gravity of the situation. Therefore, the patient was maintained on ventilatory support with an intermittent mandatory ventilation of 4 and FIO2 was switched to room air. Neo-Synephrine drops were slowly decreased, and the patient's heart stopped beating, and he was declared deceased at 2220 on [**2150-3-18**]. [**First Name8 (NamePattern2) 1339**] [**Name8 (MD) **], M.D. [**MD Number(1) 1341**] Dictated By:[**Name8 (MD) 5474**] MEDQUIST36 D: [**2150-6-4**] 12:27 T: [**2150-6-4**] 19:38 JOB#: [**Job Number 12245**]

[ "998.12", "998.2", "852.20", "E884.6", "496", "428.0", "427.31", "440.20" ]

icd9cm

[ [ [] ] ]

[ "96.04", "88.48", "39.31", "96.71", "01.24", "38.08" ]

icd9pcs

[ [ [] ] ]

1233, 2246

2264, 4996

111, 787

810, 1206

6,543

163,221

25841

Discharge summary

report

Admission Date: [**2169-6-30**] Discharge Date: [**2169-7-13**] Date of Birth: [**2109-12-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4052**] Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: PEG placement TEE History of Present Illness: 59y/o M paraparetic with chronic indwelling foley, CAD, CHF with EF 28%, h/o sacral decub ulcer with sepsis, CRI, DM found to be pulseless and apneic at 0300 this am. Staff at NH reports pt had been having penile bleeding with clots s/p accidentally pulling out foley cath. Pt was also c/o R LQ pain and plans were to bring him to ED. Nurse stepped out to get pt a drink and came back to find pt pulseless and apneic. Staff began CPR and pt received shock x 1. EMS found pt pale, dry, cool, eyes fixed and dilated in gaze, agonal RR 2-4 per min. No palpable radial pulse, carotid pulse at 140. AED pads showed wide complex tachycardia at 128. ETT placed. Started IVF and was taken to [**Hospital1 **] ED. In ED lactate was 6.0 and pt received ~2L NS, Levo, Flagyl, Vancomycin, Tylenol, Propofol, Versed. Upon arrival to [**Name (NI) 153**] pt vomited and was found to have NG tube coiled in throat. Was repositioned and CXR retaken. sBP was in 120's s/p 3L IVF. Past Medical History: CAD - severe, inoperable CAD (s/p cath, no stents); ischemic CM EF 28% in [**2167**] CRI (unknown etiology, ? baseline Cr 2.7) HTN sacral decubitus ulcer h/o UTI [**3-4**] (MDR enterobacter, h/o MRSA in urine) s/p indwelling foley ([**2167**]) [**2-1**] sacral decubitus schizophrenia (not active since in 20s) paraparesis (progressive over many years, unknown etiology) AFib (on outpt coumadin) hypercholesterolemia horseshoe kidney AAA Social History: former electrial engineer, no EtOH; h/o 20 year tobacco use, quit 2 years ago Family History: NC Physical Exam: PE: T:104.0 Rectal P: 114 BP: 97/52 R: 18 O2 sat: 100% Vent: A/C 600x14, FiO2 100% x Peep 5 Gen: sedated and intubated, moves to pain HEENT: NC/AT, PERRL, ETT placed, Neck: Right IJ placed CV: Tachy, RR, no m/r/g PULM: Mechanical breath sounds, o/w clear, no /w/r/r ABD: +BS, soft, flat, NT/ND, GU: blood clots at meatus, foley in place Ext: no c/c/e, DP/PT 1+ b/l, Muscle wasting appreciated in both extremities, sacral wound 4 x 8cm with minimally surrounding erythema and no ooze draining serosang fluid Neuro: unable to assess given sedation Pertinent Results: Admission labs: --------------- WBC 14 (16% bands) -> 17.2 (max) HCT 35 -> 27.8 INR 2.4 Na 138 K 5.9 Cl 108 BUN 64 Cr 3.5 Lactate 6.1 Trop 0.15, 0.43 MB 5, 11 * Micro: ----- Urine - many bact, 468 WBC, mod leuk [**6-30**] Urine Cx- contaminated [**7-2**] Urine Cx- <10,000 organisms [**7-3**] Urine Cx- No growth . [**6-30**] Blood Cx- 4/4 bottles positive: ENTEROBACTER CLOACAE (S to Cefipime) & STAPH AUREUS (MRSA) [**7-2**] Blood Cx- No growth [**7-3**] Blood Cx- No growth [**7-6**] Blood Cx- No growth . Radiology: ---------- [**7-7**] MRI: no evidence of acute ischemia. chronic right frontal and temporal infarction [**7-4**] ECHO: no radiographic evidence of endocarditis. no ASD/PFO. >4mm complex non-mobile atheroma in descending thoracic aorta [**7-5**] Voiding Cystogram: limited study but no evidence of vesico-ureteral fistula [**6-30**] CT head- No evidence of bleed. Brief Hospital Course: 59 y/o M w/ complicated past medical history, admitted s/p cardiac arrest at nursing home. A brief [**Hospital 11822**] hospital course is outlined below. 1)SHOCK: Etiology of shock presumed to be sepsis. However, with EF=25% a cardiogenic component also possible. On admission, pt was noted to be febrile to 104.7 with leukocytosis (17.2). He was started on broad-spectrum abx for Gram (-) rods and Gram (+) cocci on blood cx. He also initially received volume resuscitation (6L of NS) and levophed for hypotension. He maintained adequate UOP and his BP recovered within 24hrs to near his baseline. From reports, his baseline SBP is in 80-90. * Organisms were subsequently identified as enterobacter (cefepime [**Last Name (un) 36**]) and MRSA. Pt was switched to Cefepime and Vancomycin (completed 7 days in ICU) and a 14 day course was defined for bacteremia after TEE ([**2169-7-4**]) revealed no valvular vegetations. The etiology of his bacteremia was presumed from a UTI, either via a urethral tear sustained during traumatic removal of his foley, or from a enterovesical fistula (urine appeared grossly stool-contaminated and urine cx grew enteric organisms). A urology consult was obtained which did not feel there was clinical evidence of fistula. A cystogram was obtained which was negative for fistula and pt's urine subsequently cleared. Pt clinically improved on abx and surveilence blood cultures remained negative (last positive blood culture was from [**2169-6-30**]). He completed a 14 day course of Vancomycin/Cefepime on [**7-13**]. 4. S/P CARDIAC ARREST/MI: Pt has an extensive cardiac history (CAD, HTN, A-fib, CHF with EF 25% by echo). His arrest was felt likely due to demand associated arrthythmia (v-fib/VT) from underlying infectious process. He ruled in by cardiac enzymes, likely from demand ischemia due to septic shock. Cardiology consult was obtained and suggested further evaluation for possible revascularization and ICD placement be pursued after stabilization and full resolution of urosepsis. The patient was continued on ASA (81mg QD) and statin (Atorvastatin 20mg QD). Metoprolol 12.5mg [**Hospital1 **] was restarted as BP stabilized. He remained hemodynamically stable the remainder of his hospital course. # Paroxysmal Afib: Continued on amiodarone and digoxin for A-fib rate control. Coumadin initially held due to penile bleeding and then for PEG placement. Restarted post PEG placement ([**7-10**]) at 1mg/day. Will need INR monitoring and adjustment as needed for goal [**2-2**]. Patient started on amiodarone as inpatient which activates P450 system - therefore may need increased coum dose to obtain effective INR. 5. PENILE BLEEDING/ANEMIA: Pt had hct=25.9 on admission likely from penile bleeding secondary to traumatic removal of foley. Coumadin was held, Vit K given, and transfused 1U PRBCs given for h/o of CAD. Hct subsequently remained around 29, except for a drop to Hct=25 again on HD#6 for which he received another unit of PRBCs. Urology consult was obtained to evaluate penile bleeding and possible enterovesical fistula. Pt had a negative (but limited study) cystogram - repeat demonstrated no enterovesicular vistula. Q6wk foley changes per urology recs. There was no add'l signs of bleeding. 6. RLQ pain: Pt had h/o RLQ pain of unknown etiology. CT of abd/pelvis showed mild inflammatory changes near the bladder which was felt to possibly represent a resolving epiploic appendagitis. A cystogram was also obtained to r/o fistula to bladder and was negative. Pain subsided through [**Hospital 153**] hospital stay - pt denies further pain upon discharge and is tolerating tube feeds well. 7. NEURO DEFICITS: Pt has h/o paraparesis. However, on admission eyes were noted to be deviated to L. Initial head CT was negative for acute bleed. Neuro was consulted and pt had EEG w/o evidence of seizure activity. Eye deviation subsequently resolved and findings were attributed to anoxic encephalopathy. Following extubation, pt was also noted to have slurred speech. Neurology was again consulted and requested MRI/MRA. MRI demonstrated no acute changes, evidence of old ischemia. MRA was not performed [**2-1**] to patient's agitation. Therefore slurred speech was attributed to [**2-1**] cardiac arrest. (Also there is likely a compenent from unstable dental bridge which needs repair) 8. RESPIRATORY DISTRESS: Pt was intubated and ventilated in ICU. On HD #6, pt was given a SBT which he tolerated well, and was subsequently extubated without incident - some increased secretions initially, but upon d/c pt with 99-100% O2 sats on RA. 9. DECUBITUS ULCER: Pt has h/o deep sacral decubitus ulcer. During hospitalization, there was concern for sacral osteo due to proximity of ulcer to sacrum and ulcer as etiology of sepsis. However, read of abdominal CT by radiology did not show evidence of ulcer infection or osteo. Pt was started on Aloevesta and Aquagel per wound care svc recs. Wound culture was pending at the time of transfer, but preliminarily showed only skin flora. Due to a transient leukocytosis despite IV antibiotics the thought of sacral osteo re-surfaced again prior to discharge. Plain film of the pelvis was performed which could not rule out osteo due to incomplete visualization. However, since the CT was negative and the patient remained afebrile and the white count subsequently declined, conservative management was decided upon with continued wound care and clinical monitoring. 12. RENAL INSUFFICIENCY: Pt has CRI with baseline Cr=2.7. However, had Cr up to 3.5 on admission likely from contrast dye received for CT scan in ED. Cr subsequently stabilized with hydration and was back to baseline on day of transfer to floor. 13. DM: Pt nitially maintained on an insulin drip with finger stick glucose measurements. This was tapered off and the patient was initiated on NPH at 12 units [**Hospital1 **] while on tube feeds. 14. FEN: Pt received tube feeds while intubated and sedated. Following extubation, tube feeds were resumed for concern of aspiration as pt was noted to have slurred speech with difficulty handling secretions. Pt received PEG placement by interventional pulmonology on [**7-10**] in prep for d/c to NH. 15. Dental care: Pt noted to have poor dentition with loose teeth during [**Hospital Unit Name 153**] stay. Dental consult was obtained due to concern for aspiration if tooth were to fall out. Initial dental consult demonstrated loose bridge needing removal and tooth decay, but no signs of infection. Although bridge in need of removal, it was stated that this is not as concerning as a loose tooth b/c of decreased likelihood of aspiration of a whole bridge vs. a single tooth. Oral surgery was consulted and we were told that bridge removal cannot be done on inpatient basis. Patient will need dental follow upon discharge. 16. PPx: Anticoagulation was held for penile bleeding. Pt received PPI for GI prophylaxis and pneumo boots for DVT prophylaxis. Anti-coagulation re-started prior to discharge. 17. Code: Full. 18. Comm: [**Name (NI) 3508**] brother [**Name (NI) **] [**Name (NI) 14714**] (general internist in [**Location (un) 86**] area) [**0-0-**] (cell), [**Telephone/Fax (1) 64337**] (home), [**Telephone/Fax (1) 64338**] (work) Medications on Admission: Digoxin .125 mg qod Iron Sulfate 325mg qd Novolin 8 units qam, 5 units qpm, sliding scale NTG prn APAP 1g [**Hospital1 **] and prn Amiodarone 200mg qd ASA 81 qd coumadin 1.5 alternating with 2mg qd protonix 40 qd calcitriol .25 mcg qod nephrocaps 1 qd colace 100 [**Hospital1 **] Na Bicarb 650 tid zyprexa 2.5 qhs Aranesp 25 mcg qweek (Tuesdays) Vit C 500mg [**Hospital1 **] Zinc sulfate 220mg qd promod 2 scoops in liquid [**Hospital1 **] Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ascorbic Acid 90 mg/mL Drops Sig: Five (5) PO BID (2 times a day). 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 12. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 15. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) Units Subcutaneous twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 1643**] Center Discharge Diagnosis: Urosepsis, Septic shock, S/P Cardiac Arrest Discharge Condition: Stable. Afebrile. Hemodynamically stable. Discharge Instructions: Change foley catheter Q6wks Followup Instructions: Please follow up your primary care doctor, Dr. [**Last Name (STitle) 1266**] after discharge. You may be referred to cardiology for further evaluation as needed. Please follow up with your dentist for referral to oral surgeon for bridge removal. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.72", "96.6", "38.93", "00.17", "88.72", "43.11", "99.04" ]

icd9pcs

[ [ [] ] ]

12467, 12521

3417, 10703

335, 355

12608, 12651

2509, 2509

12727, 13098

1921, 1925

11194, 12444

12542, 12587

10729, 11171

12675, 12704

1940, 2490

277, 297

383, 1347

2525, 3394

1369, 1809

1825, 1905

67,673

114,831

39788

Discharge summary

report

Admission Date: [**2110-8-11**] Discharge Date: [**2110-8-14**] Service: MEDICINE Allergies: Penicillins / Amoxicillin / Sulfa (Sulfonamide Antibiotics) / Tetracycline / Erythromycin Attending:[**First Name3 (LF) 2195**] Chief Complaint: SOB- found to have gallstone pancreatitis/cholangitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: Ms. [**Name13 (STitle) **] is a [**Age over 90 **]yo woman with hx of dementia, endometrial ca, and prior CVA who initially presented to [**Hospital3 3583**] from her nursing facility with SOB on [**2110-8-10**]. In the ambulance she was given lasix 20mg IV x 1 and at [**Hospital3 **] she was given levofloxacin 750mg IV x 1 and solumedrol 125mg IV x 1 for possible asthma / COPD flare (no known history of this.) Labs revealed lipase >5000, TBili 1.8 at [**Hospital1 46**] so the patient was transferred to [**Hospital1 18**] for ERCP. She underwent ERCP and there was difficulty navigating the duodenem due to tortuosity so the ERCP was aborted with a plan for percutaneous biliary drain. The patient was improving symptomatically improving and lipase/LFTs were improving. Given her improvement and discussions with her health care proxy ([**Name (NI) **] [**Name (NI) 87604**] [**Telephone/Fax (1) 87605**]) plan was made to conservatively manage with IV abx levo/flagyl x 2 weeks and readdress perc biliary drain should she worsen. In addition the patient's blood cultures from [**Hospital3 3583**] from [**8-10**] grew gram negative rods, prelim pan sensitive without speciation yet. Blood cultures from [**Hospital1 18**] [**8-11**] no growth to date. Prior to transfer from the [**Hospital Ward Name 332**] ICU the patient feels well, denies N/V, no abd pain, no SOB, no chest pain. She is pleasantly demented and AOx1-2 but states in general she feels well. During her ICU stay the patient rec'd IV abx, underwent unsuccessful ERCP as above, and was 2.6 L + legnth of stay. She was not intubated nor on pressors. Past Medical History: Alzeimer's dementia osteoporosis Gout PMR on prednisone 5mg po daily depression anxiety anemia h/o fall frequent UTIs Past Surgical History: R THR tendon repair L hamstring TAH sebaceous cyst Social History: Nursing home resident, otherwise unknown Family History: unknown Physical Exam: VS T 98.7 HR 80 BP 114/79 RR 16 O2 99% on 3L, 97% on RA GEN: NAD, AOx1-2 (name, [**Month (only) 216**], unsure of year, thinks she is in [**Location (un) **], MA) HEENT: No scleral icterus, mucus membranes moist CV: RRR, 3/6 SEM > RUSB PULM: Crackles R side [**12-29**] way up with bilateral mild wheezes diffusely ABD: Soft, nondistended, tender on deep palpation of LLQ, no guarding or rebound tenderness, +BS Ext: No LE edema, LE warm and well perfused Pertinent Results: Imaging: RUQ US [**8-11**] IMPRESSION: Limited study demonstrating no evidence of gallbladder disease or biliary dilation. CXR PA/L [**8-11**]: IMPRESSION: Bibasilar atelectasis and small effusions. Limited exam. CXR [**2110-8-12**]: In comparison with the study of [**8-11**], the outer portion of the right hemithorax has been excluded from the image. Low lung volumes with technically limited study make it difficult to assess the size of the heart. Tortuosity of the aorta is seen in a patient with prominent kyphosis that limits evaluation on the frontal projection. Some prominence of interstitial markings could reflect elevated pulmonary venous pressure. The left hemidiaphragm is not sharply seen, raising the possibility of some atelectasis or effusion at the left base. ERCP [**2110-8-11**]: The stomach was entered and seemed to be very friable. The was severe external duodenal compression and deformity and the scope not be safely passed into the second portion. [**2110-8-12**] 04:15AM BLOOD WBC-13.4* RBC-3.25* Hgb-9.9* Hct-29.6* MCV-91 MCH-30.4 MCHC-33.4 RDW-13.6 Plt Ct-117* [**2110-8-12**] 04:15AM BLOOD Neuts-82* Bands-5 Lymphs-9* Monos-3 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2110-8-12**] 04:15AM BLOOD Glucose-81 UreaN-41* Creat-1.4* Na-144 K-4.4 Cl-111* HCO3-25 AnGap-12 [**2110-8-12**] 04:15AM BLOOD ALT-259* AST-240* LD(LDH)-224 AlkPhos-89 TotBili-0.6 [**2110-8-12**] 04:15AM BLOOD Lipase-462* [**2110-8-12**] 04:15AM BLOOD Calcium-8.0* Phos-4.0 Mg-2.3 [**2110-8-12**] 04:50AM BLOOD Lactate-1.6 Discharge Labs: [**2110-8-14**] 06:30AM WBC-10.0 RBC-3.29* Hgb-9.7* Hct-30.9* MCV-94 Plt Ct-117* Glucose-80 UreaN-29* Creat-1.0 Na-142 K-4.1 Cl-107 HCO3-29 AnGap-10 ALT-115* AST-51* AlkPhos-74 TotBili-0.6 Brief Hospital Course: Cholangitis: Likely secondary to common bile duct obstruction with stone. ERCP was unsuccessful, but patient clinically improved and LFT's and lipase decreased. She remained afebrile and pain free on Levofloxacin and Flagyl, and had her diet advanced without difficulty. She should complete a total of ten days of antibiotics. Blood cultures are pending from the 16th and 18th, but are currently no growth to date. Given friability of gastric mucosa seen on endoscopy patient was started on a PPI. Pancreatitis: Likely secondary to gallstones as above; patient never experienced abdominal pain and tolerated a PO diet. Acute Renal Failure: Resolved with IV fluids. Duodenal Extrinsic Compression: When clinically improved from current illness, discuss with patient and family further workup including further imaging with CT abd/pelvis. No current evidence of bowel obstruction Dementia: No difficulties with agitation or sundowning. Mood stable. PMR: Patient was continued on Prednisone 5mg po daily Code Status: DNR/DNI Medications on Admission: - Prednisone 5mg po daily - Folate 1mg po daily - Miralax daily - Tylenol 1g qam - Alphagan 0.1% dropps - one drop both eyes [**Hospital1 **] - Pepcid OTC 20mg po daily - Tums 500mg po daily - Vitamin D 400 units [**Hospital1 **] - Calcium 600mg po bid - Milk of mag prn Discharge Medications: 1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for SOB. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Inhalation Q6H (every 6 hours). 6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for shortness of breath or wheezing for 7 days. 7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 3 doses. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Extended Care Facility: Lifecare of [**Location (un) 3320**] Discharge Diagnosis: Cholangitis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Discharge Instructions: You were transferred to the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 19806**] ERCP to remove a gallstone. The procedure was unsuccessful, but you continued to improve with antibiotics. You were also started on nebullizers for wheezing, and were weaned off of oxygen. Aside from being started on antibiotics, no changes were made to your home medications. Followup Instructions: Please follow-up with your primary care provider within one week of discharge.

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icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

6804, 6867

4573, 5603

351, 357

6923, 6923

2813, 4343

7435, 7517

2310, 2319

5924, 6781

6888, 6902

5629, 5901

7030, 7412

4359, 4550

2183, 2236

2334, 2794

258, 313

385, 2019

6938, 7006

2041, 2160

2252, 2294

31,526

125,490

34150

Discharge summary

report

Admission Date: [**2158-5-11**] Discharge Date: [**2158-6-13**] Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 165**] Chief Complaint: angina Major Surgical or Invasive Procedure: urgent CABGx2(SVG-RCA,SVG-LCX)[**5-13**], Trach/PEG [**5-24**] History of Present Illness: 88 yo female awakened by angina in the middle of the night on [**5-10**]. Went to ER at [**Hospital1 **]. Pain subsided in 2 hours with NTG. Cardiac cath done there. This showed CX and RCA disease. Transferred to [**Hospital1 18**] on [**5-11**]. Past Medical History: CAD ARF asthma COPD HTN squamous cell CA LBBB NSTEMI [**2155**] vision loss left eye endometriosis Social History: remote tobacco use lives alone [**1-25**] martinis per night Family History: son with CAD/stents at age 65 Physical Exam: 5'2" 97 # 159/70 RR 20 skin/HEENT unremarkable neck supple, full ROM CTAB RRR, no murmur soft, NT, ND, + BS warm,well-perfused 1+ edema no obvious varicosities neuro grossly intact 2+ bilat. fems.DP/PT/radials no carotid bruits appreciated Pertinent Results: [**2158-6-13**] 04:29AM BLOOD WBC-20.1* RBC-3.23* Hgb-9.7* Hct-31.8* MCV-99* MCH-30.0 MCHC-30.4* RDW-17.4* Plt Ct-358 [**2158-6-12**] 02:11AM BLOOD WBC-27.3* RBC-3.27* Hgb-9.8* Hct-32.5* MCV-99* MCH-29.9 MCHC-30.1* RDW-17.3* Plt Ct-425 [**2158-6-10**] 12:54AM BLOOD WBC-31.7*# RBC-3.46* Hgb-10.4* Hct-33.2* MCV-96 MCH-30.2 MCHC-31.5 RDW-17.6* Plt Ct-409 [**2158-6-10**] 12:54AM BLOOD PT-17.6* PTT-33.1 INR(PT)-1.6* [**2158-6-4**] 04:07AM BLOOD PT-18.8* PTT-78.9* INR(PT)-1.7* [**2158-6-3**] 02:17AM BLOOD PT-19.0* PTT-78.0* INR(PT)-1.8* [**2158-6-13**] 04:29AM BLOOD UreaN-117* Creat-3.0* Na-142 K-3.4 Cl-116* HCO3-13* AnGap-16 [**2158-6-12**] 02:11AM BLOOD Glucose-148* UreaN-104* Creat-2.9* Na-144 K-3.6 Cl-116* HCO3-14* AnGap-18 [**2158-6-11**] 01:55AM BLOOD Glucose-124* UreaN-96* Creat-2.7* Na-144 K-4.0 Cl-117* HCO3-14* AnGap-17 [**2158-6-10**] 05:37PM BLOOD Glucose-117* UreaN-96* Creat-2.8* Na-143 K-4.0 Cl-115* HCO3-15* AnGap-17 Conclusions PRE-BYPASS: 1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2.There is mild regional left ventricular systolic dysfunction with antero septal and septal hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). 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 complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and epinephrine and is being AV paced. 1. Bi ventricular function is preserved. 2. Severe MR is seen, some [**Male First Name (un) **] is noted. MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] with [**Male First Name (un) **] therapy. 3. Aorta is intact post decannulation. 4. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2158-5-17**] 11:57 Final Report CT ABDOMEN W/O CONTRAST [**2158-5-26**] 1:01 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Reason: r/o infection source Field of view: 36 [**Hospital 93**] MEDICAL CONDITION: 88 year old woman with s/p CABG REASON FOR THIS EXAMINATION: r/o infection source CONTRAINDICATIONS for IV CONTRAST: None. CT TORSO INDICATION: 88-year-old woman status post CABG, rule out infectious source. CT TORSO WITHOUT IV CONTRAST TECHNIQUE: Multidetector scanning is performed from the thoracic inlet through the symphysis without intravenous contrast. There is no axillary, mediastinal or hilar lymphadenopathy. A tracheostoma is identified. There are [**Hospital 1192**] bilateral pleural effusions. There is atelectasis in the lower lobes bilaterally. There are ground-glass opacities in the upper lobes bilaterally, left more than right. CT OF THE ABDOMEN WITHOUT IV CONTRAST: The contour of the right lobe of the liver is quite lobular. No focal lesions are seen. The spleen is unremarkable. The pancreas is atrophic. The gallbladder contains multiple stones. There is no definite evidence for pericholecystic fat stranding. The adrenal glands are normal. In the right kidney, there is a staghorn calculus in the lower pole. There is no retroperitoneal lymphadenopathy. The small bowel is unremarkable. A G-tube is present. The ascending colon is dilated measuring 5.8 cm. Mild dilatation is also noted in the transverse and descending colon. CT OF THE PELVIS WITHOUT IV CONTRAST: The sigmoid colon is collapsed. There is no evidence for an obstructing lesion. The small bowel is normal. There is no free fluid in the pelvis and no pelvic lymphadenopathy is noted. There is anasarca in the soft tissues. IMPRESSION: 1. [**Hospital **] bilateral pleural effusions and ground-glass opacities in the upper lobes bilaterally, left more than right. These findings most likely represent pulmonary edema. However, an infectious process cannot be entirely excluded for the parenchymal opacities and followup after treatment is recommended to ensure resolution. 2. Dilated ascending to descending colon likely represents ileus. There is no wall thickening to suggest ischemia. 3. Dilated gallbladder with multiple gallstones, however, no pericholecystic fat stranding to suggest cholecystitis. 4. Small amount of ascites in the abdomen and anasarca also likely reflecting fluid overload. 5. Nodular contour of the liver concerning for cirrhosis. 6. Staghorn calculus in the right kidney. No evidence for obstruction. DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] CHEST PORT. LINE PLACEMENT [**2158-6-10**] 2:19 PM CHEST PORT. LINE PLACEMENT Reason: ? infiltrate, check line position [**Hospital 93**] MEDICAL CONDITION: 88 year old woman s/p CABG, rising wbc count, Right subclavian CVL placed REASON FOR THIS EXAMINATION: ? infiltrate, check line position CHEST HISTORY: CABG, elevate white blood count cell count subclavian line placement. One supine view. Comparison with the previous study of [**2158-6-7**]. There is continued evidence of small pleural effusions. There is biapical pleural thickening, as before. The patient is status post median sternotomy, and mediastinal structures are unchanged. A tracheostomy tube and left PICC line remain in place. A right- sided central line has been withdrawn. A right subclavian catheter has been introduced and terminates at the level of the cavoatrial junction. There is no other significant interval change. IMPRESSION: Line placement as described. Brief Hospital Course: Admitted on [**5-11**]. IV NTG continued and IV heaprin started for recurrent angina. Dental clearance obtained. Carotid U/S showed [**Country **] 40-60%, [**Doctor First Name 3098**] 60-70%. DNR/DNI suspended for consent for sugery/anesthesia. Had additional angina on drips on [**5-13**] and was taken to the OR emergently. She had a cardiac arrest requiring CPR during line placement and an emergency CABG x2 done by Dr. [**First Name (STitle) **]. Transferred to the CVICU in fair condition. Developed Afib on [**5-16**] treated with amiodarone. Remained hypotensive requiring pressors. Pancultured for an elevated WBC count. Unable to wean from vent.Dobhoff tube placed. Lasix drip started. Mutiple skin tears noted and wound care nurse as well as plastic surgery consulted. Renal consult done for acute renal failure. IV heparin restarted on POD #7. Thoracic surgery consulted on POD #9 for trach/PEG. Vit. K given in preparation and trach and PEG done by Dr. [**First Name (STitle) **] on POD #10. Tube feeds started the following day. ID consult done [**5-26**]. IV flagyl/PO vanco started for preseumed colitis and cipro continued for 7 days for serratia in sputum. Right thoracentesis for 650 cc done on POD #18. Renal followed daily to assess her need for HD. She continued to make urine and her BUN/CR remained elevated but stable. [**6-5**]: a mild ileus was noted and TF were backed off, trophic continued, and plan to advance with ileus resolution. Beta blockers and amiodarone dc'd for bradycardia. ABX continued for leukocytosis although cultures and multiple c-diffs remained negative. She was started on cefepime for GNR in sputum. She was seen by general surgery for abdominal pain, and CT abdomen was negative for acute process, was followed by serial exams and started on TPN. She and her son met with renal regarding starting dialysis for subacute uremia, and she decided against it. She was again started on tube feeds and her TPN was discontinued. Her BUN/Cr were continuing to rise however family did not want dialysis and understood risks therin. Medications on Admission: advair 2 puffs daily singulair 10 mg daily lopressor 12.5 mg [**Hospital1 **] ASA 81 mg daily trusopt 2% one gtt OU TID albuterol MDI 2 puffs TID atrovent 2 puffs TID lipitor 5 mg daily lisinopril 10 mg daily nephrocaps Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 7. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation [**Hospital1 **] (2 times a day). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 11. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 12. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) PO DAILY (Daily). 13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous HS (at bedtime). 17. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 20. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day). 21. Procrit 4,000 unit/mL Solution Sig: One (1) Injection mon, wed,.fri. 22. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Vancomycin Oral Liquid 250 mg PO Q6H through [**6-21**]. 23. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours): through [**6-14**]. 24. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours): through [**6-21**]. 25. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 27. Metoclopramide 5 mg IV Q6H Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: CAD s/p cabg x2 post op respiratory failure s/p tracheostomy/PEG tube placement post op acute renal failure, acute tubular necrosis cardiac arrest asthma COPD HTN squamous cell CA LBBB NSTEMI [**2155**] vision loss left eye endometriosis PNA Discharge Condition: stable Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: see Dr. [**Last Name (STitle) 66572**] 1-2 weeks after discharge from rehab see Dr. [**Last Name (STitle) **] 2-3 weeks after discharge from rehab see Dr. [**First Name (STitle) **] in 4 weeks after discharge from rehab [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2158-6-13**]

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icd9cm

[ [ [] ] ]

[ "38.93", "39.61", "36.12", "99.60", "31.1", "43.11", "88.72", "39.64", "99.15", "96.6" ]

icd9pcs

[ [ [] ] ]

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240, 305

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720, 782

2,592

103,303

3512

Discharge summary

report

Admission Date: [**2187-11-8**] Discharge Date: [**2187-11-28**] Date of Birth: [**2112-9-17**] Sex: M Service: MEDICINE Allergies: Oxacillin Attending:[**First Name3 (LF) 905**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Transesophageal echocardiogram ICD removal History of Present Illness: 75 yo man w/ h/o chronic atrial fibrillation, hypertension, transient ischemic attack, nonischemic cardiomyopathy (EF 30-40%) s/p ventricular fibrillation arrest [**6-29**], with clean coronaries at that time and s/p AICD placement who presents as a transfer from OSH for management of bacteremia. During [**7-3**], patient was admitted with large LGIB [**7-3**], complicated by MSSA bacteremia, thought to be related to central line. At that time, patient was treated with Vanco x 4 days, then oxacillin x 10 days. He was sent to rehab, then discharged home on [**2187-9-3**]. He was doing well until [**2187-11-3**], when c/o fever to 102 and chills. He is also reporting mild non-productive cough. Denies dyspnea, PND, orthopnea. He was admitted to [**Hospital 1474**] Hosp on [**11-3**] and blood cultures found to be positive for Staph aureus x 2 (MSSA, penicillin resist). He was treated with Rifampin/Gent/Ancef but repeat blood cultures [**2187-11-5**] remained positive for Staph, blood cx from [**11-6**], [**11-7**], [**11-8**] have no growth to date. TTE was done there with no evidence of vegetations or abscess. CXR without infiltrate. Bone scan showed abnl uptake in L ankle, L shoulder and L spine. TEE was delayed due to respiratory secretions. Given recurrent bacteremia patient was transferred to [**Hospital1 18**] for TEE and ICD system extraction. Pt is currently without significant complaints other than diffuse body aches (mostly Left shoulder, low back). Past Medical History: CHF (EF 30-40%) Atrial fibrillation Cardiac arrest [**6-29**] with V-fib s/p AICD placement (dual chamber [**Company 1543**] Gem III AT DR (V:6945, A:5076)) HTN Diverticulosis (s/p signif LGIB [**7-3**]) Colon polyps s/p polypectomy 3 yrs ago Radiation proctitis Left frozen shoulder Subdural bleed after fall [**2184**] -> keppra PPX S/P TIA Depression Prostate CA Basal cell CA C5-7 fracture s/p decompression laminectomy and c-spine fusion [**2137**] h/o Polio oral HSV Social History: Pt lives in [**Location 1475**] with his wife. [**Name (NI) **] is a retired pharmacist (previously Chief Pharmacist at [**Hospital1 **]). He does not smoke or drink, though previously drank [**6-6**] drinks/day. No drug use. Family History: Mother with hypertension, died of pulmonary embolism. Father died of renal disease. Physical Exam: VS: T 98.6 ;BP 135/80 ; HR 60; RR 16; Sat 98% 2L GEN: Pleasant man in bed lying on back at 30degrees in NAD with wife at bedside. HEENT: OP clear. MMM. Sclerae anicteric. PERRL. NECK: JVP not elevated. CV: Normal S1/S2, irrer irreg. II/VI HSM at LSB. RESP: rare exp wheeze Abd: NABS, Soft, obese, non-tender. Ext: No edema. Back: no spinal tenderness Skin: 3 x 3 cm area of clustered papules + small amt of eschar. Rectal: yellow, guaiac (-) stool Pertinent Results: [**2187-11-8**] 09:49PM BLOOD WBC-10.1# RBC-3.17* Hgb-10.5* Hct-29.4* MCV-93 MCH-33.1* MCHC-35.7*# RDW-14.4 Plt Ct-217 [**2187-11-12**] 12:30PM BLOOD WBC-11.1* RBC-2.36* Hgb-7.7* Hct-22.5* MCV-96 MCH-32.8* MCHC-34.4 RDW-14.2 Plt Ct-344 [**2187-11-25**] 09:00AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.5* Hct-28.2* MCV-93 MCH-31.3 MCHC-33.6 RDW-16.6* Plt Ct-313 [**2187-11-8**] 09:49PM BLOOD Neuts-85.2* Lymphs-9.0* Monos-2.2 Eos-3.0 Baso-0.5 [**2187-11-20**] 06:20AM BLOOD Neuts-78.5* Lymphs-15.0* Monos-3.4 Eos-2.6 Baso-0.5 [**2187-11-8**] 09:49PM BLOOD PT-14.7* PTT-27.4 INR(PT)-1.5 [**2187-11-8**] 09:49PM BLOOD Plt Ct-217 [**2187-11-25**] 09:00AM BLOOD Plt Ct-313 [**2187-11-8**] 09:49PM BLOOD ESR-80* [**2187-11-17**] 06:33AM BLOOD ESR-58* [**2187-11-24**] 05:26AM BLOOD Glucose-77 UreaN-76* Creat-3.2* Na-131* K-4.9 Cl-100 HCO3-22 AnGap-14 [**2187-11-8**] 09:49PM BLOOD Glucose-123* UreaN-21* Creat-0.9 Na-132* K-4.7 Cl-99 HCO3-26 AnGap-12 [**2187-11-12**] 05:00AM BLOOD Glucose-81 UreaN-32* Creat-1.4* Na-130* K-4.5 Cl-98 HCO3-25 AnGap-12 [**2187-11-13**] 04:24AM BLOOD Glucose-113* UreaN-38* Creat-1.6* Na-130* K-5.1 Cl-101 HCO3-22 AnGap-12 [**2187-11-14**] 04:07AM BLOOD Glucose-84 UreaN-45* Creat-2.0* Na-133 K-4.7 Cl-101 HCO3-22 AnGap-15 [**2187-11-18**] 05:04AM BLOOD Glucose-72 UreaN-57* Creat-2.8* Na-132* K-5.1 Cl-100 HCO3-23 AnGap-14 [**2187-11-18**] 10:08PM BLOOD Glucose-86 UreaN-60* Creat-3.0* Na-132* K-4.9 Cl-101 HCO3-23 AnGap-13 [**2187-11-19**] 01:31AM BLOOD Glucose-76 UreaN-61* Creat-3.2* Na-132* K-4.5 Cl-100 HCO3-23 AnGap-14 [**2187-11-22**] 07:16AM BLOOD Glucose-67* UreaN-72* Creat-3.3* Na-133 K-5.2* Cl-101 HCO3-22 AnGap-15 [**2187-11-8**] 09:49PM BLOOD ALT-8 AST-28 LD(LDH)-164 AlkPhos-333* TotBili-1.1 [**2187-11-10**] 05:30AM BLOOD ALT-5 AST-24 CK(CPK)-10* AlkPhos-290* TotBili-0.5 [**2187-11-13**] 04:24AM BLOOD ALT-1 AST-17 AlkPhos-168* Amylase-68 [**2187-11-20**] 06:20AM BLOOD ALT-3 AST-16 LD(LDH)-162 AlkPhos-146* TotBili-0.5 [**2187-11-8**] 09:49PM BLOOD Albumin-2.3* Calcium-8.6 Phos-3.5 Mg-1.8 [**2187-11-24**] 05:26AM BLOOD Calcium-8.2* Phos-6.1* Mg-2.0 [**2187-11-13**] 12:11AM BLOOD Hapto-104 [**2187-11-8**] 09:49PM BLOOD CRP-162.4* [**2187-11-17**] 06:33AM BLOOD CRP-96.9* [**2187-11-18**] 05:04AM BLOOD C3-31* C4-24 [**2187-11-8**] 09:49PM BLOOD Genta-1.2* [**2187-11-10**] 08:38PM BLOOD Genta-5.4 [**2187-11-10**] 08:39PM BLOOD Genta-2.5* [**2187-11-13**] 09:44PM BLOOD Genta-1.1* [**2187-11-12**] 11:44AM BLOOD Glucose-155* Na-127* K-4.2 [**2187-11-12**] 11:44AM BLOOD Hgb-9.3* calcHCT-28 [**2187-11-12**] 11:44AM BLOOD freeCa-1.17 [**2187-11-26**] 03:22AM BLOOD WBC-7.8 RBC-2.85* Hgb-9.0* Hct-27.2* MCV-95 MCH-31.4 MCHC-33.0 RDW-16.7* Plt Ct-313 [**2187-11-28**] 05:27AM BLOOD WBC-6.4 RBC-2.94* Hgb-9.1* Hct-26.9* MCV-92 MCH-31.2 MCHC-34.0 RDW-17.0* Plt Ct-263 [**2187-11-25**] 09:00AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.5* Hct-28.2* MCV-93 MCH-31.3 MCHC-33.6 RDW-16.6* Plt Ct-313 [**2187-11-25**] 07:45AM BLOOD WBC-6.3 RBC-2.83* Hgb-8.9* Hct-26.9* MCV-95 MCH-31.5 MCHC-33.2 RDW-16.6* Plt Ct-318 [**2187-11-20**] 06:20AM BLOOD Neuts-78.5* Lymphs-15.0* Monos-3.4 Eos-2.6 Baso-0.5 [**2187-11-28**] 05:27AM BLOOD Plt Ct-263 [**2187-11-27**] 03:51AM BLOOD PT-13.6* PTT-34.2 INR(PT)-1.2 [**2187-11-17**] 06:33AM BLOOD ESR-58* [**2187-11-28**] 05:27AM BLOOD Glucose-79 UreaN-75* Creat-2.7* Na-130* K-4.6 Cl-101 HCO3-23 AnGap-11 [**2187-11-27**] 03:51AM BLOOD Glucose-86 UreaN-75* Creat-2.8* Na-132* K-4.6 Cl-100 HCO3-22 AnGap-15 [**2187-11-26**] 03:22AM BLOOD Glucose-73 UreaN-74* Creat-2.8* Na-133 K-4.8 Cl-101 HCO3-22 AnGap-15 [**2187-11-25**] 09:00AM BLOOD Glucose-82 UreaN-74* Creat-3.0* Na-134 K-4.8 Cl-103 HCO3-22 AnGap-14 [**2187-11-25**] 07:45AM BLOOD Glucose-99 UreaN-74* Creat-3.2* Na-132* K-5.6* Cl-105 HCO3-19* AnGap-14 [**2187-11-23**] 06:20AM BLOOD Glucose-75 UreaN-75* Creat-3.2* Na-133 K-4.9 Cl-105 HCO3-22 AnGap-11 [**2187-11-22**] 07:16AM BLOOD Glucose-67* UreaN-72* Creat-3.3* Na-133 K-5.2* Cl-101 HCO3-22 AnGap-15 [**2187-11-21**] 07:15AM BLOOD Glucose-66* UreaN-67* Creat-3.2* Na-131* K-4.7 Cl-100 HCO3-22 AnGap-14 [**2187-11-20**] 06:20AM BLOOD Glucose-68* UreaN-64* Creat-3.2* Na-131* K-4.6 Cl-100 HCO3-21* AnGap-15 [**2187-11-19**] 01:31AM BLOOD Glucose-76 UreaN-61* Creat-3.2* Na-132* K-4.5 Cl-100 HCO3-23 AnGap-14 [**2187-11-18**] 05:04AM BLOOD Glucose-72 UreaN-57* Creat-2.8* Na-132* K-5.1 Cl-100 HCO3-23 AnGap-14 [**2187-11-17**] 06:33AM BLOOD Glucose-69* UreaN-53* Creat-2.6* Na-130* K-4.7 Cl-99 HCO3-23 AnGap-13 [**2187-11-16**] 06:02AM BLOOD Glucose-76 UreaN-47* Creat-2.3* Na-134 K-4.7 Cl-102 HCO3-24 AnGap-13 [**2187-11-15**] 05:16AM BLOOD Glucose-82 UreaN-48* Creat-2.2* Na-133 K-4.5 Cl-102 HCO3-23 AnGap-13 [**2187-11-13**] 12:11AM BLOOD K-5.2* [**2187-11-12**] 08:15PM BLOOD Glucose-75 UreaN-35* Creat-1.5* Na-132* K-5.2* Cl-102 HCO3-22 AnGap-13 [**2187-11-12**] 12:30PM BLOOD Glucose-103 UreaN-32* Creat-1.3* Na-131* K-4.6 Cl-102 HCO3-21* AnGap-13 [**2187-11-12**] 05:00AM BLOOD Glucose-81 UreaN-32* Creat-1.4* Na-130* K-4.5 Cl-98 HCO3-25 AnGap-12 [**2187-11-11**] 06:21AM BLOOD Glucose-81 UreaN-28* Creat-1.2 Na-133 K-4.4 Cl-98 HCO3-25 AnGap-14 [**2187-11-10**] 05:30AM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-133 K-4.6 Cl-98 HCO3-25 AnGap-15 [**2187-11-9**] 05:49AM BLOOD Glucose-89 UreaN-22* Creat-0.9 Na-135 K-4.7 Cl-101 HCO3-27 AnGap-12 [**2187-11-8**] 09:49PM BLOOD Glucose-123* UreaN-21* Creat-0.9 Na-132* K-4.7 Cl-99 HCO3-26 AnGap-12 [**2187-11-20**] 06:20AM BLOOD ALT-3 AST-16 LD(LDH)-162 AlkPhos-146* TotBili-0.5 [**2187-11-13**] 04:24AM BLOOD ALT-1 AST-17 AlkPhos-168* Amylase-68 [**2187-11-10**] 05:30AM BLOOD ALT-5 AST-24 CK(CPK)-10* AlkPhos-290* TotBili-0.5 [**2187-11-8**] 09:49PM BLOOD ALT-8 AST-28 LD(LDH)-164 AlkPhos-333* TotBili-1.1 [**2187-11-28**] 05:27AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.8 [**2187-11-27**] 03:51AM BLOOD Calcium-8.5 Phos-5.5* Mg-1.9 [**2187-11-26**] 03:22AM BLOOD Calcium-8.2* Phos-5.8* Mg-1.8 [**2187-11-25**] 09:00AM BLOOD Calcium-8.2* Phos-5.6* Mg-1.9 [**2187-11-25**] 07:45AM BLOOD Calcium-10.2 Phos-5.7* Mg-2.7* [**2187-11-24**] 05:26AM BLOOD Calcium-8.2* Phos-6.1* Mg-2.0 [**2187-11-23**] 06:20AM BLOOD Calcium-8.1* Phos-6.7* Mg-1.9 [**2187-11-22**] 07:16AM BLOOD Calcium-8.2* Phos-7.0* Mg-2.0 [**2187-11-21**] 07:15AM BLOOD Calcium-8.0* Phos-6.5* Mg-2.0 [**2187-11-20**] 06:20AM BLOOD Calcium-8.2* Phos-6.3* Mg-1.9 [**2187-11-19**] 01:31AM BLOOD Calcium-7.9* Phos-6.3* Mg-1.9 [**2187-11-13**] 12:11AM BLOOD Hapto-104 [**2187-11-17**] 06:33AM BLOOD CRP-96.9* [**2187-11-24**] 06:28PM BLOOD C3-4* C4-23 [**2187-11-18**] 05:04AM BLOOD C3-31* C4-24 [**2187-11-13**] 09:44PM BLOOD Genta-1.1* [**2187-11-10**] 08:39PM BLOOD Genta-2.5* [**2187-11-10**] 08:38PM BLOOD Genta-5.4 [**2187-11-8**] 09:49PM BLOOD Genta-1.2* [**2187-11-12**] 11:44AM BLOOD freeCa-1.17 Femoral Vascular Ultrasound [**2187-11-26**]: In the anterior subcutaneous tissues of the left groin, there is a sizable localized hematoma which measures up to 9.5 cm transverse x 12.3 cm sagittal x up to 4.8 cm in maximal AP dimension. (Marginally larger than on the previous ultrasound of [**11-13**]). Normal arterial flow demonstrated with Doppler in the common femoral artery, common normal phasic venous flow within the left common femoral vein. No evidence of pseudoaneurysm or an atriovenous fistula. Right upper extremity ultrasound [**2187-11-26**]: The right upper limb veins are patent and compressible with normal phasic venous flow demonstrated. There is a PICC line within the right brachial vein, no adjacent thrombus demonstrated on the current study. (The patient has had interval treatment with heparin. Clinical improvement in the arm swelling since the previous ultrasound of [**2187-11-24**]). Right upper extremity ultrasound [**2187-11-24**]: Examination of the right IJ, subclavian, axillary and brachial veins was performed. Exam was limited by positioning. No evidence of thrombus in the right internal jugular, subclavian, and axillary veins. One of the paired brachial veins appears patent with no evidence of thrombus. The second brachial vein, the vein containing the PICC demonstrates incomplete compressibility and echogenic material consistent with thrombus. Venous flow was demonstrated through this area of likely thrombus. Tagged WBC study [**2187-11-20**]: Mild increased uptake at T12 is concerning for presence of infection. MRI Lumbar Spine [**2187-11-17**] IMPRESSION: 1. Increased STIR signal abnormalities within several intervertebral discs as described, with corresponding increased signal intensity throughout the T12, severely compressed L1, L3, and L4 vertebral bodies. These findings could be indicative of multifocal discitis/osteomyelitis of the lumbar spine. No paraspinal or epidural masses are otherwise found. 2. Heterogeneously low T1 signal abnormality of the lumbar spine and focal dark T1 signal abnormality of the T12 vertebral body also raise the possibility of metastatic disease, although corresponding increased STIR signal intensity, particularly within the T12 vertebral body would be atypical for osteoblastic metastases tyipcally seen from prostate cancer. However, a repeat bone scan is recommended for complete anatomical survey and further evaluation of this possibility. 3. Multilevel disc degenerative change with severe spinal stenosis at L3-4; moderate stenosis at L2-3. Brief Hospital Course: Mr. [**Known lastname 7749**] is a 75 yo man with history of chronic atrial fibrillation, hypertension. transient ischemic attacks, nonischemic cardiomyopathy (EF 30-40%) status post ventricular fibrillation arrest [**6-29**], with clean coronaries at that time and status post AICD placement who presents as a transfer from an outside hospital for management of bacteremia. During [**7-3**], patient was admitted with large LGIB [**7-3**], c/b MSSA bacteremia, thought to be related to central line placement. At that time, patient was treated with Vanco x 4 days, then oxacillin x 10 days. He was sent to rehab, then discharged home on [**2187-9-3**]. He was doing well until [**2187-11-3**], when c/o fever to 102 and chills. He was admitted to [**Hospital 1474**] Hosp on [**11-3**] and blood cultures found to be positive for Staph aureus x 2 (MSSA, penicillin resist) on [**11-3**] and [**11-4**]. He was treated with Rifampin/Gent/Ancef, and blood cx from [**11-6**], [**11-7**], [**11-8**] have been NGTD. TTE was done there with no evidence of vegetations or abscess. CXR without infiltrate. Bone scan showed abnl uptake in L ankle, L shoulder and L spine. TEE was delayed due to respiratory secretions. Given recurrent bacteremia patient was transferred to [**Hospital1 18**] for TEE and ICD system extraction. . In-house, serial blood cultures showed no additional growth, with no new growth on blood cultures done at the outside hospital. He did, however, become febrile to 101F on hospital day #2. He was treated with cefazolin 2gm IV q8h per ID recs. Gentamicin temporarily added for synergy, and was eventually discontinued as surveillance cultures failed to show growth. Mr. [**Known lastname 7749**] was also treated with acyclovir for HSV rash (HSV-1 positive on DFA and viral cultures). . Given results of outside hospital bone scan, Mr. [**Known lastname 7749**] had several imaging studies to rule out osteomyelitis as etiology of MSSA bacteremia. Plain films of L ankle, L shoulder, and C-spine, and non-contrast CT of L-spine showed no evidence of osteomyelitis. Contrast head CT showed no evidence of mets or septic emboli. . Mr. [**Known lastname 7749**] was taken to OR on [**11-12**] for TEE and explantation of ICD. TEE showed 1.1cm TV vegetation with tricuspid valve regurgitation. Intra-op, ICD pocket appeared infected, but culture eventually had no growth. Explantation was complicated by a left groin hematoma, and hct drop to 22.5 from 26.5. Immediately post-op, the patient's systolic blood pressure dropped to the 80s, he was treated with neosynephrine to keep MAP>60, given 2 units of PRBC, with inadequate hematocrit response. Femoral ultrasound showed evidence of large left hematoma. His lower extremities were cool, but dopplerable pulses were noted in the lower extremities bilaterally. Due to unstable hemodynamics and dropping hematocrit, Mr. [**Known lastname 7749**] was transferred to the CCU for more intensive monitoring. He was transfused a total of six units over first 24 hours, hematocrit stabilized at 30 (baseline hct), he was weaned off neosynephrine, and started on low dose isosorbide mononitrate and hydralazine once blood pressure had been stable for over 24 hours. He underwent noncontrast CT scan which ruled out retroperitoneal bleed. Repeat ultrasound showed hematoma, but adequate flow; no signs or symptoms of compartment syndrome were noted. Patient also had rising creatinine (to 2.2 from admission creatinine of 0.9), rising phos (as high as 6.2), elevated K to 5.3, and decreased urine output. This acute renal failure was thought to be secondary to hypovolemia and likely gentamycin-induced renal toxicity. The renal service was consulted, and they suspected gentamycin-induced toxicity vs acute interstitial nephritis, and recommended diuresis with lasix for elevated K, renally dosed meds, and TUMS for elevated phos. The pt was started on Cefazolin (renally dosed) for treatment of bacteremia. Nutrition consult also placed as patient's albumin on transfer was 1.9 and he was edematous. teh nutrition team suggested a full liquid diet with shake supplements. ID recommended continung acyclovir for total 7 days, which was done, and cefazolin for total 6 weeks. Patient transferred back to [**Hospital Unit Name 196**] on [**11-15**] for further management. On [**Hospital Unit Name 196**] service, renal function continued to deteriorate. Creatinine climbed to 3.3 by [**2187-11-22**]. Rare positive urine eosinophils were noted, but there was no peripheral eosinophilia that would suggest acute interstitial nephritis. Spot protein/creatinine ratio was 2.2, C3 was 4 and C4 was noted to be 24. FEUrea was noted to be 34%, so the lasix dose was titrated to a ensure gentle diuresis due to concerns of prerenal component of ARF and the likelihood that diuresis may be contributing to hyponatremia. Through discussions with infectious diseases team and renal services, decided that evidence was not sufficiently strong for acute interstitial nephritis. However, to address the possibility of Cefazolin as a contributing [**Doctor Last Name 360**] for possible AIN, the antibiotic was switched to Daptomycin. The urine creatinine plateaued and then trended downward as a consequence of this change and was 2.7 on the day of discharge. The patient will need to be continued on lasix for active diuresis, given his siginificant edema. During his hospitalization he was relatively refractory to lasix and was diuresed with 120mg IV lasix. From admission to date, Mr. [**Known lastname 7749**] has had a nett gain of 10kg. The lasix will need to be titrated to achieve a diuresis goal of 0.5 to 1 kg daily (corresponding to nett output of 500 to 1000cc daily) with a targeted weight loss of 5 to 10kg or until edema has significantly resolved. The patient's electrolytes and creatinine will need to be measured daily and the electrolytes need to be repleted as needed. . During his hospital stay, the pt also started complaining of lower back pain. A L-spine MRI and R shoulder MRI were obtained, which demonstrated increased signal intensity throughout the T12, severely compressed L1, L3, and L4 vertebral bodies. This study was followed up by a tagged WBC study, per infectious disease team recommendation. The WBC scan showed mildly increased uptake at T12 that was concerning for presence of infection, suggestive of osteomyelitis. Based on the infectious diseases team's recommendation the patient will be continued on Daptomycin for a 10 week duration with weekly monitoring of CBC, Creatinine, liver function tests and CK at the rehabilitation facility and then as an outpatient. The patient needs to be followed up as an out-patient 5 weeks after discharge with the Infectious Disease clinic. . Mr. [**Known lastname 16127**] hospital stay was also complicated by a non-obstructive clot around the right PICC line ([**2187-11-24**]) that was treated with heparin. The non-occlusive clot was not present on a repeat right upper extremity ultrasound on [**2187-11-26**]. While on heparin, Mr. [**Known lastname 7749**] was noted to have a recurrence of his previous left groin hematoma. An ultrasound of the left groin showed normal arterial flow with Doppler in the common femoral artery, common normal phasic venous flow within the left common femoral vein. There was no evidence of pseudoaneurysm or an atriovenous fistula. The groin has been marked and needs to be followed up at the rehabillitation facilility. Mr. [**Known lastname 7749**] also had a traumatic foley placement with some clots. The clots subsequently resolved and the patient's foley drained clear urine. The patient will need close monitoring of his hematocrit (daily) in teh setting of a groin hematoma and a few clots in his foley. . Mr. [**Known lastname 7749**] was also noted to have a positive urine culture (yeast 10,000-100,000/ml) that was suggestive of a likely colonization. He was treated with a 7 day course of Fluconazole and his foley was changed. . While in hospital, Mr. [**Known lastname 16127**] coumadin was held in the setting of dropping hematocrit (see above). While off coumadin, he was noted to occasionally revert back into his baseline atrial fibrillation. The risks and benefits of being off coumadin have been discussed extensively with the patient and his family and they would like the coumadin to be held until the hematoma resolves and the patient has been reevaluated by the physicians at the rehabilitation facility and the patient's cardiologist Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**] (Phone:[**Telephone/Fax (1) 902**]). . Due to his extended hospital stay Mr. [**Known lastname 7749**] became physically deconditioned. It is anticipated that he will need extensive physical rehabilitation at the rehab facility to resume his baseline functional status. Medications on Admission: Ultram Nystatin Guaifenisen Rifampin 300mg q8 Albuterol Lisinopril 40 [**Hospital1 **] Lopressor 50 [**Hospital1 **] Allopurinol 100 daily lasix 40 daily spirinolactone 25 daily protonix 40 daily tylenol prn cefazolin 2g q8 famvir 500 [**Hospital1 **] gentamicin 92mg q 8 zofran prn 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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q DAY (12 HOURS ON, 12 HOURS OFF) () as needed for R shoulder pain. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0* 4. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. Disp:*30 ML(s)* Refills:*0* 5. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours) as needed for back pain. Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0* 12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). Disp:*3600 ML(s)* Refills:*0* 13. Daptomycin 500 mg Recon Soln Sig: One (1) Intravenous Q48H for 9 weeks: To be continued for a total of 10 weeks for osteomyelitis. Daptomycin started on [**2187-11-18**]. Dose to be re-evaluated by infectious diseases specialist as an out-patient 5 weeks after discharge. . Disp:*qs * Refills:*0* 14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*30 ML(s)* Refills:*0* 15. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): For elevated phosphate levels. The dose is to be titrated by the physicians at the rehabilitation facility. . Disp:*270 Tablet(s)* Refills:*2* 16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days: Total 7 day course. Disp:*4 Tablet(s)* Refills:*0* 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): SC Heparin for DVT prophylaxis. Disp:*30 * Refills:*2* 18. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily): Hold for systolic blood pressure <100 and heart rate <60. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 19. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea 20. lasix Sig: One [**Age over 90 **]y (120) Intravenous (only) once a day: The physicians at the rehabilitation facility will titrate the dose of lasix based on nett urine output and creatinine levels. . Disp:*7 * Refills:*0* 21. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Methicillin sensitive staph aureus bacteremia Endocarditis Urinary tract infection (yeast) Osteomyelitis Acute renal failure Nonocclusive thrombus (PICC) Hematoma (groin) Atrial fibrillation Hypertension Nonischemic cardiomyopathy Compression fracture Discharge Condition: Stable Discharge Instructions: You will need to weight yourself daily. If you note an increase in weight of >3lbs, please report to your primary care physician for evaluation. Please follow a low-salt, heart healthy diet. Please restrict total fluid intake to 1000cc daily. If you have any chest pain, fever, chills, nausea/vomiting/diarrhea, blood in bowel movements, abdominal pain or increased swelling of your feet or body, please report to the nearest Emergency Department. You will need to follow-up with the renal (kidney) and infectious diseases specialists (indicated below). You will also need to see your primary care physician within the next two weeks. . There have been some changes to your medication regimen. Please carefully read the medication list and follow the instructions. Followup Instructions: PROVIDER: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] D.:[**Telephone/Fax (1) 3329**] Date/Time:[**2187-12-7**] 1.30PM . Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN (Infectious Diseases Specialist) Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2187-12-21**] 10:00am. . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **] (Renal specialist at the [**Last Name (un) **] Diabetes Center) Phone: [**Telephone/Fax (1) 3637**]. Date/time: [**2187-1-9**] at 9AM. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2187-11-28**]

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26744

Discharge summary

report

Admission Date: [**2142-6-27**] Discharge Date: [**2142-7-13**] Date of Birth: [**2088-5-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5569**] Chief Complaint: Liver failure Major Surgical or Invasive Procedure: Intubation Central venous line placement Dobhoff feeding tube placement Swan ganz catheter placement Hemodialysis line placement EGD Colonoscopy History of Present Illness: 54M w/ liver failure, child C cirrhosis from EtOH and HCV p/w worsening liver enzymes and worsening abdominal distention. Pt does have a history of HCC with nodules measuring 2.9 x 2.2 cm and 1.3 x 1.1 cm (segment 8) with attempted EtOH ablation. However, patient decompensated during the procedure and only one tumor was successfully ablated. Per OMR note in liver tumor board, patient does have residual tumor (2.6 x 1.7 cm) and was considered a non-candidate for further procedures. He was admitted to [**Hospital1 112**] from [**2142-6-22**] - [**2142-6-27**] for abdominal pain, jaundice, and melena. He was admitted to the MICU because of hypotension, requiring pressor support. His abdominal pain was thought to be related to gall bladder etiology; however, reports of a negative HIDA scan in setting of worsening ascites. Patient was transfused 3 units pRBC for Hct 20 on presentation. His INR was 5.7 and rose to 11 on his day of discharge. No attempts for paracentesis or endoscopies. He was treated conservatively with blood products and antibiotics for SBP prophylaxis. With initial laboratory values, MELD 33 on admission. He was discharged on [**2142-6-27**]. Due to worsening symptoms of lethargy and persistent melena, patient reported to [**Hospital1 18**] for further evaluation. On arrival, INR found to be 8.5. From labs, MELD score 46. Admitted to MICU for upper endoscopy, which only showed esophageal varices. Patient still with Hct 20's and currently transfused 3u pRBC, 8u FFP, 2u platelets, 4u cryoprecipitate. CT scan negative for any intra-abdominal bleeding. He is receiving vancomycin for one blood culture positive for coag negative stap and cipro for SBP prophylaxis. Plan for colonoscopy this evening. Per patient, reports weight gain of 30lbs over 1 month, acute worsening jaundice and feeling fatigued. Denies any fevers, SOB, or chest pains. Frequent diarrhea bc of lactulose. His last drink was [**2142-3-3**]. All other ROS negative. Past Medical History: Hep C (genotype unknown, treatment naive) & ETOH cirrhosis dx [**2135**] c/b ascites, peripheral edema and varices; s/p variceal bleed in [**2134**] and variceal banding [**2137**]; Past heavy ETOH use now sober per report since [**2142-3-3**]; 2 liver nodules seen [**2141-6-28**] concerning for HCC one measuring 2.9 x 2.2 cm and the other lesion measuring 1.3 x1.1 cm s/p CT- guided ETOH ablation at [**Hospital1 112**] [**10-6**]- pt coded in scanner ? [**1-30**] narcotics. Was intubated and later tracheostomy placed; anxiety; OA of right hip s/p THR [**2137**]; L5-S1 laminectomy in [**2117**]; repair of a right inguinal and an umbilical hernia in [**2132-3-29**]; h/o right knee cellulitis following trauma Social History: - Tobacco: started smoking at 49 yo, current smoker 2 cig/day - Alcohol: Per report, sober since [**2142-3-3**] - Illicits: past cocaine use in 20s. no other ilicits Works in manufacturing for his family business. Remarried with children aged 17 and 19. Family History: Mother- current 81 [**Name2 (NI) **] s/p MI with [**Name (NI) 2481**] Father- 83- alive and well along with 2 brothers [**Name (NI) 12408**] died at 51 of pancreatic ca Son- ASD vs valvular disease s/p repair Physical Exam: General Appearance: Well nourished, No acute distress, Overweight / Obese, Not Anxious Eyes / Conjunctiva: Scleral icterus Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral Vascular: (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear, No Crackles, No Wheezes, No Rhonchi) Abdominal: Soft, Bowel sounds present, Distended, Not Tender Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+ Skin: Warm, Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented x3, Tone: Not assessed, slight asterixis Pertinent Results: Labs on Admission: GLUCOSE-86 UREA N-17 CREAT-1.8* SODIUM-134 POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-21* ANION GAP-17 IRON-111 calTIBC-121* FERRITIN-820* TRF-93* CORTISOL-5.7 HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-POSITIVE HCV Ab-POSITIVE* WBC-8.9 RBC-1.91* HGB-6.8* HCT-19.0* MCV-100* MCH-35.6* MCHC-35.7* RDW-22.7* ETHANOL-NEG WBC-11.2*# RBC-2.54* HGB-8.9* HCT-25.4* MCV-100*# MCH-35.1* MCHC-35.0 RDW-22.4* NEUTS-79.2* LYMPHS-10.5* MONOS-8.4 EOS-1.5 BASOS-0.5 . . [**2142-6-26**] Renal U/S IMPRESSION IMPRESSION: 1. Cirrhosis of the liver without concerning liver lesions. 2. Splenomegaly and ascites, suggests portal hypertension. 3. Reversal of flow in the main portal vein. . . [**2142-6-27**] Echo IMPRESSION There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). A mid-cavitary gradient is identified. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . . [**2142-6-28**] CT Chest w/out contrast IMPRESSIONS: 1. No evidence of intraperitoneal or retroperitoneal hemorrhage to explain drop in hematocrit. 2. Cirrhotic liver with splenomegaly and intra-abdominal and esophageal varices, and a small amount of ascites, compatible with portal hypertension. 3. Small bilateral pleural effusions, with greater than expected degree of consolidation at the right lung base, and scattered foci of nodular ground glass opacity bilaterally, which is concerning for aspiration or infection. 4. Mild anasarca and mesenteric stranding compatible with third spacing. . . [**2142-6-28**] CT Abdomen w/out contrast IMPRESSION 1. No evidence of intraperitoneal or retroperitoneal hemorrhage to explain drop in hematocrit. 2. Cirrhotic liver with splenomegaly and intra-abdominal and esophageal varices, and a small amount of ascites, compatible with portal hypertension. 3. Small bilateral pleural effusions, with greater than expected degree of consolidation at the right lung base, and scattered foci of nodular ground glass opacity bilaterally, which is concerning for aspiration or infection. 4. Mild anasarca and mesenteric stranding compatible with third spacing. . . [**7-2**] Bone Scan: 1. No evidence of osseous metastatic disease. 2. Findings compatible with diffuse anasarca and possible ascites as described above. 3. Altered biodistribution of the radiopharmaceutical with relative poor uptake in the bones and increased uptake in the kidneys of unclear etiology. . . [**7-2**] MRI/MRA Liver: 1. Three lesions in the segment VIII of the liver at the dome, the largest one measuring 2.5 cm and arterial enhancing with washout at delayed phase. Two additional 1 cm lesions demonstrates only arterial enhancement without washout, but that are new as compared to the prior examination. In the known history of cirrhosis, these lesions most probably correspond to foci of HCC. . 2. Bilateral small-to-moderate pleural effusion. . 3. Small amount of ascites. . 4. Large recanalized paraumbilical vein. . 5. Mild splenomegaly. . 6. Irregular mild intrahepatic biliary dilatation. . . [**7-5**] CXR As compared to the previous radiograph, there is no relevant change. Mild pulmonary edema, as manifested by perihilar haziness and increase in diameter of the central pulmonary vessels. Moderate cardiomegaly, retrocardiac atelectasis. Minimal blunting of the left costophrenic sinus, so that the presence of a pleural effusion cannot be ruled out. Labs prior to expiration: WBC-6.9 RBC-2.64* Hgb-8.8* Hct-24.1* MCV-92 MCH-33.2* MCHC-36.3* RDW-22.2* Plt Ct-56* PT-34.9* PTT-78.3* INR(PT)-4.0* FDP-320-640* Fibrino-89* Glucose-48* UreaN-32* Creat-2.9* Na-136 K-4.0 Cl-97 HCO3-25 AnGap-18 ALT-30 AST-103* CK(CPK)-155 AlkPhos-98 TotBili-33.1* CK-MB-16* MB Indx-10.3* Albumin-3.6 Calcium-9.7 Phos-3.8 Mg-1.8 Yype-ART pO2-78* pCO2-49* pH-7.33* calTCO2-27 Base XS-0 Brief Hospital Course: Patient was admitted to the medical service on [**2142-6-27**]. Liver transplant evaluation initiated as patient was listed for potential organ. He was transferred to the floor shortly but required further intensive care support. The surgical service assumed care as another liver offer was made. However, patient was severely decompensated with multiple organ failure. He was made CMO and expired on [**2142-7-13**]. His hospital course can be summarized by the following review of systems: Neuro: Patient with worsening encephalopathy despite lactulose and rifaximin. Pulm: With worsening mental status, he was intubated on [**7-10**] for airway support. His oxygen saturation continue to decline despite ventilator support. Cardio: Several echocardiogram performed to assess for pulmonary hypertension. Patient did require vasopressor support to maintain blood pressures. GI: Summary per medical service and hepatology - # Worsening ESLD- The patient presented after discharge from OSH with a worsening INR and T bili consistent with worsening liver disease. The differential for the acute change acute worsening is broad and included recent sepsis with perhaps persistent SBP (got 5D ceftaz, flagyl at OSH), other infection(PNA or UTI), alcoholic hepatitis (although pt and wife state no ETOH since [**3-7**]) and gastro-intestinal bleed. On the evening of admission the combination of the patient's, acute worsening liver disease and renal failure, he was started on octreotide, midodrine and 50mg of albumin and lactulose. He was continued on lactulose and octreotide until the time of his transfer. A non contrast CT of the liver on [**6-28**] revealed a cirrhotic liver with mild ascites and intra-abdominal and esophageal varices. The patient's LFTs throughout his stay in the MICU remained elevated, likely secondary to extensive hepatic injury. Following transfer to the floor his coagulopathy worsened with a peak INR of 8.5. This required serial monitoring of coag labs and near daily transfusions of FFP, cryoprecipitate, and platelets with goals of INR<4, Fibrinogen >100, Plt>50. On [**7-5**] a dobhoff was placed for [**Street Address(1) 65886**] recs and tube feeds started. On [**7-6**] the patient removed the tube. The following morning he was taken to surgery for an aborted transplant operation. The tube was replaced upon his return to the floor and tube feeds were re-initiated. With worsening mental status and heavy transfusion requirement, he was transferred to the MICU for further care and then to the surgical service. # Liver Transplant - The liver transplant team was consulted. The patient states he has been sober since [**2142-2-26**]. His MELD listing on admission was 48. Transplant criteria lab tests and studies were initiated upon admission to the MICU. An echo was performed (results in pertinent results) and transplant studies were sent. On [**7-2**] MRI/MRA showed 2 new lesions thought to be HCC that were approximately 1cm in diameter. These findings coupled with his pre-existing 2.5cm HCC still feel within the [**Location (un) **] criteria for transplantation. His bone scan was negative for mets and he was placed at the top of the transplant list. On [**7-7**] he was offered a donor liver but it was deemed to be unfit for transplant secondary to overall quality. Another offer was made but due to overall hemodynamic instability and high mortality rate, it was withdrawn. Patient resumed on supportive care but due to worsening overall condition, family discussions with medical services concluded in withdrawing all care. Patient made CMO on [**2142-7-13**] and shortly expired. GU/Renal/FEN: . # Acute Renal Failure - The patient's baseline creatinine was up to 2.2 on admission from a baseline of 1.0. The patient's acute renal failure was initially concerning for hepatorenal syndrome in the setting of worsening liver function versus pre-renal etiology from volume depletion in the setting of sepsis at outside hospital. The patients FeNa was 0 on admission consistent with both etiologies. The patient was given albumin on admission and received a fluid challenge on [**6-29**] and [**6-30**]. Mr. [**Known lastname 3728**] creatinine trended down and was 1.6 at the time of transfer making hepatorenal syndrome less likely as he responded favorably to a fluid challenge and auto-diuresed. . On the floor the patient continued to autodiurese and his Cr corrected to 0.8. Diuresis was initiated with IV lasix and spironolactone given his fluid status (see below) but the following morning his Cr had nearly doubled to 1.5. given fluid overload we restarted his diuretics. Over the next several days his Cr was monitored and when below 1.0 he was given 10mg IV lasix doses in an effort to remove the large amount of fluid he was retaining secondary to his multiple transfusions. His kidney function continued to worsen during the remainder of his hospital course as he became anuric, not responding to diuretics. With significant amount of transfusions, patient remained volume overloaded. CVVH was initiated on [**2142-7-11**]. However, due to labile blood pressures, diuresis was attempted but unsuccessful due to pressor need. Nephrology continued to follow patient with recommendations. . #Anasarca: Likely [**1-30**] large volumes of IVF and blood products given in the MICU. The patient had presented a unique fluid balance challenge and an effort was made to find a compromise between correcting his coagulopathy and avoiding fluid overload while protecting his kidney function. On [**7-5**] he developed an O2 requirement and a cxr demonstrated evidence of fluid overload. This is consistent with the large volumes of blood products he's been getting. He was diuresed with a return to o2 sats in the high 90's on room air. Unfortunately his Cr doubled (see above). To improve nutritional status, enteral feeding was initiated per nutritional recommendations. Heme: . # Low Hematocrit - The patient presented with guaiac positive stools and low hematocrit of 22.9. Initially there was concern was that the etiology of his acute blood loss was from a GI bleed, he had a prior history of two variceal bandings. His hematocrit dropped precipitously 3 points from his arrival in the ED to admission in the MICU. The patient was transfused 4 units of FFP before a central line was placed and 1 additional unit of FFP, 2 units of PRBC and platelets were transfused overnight. An upper endoscopy on the evening of admission, [**6-27**] revealed small varcies, gastropathy and no active bleeding. Vitamin K, Nadolol, IV protonix and IV cipro were started and additional units of PRBC, FFP and cryoglobulin were given. A CT of the patients torso was performed on [**6-28**] and ruled out evidence of lower GI bleeding. A colonoscopy on [**6-29**] showed no evidence of acute gastro-intestinal bleed. The patient's hematocrit was stable in the low 20s with no acute drops. No further transfusions were required and transfusion requirements were liberalized (INR>5, PLt <50 Hct < 21) as the patient was not actively bleeding. IV cipro and protonix were changed to PO medications on [**6-30**] as the patient was started on a soft diet and transferred to the floor. Over the next week the patient's hct continued to drop. Indirect bilirubinemia and schistocytes on smear indicated possible hemolysis. Coombs negative. The persistent anemia was thought to be secondary to splenic sequestration and active blood loss at IJ site and recent bleeding foley. The patient received intermittent transfusions. Criteria were as follows - fibrinogen > 100, platelets >50, Hct>25. His final amount of transfusions were 18 units of pRBC, 36 units of FFP, 8 units of platelets, and 23 units of cryoprecipitate. ID: Patient maintained on cipro initially for SBP prophylaxis. He was then switched to vancomycin, zosyn, and micafungin for presumed sepsis. All culture data negative. Infectious disease consulted for antibiotic approval and recommendations. Disposition: Patient made CMO and expired on [**2142-7-13**]. This was after discussion with social workers, hepatology and surgical services. Patient's family expressed clear understanding of his disease process and elected to remove all intervention. Medications on Admission: Cipro 750 Q wk Folic acid 1mg daily lactulose 30ml 4x daily nadolol 20mg daily omeprazole 20mg [**Hospital1 **] spironolactone 50 daily MVI 1 daily thiamine 100mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Liver failure Discharge Condition: CMO - expired [**2142-7-13**] Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "96.6", "89.64", "38.93", "96.04", "38.95", "45.13", "45.23", "39.95", "38.91" ]

icd9pcs

[ [ [] ] ]

17476, 17485

8949, 17227

327, 473

17542, 17573

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3234, 3490

27,396

191,684

34383

Discharge summary

report

Admission Date: [**2147-7-17**] Discharge Date: [**2147-7-19**] Date of Birth: [**2097-10-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 49 y/o M with PMH of bipolar disorder who was brought in by EMS after being found sleeping on a bench in a cemetery. Patient unable to recall today's events but reports that he remembers going to a cemetery to walk dogs. Per EMS the patient was initially minimally responsive to sternal rub. Reportedly had pinpoint pupils in field and received 4mg narcan with minmal improvement. FSBG was 144. On arrival to the ED had episode of desaturation on 2LNC to 89% and was placed on NRB with sat 100%. Patient continued to be somnolent in ED but arousable. He reports a recent episode of mania with racing thoughts, increased energy and decreased sleep. He denies depressed mood or suicidal ideation. He denies drug use but thinks that he may have taken some of his friend's adderall. He reports a recent hospitalization one month ago for 20 days following another manic episode. At that time he broke into a house mistaking it for his own and police were called. He notes that other than the current mania he has been feeling well. Per discussion with his friend [**Name (NI) **] he has been struggling with rapid cycling bipolar his entire adult life and has not been able to find a stable treatment regimen. She spoke with the patient today and notes that he seemed "hyper". The patient and his friend note that frequently after manic episodes he becomes excessively tired and sleepy. He reports that he has been taking his medications appropriately. . In the ED, vitals were T 98 BP 112/75 HR 98 RR 16 O2sat 95%RA. Serum and urine tox sent and remarkable only for positive amphetamines. Patient was found to have newly filled ativan bottle with only 43/60 pills, he denies intentionally taking them. UA and electrolytes normal. Hct 35.3. he received 2LNS and given his somnolence was admitted to the ICU for close observation. Currently he feels tired and thirsty but denies other complaints. ROS: Negative for fevers, chills, nightsweats, chest pain, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia, hematemesis, dysuria. No HA/dizzyness/paresthesias or weakness. Past Medical History: Bipolar disorder, rapid cycling s/p Lap band surgery [**2144**] h/o unintentional OD with methadone 5 years ago Social History: Lives alone in [**Location (un) 745**]. Works as a dog walker. Prior h/o tobacco use, 3ppd x10 years. Quit 5 years ago. Rare EtOH use. Denies IV drug use. Family History: history of depression in mother, otherwise NC Physical Exam: Admission Physical Exam VS: T 95.4 BP 120/76 P 72 RR 14 O2 sat 99% 3L NC GEN: lethargic, easily arousable to sternal rub, conversant, appropriate, NAD HEENT: NCAT, EOMI, pupils pinpoint, reactive, symmetric, oropharynx clear, MM dry NECK: Supple, no LAD, no appreciable JVD CV: RRR, normal S1S2, no murmurs, rubs or gallops PULM: CTAB, no w/r/r, good air movement bilaterally ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema NEURO: AAOx3, responds appropriately to questions, CN 2-12 grossly intact, muscle strength 5/5 in all 4 ext. DTRs 2+ and symmetric. . Discharge Physical Exam: ([**2147-7-19**] 9am) VS" T 97.9 98/66 87 18 98%RA GEN: NAD, AOx3, lying comfortably in bed HEENT: NCAT, EOMI, pupils 1-2mm, reactive, symmetric, oropharynx clear, MMM NECK: Supple, no LAD, no appreciable JVD CV: RRR, normal S1S2, no murmurs, rubs or gallops PULM: CTAB, no w/r/r, good air movement bilaterally ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema NEURO: AAOx3, responds appropriately to questions, CN 2-12 grossly intact, muscle strength 5/5 in all 4 ext. DTRs 2+ and symmetric. Pertinent Results: Admission Labs: [**2147-7-17**] 11:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2147-7-17**] 11:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2147-7-17**] 06:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-POS mthdone-NEG [**2147-7-17**] 06:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2147-7-17**] 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2147-7-17**] 06:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0, AMORPH-MOD, MUCOUS-MANY [**2147-7-17**] 05:18PM GLUCOSE-141* LACTATE-1.0 NA+-142 K+-4.1 CL--101 TCO2-30 [**2147-7-17**] 05:18PM HGB-12.4* calcHCT-37 [**2147-7-17**] 05:10PM GLUCOSE-150* UREA N-16 CREAT-0.7 SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-29 ANION GAP-11 [**2147-7-17**] 05:10PM ALT(SGPT)-28 AST(SGOT)-24 LD(LDH)-215 CK(CPK)-263* ALK PHOS-95 TOT BILI-0.5 [**2147-7-17**] 05:10PM CK-MB-6 cTropnT-LESS THAN [**2147-7-17**] 05:10PM ALBUMIN-4.2 IRON-40* [**2147-7-17**] 05:10PM calTIBC-475* FERRITIN-25* TRF-365* [**2147-7-17**] 05:10PM LITHIUM-0.2* [**2147-7-17**] 05:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2147-7-17**] 05:10PM WBC-8.6 RBC-4.40* HGB-11.6* HCT-35.3* MCV-80* MCH-26.3* MCHC-32.8 RDW-14.1 [**2147-7-17**] 05:10PM NEUTS-67.1 LYMPHS-23.2 MONOS-9.2 EOS-0 BASOS-0.5 [**2147-7-17**] 05:10PM PLT COUNT-442* . Pertinent Labs: [**2147-7-19**] 05:40AM BLOOD WBC-7.7 RBC-4.31* Hgb-11.4* Hct-34.8* MCV-81* MCH-26.4* MCHC-32.8 RDW-15.1 Plt Ct-417 [**2147-7-17**] 05:10PM BLOOD Neuts-67.1 Lymphs-23.2 Monos-9.2 Eos-0 Baso-0.5 [**2147-7-19**] 05:40AM BLOOD Glucose-101 UreaN-11 Creat-0.6 Na-139 K-4.1 Cl-105 HCO3-27 AnGap-11 [**2147-7-18**] 05:10AM BLOOD CK(CPK)-137 [**2147-7-17**] 05:10PM BLOOD calTIBC-475* Ferritn-25* TRF-365* [**2147-7-18**] 03:29AM BLOOD %HbA1c-6.3* . CXR: ([**2147-7-18**]) The cardiomediastinal and hilar contours are unremarkable. There are increased bibasilar band-like opacities, likely representing atelectasis. There are no pleural effusions identified. The osseous structures are grossly unremarkable. IMPRESSION: Bibasilar band-like opacities likely representing atelectasis. Brief Hospital Course: ASSESSMENT AND PLAN: 49 y/o M with PMH of bipolar disorder, rapid cycling, presents from EMS with somnolence following recent manic episode. Tox screen positive for amphetamines. . # Sommonlence following and Acute Manic Episode: Patient has a long history of rapid-cycling with frequent manic episodes. Per pt. episodes are occurring more frequently. Patient was lethargic on exam upon presentation, however rousable to sternal rub and AAO x3. Able to answer questions appropriately and his answers were coroborated with his friend. [**Name (NI) **] denied intentional overdose and tox screen only possible for amphetamines, however ingestion is certainly high on the differential. Some of his symptoms are consistant with adderall OD which he endorses taking. He is afebrile, no focal signs of infection. UA negative. Metabolic work-up unrevealing. Neuro exam non-focal and reassuring. The patient was seen by psychiatry that stated his recent behavior and recurrent mania was concerning. They also noted he has been maintained on subtherapeutic doses of medications as an outpatient. Furthermore, he has not yet restarted his psychopharm regimen which require titration, and his psychopharmacologist is out of town. Given these concerns, he would most likely require inpt psych hospitalization for stabilization and med eval. . # Anemia: Unknown baseline. Has a history of lapband surgery so could be nutritional. Iron studies suggestive of borderline iron deficiency. Will follow and recommend outpatient follow-up. . # Hyperglycemia: Glucose 150 on admission, 105 today. Unknown DM history. HbAlC 6.3. Stable. Recommend outpatient follow-up with PCP. . The patient is medically cleared for transition to an in-patient psychiatric facility. Medications on Admission: Seroquel 25mg qhs Ativan 1mg daily prn Lamictal 100mg daily Nardil 60mg daily Abilify, 6mg Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 2. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: Primary Diagonis - Acute Manic Episode - Lethargy Discharge Condition: Good. Patient taking PO, stable mood, ambulating and at his mental and physical baseline. Discharge Instructions: You were admitted to the hospital following a manic episode in which you were found lethargic in a cemetary. You were admitted and evaluated for possible drug overdose, which were negative. . Please continue to take all of your medications as prescribed by the psychiatry team. These are listed below and a number of changes have been made. . Please return to the hospital if you experience fevers, chills, loss of consciousness, shortness of breath or chest pain. Followup Instructions: Arrangements will be made by the [**Hospital1 18**] psychiatry service [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

[ "305.70", "296.40", "V45.86", "285.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8767, 8812

6502, 8249

337, 343

8906, 8998

4143, 4143

9511, 9714

2806, 2853

8391, 8744

8833, 8885

8275, 8368

9022, 9488

2868, 3516

276, 299

371, 2482

4159, 5685

5701, 6479

2504, 2618

2634, 2790

3541, 4124

26,673

162,810

51122

Discharge summary

report

Admission Date: [**2117-12-19**] Discharge Date: [**2117-12-22**] Date of Birth: [**2043-11-11**] Sex: F Service: [**Hospital1 **] MED CHIEF COMPLAINT: Melena. HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname 805**] is a 74 year old woman with an extensive past medical history including a history of atrial fibrillation and flutter, seizure disorder, dementia secondary to alcohol abuse and a history of lower GI bleed with recently diagnosed diabetes mellitus who presents to [**Hospital1 69**] from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] after she was found to be passing large amounts of dark stool with clots of blood. The patient, upon presentation to the Emergency Department denies abdominal pain or any other pain, nausea, vomiting, diarrhea, or constipation. She denies fever or chills or dysuria. She denies hematochezia. At baseline, the patient is quite demented and most of her history is thus obtained from the Emergency Department and from paperwork from the nursing home. In the Emergency Room, the patient was NG lavaged with no coffee ground or bright red blood noted. It was not documented whether NG lavage revealed any bilious material. The NG tube was subsequently removed. The patient was noted to be orthostatic. She was typed and crossed and one unit of packed red blood cells was given in the Emergency Department as well as normal saline at 150 cc per hour. The patient is admitted to Medicine at this point for further treatment. PAST MEDICAL HISTORY: 1. Seizure disorder. 2. History of atrial fibrillation/flutter. 3. Osteoarthritis. 4. Osteoporosis. 5. Dementia felt to be secondary to alcohol abuse. 6. History of lower GI bleed from diverticula. 7. Diabetes mellitus, type 2, diagnosed in [**2117-4-13**]. 8. Cerebrovascular accident of the left frontal lobe with resulting ataxia and right hemi-CVA. 9. History of falls. 10. Cataracts. 11. History of decubitus ulcer in the right buttock. 12. History of hyponatremia. MEDICATIONS: 1. Folate. 2. MVI. 3. Vitamin D. 4. Glyburide 2.5 mg q. day. 5. TUMS. 6. Milk of Magnesia. 7. Colace. 8. Celebrex 200 mg twice a day. 9. Dilantin 150 mg twice a day. 10. Trazodone 12.5 mg/37.5 mg. 11. Phenobarbital 75 mg q. day. 12. Diltiazem SR 120 mg q. day. 13. Aspirin 325 mg q. day. SOCIAL HISTORY: The patient is a resident of [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Does not smoke. Has a history of alcohol abuse (used to drink one pint of vodka per day). Son is involved in care. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: In the Emergency Department, temperature 98.6 F.; blood pressure 140/60; pulse 73, respiratory rate 20; O2 saturation 99% on room air. In general, this is an elderly female, alert, in bed, in no acute distress. Normocephalic, atraumatic. Pupils surgical. Extraocular muscles are intact. Sclerae anicteric. Mucous membranes slightly dry. Neck is supple with no lymphadenopathy and no jugular venous distention. Chest is clear to auscultation bilaterally with scattered crackles which clear with cough. Cardiovascular: Regular rhythm with II/VI systolic ejection murmur. Abdomen is soft, nontender, nondistended. Normoactive bowel sounds. No palpable masses noted with heme positive stool. Extremities: No cyanosis, clubbing or edema. Thready peripheral pulses with well healed scar on the lateral surface of the right leg. Neurological: Alert, confused, knows name only. Moves all four extremities and follows commands. LABORATORY: Notable labs upon admission are white blood cell count of 10,000, hematocrit of 30.8 down from baseline of 38, platelets 337,000. ALT 20, AST 25, LDH 249, alkaline phosphatase of 161. Potassium of 6.4 and upon repeat 5.7. EKG is sinus at 75 beats per minute, intervals with PR interval at 220; otherwise intervals within normal limits; [**Street Address(2) 12255**] depressions in V3, but no acute ST-T wave changes. HOSPITAL COURSE: 1. Gastrointestinal: The patient was admitted to the Medical Wards for further management of her GI bleeding. Over the next 12 hours, the patient was noted to have two more episodes of dark magenta stools with clots and had been transfused a total of two units of packed red blood cells. On the morning of [**12-19**], her hematocrit was 27.0, down from 30 the evening before. An upper endoscopy was performed and a 1 cm antral ulcer was identified without any active bleeding which was felt to the be the source of the patient's bleeding (upper endoscopy was performed as the patient's BUN was elevated and it was felt that an upper source of bleeding may be possible). The patient returned to the floor but continued to have multiple episodes of magenta stools per rectum, which progressively became more bright and red in quality, concerning for a lower GI source of bleeding. The patient received two more units of packed red blood cells and her hematocrit remained stable at 27 to 28. The patient's converted to atrial fibrillation and her blood pressures began to drop into the 90s and she was transferred to the Medical Intensive Care Unit for further evaluation. A tagged red blood cell scan did not demonstrate any active bleeding on the evening of [**12-20**]. A colonoscopy the next day was non-diagnostic as the patient still had significant amounts of stool in her colon. The patient received two more units of red blood cells and the output of bright red blood per rectum began to decrease. On the morning of [**12-21**], the patient had a repeat colonoscopy which demonstrated multiple diverticula throughout the course of the colon, but did not show signs of any active bleeding. On the afternoon of [**12-21**], the patient was transferred back to the Medical Floor where she remained until discharge with a blood pressure stable in the 120s to 140s systolic over 60s to 70s diastolic, a heart rate which was variable between normal sinus rhythm and atrial fibrillation in the 120s to 130s, and with no further episodes of bright red blood per rectum. The patient was maintained on high-dose intravenous Protonix for the first several days of her hospitalization, but will continue Protonix 40 mg p.o. q. day as an outpatient. The patient also tested positive for H. pylori and will undergo a course of eradication of this organism. She will continue Colace 100 mg p.o. twice a day to soften her stools. 2. Cardiovascular: The patient was noted to be in paroxysmal atrial fibrillation after returning to the Floor on [**12-21**]. Her atrial fibrillation is well controlled on Diltiazem and she will be discharged on an increased dosage of 180 mg of Cardizem CD p.o. q. day. Pulmonary: The patient was noted to be in some slight fluid overload, having been positive about eight liters from the Intensive Care Unit upon presentation to the Floor with some bilateral rales noted on examination. The patient auto-diuresed over the next 24 hours and was then given 20 mg of Lasix with good urine output. Upon discharge, the patient was having good oxygen saturation on room air. 3. Infectious Disease: The patient was noted to have a urinary tract infection by urinalysis and was treated with three days of Bactrim while in hospital with good results. 4. Neurology: The patient was continued on her regular doses of Dilantin and phenobarbital for her history of seizure disorder. Her levels were noted to be within normal limits and she was continued on the same dose with no complications. 5. Fluids, electrolytes, nutrition: The patient was maintained on a clear liquid diet throughout much of her hospitalization and upon transfer to the floor tolerated an American Diabetic Association diet very well. DISPOSITION: The patient is discharged on the evening of [**12-22**], back to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] on the medications listed below. DISCHARGE DIAGNOSES: 1. Peptic ulcer disease. 2. Diverticulosis. 3. Anemia. 4. Dementia. 5. Diabetes mellitus. 6. Paroxysmal atrial fibrillation. 7. Urinary tract infection. 8. Seizure disorder. DISCHARGE MEDICATIONS: 1. Diltiazem CD, (Cardizem CD), 180 mg p.o. q. day. 2. Colace 100 mg p.o. twice a day. 3. Multivitamins one tablet p.o. q. day. 4. Folate 1 mg p.o. q. day. 5. Trazodone 37.5 mg p.o. q. h.s. p.r.n. insomnia. 6. Vitamin D 800 IU p.o. q. day. 7. TUMS 500 mg p.o. twice a day. 8. Protonix 40 mg p.o. twice a day times 14 days and then q. day. 9. Dilantin phenytoin 150 mg p.o. twice a day. 10. Phenobarbital 75 mg p.o. q. day. 11. Glyburide 2.5 mg p.o. q. day. 12. Clarithromycin 500 mg p.o. twice a day times 14 days. 13. Amoxicillin 1 gram p.o. twice a day times 14 days. (Please note that aspirin and Celebrex have been discontinued secondary to the patient's GI bleed). 14. Tylenol 650 mg p.o. q. four to six hours p.r.n. pain. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-500 Dictated By:[**Last Name (un) 106151**] MEDQUIST36 D: [**2117-12-22**] 15:29 T: [**2117-12-22**] 16:05 JOB#: [**Job Number **]

[ "V11.3", "562.12", "599.0", "276.1", "285.1", "780.39", "427.31", "531.40", "041.86" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.13" ]

icd9pcs

[ [ [] ] ]

2625, 2643

8037, 8220

8243, 9208

4055, 8016

2666, 4037

174, 183

212, 1555

1577, 2373

2390, 2608

46,723

143,949

40082

Discharge summary

report

Admission Date: [**2181-12-14**] Discharge Date: [**2181-12-18**] Date of Birth: [**2101-9-20**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: Headache Major Surgical or Invasive Procedure: Right Craniotomy for Subdural Hematoma History of Present Illness: This is an 80 year old man who was brought to [**Hospital1 2436**] ED by EMS with complaint of sudden severe onset headache, left sided hemiparesis, and decreased LOC. CT brain was performed and this showed a large right frontotemporal acute SDH with 14 mm of midline shift. At 1510 hrs patient had an abrupt deterioration in the ED, becoming minimally responsive, and he was intubated. Past Medical History: 1) [**2101**], admitted to [**Hospital3 2783**] 2) bilateral lower extremity cellulitis 3) chronic venostasis with dermatitis 4) HTN 5) hyperlipidemia 6) COPD 7) bovine aortic valve replacement with CABGx1 vessels [**Month (only) **] Social History: He is married. Family History: NC Physical Exam: On Admission: O: T: BP: 95/63 HR:67 R 16 O2Sats 100% ventilated Gen: intubated and sedated post op HEENT: Pupils: L 3mm fixed, R 3.5mm fixed EOMs: patient sedated Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: GCS 3 + T, absent corneals and no gag, pupils as above Mental status: GCS 3 Cranial Nerves: not tested Motor: not tested as patient was intubated Sensation: not tested On Discharge: Patient Expired Pertinent Results: CT head [**2181-12-15**]: Right frontal intraparenchymal blood products with mild shift of midline structures. Mild periventricular and subcortical white matter hypoattenuation likely represents sequelae of small vessel ischemic disease. No prior study available. Correlation with pre-surgical study will help for better assessment. Chest X-ray [**2181-12-18**]: In comparison with the study of [**12-17**], the monitoring and support devices remain in place. Continued enlargement of the cardiac silhouette with right pleural effusion and some elevation of pulmonary venous pressure. The obliquity of the patient's scoliosis makes it somewhat difficult to evaluate the lungs. Left hemidiaphragm is not sharply seen, consistent with volume loss or effusion at the left base. Brief Hospital Course: Mr. [**Known lastname 9780**] was taken emergently to the OR with Dr. [**Last Name (STitle) 548**] for a right craniotomy for evacuation of SDH. A JP drain was left in place. He was transferred to the ICU intubated. His exam remained poor with sluggish pupils, no dolls eyes, positive corneal and gag, and decerebrate posturing. CT head on [**2181-12-15**] showed good decompression and no new hemorrhage. The drain was left in place. On [**12-16**] his subdural drain was switched to a non-suction drainage system as he had increased output. His exam remained unchanged. On [**12-17**] Dr. [**Last Name (STitle) 548**] spoke with the patient's wife regarding prognosis and plan. His drain was removed and stitch was placed. On [**12-18**], Mr. [**Known lastname 88115**] exam was unchanged. The family decided to initiate CMO status. THe patient was extubated, and all recussitation efforts were stopped. The patient expired around [**2201**] on [**12-18**] with his family at his bedside. Medications on Admission: 1) norvasc 10 mg qd 2) avapro 300 mg qd 3) metoprolol 25 mg [**Hospital1 **] 4) simvastatin 20 mg qhs 5) flomax 0.4 mg qhs Discharge Medications: . Discharge Disposition: Expired Discharge Diagnosis: Right Subdural Hematoma Right Frontal Intraparnchymal Hemorrhage Compression of Brain Discharge Condition: Expired Discharge Instructions: . Followup Instructions: . Completed by:[**2181-12-18**]

[ "459.81", "272.4", "V45.81", "432.1", "414.8", "401.9", "458.29", "276.1", "431", "348.4", "V43.3", "496", "342.90" ]

icd9cm

[ [ [] ] ]

[ "01.31", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

3627, 3636

2429, 3426

330, 371

3766, 3775

1627, 2406

3825, 3858

1093, 1097

3601, 3604

3657, 3745

3452, 3578

3799, 3802

1112, 1112

1591, 1608

282, 292

399, 787

1500, 1577

1126, 1463

1478, 1484

809, 1045

1061, 1077