ChanBeDu/relevant_section_length · Datasets at Hugging Face

31,205

194,388

43839

Discharge summary

report

Admission Date: [**2110-7-29**] Discharge Date: [**2110-8-5**] Date of Birth: [**2029-11-30**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Metastatic colon cancer to the liver and cholelithiasis. Major Surgical or Invasive Procedure: Segment VII and VIII resection, cholecystectomy, intraoperative ultrasound. History of Present Illness: The patient is an 80-year- old female who underwent laparoscopic takedown of the splenic flexure, open extended sigmoid colectomy, and excision of right facial cyst performed on [**2109-9-10**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for a pT3, tN1, pMX low grade adenocarcinoma of the sigmoid colon. There were 3 of 18 lymph nodes involved with metastatic tumor. Margins were negative and there was no evidence of lymphatic, venous or perineural invasion. She was treated with 6 months of Xeloda. On [**2110-7-5**] a follow-up CT scan of the chest, abdomen and pelvis demonstrated no evidence of pulmonary metastases but she did have cholelithiasis. The liver also contained hypodense lesions in segment 7 and 8 measuring 4.5 x 3.4 cm and 2.7 x 1.6 cm respectively concerning for metastases. She also had a small hemangioma in segment 2 and a small hemangioma at the junctions of segment 7 and 8. A PET scan performed on [**7-16**] demonstrated 2 large FDG avid lesions in the right lobe compatible with metastatic disease and consistent from the CT on [**7-5**]. She was evaluated and found to be a suitable candidate for right hepatic lobectomy and cholecystectomy or possibly segmental resection plus cholecystectomy. She has provided informed consent and is now brought to the operating room for segmental resection, cholecystectomy, possible right hepatic lobectomy, and intraoperative ultrasound. Past Medical History: NIDDM, OA Social History: Social History: She is from [**Country 2559**], has been in US for over 40 years. She is widowed, has two grown children, one living in New [**Location (un) **]. She is a housewife. Quit smoking in [**2077**]. No alcohol use. No drug use. Family History: . Family Medical History: Positive for lung cancer and throat cancer. No family history of diabetes, hypertension, or heart disease. Physical Exam: Wt 83kg, height 142cm HR 68 174/74 RR 20 O2 95% NAD cor RRR Lungs clear abd soft, non-tender, no mases or organomegaly ext no cce Pertinent Results: [**2110-8-1**] 04:50AM BLOOD WBC-8.0 RBC-2.97* Hgb-8.6* Hct-26.1* MCV-88 MCH-29.0 MCHC-33.0 RDW-14.5 Plt Ct-143* [**2110-8-1**] 04:50AM BLOOD Glucose-133* UreaN-14 Creat-0.5 Na-136 K-3.9 Cl-106 HCO3-25 AnGap-9 [**2110-8-1**] 04:50AM BLOOD Albumin-2.7* Calcium-7.5* Phos-1.4* Mg-1.8 Brief Hospital Course: On [**2110-7-29**], she underwent Segment 7 and 8 resection, cholecystectomy, intraoperative ultrasound for metastatic colon cancer to the liver and cholelithiasis. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Operative findings were as follows: 2lesions, one in segment 7 and one in segment 8 as demonstrated on the preop CT. Intraoperative ultrasound demonstrated the hemangiomas but no additional metastatic deposits in the liver. 25-minute Pringle maneuver was utilized followed by 10 minutes of reperfusion followed by another 24 minutes of Pringle maneuver. Two [**Location (un) 1661**]-[**Location (un) 1662**] drains were placed. Please refer to operative report for complete details. Postop,she was hypotensive and oliguric treated with IV fluid boluses and PRBC. She responded appropriately. She was transferred to the SICU because of this as well as mild hypoxia and hypercapnia. Vital signs stablized. Pain was treated with morphine pca. This was later switched to intermittent IV morphine. Pulmonary status improved. LFTs were noted to elevated. This likely related to the Pringle maneuver. LFTs improved daily. She was transferred out of the SICU on [**7-31**]. Diet was slowly advanced. JP drain outputs were serousanguinous. Volume of output decreased. On [**8-4**], the lateral JP was removed. On [**8-1**], lasix was started as her weight was up to 90kg from 83kg preop and she appeared edematous. Weight decreased to 86.7 kg by [**8-4**], but she still had some crackles and O2 sats were in high 80s-low 90s with O2. Lasix was continued with improvement of volume status. The patient is now 96% on room air, doing well, her last JP was discontinued on [**8-5**] and she is being discharged without additional lasix. Pt evaluated and recommended rehab. Rehab screening was done and a bed was obtained at [**Hospital6 **] in [**Hospital1 3597**]. Medications on Admission: Fosamax 70', glipizide 5', ibuprofen 60', metformin 500'', mvi Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: metastatic colon ca to liver DM Discharge Condition: good Discharge Instructions: please call Dr. [**Last Name (STitle) **] if you experience fever, chills, nausea, vomiting, increased abdominal pain, incision redness/bleeding/drainage No heavy lifting Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2110-8-13**] 9:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-9-15**] 11:00 Provider: [**First Name8 (NamePattern2) 25**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-9-15**] 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

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icd9cm

[ [ [] ] ]

[ "51.22", "38.93", "50.22" ]

icd9pcs

[ [ [] ] ]

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371, 449

5564, 5571

2528, 2811

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5595, 5767

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274, 333

477, 1916

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1981, 2208

8,185

152,849

30701

Discharge summary

report

Admission Date: [**2118-6-8**] Discharge Date: [**2118-6-23**] Date of Birth: [**2054-10-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Internal Jugular Venous Dialysis Catheter Placement Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 63 woman with hypertension and diabetes who was in her usual state of health until about 3 weeks ago when she awoke suddenly with shortness of breath. Her husband used his nebulizer treatments on her to no avail. She was admitted to [**Hospital1 **] and diagnosed with AVNRT (full hx not entirely clear). At discharge, the patient continued to feel short of breath, nausea, and fatigue. She was so tired that she quit her job as a monitor on a school bus. . She presented to her PCP who attempted to diarese her with lasix, and treated a presumed PNA with ceftriaxone and steroids. However, she noted decreased urine output and she continued to feel fatigue and nausea. After 5 days of visiting her PCP's office, the patient presented to [**Hospital3 **] on [**6-6**] with dry heaves and shortness of breath. There, she was given gram of rocephin, methylprednisolone, and 100 mg of doxycyline. She was transferred to [**Hospital3 **] where she was discovered to be in ARF with a creatinine of 4.3 up from her baseline of 1.5. She was transfused 2 units PRBCs O+ blood on [**6-7**] for a hemolytic anemia. Her creatinine continued to rise to 6.8 and her platelets to fall, so she was transferred to [**Hospital1 18**] for plasmapheresis for concern for TTP. Currently, she complains of mild HA and admits to palpitations and chills. She has several ecchymosis that she attributes to her last hospitalization . ROS: denies chest pain, fevers, confusion, hematuria, hematochezia, dark urine, dysuria, pedal edema, visual changes, tingling Past Medical History: DM HTN hypercholesterolemia iron deficiency anemia h.o c.diff h.o PNA left breast lumpectomy diverticulitis GERD glaucoma Social History: denies EtOH, tobacco, illicits. Lives with husband who smokes. Family History: mother died with CRI and 1 functioning kidney. Her father died of unknown causes. She has 3 brothers with arthritis, diabetes, and asthma Physical Exam: T 98.4, 163/62, HR 73, O2 91% on RA Gen: pleasant, cooperative, slightly anxious HEENT: dry MM, no scleral icterus Neck: supple 7 cm JVD, no LAD Cor: tachy, regular, no murmur Pulm: CTAB, initially mild crackles at bases Abd: obese, soft, NT, ND, + BS, no HSM Ext: WWP, DP/PT 2+ bilaterally, strength upper and lower extremities [**6-18**] bilaterally Neuro: CN II-XII individually tested and intact Skin: multiple ecchymosis on arms and shoulders, none on abdomen Pertinent Results: OSH labs from [**6-8**]: . 9.5 WBC, HCT 31.1, Plt 114, few schistocytes, ESR 53, 2.3 retics, BUN 140, creatinine 6.8, glucose 154 LDH 1591 Hgb A1C 5.8 . CT scan at OSH: CHF, small pleural effusions, mild scattered ground glass opacities, heterogeneous appearance of right lobe of thyroid gland, left renal cyst. . EKG: a.fib with normal axis, normal QRS and QT intervals. No ST changes or TWI. . CXR: AP view. My interpretation. ? small bilateral pleural effusions and right lower lobe infiltrate . peripheral smear: [**2-15**] schistocytes per high power field. + Burr cells, few platelets . [**2118-6-20**] CXR: There is a dual lumen catheter, which has been tunneled via a right internal jugular approach, replacing the temporary catheter, which had been in placed on [**6-15**]. The tip terminates in the right atrium. The cardiac and mediastinal contours are unchanged. The lung volumes remain low, with mild pulmonary vascular congestion. No pleural effusions are seen. There is degenerative change at multiple levels of the spine. . IMPRESSION: Stable mild pulmonary vascular congestion. Temporary dialysis catheter has been replaced with a tunneled dialysis catheter in the interim since the prior study. . [**2118-6-20**] Renal biopsy: The acute changes of thrombotic microangiopathy are superimposed on considerable chronic scarring and prominent chronic vascular injury (? chronic hypertension and or prior episodes of TMA). Light Microscopy: The specimen consists of renal cortex and medulla, containing approximately 15 glomeruli, of which 7 is globally sclerotic. The remainder show varying degrees of compensatory hypertrophy and ischemic change. Several thrombi are noted. Occasional double contours are seen. Three [**Hospital1 **] show segmental sclerosis. . There is moderate interstitial fibrosis and tubular atrophy that appears even worse in the subcapsular zone. Mild chronic inflammation accompanies the scarring. . Arteries show marked intimal fibroplasia. . Arterioles show marked mural thickening, with frequent hyaline change. Several show varying degrees of mucoid intimal hyperplasia and thrombus formation. . Immunofluorescence: The specimen consists of renal cortex only, containing approximately 5 glomeruli, of which 2 are globally sclerotic. There is no staining for IgG, IgA, IgM, Kappa, Lambda, or C1q. 2+ C3 is seen along capillary loops and trace in vessels. Albumin and fibrin (no thrombi) are non-contributory. . Electron microscopy: Findings will be issued in an addendum. . Comment: The acute changes of thrombotic microangiopathy are superimposed on considerable chronic scarring and prominent chronic vascular injury (? chronic hypertension and or prior episodes of TMA). Brief Hospital Course: Ms. [**Known lastname **] is a 63 year old woman with PMH of DM 2 and HTN who presented with symptoms of SOB, nausea and fatigue, treated for suspected pneumonia, who then presented to an outside hospital with acute renal failure. She was transferred to [**Hospital1 18**] with ARF, hemolytic anemia, and thrombocytopenia for possible plasmapheresis out of concern for TTP. She was found to have a hemolytic anemia, however peripheral blood examination and further workup was not consistent with TTP, and the patient did not undergo plasmapheresis. The patient required initiation of hemodialysis for her renal failure. . # Acute renal failure: Renal failure in combination with the hemolytic anemia initially raised the concern for TTP. Smear showed few schistocytes (although somewhat difficult to interpret as she had already been transfused PRBCs) consistent with microangiopathic hemolytic anemia. Renal ultrasound was normal. ADAMTS13 was sent and was not consistent with TTP as etiology. Although she did report diarrhea prior to her transfer to [**Hospital1 18**], stool cultures were negative for E. coli, campylobacter, salmonella, shigella, and yersinia, thus HUS also seemed unlikely. Autoimmune or drug-induced were also evaluated as possibilities, however anti-GBM was negative and there were no medications were clearly implicated. [**Doctor First Name **]/ANCA were negative in terms of vasculitis workup. Complement levels were normal. UPEP showed albumin only, no Bence [**Doctor Last Name 49**] proteins. Renal biopsy showed global and focal glomerulosclerosis and acute as well as chronic TMA. Anticardiolipin Abs were normal and lupus anticoagulant was negative as potential causes of TMA as seen on biopsy. Given her history of poorly controlled hypertension, it is thought that her renal disease and TMA is likely secondary to malignant/poorly controlled hypertension. She was initiated on hemodialysis and, given results of renal biopsy showing irreversible changes, outpatient hemodialysis was arranged. She was started on phosLo and renagel for phosphate lowering. A right tunnelled catheter was placed and venous mapping was performed for future fistula placement. . # Anemia/Thrombocytopenia: Initial labs revealed grossly elevated LDH and haptoglobin <20 and smear as above. Fibrinogen, originally elevated as acute phase reactant, normalized (never dropped below 100) and coags remained normal so as not to suggest DIC. Appeared to be microangiopathic process, unlikely antibody mediated. Coombs negative and cold agglutinins (for question of mycoplasma infection) were not performed by lab as direct Coombs was negative. Additionally, mycoplasma serologies were negative. Please see additional workup as above. Platelets normalized during her stay and her hematocrit remained stable (27-30). She required a total of 4U prbcs throughout her stay (last transfusion [**6-17**]). As above, she did not undergo plasmapheresis as her presentation was not deemed consistent with TTP. Has received total 4U prbcs here (and 2 at OSH); last transfusion [**6-17**]. Hemolysis labs revealed decreasing LDH (previously grossly elevated) and normalized haptoglobin (previously consistently <20). CBC should be monitored upon discharge. . # Hypoxia: During her stay, she maintained oxygen saturations in the low to mid 90s on room air. This was thought to be multifactorial in the setting of fluid overload given oliguric renal failure, HD dependent, and compressive atelectasis given largely bedbound. CXRs showed stable mild pulmonary vascular congestion and renal team worked to remove additional fluid at HD with some improvement in her O2 sats. Infective process was thought unlikely as she was without cough, elevated WBC count and no focal infiltrates on CXR. Despite low grade hypoxia and new a. fib, her hypoxia was thought [**3-18**] to combination of above factors and not with pulmonary embolism. . # Atrial fibrillation: A. fib new this hospitalization as she was in NSR previously on EKGs from PCP's office. The etiology is not entirely clear, but is most likely a result of her underlying acute illness and fluid overload causing atrial dilatation. She was started on diltiazem and lopressor and rates remains in the high 90s to low 100s on max dose diltiazem and 75mg PO lopressor tid. Her CHADS score given DM2 and HTN reveals 2.5% risk of stroke/year off anticoagulation, but initiation of anticoagulation was originally held due to her unclear hematologic picture and then for 1 week post renal biopsy. Cardiology was consulted and felt that current regimen of diltiazem and lopressor was sufficient for now. They recommended 4 weeks of anticoagulation prior to possible attempt at either pharmacologic for electrical cardioversion. She is scheduled for outpatient cardiology and should be started on coumadin at rehabilitation on [**2118-6-27**] (which reflects one week post renal biopsy) with goal of INR [**3-19**]. . # Elevated ALT and alkaline phosphatase: Were found to be mildly elevated and given isolated ALT elevation (AST normal) appeared more c/w drug etiology. GGT was also up so alkaline phosphatase was liver specific. Hep C Ab negative, Hep B serologies also negative (including Hep B surface Ab). Discussed medication causes with pharmacy and it appeared most likely secondary to frequent compazine administration for nausea/vomiting. Escitalopram and diltiazem can also cause LFT abnormalities, but she had been on escitalopram without problems on admission and her LFTs have since normalized despite continued diltiazem. With decreased need for compazine, LFTs normalized. . # Hypertension: Her systolic blood pressure was originally 140-180 range and was reflection of longterm poorly controlled hypertension (especially given [**Doctor First Name **] and renal TMA now thought most probably secondary to malignant/poorly controlled HTN) as well as fluid overload in the setting of oliguric renal failure. Her ACE-I was originally held with the thought renal process was potentially reversible. Despite lopressor and diltiazem better rate controllers and less good blood pressure control, her blood pressure improved to SBPs of 110s-130s consistently with continued HD. Thus, no additional agents were added back for control. . # Nausea/vomiting: Upon admission, she had nearly persistent nausea and vomiting thought most likely a result of uremia as her BUN was elevated to 100s range. Her nausea improved with continued HD, although she continues to experience bouts of N/V. She is however, tolerating PO food and fluids and her nausea has been well controlled with ativan and phenergan. She was also started on reglan for improved motility. . # Type 2 diabetes mellitus: She was on oral agents at home with good control as recent hemoglobin Ac1 was at goal. Metformin was discontinued given her renal failure. Her blood sugar was elevated when she began taking PO, but she was started on lantus and continued on insulin sliding scale with improved control. Her lantus can continue to be uptitrated as required. . # Depression/anxiety: She was continued on her outpatient dose of lexapro with PRN ativan. . # PPX: Subcutaneous heparin, bowel regimen. . # FEN: Cardiac/[**Doctor First Name **]/renal diet, renagel and phoslo for hyperphosphatemia . # Access/Tubes: Right tunnelled line in place. Left EJ. No foley. . # Communication: [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 19122**] [**Telephone/Fax (1) 72733**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19122**] [**Telephone/Fax (1) 72734**] (C), [**Telephone/Fax (1) 72735**] (H) . # FULL CODE Medications on Admission: Medications at Home: - meformin 500 [**Hospital1 **] - lisinopril 20 [**Hospital1 **] - lexapro 10 mg HS - vytorin 20 mg HS - MVI QD - avandia 8 mg QD - norvasc 10 mg QD - Cozaar 100 mg QD - ASA 81 mg QD . Medications on TRANSFER from [**Hospital3 **]: - zofran 4 mg IV Q8 - ferrous sulfate 325 mg QD - regular insulin sliding scale - protonix 40 mg QD - duonebs 1 meb Q4 PRN SOB - toprol XL 50 mg QD - MVI QD - lexapro 10 QHS - norvasc 10 QD - ASA 81 mg . Medications on TRANSFER from [**Hospital Unit Name 153**]: - Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN - Insulin SC Sliding Scale - Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN - Aluminum Hydroxide Suspension 30 ml PO BID - Lorazepam 0.5-1 mg IV Q4H:PRN - Calcium Acetate [**2112**] mg PO TID W/MEALS - Maalox/Diphenhydramine/Lidocaine 30 ml PO TID:PRN nausea - Diltiazem 120 mg PO QID - Ondansetron 2-4 mg IV Q8H:PRN - Pantoprazole 40 mg IV Q24H Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Vytorin [**12-3**] 10-20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Zofran 2 mg/mL Solution Sig: Two (2) mg Intravenous every 6-8 hours as needed for nausea. 15. Prochlorperazine 10 mg IV Q6H:PRN nausea 16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 17. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for nausea. 18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-15**] Sprays Nasal QID (4 times a day) as needed. 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 20. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: variable Subcutaneous four times a day: per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Acute on chronic renal failure Initiation of hemodialysis for ESRD Hemolytic anemia Thrombocytopenia Hypertension . Secondary: Type 2 Diabetes mellitus Hypercholesterolemia GERD Discharge Condition: Stable hematocrit, platelets normalized, on regular HD schedule. Discharge Instructions: You were admitted with acute renal failure, anemia, low platelets. You were started on hemodialysis for your renal failure and a renal biopsy was performed which showed the process causing your renal failure is unlikely to reverse. Your platelet counts have normalized and your red blood cell count has remained stable, although you are still anemic. . Please call your doctor or return to the emergency room if you develop fevers/chills, shortness of breath, chest pain, persistent nausea/vomiting, inability to tolerate food or fluids or any other symptoms that concern you. . Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below. Followup Instructions: Please follow up with your primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4899**], on [**7-6**] at 1pm. . Please follow up with your kidney doctor, Dr. [**First Name (STitle) 805**] ([**Telephone/Fax (1) 806**] on [**7-19**] at 2pm. Your appointment is in [**Last Name (un) **] Diabetes Center on the [**Hospital Ward Name **] of [**Hospital1 **]. . Please follow up with cardiology ([**Telephone/Fax (1) 9490**] on [**7-5**] at 9am with Dr. [**Last Name (STitle) 73**] in [**Hospital Ward Name 23**] building ([**Location (un) 436**]) on [**Hospital Ward Name **]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "55.23" ]

icd9pcs

[ [ [] ] ]

16152, 16231

5636, 13333

334, 400

16462, 16529

2881, 5613

17258, 17985

2240, 2379

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16252, 16441

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275, 296

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53,974

150,482

3439

Discharge summary

report

Admission Date: [**2111-11-5**] Discharge Date: [**2111-11-15**] Date of Birth: [**2063-3-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2344**] Chief Complaint: Respiratory Failure and Surgical Evaluation Major Surgical or Invasive Procedure: Intubation Mechanical Ventilation PICC line TPN History of Present Illness: 48 year old male patient of Dr. [**Last Name (STitle) **] transferred from [**Hospital1 4494**] for respiratory failure and further management. The patient was originally admitted to OSH 7 days ago with abdominal pain, nausea, and vomiting and found to have pancreatitis with lipases to 280s. Recently increased EtOH use. CT at OSH showed necrosis in tail of pancreas. Surgery was not consulted. He was treated with bowel rest, fluids and imipenem/cilastan. Pancreatic enzymes were trending down at the time of transfer. . On [**11-3**] he started having significant signs of alcohol withdrawal and became agitated. Intermittently febrile to 103-104. Continued on imipenem. He also had a fall on [**11-3**] but a negative head CT. On the day prior to transfer ([**11-4**]) he was requiring increasing doses of ativan for agitation and concern for DTs. Per report pt was having auditory hallucations as well as fomication. At around 8pm he developed respiratory distress and required intubation. No ABG available/drawn at that time. He self extubated overnight at 5am and was reintubated this morning. Post-reintubation ABG was 7.3/60/189 (unknown FiO2). . prop 50 ativan 10 presedex . On arrival patient was heavily sedated and virtually nonresponsive. Sats were ~100% on FiO2 of 50%. . ROS: unable to obtain from pt per wife: +cough +fever +nausea +vomiting +abdominal pain Past Medical History: EtOH Abuse Depression Medial meniscus tear w/ruptured [**Hospital Ward Name 4675**] cyst Lyme positive serology Social History: Runs private printing buisness. Lives with wife. EtOH abuse Family History: HTN, PKD in father. DM in mother's side of family. Physical Exam: Admission: VS: 98.0 78 130/80 100%/60% General: middle aged man intubated slightly diaphoretic Lungs: coarse breath sounds bilaterally heart: RRR, unable to appreciate any R/G/M Abdomen: mildly distended but soft, nontender but unable to fully assess given pt's mental status, hypoactive bowel sounds, +hepatomegaly Extremities: no edema Discharge: . VS: 98.8 81 115/53 20 99%RA General: NAD HEENT: non icteric, OP clear, MMM Lungs: CTA heart: RRR, no R/G/M Abdomen: soft, NTND, no appreciable HSM, BS+. Extremities: no edema, no clubbing, no signs of DVT Neuro: A+OX3, no asterexis, no gross deficit Pertinent Results: On admission: [**2111-11-5**] 03:59PM BLOOD WBC-4.2# RBC-2.99*# Hgb-9.1*# Hct-28.0*# MCV-94 MCH-30.5 MCHC-32.5 RDW-15.0 Plt Ct-228 [**2111-11-5**] 03:59PM BLOOD Neuts-71.7* Lymphs-19.2 Monos-5.5 Eos-2.8 Baso-0.9 [**2111-11-5**] 03:59PM BLOOD PT-14.4* PTT-26.5 INR(PT)-1.2* [**2111-11-5**] 03:59PM BLOOD Glucose-179* UreaN-7 Creat-0.9 Na-141 K-3.5 Cl-108 HCO3-27 AnGap-10 [**2111-11-5**] 03:59PM BLOOD ALT-38 AST-27 LD(LDH)-307* AlkPhos-55 TotBili-0.6 [**2111-11-5**] 03:59PM BLOOD Lipase-238* [**2111-11-5**] 03:59PM BLOOD Albumin-2.5* Calcium-8.1* Phos-2.1* Mg-2.3 [**2111-11-5**] 04:09PM BLOOD Type-ART Temp-36.5 pO2-244* pCO2-43 pH-7.44 calTCO2-30 Base XS-5 [**2111-11-5**] 04:09PM BLOOD Glucose-167* Lactate-1.5 Na-141 K-3.2* [**2111-11-5**] 04:09PM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-99 [**2111-11-5**] 04:09PM BLOOD freeCa-1.15 [**2111-11-6**] 04:26AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2111-11-6**] 04:26AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-TR [**2111-11-6**] 04:26AM URINE RBC-221* WBC-3 Bacteri-NONE Yeast-NONE Epi-<1 [**2111-11-6**] 04:26AM URINE Hours-RANDOM Na-134 K-44 Cl-207 Calcium-0.7 Phos-25.1 Mg-1.3 HCO3-LESS THAN [**2111-11-6**] 04:26AM URINE Osmolal-586 . On discharge: [**2111-11-12**] 04:52AM BLOOD WBC-9.0 RBC-3.19* Hgb-9.6* Hct-29.4* MCV-92 MCH-30.1 MCHC-32.6 RDW-15.2 Plt Ct-779* [**2111-11-12**] 04:52AM BLOOD PT-13.7* PTT-25.6 INR(PT)-1.2* [**2111-11-11**] 03:14PM BLOOD Fibrino-427* [**2111-11-12**] 04:52AM BLOOD Glucose-151* UreaN-12 Creat-1.0 Na-145 K-4.2 Cl-109* HCO3-29 AnGap-11 [**2111-11-12**] 04:52AM BLOOD ALT-19 AST-19 LD(LDH)-285* AlkPhos-49 TotBili-0.5 [**2111-11-12**] 04:52AM BLOOD Lipase-178* [**2111-11-12**] 04:52AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.9 Mg-2.4 [**2111-11-11**] 03:14PM BLOOD calTIBC-177* VitB12-1129* Folate-19.6 Ferritn-383 TRF-136* [**2111-11-11**] 03:25AM BLOOD Triglyc-261* Blood Culture, Routine (Final [**2111-11-12**]): NO GROWTH. URINE CULTURE (Final [**2111-11-8**]): NO GROWTH. GRAM STAIN (Final [**2111-11-7**]): [**10-19**] PMNs and >10 epithelial cells/100X field. . CXR [**2111-11-5**]: 1. Left pleural effusion and atelectasis. Given the patient's clinical circumstance, cannot exclude pneumonia in this area. 2. Right PICC appears to terminate in the axillary-subclavian vein at the level of the shoulder. 3. Endotracheal tube in appropriate position. .X-ray abdomen [**2111-11-6**]: IMPRESSION: Air throughout large bowel. One dilated loop of bowel may represent sentinel loop. . CT Chest/Abdomen/Pelvis [**2111-11-6**]: 1. Acute pancreatitis with unchanged fluid collection predominantly filling the left anterior pararenal space and tracking down into the pelvis. There is no organized collection with rim enhancement or fibrous border to suggest abscess or pseudocyst. Diminished enhancement of the distal pancreas, suggesting pancreatic necrosis. 2. Thrombosis of the splenic vein, new since the prior study. 3. No evidence of CBD dilatation, intra- or extra-hepatic biliary duct dilatation or stone within the CBD duct. 4. Esophageal, gastric and splenic varice. . ECG [**2111-11-7**]: Sinus tachycardia. Baseline artifact in precordial leads. No previous tracing available for comparison. . CXR [**2111-11-13**]: Homogeneous opacification in the left lower lung is more pronounced today than on [**11-11**], could be due to progressive pneumonia. Although heart size is normal, there is greater distention of upper lobe pulmonary and mediastinal veins suggesting mild volume overload, although there is no pulmonary edema. Brief Hospital Course: 48 year old gentleman history of EtOH abuse, Depression, [**Hospital 2754**] transferred from OSH with acute alcoholic pancreatitis. . Hospital Course: . Initially admitted to OSH for Pancreatitis in the setting of increased EtOH consumption. Was treated with bowel rest, fluids and 7 day course of imipenem/Cilastin. On [**11-3**] he started having significant signs of alcohol withdrawal. He also had a fall on [**11-3**] with a negative head CT. On the day prior to transfer ([**11-4**]) he was requiring increasing doses of Ativan for agitation and concern for DTs culminating in intubation for continued sedation. He self extubated overnight and was re intubated prior to transfer. Transferred to [**Hospital1 18**] on [**11-5**] for resp distress and pancreatic necrosis per radiography. CXR showed left sided pleural effusion but no clear consolidation. Extubation was limited largely by mental status. He was started on Haldol and Zyprexa for agitation as sedation was weaned off. A CT scan of the abdomen and chest was repeated and showed acute pancreatitis with unchanged fluid collection in the left anterior pararenal space tracking down to the pelvis and necrosis of the distal pancreas. CT also revealed thrombosis of the splenic vein and esophageal, gastric, and splenic varices as well as bilateral pleural effusion with underlying atelectasis and possible LLL consolidation. He spiked a temperature of 101 pm [**2111-11-6**] and was restarted on imipenem (he had completed a 7 day course at OSH) as well as vancomycin. He was started on PPN and then transitioned to TPN for nutrition. He was given minimal doses of iv Lasix for diuresis given anasarca and pleural effusions, which he responded well to. On [**2111-11-9**], pt self-extubated and tolerated well, satting in the high 90s. However, he remained agitated, requiring Valium as well as Haldol. Alcohol withdrawal was unlikely as he had been abstinent 1 week upon arrival to [**Hospital1 18**]. He was given thiamine, MVI, and folate. Valium was eventually d/c-ed as his mental status changes appeared more consistent with delirium. He was started on standing Haldol; His low grade temps eventually subsided and vancomycin and imipenem were discontinued on [**2111-11-12**]. He had a swallowing evaluation on [**11-13**] which he passed and was transitioned to oral feeds and medications. Transferred to the medicine floor on [**11-13**] where he remained stable. Discharged home [**11-15**]. . Problem Summary: . # Acute Pancreatitis: associated with recent increase in EtOH consumption and complicated by distal pancreatic necrosis and splenic vein thrombosis (see below) per CT. Managed with IVF, antibiotics and TPN. Interval CT unchanged. Subsequently complete resolution of abdominal pain and transition to oral nutrition which he tolerated well. In [**Hospital1 18**] lipase initially trended down from 238 on admission [**11-5**] to 126 [**11-10**], then trended up to 209 likely [**1-27**] to stimulation of exocrine pancreas in the setting of renewed oral nutrition. Lipase at discharge was 177 and should be further followed in the outpatient setting. Complete abstinence from alcohol(see below) and out-patient GI follow up was advised. . # Hypoxia and Resp distress: Patient was initially intubated due to requirement for high doses of BZD in the setting of alcohol withdrawal, later developed resp distress due to anasarca with bil pulmonary effusion and pul congestion [**1-27**] to overhydration as well as atelectasis and possible LLL pneumonia. Treated with diuresis and Abx in MICU to good effect. Self-extubated [**11-9**] and tolerated well with occasional desats to low 90's which subsequently resolved. CXR [**11-13**] showed resolved pleural effusion with some residual signs of congestion w/o pulmonary edema as well as residual LLL opacification. On the floor patient was clinically euvolemic, afebrile and well saturated on room air at rest and exertion and did not require further diuresis or Abx. . # Fever: Had recurrent fevers [**1-27**] to his pancreatitis and necrosis vs. possibly left lower lobe pneumonia. Blood and Urine Cx were negative throughout his stay. Treated with 7 day course of Imipenem/cilastatin in OSH then another 7 day course of imipenem + vanco at [**Hospital1 18**]. Was subsequently off antibiotics and afebrile > 72 hours prior to discharge. CXR of [**11-13**] showed homogeneous opacification in the left lower lung concerning for progressive pneumonia, but as this did not correlate with patient's obvious clinical improvement continued Abx were not deemed necessary. Patient was instructed to seek immediate medical attention for any fever or respiratory symptoms. He will require repeat CXR in 6 weeks. . # splenomegaly, gastrosplenic varices, GIB, anemia: this was likely secondary to splenic vein thrombosis complicating acute pancreatitis. Patient did have history of alcohol abuse but LFTs were not abnormal and CT appearance of liver was Fatty but no Cirrhotic. He did not have other manifestation to suggest portal HTN. On admission he had melena and downtrending Hct from 28 to 23. Source was thought likely to be variceal hemorrhage. He was treated with IV PPI. Melena subsequently resolved and Hct stabilized w/o need for PRBC. His last three stool guaiacs were negative. Hct at discharge was 27.5. He is discharged on Oral Pantoprazole 40mg [**Hospital1 **] and metoprolol to reduce risk of recurrent variceal bleed. He will require follow-up of his Hct as well as GI consultation in the out-patient setting. . # Alcohol Abuse: Patient was admitted for alcoholic pancreatitis and developed severe Alcohol withdrawal symptoms on day 4 of OSH course. He was treated with benzodiazepines of which he required high doses and eventually intubation. He also received supplementation of folic acid, thiamin and iron which he will continue post discharge. After transfer to the floor patient was seen by our social worker together with his wife and stated that he will not drink again. Options for outpatient alcohol abstinence support were presented. . # Delirium: In the [**Hospital1 18**] MICU patient had mental status changes and agitation consistent with delirium. Alcohol withdrawal was thought unlikely at this stage as he was by then more than a week abstinent. He was weaned off benzodiazepines and started on Haldol for presumed ICU delirium with good effect. After transfer to the floor Haldol was d/c-ed and patient remained A+O X 3, concentrated and with no further mental status changes. . # HTN: At home was on HCTZ 25mg and lisinopril 5mg. These were held in OSH d/t unstable intravascular volume. During his hospital course he developed labile BPs upto 180s and was started on Metoprolol tartrate followed by restarting of home lisinopril with good effect. He is discharged on Metoprolol succinate and Lisinopril. HCTZ continues to be held at discharge. Will require continued out patient management of HTN. Medications on Admission: On Transfer from OSH: propofol gtt dexmedetomidine gtt lorazepam gtt pantoprazole 40mg iv daily albuterol-ipratropium nebs insulin humalin sliding scale haldol 2mg iv metoprolol 5mg IV q6H zofran 4mg iv q6h prn dilaudid 2mg IV q2 hr morphine 1-3mg iv q1hr prn respiratory discomfort lorazepam 2mg q3h if needed . Home Medications: clonazepam 0.5mg 1-2 tablets po bid prn alprazolam 500mcg [**12-27**] prn fear of flying HCTZ 25mg lisinopril 5mg trazadone 100mg 0.5 to 5 tab PO QHS PRN venlafaxine 75mg SR po daily ?seroquel Discharge Medications: 1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. metoprolol succinate 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* 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. venlafaxine 75 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Tablet Extended Rel 24 hr(s) 8. clonazepam 0.5 mg Tablet, Rapid Dissolve Sig: [**12-27**] Tablet, Rapid Dissolves PO twice a day as needed for anxiety. 9. trazodone 100 mg Tablet Sig: One (1) Tablet PO once a day as needed for sleep. Discharge Disposition: Home Discharge Diagnosis: primary: Acute Alcoholic Pancreatitis Secondary: Pancreatic Necrosis Splenic vein thrombosis Varicces upper GI bleeding Alcohol Withdrawal Anasarca Respiratory Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of an inflammation in your pancreas caused by alcohol consumption. Your illness was complicated by alcohol withdrawal, respiratory failure, infection and intestinal bleeding. You received care in the intensive care unit where you were required life support including mechanical ventilation, medication, fluid and nutrition which which were administered intravenously. Your condition gradually improved and you were subsequently transferred to the medical floor. You are now ready for discharged home and will need medical follow up with your primary care physician and specialist doctors as listed below. . The most important thing that you can do for your health is to abstain completely from alcohol. You are strongly urged to enroll in a program for alcohol abstinence using the information provided to you by our social worker. . The following changes were made to your medications: - STOP hydrochlorothiazide . - PLEASE START THE FOLLOWING MEDICATIONS: - Lisinopril 5 mg tablet. Take 1 tablet once daily for blood pressure control. - Metoprolol Succinate 50mg SR tablet. Take one tablet once daily for blood pressure control. - Pantoprazole 40mg tablet. Take one tablet twice daily to help prevent intestinal bleeding. - Thiamine 100mg tablet. Take one tablet once daily. - Folic Acid 1mg. Take one tablet once daily. - Multivitamin tablet. Take one tablet once daily. Followup Instructions: Please call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. at [**Telephone/Fax (1) 4775**] to make an appointment for the week following your discharge. . You will also need a referral to a gastroenterology specialist for your splenic vein thrombosis and gastric varices. Completed by:[**2111-11-18**]

[ "518.81", "291.81", "577.0", "289.59", "303.91" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "99.15" ]

icd9pcs

[ [ [] ] ]

15026, 15032

6380, 6515

360, 410

15244, 15244

2736, 2736

16819, 17150

2045, 2097

13932, 15003

15053, 15223

13383, 13696

6532, 13357

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2112, 2717

13714, 13909

4021, 6357

277, 322

438, 1815

2751, 4007

15259, 15371

1837, 1951

1967, 2029

26,542

181,675

25191

Discharge summary

report

Admission Date: [**2120-8-9**] Discharge Date: [**2120-8-23**] Date of Birth: [**2101-1-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: hypoxia/ARDS Major Surgical or Invasive Procedure: Intubation Central line placement and removal Thoracentesis x 2 History of Present Illness: Pt is a 19yo M with no significant [**Hospital **] transferred from OSH with pneumonia and respiratory distress. Pt presented to his PCP's office with a 2 day h/o nausea, vomiting and abdominal pain. He had no associated diarrhea, fever. It was thought to [**Last Name (un) **] viral process and pt was prescribed Motrin and an antiemetic. Later that night he developed a cough productive of yellow sputum and SOB. He presented to the ED, and was found to be febrile to 102 with coughing and tachypnea. His ABG was 7.47/29/72 and WBC was 43,000 (33% bands). He received azithromycin and ceftriaxone. He was admitted to [**Hospital1 1474**] on [**2120-8-8**] for pneumonia, ARF, and dehydration. O2 was 85% on RA, 97-100% on 100% face mask. Ceftazidime and vancomycin were added to his antibiotic regimen. He was transferred to the ICU on the morning of [**2120-8-9**] for hypoxia and tachypnea. In the ICU he was maintained on 100% FM. . Upon arrival to the [**Name (NI) 153**], pt was satting 94-97% on 80% FM but was markedly tachypneic. He was started on BiPAP to decrease his work of breathing, but continued to have RR in the 30s-40s. The decision was made to intubate him urgently before he tired out. Upon intubation, he was found to have thick [**Name (NI) **]-colored endobronchial secretions. He was put on AC with high PEEP but had O2 saturations in the 60s-70s. He was then ambu-bagged and suctioned, then sedated, paralyzed, and put back on the vent with resulting increase in O2 sats to the 80s. He gradually increased his sats to 99-100% on AC 600/28/1.0 with PEEP 15. Past Medical History: Croup as a child, requiring multiple hospital admissions between the ages of 2 and 9, has had no pulmonary disease since then Social History: Single, works as office partition installer; nonsmoker; no EtOH use 1 wk PTA, smoked pot but no cocaine use or IVDA; sexually active w/ condom use every time; lives near farm w/ occ. exposure to livestock. Family History: no history of pulmonary disease, hematologic disease, immunologic disease Physical Exam: On discharge: Vitals - Temp curve 98.1 Tmax 99.5 BP:120-135/70-82 HR:64-91 RR 18 99%RA. Gen: Alert young well-appearing man in NAD. Neck: No LAD, no JVP appreciated. HEENT: OP clear, EOMI. Chest: CTAB. CV: RRR. Nl S1 and physiologic split in S2. No murmurs, rubs or gallops. Abd: S, NT, ND without hepatosplenomegaly. Ext: Warm, well perfused. No stigmata of endocarditis. Neuro: CN 2-12 grossly intact. Pertinent Results: [**2120-8-9**] 08:31PM WBC-26.8* RBC-5.12 HGB-14.3 HCT-40.5 MCV-79* MCH-28.0 MCHC-35.4* RDW-12.9 [**2120-8-9**] 08:31PM GLUCOSE-104 UREA N-12 CREAT-0.9 SODIUM-136 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-20* ANION GAP-15 [**2120-8-9**] 11:00PM LACTATE-1.4 [**2120-8-9**] 11:00PM TYPE-ART O2-100 PO2-65* PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--2 AADO2-623 REQ O2-99 INTUBATED-NOT INTUBA [**2120-8-9**] 08:31PM PT-15.6* PTT-37.9* INR(PT)-1.6 [**2120-8-9**] 08:31PM NEUTS-61 BANDS-33* LYMPHS-4* MONOS-1* EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2120-8-9**] 08:31PM ALBUMIN-2.6* CALCIUM-7.3* PHOSPHATE-2.5* MAGNESIUM-1.7 OSH imaging (reports): CXR ([**2120-8-8**]): diffuse bilateral pulmonary infiltrates with b/l pleural effusions, infiltrates slightly nodular. CXR ([**2120-8-9**]): extensive b/l pulmonary infiltrates with perhaps a little improvement overall as seen yesterday. KUB ([**2120-8-9**]): unremarkable abdomen. CT chest ([**2120-8-9**]): diffuse nodular pattern, small bilateral pleural effusions Brief Hospital Course: #ID/Pulm: Mr. [**Known lastname 63138**] was admitted acute respiratory distress, no known cardiac problems, and bilateral pulmonary infiltrates on CXR. The patient was intubated promptly in the ICU and remained on ventilator for 10 days, with excellent O2 sats upon extubation. The precipitant was thought to be most likely an infectious process as he presented to the OSH with fever, cough, and bandemia. The differential included bacterial pneumonia, such as Strep. pneumo, which would be the most likely cause as it is community-acquired and not uncommonly has negative cultures. Other entities considered included atypicals, and less likely viral and diffuse fungal pneumonia. An extensive workup was performed, including testing for atypical serologies (including Coxiella, Tularemia, Hantavirus) which were pending at time of discharge. No serologies returned positive (including Ehrilichia, HIV testing, and Legionella antigen). All C diff and urine cultures were negative. Blood cultures from the OSH were negative. While in house, two blood cultures grew positive for coagulase-negative Staph species; this was treated with a 7 day course of vancomycin with no further growth of blood cultures. Serum IgG was checked toward the end of admission to ensure that the negative serologies were not a consequence of hypogammaglobulinemia/immunodeficiency; SPEP returned within normal limits. He was treated with several kinds of antibiotics to cover bacterial, atypical, and viral pneumonias. He did develop increased nasal discharge after several days on intubation and a CT of the sinuses showed diffuse opacification; he was discharged on a 7 day course of levofloxacin for sinusitis. Procedures performed included a bronchoscopy (BAL culture was negative for PCP and AFB). Thoracenteses were performed on both the right and left sides over his ICU stay, revealing a exudative effusion, eosinophils, and negative cultures. Several studies were still pending at the time of discharge. The patient's primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was updated on the patient's course and will follow these studies as an outpatient. . #GI: The patient had elevations in amylase and lipase over his hospital course with essentially normal LFTs. These were associated with no abdominal pain or tenderness but mild diarrhea and some transient abdominal distention in the ICU. Workup was entirely negative with no ascites on abdominal, negative OSH CT abdomen/pelvis, negative KUB for obstruction, negative stool studies were negative, including C. diff. He developed recurrent leukocytosis in the setting of being hospitalized and on several antibiotics, so C. diff colitis is on the differential. . #Endocrine: There was a question of adrenal insufficiency during the patient's ICU stay manifested by a baseline cortisol of 0.8. The patient responded adequately to stim testing, and serum ACTH returned within normal limits. Endocrine consultation was obtained; it was felt that the patient was euadrenal and steroid supplementation was held. #eosinophilia: Eosinophils were found in the peripheral smear (30%) and also in the patient's pleural effusion. DDx includes drug reaction (although likely too high) versus parasite infection. Stronglyoides serology was sent and pending at discharge. After the patient's course of antibiotics for pneumonia, his Augmentin was changed to levofloxacin out of concern for a possible eosinophilic reaction to clavulonate. #anemia: The patient was found to be anemic over the course of his admission in the setting of being +7 liters in fluid balance. No baseline was available for comparison; however ongoing losses were deemed to be unlikely as the Hct was stably in the low 30s throughout with no clear trend. Medications on Admission: None Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Acute respiratory distress syndrome Presumed S. epidermidis line infection Secondary: sinusitis pancreatitis eosinophilia anemia Discharge Condition: Good, ambulating, taking po's, afebrile, with improved respiratory status and favorable physical exam. Discharge Instructions: Please return to care if you notice chest pain, difficulty breathing, fevers, cough, chills, nausea/vomiting/belly pain, signs of infection, or any other symptoms of concern. Please refrain from any heavy exertion until cleared by your primary care physician. [**Name10 (NameIs) **] may resume other daily activities as tolerated. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and with infectious disease with Dr. [**Last Name (STitle) **]. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**First Name (STitle) **] Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2120-9-27**] 10:00 Dr. [**Last Name (STitle) **], your primary care physician, [**Name Initial (NameIs) 176**] 7-10days ([**Telephone/Fax (1) 3183**]). Completed by:[**2120-8-24**]

[ "577.0", "518.82", "996.62", "276.6", "481", "461.9", "288.3", "285.9", "458.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "33.24", "34.91", "93.90", "38.91", "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

7967, 7973

3969, 7780

326, 392

8156, 8261

2925, 3946

8816, 9192

2409, 2484

7835, 7944

7994, 8135

7806, 7812

8285, 8793

2499, 2499

2513, 2906

274, 288

420, 2020

2042, 2169

2185, 2393

9,419

113,623

26944

Discharge summary

report

Admission Date: [**2127-2-10**] Discharge Date: [**2127-2-14**] Date of Birth: [**2088-11-1**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 7055**] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: none History of Present Illness: 38 M with PMH ARDS [**2122**], presents with SSCP x 2 days. SSCP started suddenly on Sat (time unknown), [**6-16**], pt holds up clenched fist to describe chest pressure, constant but worse with exertion, no noticed relief with rest, no association with food, radiated to back of L shoulder which ached. Pt has had severe fatigue, sore throat, diffuse myalgias. No F/C/N/V/diaphoresis, no SOB. SSCP was relieved at 1 am on Sun AM, and pt slept to see if CP would resolve by Sun morning. Pt woke up on Sun AM and still had SSCP. He went to [**Hospital 47**] Hospital, where he was found to have STE in anterolateral leads, NSR 92. Pt was placed on ASA, heparin, integrilin, and was taken to emergent cath. . At cath, pt was found to have 100% proximal LAD occlusion, RCA generally patent, LCX generally patent. Was able to pass wire down LAD, but LAD took a sharp U-turn anteriorly, and had no flow in LAD on contrast injection. Stented mid-LAD, with minimal flow to LAD. Wire was maneuvered more distally into LAD and contrast injection showed perforation into distal LAD, with contrast flowing into ventricle (likely LV). Perforation appeared to be into the ventricle, not into the pericardium. Balloon was inflated for relatively prolonged periods at 2 sites near perforation, which was successful in diminishing contrast leakage from LAD. Pt was airlifted to [**Hospital1 18**], hemodynamically stable with HR 80s, BP 110-120s, for further management of LAD perforation. Past Medical History: Was hospitalized for 2.5 mo with intubation at [**Hospital3 **] for ARDS and a "mold lung infection" in [**2122**], was in coma for 1 month. Otherwise has never been hospitalized. Hypercholesterolemia Social History: Used to be heavy EtOH user but last drink few mo ago. 23 pky smoking hx per one person's history, 46 pky smoking hx per another person's history. +marijuana use, last 1.5 weeks ago, never tried cocaine, heroin. Lives with father and stepmother. Family History: Father had MI at 52, quintuple bypass at 66. Physical Exam: 97.0 / 101/68 / 94 / 16-24 / 100% 2.5L nc Gen: Sleepy in bed HEENT: JVD difficult to assess, no LAD, dry mm Lungs: Rales diffuse bl Heart: [**2-10**] holosystolic blowing murmur heard best at apex, no r/g, regular, tachy Abdomen: Soft, ND, NT, +BS, mildly obese Extr: No c/c/e, 2+ DP bilaterally, minimal bleeding Neuro: [**4-11**] motor in UE, sensation equal and intact bl Skin: No ecchymoses, no rash Pertinent Results: EKG: STE in anteroseptal leads . CXR: Swan ends in PA, mediastinum little wide, focal indentation in trachea around L clavicle area (narrowed trachea 15-20% likely from intubation) . Echo: Conclusions: The left atrium is elongated. The left ventricular cavity size is normal. LV systolic function appears moderately to severely depressed. Resting regional wall motion abnormalities include anteroseptal hypokinesis/akinesis, mid to distal anterior akinesis, apical akinesis/dyskinesis. No definite apical thrombus seen but cannot exclude. Right ventricular chamber size is normal. There is focal hypokinesis of the apical free wall of the right ventricle. The aortic root is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no regurgitation. There is no aortic valve stenosis. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . Cath at OSH: Proximal 100% LAD occlusion, poor flow upon opening LAD, LAD Class III perforation with extravasation of contrast into RV. RCA and LCX are patent. . [**2127-2-10**] 11:36PM CK(CPK)-137 [**2127-2-10**] 11:36PM CK-MB-13* MB INDX-9.5* cTropnT-2.07* [**2127-2-10**] 12:09PM CK(CPK)-142 [**2127-2-10**] 12:09PM CK-MB-17* MB INDX-12.0* cTropnT-2.03* [**2127-2-10**] 12:09PM HCT-35.1* [**2127-2-10**] 09:30AM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG [**2127-2-10**] 09:30AM URINE HOURS-RANDOM [**2127-2-10**] 09:30AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2127-2-10**] 09:23AM HCT-33.8* [**2127-2-10**] 06:19AM O2 SAT-71 [**2127-2-10**] 05:06AM TYPE-ART PO2-136* PCO2-35 PH-7.35 TOTAL CO2-20* BASE XS--5 [**2127-2-10**] 05:06AM O2 SAT-97 [**2127-2-10**] 05:06AM freeCa-1.06* [**2127-2-10**] 04:42AM GLUCOSE-98 UREA N-20 CREAT-1.0 SODIUM-136 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-19* ANION GAP-16 [**2127-2-10**] 04:42AM CK(CPK)-127 [**2127-2-10**] 04:42AM CK-MB-12* MB INDX-9.4* cTropnT-2.25* [**2127-2-10**] 04:42AM CALCIUM-7.2* PHOSPHATE-4.8* MAGNESIUM-1.6 [**2127-2-10**] 04:42AM WBC-13.7* RBC-3.90* HGB-11.7* HCT-34.4* MCV-88 MCH-30.1 MCHC-34.0 RDW-12.5 [**2127-2-10**] 04:42AM PLT COUNT-204 [**2127-2-10**] 04:42AM PT-14.1* PTT-38.9* INR(PT)-1.2* Brief Hospital Course: 38 M with PMH ARDS [**2122**], presents with STEMI and perforated LAD post-stenting, with partial revascularization. . # Cardiac: Ischemia: Subacute anteroseptal STEMI upon presentation, likely 3-5 days old. Proximal 100% LAD occlusion with mid-LAD stent, but LAD flow was not restored, LAD territory likely unable to be recovered. LAD was perforated during procedure. Post-cath, hemos were CO: 5.9, Index: 2.76, Wedge 17, PAP 28/15. On ASA, plavix, statin, ACE, BB. Will follow up for repeat TTE to assess EF for possible ICD in 1 month. . Pump: EF 30% on TTE after STEMI, wedge 21-22, severe anteroseptal and inferior hypokinesis, small anterior pericardial effusion. Pt was discharged on coumadin for 1 month for large anteroseptal infarct with apical hypokinesis. He needs INR checks for goal INR 2.0-3.0, and was discharged on lovenox for bridge to coumadin. Immediately post-cath, patient had a murmur on exam, but after 24 hrs, pt did not have a murmur for the remainder of admission. . Rhythm: Pt was in NSR on tele. . # Class III LAD perforation: LAD was perforated into LV at the location of distal LAD. LAD perforation complications include: pericardial tamponade, MI, intramural hematoma, arrhythmia, coronary dissection, cardiogenic shock. Treatment is either CABG for emergent revascularization or prolonged inflation with PTCA balloon or perfusion catheter or stent. . The PTCA balloon was put up for extended period in 2 sites in the LAD, to inhibit extravasation of contrast post-LAD perforation. Perforations are classified into: Class I - extraluminal crater without extravasation Class II - pericardial or myocardial blushing Class III - perforation 1 mm in diameter with contrast streaming and cavity spilling . Serial pulsus checks were negative. CABG was not recommended to patient because MI likely occurred 3-4 days before presentation (according to presenting cardiac enzymes) so myocardium cannot be reperfused with revascularization. Medications on Admission: Medications on Admission: Lipitor Wellbutrin . ALL: PCN Discharge Medications: 1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Start taking this medication on [**2127-2-17**]. Disp:*30 Tablet(s)* Refills:*2* 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime for 3 days: Take one tablet on [**2127-2-14**], [**2127-2-15**], and [**2127-2-16**], then start taking Warfarin 5 mg by mouth every night instead. Disp:*3 Tablet(s)* Refills:*0* 9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-9**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 10. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours). Disp:*20 20 syringes ([**2120**] mg total)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Large ST elevation Myocardial Infarction LAD perforation into left ventricle Discharge Condition: hemodynamically stable Discharge Instructions: 1. Please eat a low salt diet. No more than 2 mg per day. 2. Weigh yourself daily. If you have a weight gain > 3 lbs, please call your doctor. 3. Please take all medications as prescribed. ALWAYS take your aspirin and plavix. 4. Please keep all follow-up appointments. You have an appointment for an echocardiogram in 1 month followed by an appointment with an electrophysiology cardiologist, Dr. [**Last Name (STitle) **]. Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2127-3-11**] 2:30. [**Hospital1 **] [**Last Name (Titles) 516**], [**Hospital Ward Name 23**] 7 2. Please make a followup appointment with Dr. [**Last Name (STitle) 1655**]. INR check Monday morning in Dr.[**Name (NI) 64536**] office. Completed by:[**2127-2-14**]

[ "V58.61", "V45.82", "305.93", "410.11", "V17.3", "305.1", "411.0", "998.2" ]

icd9cm

[ [ [] ] ]

[ "89.64" ]

icd9pcs

[ [ [] ] ]

8718, 8724

5174, 7139

287, 294

8845, 8870

2797, 5151

9346, 9752

2312, 2358

7245, 8695

8745, 8824

7191, 7222

8894, 9323

2373, 2778

233, 249

322, 1809

1831, 2033

2049, 2296

71,119

123,743

46095

Discharge summary

report

Admission Date: [**2148-2-27**] Discharge Date: [**2148-3-3**] Date of Birth: [**2086-12-19**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: [**2148-2-27**] - Coronary artery bypass grafting x5 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the distal right coronary artery, first obtuse marginal artery, first and second diagonal artery. History of Present Illness: This 61 year old male has a history of an NSTEMI in [**2133**] with stenting of the LAD lesion at [**Hospital6 **]. About one month ago he began to notice that after he walks for [**10-14**] minutes, particularly when going uphill or when walking rapidly, he feels a dull substernal pressure associated with some shortness of breath, sometimes with nausea. With relaxation, his symptoms will resolve. He has not had any symptoms at rest. Recent stress testing has revealed an anteroseptal and inferoseptal perfusion defect with a small amount of reversibility. He was referred for cardiac catheterization to further evaluate. He was found to have in stent restenosis and three vessel disease. He is now being admitted to cardiac surgery for revascularization. Past Medical History: [**2-/2134**]: non ST elevation MI, s/p LAD stenting Hypertension Hyperlipidemia Diabetes Neuropathy Hx of non healing right foot ulcers s/p surgery [**2145**] Osteomyelitis of right foot s/p I&[**Initials (NamePattern4) **] [**2147-5-31**] History of anemia Prior mention of bipolar disorder in OMR (patient disagrees with diagnosis) Depression Prostate cancer, followed by Dr. [**Last Name (STitle) 27078**] currently under observation only, scheduled for another biopsy in [**2148-4-30**], 1st biopsy was [**2147-4-30**] GERD Social History: Race:African american Last Dental Exam:2 months ago Lives with: wife Contact:[**Name (NI) 98087**] (wife cell) [**Telephone/Fax (1) 98088**] [**Name2 (NI) 27057**]tion:Retired- previously worked as a communication director for the [**State 1558**] Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [x] [**2-6**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- Mother had CHF,died at 86 Physical Exam: Pulse:74 Resp:14 O2 sat:100/RA B/P Right:157/94 Left:129/93 Height:5'1" Weight:89 kgs General: awake, alert, NAD 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 [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _none_ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: palp Left: palp PT [**Name (NI) 167**]: palp Left: palp Radial Right: palp Left: palp R radial art puncture c/d/i, no bleed/hematoma Carotid Bruit Right: none Left: none Pertinent Results: [**2148-2-27**] ECHO PRE-CPB: No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. No thoracic aortic dissection is seen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. [**2148-3-1**] 05:35AM BLOOD WBC-9.7 RBC-3.33* Hgb-10.1* Hct-29.2* MCV-87 MCH-30.2 MCHC-34.6 RDW-12.6 Plt Ct-180 [**2148-2-27**] 01:01PM BLOOD WBC-10.3 RBC-3.25* Hgb-9.8* Hct-27.7* MCV-85 MCH-30.1 MCHC-35.3* RDW-12.7 Plt Ct-133* [**2148-3-1**] 05:35AM BLOOD Glucose-152* UreaN-22* Creat-1.4* Na-138 K-4.0 Cl-103 HCO3-26 AnGap-13 [**2148-2-27**] 02:15PM BLOOD UreaN-16 Creat-1.1 Na-137 K-4.1 Cl-108 HCO3-23 AnGap-10 [**2148-2-29**] 02:15AM BLOOD ALT-7 AST-28 LD(LDH)-165 AlkPhos-37* Amylase-24 TotBili-0.3 [**2148-3-3**] 05:30AM BLOOD WBC-6.4 RBC-3.24* Hgb-9.7* Hct-27.3* MCV-84 MCH-29.9 MCHC-35.5* RDW-12.5 Plt Ct-233 [**2148-3-1**] 05:35AM BLOOD WBC-9.7 RBC-3.33* Hgb-10.1* Hct-29.2* MCV-87 MCH-30.2 MCHC-34.6 RDW-12.6 Plt Ct-180 [**2148-3-3**] 05:30AM BLOOD Glucose-182* UreaN-18 Creat-1.3* Na-138 K-4.0 Cl-100 HCO3-32 AnGap-10 [**2148-3-2**] 05:30AM BLOOD UreaN-21* Creat-1.2 Na-140 K-3.8 Cl-103 [**2148-3-1**] 05:35AM BLOOD Glucose-152* UreaN-22* Creat-1.4* Na-138 K-4.0 Cl-103 HCO3-26 AnGap-13 [**2148-2-29**] 02:15AM BLOOD Glucose-99 UreaN-15 Creat-1.3* Na-137 K-4.7 Cl-105 HCO3-23 AnGap-14 Brief Hospital Course: As a same day admit he was taken to the Operating room where underwent coronary artery bypass grafting x5 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the distal right coronary artery, first obtuse marginal artery, first and second diagonal artery. See operative note for details. He weaned from bypass easily on NeoSynephrine and Propofol. POD 1 found the patient awake and alert, extubated without incidence. He required pressors until the second postoperative day when it was weaned to off. He then transferred to the floor on POD #2 in stable condition. Lopressor was started and titrated up for blood pressure control. Oral hyperglycemic agents were added back and titrated for blood sugar control. Chest tubes were removed per cardiac surgery protocol. He had a small left apical pneumothorax after chest tube pull which was stable at the time of discharge. Pacing wires were removed on POD 3 per protocol. Physical Therapy evaluated him for strength and mobility and he was cleared for home. He was nauseated on POD 4 and discharge was held. He was started on Reglan and had a bowel movement with resolution of nausea the following day. On POD 5 he was ambulating in the halls with assistance, tolerating a full oral diet and incisions were healing well. It was thought that he was safe for discharge at this time. All follow up appointments were advised and instructions for medications and activity were discussed. Medications on Admission: LISINOPRIL 10 mg daily METFORMIN 850 mg TID METOPROLOL TARTRATE 75 mg [**Hospital1 **] NITROGLYCERIN 0.3 mg Tablet, Sublingual - 1 Tablet sublingually every 5 minutes to the maximum of three as needed for chest pain CRESTOR 20 mg daily ASPIRIN 325 mg daily MULTIVITAMIN 1 Tablet daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. Tablet(s) 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet Extended Release(s)* Refills:*0* 10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Amaryl 1 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*0* 12. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 14. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: right atrial mass s/p excision of right atrial mass coronary artery disease s/p LAD stenting Hypertension Hyperlipidemia noninsulin dependent Diabetes mellitus Neuropathy h/o nonhealing right foot ulcers -s/p surgery [**2145**] h/o anemia bipolar disorder Depression Prostate cancer gastroesophageal reflux Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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) **]([**Telephone/Fax (1) 170**]) on [**2148-3-28**] at 1:30pm Cardiologist:Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] on [**2148-3-13**] at 10:40am Office will call patient with wound check appointment Please call to schedule appointments with: Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 7976**]in [**4-4**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** VNA to CHECK BUN/CREA/K on [**2148-3-5**] and call results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3142**] at [**Telephone/Fax (1) 170**] Completed by:[**2148-3-3**]

[ "V70.7", "357.2", "530.81", "414.01", "296.80", "250.62", "285.1", "412", "512.89", "401.9", "355.9", "185", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "36.14" ]

icd9pcs

[ [ [] ] ]

8367, 8426

4922, 6410

334, 594

8778, 9000

3210, 4899

9889, 10735

2370, 2433

6746, 8344

8447, 8757

6436, 6723

9024, 9866

2448, 3191

271, 296

622, 1384

1406, 1937

1953, 2354

13,033

147,192

43266

Discharge summary

report

Admission Date: [**2182-2-15**] Discharge Date: [**2182-2-20**] Date of Birth: [**2148-4-23**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: Patient is a 33-year-old male with a history of type 1 diabetes as well as labile hypertension and gastroparesis. The patient was most recently admitted from [**Date range (1) 59492**] for nausea and vomiting as well as hypertensive crisis. The patient was discharged home on a new and increased dose of labetalol which was 400 po in the morning and 800 po at night. It is believed that patient was taking some, but not all of his medications. The patient stated that he had felt well for a day after discharge, but awoke in the morning of admission and checking his blood pressure, had blood pressures in the 180s and began to feel nauseous and have vomiting. Emesis was nonbloody, nonbilious. Patient was not able to take his sublingual Ativan, which had been prescribed to prevent nausea. The patient denied chest pain, headache, blurry vision, loss of vision, but decided to come to the Emergency Room since his nausea and vomiting was persistent. He also had onset of diffuse abdominal pain. The patient also states that he had not checked his fingersticks in the last two days, and was unable to take his insulin on the day of admission secondary to his nausea and vomiting. In the Emergency Department, the patient's nausea and vomiting persisted even with IV ativan and was found to have a blood pressure of 220/120. The patient was started on a Nipride drip. The patient had a total of 10 episodes of emesis in the Emergency Department, some of which produced coffee ground-like material. The patient refused a nasogastric lavage. The patient's blood pressures were controlled to systolic range of 180 on the Nipride drip, and the patient was hydrated with normal saline. Electrocardiogram at the time of admission was unchanged from the previous admissions. PAST MEDICAL HISTORY: 1. Type 1 diabetes which presented as diabetic ketoacidosis at the age of 21. 2. Autonomic dysfunction with severe orthostatic hypotension. 3. Diabetic gastroenteropathy. 4. Gastroparesis likely secondary to diabetic complications. The patient is on a full liquid diet and is followed by Dr. [**First Name (STitle) 17185**] in GI. 5. Labile hypertension possibly secondary to autonomic dysfunction. 6. Gastroesophageal reflux disease. 7. Coronary artery disease with 50% left anterior descending artery lesion. 8. Had an episode recently of prostatitis. MEDICATIONS ON ADMISSION: 1. Labetalol 400 mg q am, 800 mg q pm. 2. Lisinopril 10 mg po q day at night. 3. Lantus 18 units q hs. 4. Humalog 4 units at breakfast, 6 units at lunch, 6 units at dinner. 5. Micronase 5 mg q day. 6. Sublingual Ativan prn. 7. Protonix 40 mg q day. 8. Reglan 10 mg qid. 9. Clonidine 0.1 mg patch changed every Friday. 10. [**Male First Name (un) **] stockings to his legs while asleep. ALLERGIES: The patient had no known drug allergies. SOCIAL HISTORY: The patient used to work as a truckdriver, but has been disabled by his frequent bouts of hypertensive urgency. The patient denies alcohol use and says he has no history of IV drug use. FAMILY HISTORY: Significant for diabetic nephropathy. PHYSICAL EXAM ON ADMISSION: The patient was afebrile, had a blood pressure ranging from 180-191/95-101, heart rate of 105, respiratory rate of 18, and sating 98% on room air. Generally speaking, the patient was uncomfortable, nauseous, and vomiting. HEENT was remarkable for no hemorrhages on ophthalmic examination and dry mucous membranes. Neck examination revealed no jugular venous distention. Cardiac examination was remarkable for a normal S1, S2, no murmurs were appreciated. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended with active bowel sounds. Extremities were no edema and the patient's rectal examination revealed occult blood negative brown stool. LABORATORIES ON ADMISSION: Patient had a white count of 6.5, hematocrit of 33, platelets of 233. Differential on the white count was 56 neutrophils and 33 lymphocytes, no bands. Electrolytes on admission: Sodium 141, potassium 4.9, chloride 106, bicarb 21, BUN 31, creatinine 1.8. Patient's baseline creatinine ranges from 1.7-2.2 and glucose of 230. Patient's LFTs were all within normal limits with the exception of his lipase which was slightly elevated at 109 and amylase which is slightly elevated at 64. Patient's magnesium was also low at 1.3. Patient's urinalysis showed no ketones. In short, this is a 33-year-old male with type 1 diabetes, gastroparesis, and labile blood pressures secondary to autonomic dysfunction, who presented again with hypertensive urgency. The patient was started on Nipride drip and transferred to the MICU. HOSPITAL COURSE BY PROBLEM: 1. Blood pressure: Patient was maintained on Nipride drip for several hours after admission, however, he was weaned off of the drip by 3 o'clock the morning after admission at which time, he was started on Hydralazine 10 mg IV q4-6h prn. The patient was maintained on intravenous hydralazine, the dose was changed to 5 mg q6h because the 10 mg dose was dropping the patient's blood pressures down to below a range systolics of 110. Patient did well on this regimen for several hours until he was transferred out of the Medical Intensive Care Unit at which point, he had a blood pressure of 190/110. The patient was given another 5 mg of intravenous Hydralazine and had his blood pressure come down to 120/80, however, several hours later, the patient developed nausea, vomiting, and systolic blood pressure of 230. Patient was then treated with intravenous Lopressor. The patient received two doses of intravenous Lopressor 5 mg which brought his blood pressure down to 175/110. Electrocardiogram at that time showed sinus at 110, however, there was flattening of ST-T segments in V1 through V6 and T-wave inversions in V4 through V6 that were new. Because of nonspecific changes, the patient was ruled out for myocardial infarction and had three sets of negative enzymes. The patient continued to be nauseous and to control his blood pressure while he was unable to take po, patient was treated with 5 of IV Lopressor q6h and 5 of IV hydralazine q6h with three hours in between the Hydralazine and Lopressor doses. This controlled the patient's blood pressure adequately for 24 hours at which time, he was no longer nauseous and began to take po pain medications. The patient was started on his labetalol in the morning of [**2-18**] and then started on his ACE inhibitor at night on the evening of [**2-18**]. Patient was gradually advanced to his full home regimen of blood pressure medications and had systolic blood pressures ranging between 120-160 over the 24 hours prior to discharge. The patient was ambulating in the halls and denied any symptoms of dizziness or orthostasis. 2. Nausea and vomiting: It still remains unclear whether this patient's nausea and vomiting is secondary to his gastroparesis or secondary to his hypertensive crisis. Most likely, the nausea and vomiting is the result of the patient's hypertensive crises. However, while the patient was in the hospital, he had a blood pressure that was relatively well controlled and began vomiting, and then subsequently had systolic blood pressures over 200. Patient was treated aggressively with Zofran, Ativan, and Phenergan for his nausea. Patient was able to start taking liquids on the morning of [**2182-2-18**], and was advanced throughout the day. The patient was taking regular diet on [**2182-2-19**] without nausea or vomiting. 3. Diabetes: The patient was maintained on his Lantus while in house. The patient was also treated with Humalog scale at breakfast, lunch, and dinner. The patient was evaluated by [**Last Name (un) **] while in house, who did a thorough history and felt that given his family history, the patient's diabetes was perhaps more compatible with maturity onset diabetes young rather than type 1 diabetes. Patient will follow up with [**Hospital **] Clinic for genetic testing for him and his family to further elucidate this possibility. Patient was discharged on [**2182-2-20**] in good condition. He will follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17185**] of GI. He will follow up with Dr. [**Last Name (STitle) **] for primary care, and he will follow up with the [**Hospital **] Clinic for care of his diabetes. 4. Gastroparesis: Patient was evaluated by his GI physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 17185**] while he was in house. Dr. [**First Name (STitle) 17185**] and the patient discussed placement of a J tube to help the patient take his blood pressure medications when he is feeling nauseous. Surgery was consulted for this problem, and felt reluctant to perform any such procedure on this patient since the patient himself was uncertain that this would be of benefit to him. The patient agreed to return and agreed to have a N-J tube placed to evaluate whether a J tube would be of benefit to him in taking his medications when he is feeling nauseous. DISCHARGE MEDICATIONS: 1. Labetalol 400 mg q am, 800 mg q pm. 2. Lisinopril 20 mg po q at night. 3. Hydrochlorothiazide 25 mg po q day. 4. Clonidine 0.1 mg patch q week changed on Friday. 5. Norvasc 10 mg po q day in the morning. 6. Lantus 20 mg po q hs. 7. Humalog sliding scale with breakfast, lunch, dinner, and before bed. 8. Protonix 40 mg po q day. 9. Ativan prn nausea. 10. Reglan 10 mg po qid. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2182-2-20**] 13:54 T: [**2182-2-21**] 07:15 JOB#: [**Job Number 44355**]

[ "536.3", "333.0", "593.9", "357.2", "250.60", "414.01", "401.9", "285.9", "530.7" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3212, 3265

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2549, 2990

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10,694

138,159

45635

Discharge summary

report

Admission Date: [**2153-8-11**] Discharge Date: [**2153-8-27**] Service: MEDICINE Allergies: Penicillins / Darvon / Iodine-Iodine Containing / Ciprofloxacin / Moxifloxacin Attending:[**First Name3 (LF) 3984**] Chief Complaint: Hypoxemic respiratory failure; PEA arrest; Sepsis Major Surgical or Invasive Procedure: Left IJ CVC History of Present Illness: 86yo F from [**Hospital3 **] Center with SOB x few days. Today, pt. was increasingly tachypneic and short of breath with O2 sats dropping to 67%. Able to get sats up to high 80s on non-rebreather. Pt.'s weight was up 8 lbs. from admission, and she was thought to be volume overloaded on exam. She received IV Lasix 40mg x 2 with little improvement in respiratory status. Brought to [**Hospital1 18**] ED on CPAP. O2 sat in 80s on arrival, pt. very lethargic. Decision was made to intubate. Pressures were ok on arrival but right before intubation, started to drop. Fentanyl and norepinephrine drip started. SBP up to 90s. intubated with roc and etomidate. Did ok for 2 minutes, then SBP began to drop to 60s, then 40s. Pulse was lost and CPR started. Gave 1mg epi. did cpr x 90seconds. Increased norepi and started dopamine. ROSC after 90 seconds of CPR. Ultrasound showed no pericardial effusion. During resuscitation, right femoral line was placed. Of note, pt. was recently hospitalized at [**Location 1268**] VA [**Date range (1) **] for GI bleed and E. Coli UTI. Was given 2units PRBCs. Declined EGD, but found to be H. Pylori positive, tretated with omeprazole, clarithromycin, and amoxicillin. Home prednisone 10mg daily for inflammatory arthritis was also discontinued in setting of likely PUD. UTI treated with cipro. Pt. was discharged to [**Hospital3 **] Center in [**Location (un) 2312**], MA on [**7-26**]. In the ED, initial VS were: pulse 78, bp 89/32, 92% sat on FiO2 100%. CMV, 350, 22, peep 12. Labs notable for: ABG 7.03/47/80/13; UA LE+, bld+, RBC>182, WBC>182, Bacteria Many, Epi 23; WBC 14.7, HCT 32.3, Plt 544; INR 1.6; Na 138, K 5.2, Cl 106, Glu 117; Lactate 5.3; Serum tox screen neg. She was started on vancomycin, cefepime, levofloxacin. On arrival to the MICU, pt. was intubated, sedated, and hypothermic on with Arctic Sun cooling system in place. Past Medical History: Past Medical History - Bladder Cancer--s/p TURBT [**2147-7-28**] - Coronary artery disease (s/p CABG [**2126**], multiple caths, 2 stents placed [**4-1**]) - Hypertension - Hyperlipidemia - Peripheral vascular disease - Atrial Fibrillation/Atrial Flutter - on coumadin - Dementia - likely Alzheimers per [**Female First Name (un) **] note, CT with microvascular disease PAST SURGICAL HISTORY: - CABG [**2126**] (LIMA to LAD, SVG to OM and RIMA to RCA) - Cardiac Cath [**4-1**]--Three vessel coronary artery disease. Patent LIMA and RIMA. Patent SVG to OM. Placement of a drug-eluting stent in the LAD and placement of a bare metal stent in the LCX. - TURBT - Bilateral total knee replacements [**2139**] c/b post-op pulmonary embolism - Left total hip replacement [**2141**] - Bladder suspension surgery - Cataract surgery - Cholecystectomy - Carpal tunnel surgery [**2143**] Social History: Married. Lives with her husband who is blind. Daughter lives in apt above. Retired secretary. Used to own an antique shop. Family History: Father died of an MI at age 58. Physical Exam: Admission Physical Exam: Vitals: T: 32.5C BP: 125/47 P: 67 SpO2 100% on CMV TV 350, RR 22, PEEP 12, FiO2 100% Neuro: intubated, sedated HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, pinpoint pupils b/l, sluggish reaction to light Neck: supple, JVP not elevated, no LAD CV: irregular rhythm, regular rate, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffuse rales and ronchi upon anterior auscultation. Abdomen: soft, non-distended, bowel sounds present, no organomegaly GU: foley Ext: cold, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2153-8-11**] 10:30PM TYPE-[**Last Name (un) **] TEMP-33.2 PO2-50* PCO2-50* PH-7.00* TOTAL CO2-13* BASE XS--19 [**2153-8-11**] 10:30PM GLUCOSE-165* LACTATE-4.1* K+-4.3 [**2153-8-11**] 10:30PM O2 SAT-78 [**2153-8-11**] 10:30PM freeCa-1.05* [**2153-8-11**] 10:25PM GLUCOSE-180* UREA N-126* CREAT-3.7* SODIUM-138 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-11* ANION GAP-25* [**2153-8-11**] 10:25PM ALT(SGPT)-17 AST(SGOT)-29 LD(LDH)-252* CK(CPK)-56 ALK PHOS-121* TOT BILI-0.5 [**2153-8-11**] 10:25PM CK-MB-5 cTropnT-0.08* [**2153-8-11**] 10:25PM ALBUMIN-2.6* CALCIUM-7.0* PHOSPHATE-7.9* MAGNESIUM-2.4 [**2153-8-11**] 10:25PM WBC-15.5* RBC-3.74* HGB-9.3* HCT-32.6* MCV-87 MCH-25.0* MCHC-28.7* RDW-18.0* [**2153-8-11**] 10:25PM PT-18.1* PTT-41.0* INR(PT)-1.7* [**2153-8-11**] 10:25PM PLT COUNT-579* [**2153-8-11**] 09:20PM URINE COLOR-DkAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016 [**2153-8-11**] 09:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2153-8-11**] 09:20PM URINE RBC->182* WBC->182* BACTERIA-MANY YEAST-NONE EPI-23 [**2153-8-11**] 09:20PM URINE MUCOUS-MOD [**2153-8-11**] 08:41PM TYPE-ART PO2-95 PCO2-36 PH-7.04* TOTAL CO2-10* BASE XS--20 INTUBATED-INTUBATED COMMENTS-[**First Name8 (NamePattern2) **] [**Last Name (un) **] [**2153-8-11**] 08:18PM PO2-80* PCO2-47* PH-7.03* TOTAL CO2-13* BASE XS--18 COMMENTS-GREEN TOP [**2153-8-11**] 08:18PM GLUCOSE-117* LACTATE-5.3* NA+-138 K+-5.2* CL--106 TCO2-12* [**2153-8-11**] 08:10PM UREA N-136* CREAT-4.2* [**2153-8-11**] 08:10PM estGFR-Using this [**2153-8-11**] 08:10PM LIPASE-14 [**2153-8-11**] 08:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2153-8-11**] 08:10PM WBC-14.7* RBC-3.77* HGB-9.8* HCT-32.3* MCV-86 MCH-26.0* MCHC-30.3* RDW-18.2* [**2153-8-11**] 08:10PM PLT COUNT-544* [**2153-8-11**] 08:10PM FIBRINOGE-827* [**2153-8-13**] 06:33AM BLOOD WBC-30.4* RBC-3.86* Hgb-10.0* Hct-31.6* MCV-82 MCH-25.8* MCHC-31.5 RDW-18.5* Plt Ct-458* [**2153-8-13**] 01:28PM BLOOD WBC-27.3* RBC-3.71* Hgb-9.6* Hct-30.2* MCV-82 MCH-25.9* MCHC-31.8 RDW-19.1* Plt Ct-412 [**2153-8-14**] 04:43AM BLOOD WBC-28.8* RBC-3.44* Hgb-8.9* Hct-28.2* MCV-82 MCH-26.0* MCHC-31.7 RDW-18.8* Plt Ct-406 [**2153-8-15**] 03:33AM BLOOD WBC-20.4* RBC-2.93* Hgb-7.6* Hct-23.4* MCV-80* MCH-25.9* MCHC-32.4 RDW-18.9* Plt Ct-253 [**2153-8-15**] 09:25AM BLOOD Hct-22.3* [**2153-8-15**] 10:13PM BLOOD Hct-28.6*# [**2153-8-13**] 01:28PM BLOOD Glucose-150* UreaN-113* Creat-3.4* Na-133 K-4.5 Cl-97 HCO3-19* AnGap-22* [**2153-8-14**] 04:43AM BLOOD Glucose-187* UreaN-108* Creat-3.4* Na-133 K-4.1 Cl-98 HCO3-19* AnGap-20 [**2153-8-14**] 05:39PM BLOOD Glucose-174* UreaN-107* Creat-3.3* Na-134 K-4.2 Cl-100 HCO3-18* AnGap-20 [**2153-8-15**] 03:33AM BLOOD Glucose-216* UreaN-107* Creat-3.2* Na-133 K-3.8 Cl-100 HCO3-17* AnGap-20 [**2153-8-12**] 06:19AM BLOOD CK-MB-6 cTropnT-0.10* [**2153-8-13**] 06:33AM BLOOD Calcium-8.1* Phos-6.5* Mg-1.9 [**2153-8-13**] 01:28PM BLOOD Calcium-8.4 Phos-6.6* Mg-1.9 [**2153-8-14**] 04:43AM BLOOD Calcium-8.2* Phos-6.3* Mg-1.9 [**2153-8-14**] 05:39PM BLOOD Calcium-8.4 Phos-6.2* Mg-1.9 [**2153-8-15**] 03:33AM BLOOD Calcium-8.2* Phos-6.6* Mg-1.9 [**2153-8-12**] 01:57AM BLOOD Cortsol-51.0* [**2153-8-12**] 02:01AM BLOOD Type-ART Temp-33.0 Rates-28/1 Tidal V-350 PEEP-5 FiO2-100 pO2-63* pCO2-49* pH-7.12* calTCO2-17* Base XS--13 AADO2-604 REQ O2-98 Intubat-INTUBATED Vent-CONTROLLED [**2153-8-12**] 07:43AM BLOOD Type-ART Temp-33.4 Rates-28/ Tidal V-320 PEEP-18 FiO2-100 pO2-70* pCO2-39 pH-7.25* calTCO2-18* Base XS--9 AADO2-607 REQ O2-99 Intubat-INTUBATED Vent-CONTROLLED [**2153-8-12**] 03:10PM BLOOD Type-ART Temp-32.9 Rates-28/ Tidal V-320 PEEP-20 FiO2-80 pO2-120* pCO2-26* pH-7.38 calTCO2-16* Base XS--7 AADO2-428 REQ O2-74 Intubat-INTUBATED Vent-CONTROLLED [**2153-8-13**] 06:45AM BLOOD Type-ART Temp-35 Rates-25/30 Tidal V-320 PEEP-20 FiO2-50 pO2-77* pCO2-34* pH-7.37 calTCO2-20* Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [**2153-8-14**] 12:47PM BLOOD Type-ART pO2-90 pCO2-35 pH-7.34* calTCO2-20* Base XS--5 [**2153-8-15**] 05:03PM BLOOD Type-ART Temp-36.9 pO2-101 pCO2-30* pH-7.39 calTCO2-19* Base XS--5 Intubat-INTUBATED [**2153-8-15**] 10:17AM BLOOD Type-ART Temp-36.8 Rates-25/ Tidal V-320 PEEP-14 FiO2-40 pO2-113* pCO2-28* pH-7.39 calTCO2-18* Base XS--6 Intubat-INTUBATED [**2153-8-11**] 08:18PM BLOOD Glucose-117* Lactate-5.3* Na-138 K-5.2* Cl-106 calHCO3-12* [**2153-8-12**] 02:01AM BLOOD Glucose-294* Lactate-3.6* K-4.0 [**2153-8-12**] 10:05AM BLOOD Lactate-3.7* K-3.8 [**2153-8-12**] 10:50AM BLOOD Lactate-4.7* [**2153-8-13**] 06:45AM BLOOD Glucose-140* Lactate-2.3* K-3.8 [**2153-8-13**] 08:10AM BLOOD Lactate-2.0 [**2153-8-15**] 10:17AM BLOOD Lactate-1.3 MICROBIOLOGY: [**2153-8-15**] 3:33 am BLOOD CULTURE Source: Line-Aline. Blood Culture, Routine (Pending): __________________________________________________________ [**2153-8-14**] 11:53 am URINE Source: Catheter. **FINAL REPORT [**2153-8-15**]** URINE CULTURE (Final [**2153-8-15**]): YEAST. >100,000 ORGANISMS/ML.. __________________________________________________________ [**2153-8-13**] 1:55 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2153-8-15**]** GRAM STAIN (Final [**2153-8-13**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2153-8-15**]): SPARSE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. GRAM NEGATIVE ROD(S). RARE GROWTH. SPECIATION AND SENSITIVITIES REQUESTED BY EDW. [**Doctor Last Name 14775**] #[**Numeric Identifier **]; TO BE SET UP ON CULTURE # 354-6007H [**2153-8-12**]. __________________________________________________________ [**2153-8-12**] 5:02 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2153-8-12**]): [**9-20**] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. SPECIATION AND SENSITIVITIES REQUESTED BY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14775**] #[**Numeric Identifier **]. YEAST. SPARSE GROWTH. OF THREE COLONIAL MORPHOLOGIES. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2153-8-13**]): SPECIMEN NOT PROCESSED DUE TO: IMPROPER SPECIMEN COLLECTION Induced sputum required. PLEASE SUBMIT ANOTHER SPECIMEN. TEST CANCELLED, PATIENT CREDITED. Reported to and read back by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2153-8-13**], 11:40A. __________________________________________________________ [**2153-8-11**] 10:24 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2153-8-14**]** MRSA SCREEN (Final [**2153-8-14**]): No MRSA isolated. __________________________________________________________ [**2153-8-11**] 8:50 pm BLOOD CULTURE **FINAL REPORT [**2153-8-14**]** Blood Culture, Routine (Final [**2153-8-14**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 354 5862E [**2153-8-11**]. Aerobic Bottle Gram Stain (Final [**2153-8-12**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**Doctor Last Name **] [**2153-8-12**] 8:52AM. Anaerobic Bottle Gram Stain (Final [**2153-8-12**]): GRAM NEGATIVE ROD(S). __________________________________________________________ [**2153-8-11**] 9:20 pm URINE **FINAL REPORT [**2153-8-13**]** URINE CULTURE (Final [**2153-8-13**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R __________________________________________________________ [**2153-8-11**] 8:10 pm BLOOD CULTURE TRAUMA. **FINAL REPORT [**2153-8-14**]** Blood Culture, Routine (Final [**2153-8-14**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [**2153-8-12**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**Doctor Last Name **] [**2153-8-12**] 8:52AM. Anaerobic Bottle Gram Stain (Final [**2153-8-12**]): GRAM NEGATIVE ROD(S). IMAGING: EEG [**8-11**]: This continuous recording shows a severe diffuse encephalopathy. The manifestation of this encephalopathy is predominantly noted by an extreme suppression of electrical activity over all head regions. There are, however, bursts lasting upwards of six to eight seconds in duration of low voltage irregular theta delta activity. Some of this activity is sharply contoured on occasion but no clear epileptiform transients were identified. CXR [**8-11**]: Single AP upright portable view of the chest was obtained. The patient's chin and external artifact overlie the left lung apex, obscuring the view. The patient is status post median sternotomy. The cardiac silhouette is enlarged. There is obscuration of the left hemidiaphragm and costophrenic angle suggesting pleural effusion with overlying atelectasis, underlying consolidation cannot be excluded. Small area of right mid lung lateral opacity may be due to atelectasis/scarring, although a small focus of consolidation is not excluded. No definite evidence of pneumothorax. Renal US [**8-12**]: IMPRESSION: No hydronephrosis. Art. duplex [**8-13**]: Scan demonstrates patency of the distal radial, distal ulnar, and palmar arch arterial vasculature as described. No occlusion or thrombus was identified. TTE [**8-14**]: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Dilated and moderately hypokinetic right ventricle. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Head CT [**8-15**]: IMPRESSION: 1. No parenchymal hemorrhage. 2. Partial fluid-opacification of the air cells at the right mastoid apex, new since [**2152-1-25**], which may relate to intubation. Chest CTA [**8-15**]: IMPRESSION: PRELIMINARY REPORT . No pulmonary embolism or aortic pathology. 2. Bilateral pleural effusions, partially loculated on the left. 3. Extensive secretions noted in the left lower lobe bronchial tree with associated partial collapse of the left lower lobe. Additional partial right lower lobe collapse is noted, but to a lesser degree. 4. Right ventricular enlargement with findings suggesting heart failure. Extensive coronary artery calcifications with non-opacification of the distal end of the cardiac bypass graft suggesting occlusion or stenosis. 5. Medical devices appear well positioned. Brief Hospital Course: 88 yo female w/ unknown medical history presents from nursing home with 3 day h/o worsening SOB and hypoxemia. Intubated in ED for hypoxemic respiratory failure w/ subsequent PEA arrest. ROSC after 90 seconds, now on neuroprotective induced hypothermia protocol. #. PEA arrest: Potential causes of pt.'s arrest include significant hypovolemia exacerbated by fentanyl in setting of intubation. Her worsening hypotension may also be secondary to sepsis in setting of tachypnea, leukocytosis, tachycardia and UA concerning for infection. Also, significant hypoxia and acidemia may have been contributing factors. Pulmonary embolism is a possible contributing factor, especially given acute onset hypoxic respiratory failure. Bedside u/s r/o pericardial effusion. No evidence of PTX on CXR. No significant electrolyte abnormalities were identified. PT placed on hypothermia protocol.She was warmed on [**8-13**] and has since been unresponsive. Neurology was consulted for unresponsiveness. Cont. EEG ordered. Patient demonstrated some neurological improvement and was able to communicate with mouthing, eyes and moving arms and legs. Very diminished hearing acuity as baseline. # Hypoxemic Respiratory Failure - Pt. is severely hypoxemic on ventilator with P/F ratio of 63. Also, pt. with high peak pressures, despite 6cc/kg tidal volumes. Differential for includes CHF w/ pulmonary edema, pulmonary embolism, and pneumonia. Pt. with CXR not remarkable for pulmonary edema or significant inflitrate, making PE more likely. Heparin drip started to treat PE empirically since CTA was not done due to pt renal function. Prolonged medchanical ventilation and limited overall progress with working towards extubation, but extubation trial attempted on [**2153-8-25**]. Gradual deterioration in resp. status prompted interval use of mask ventilation with stabalization. Upon exetnsive discussions with patient's HCP [**Name (NI) **], all agreed that patient would not want trachetomy and chronic ventilatotory support. Pt was DNR/DNI. Mask was removed, and patient quiety passed away with family members present in her room. PT had an attempt at extubation and had to be placed on CPAP due to decline of O2 sat. PT daughter confirmed that pt was not to be intubated again. PT was cont on CPAP until she passed. #. Septic shock - meets [**1-28**] SIRS criteria with leukocytosis, tachycardia, and tachypnea with UA suggestive of infection, with hypotension. Pt was placed on norepinephrine, vancomycin, cefepime, and levofloxacin and lactates trended. PT blood pressure stabilized and pressors were no longer needed. #. [**Last Name (un) **] - baseline Cr 1.2 now up to 4.2, with BUN 136. Pt responded to IV fluids and her CR went down. PT had increase in urine output. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Gabapentin 100 mg PO TID 4. Insulin SC Sliding Scale 5nsulin SC Sliding Scale using REG Insulin 6. Lidocaine 5% Patch 1 PTCH TD DAILY 12 hours on, 12 hours off 7. Metoprolol Tartrate 12.5 mg PO BID 8. Omeprazole 40 mg PO DAILY 9. Pravastatin 80 mg PO DAILY 10. Sertraline 50 mg PO DAILY 11. Sodium Bicarbonate 650 mg PO BID Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "V45.81", "403.90", "294.10", "578.1", "V49.86", "518.81", "331.0", "785.52", "585.9", "584.5", "995.92", "599.0", "276.2", "714.9", "272.4", "486", "280.9", "427.31", "250.00", "733.11", "780.01", "349.82", "443.9", "276.8", "427.5", "428.0", "038.42" ]

icd9cm

[ [ [] ] ]

[ "96.72", "99.60", "96.6" ]

icd9pcs

[ [ [] ] ]

20395, 20404

17182, 19956

336, 350

20455, 20591

3979, 8827

3335, 3369

20425, 20434

19982, 20372

2689, 3174

3410, 3960

10185, 17159

8861, 10144

247, 298

378, 2273

2295, 2666

3190, 3319

5,343

168,420

3525+3526

Discharge summary

report+report

Admission Date: [**2176-8-2**] Discharge Date: [**2176-8-4**] Date of Birth: [**2124-7-12**] Sex: F Service: [**Hospital1 **] A HISTORY OF PRESENT ILLNESS: This is a 52 year old woman status post aortic valve replacement on [**2176-7-17**] who presents with a subtherapeutic INR of 1.8. The patient had a longstanding aortic stenosis of uncertain etiology, which became symptomatic in [**2176-3-5**]. On [**2176-7-17**], she received a mechanical aortic valve transplant. The patient tolerated the procedure well, and was coumadinized after surgery with a goal INR of 2.5 to 3. Ms [**Known lastname 14738**] was discharged on [**2176-7-25**] to home with [**First Name (Titles) 407**] [**Last Name (Titles) 11807**] coming to check her INR frequently. Her last INR before discharge on [**2176-7-25**] was 3.6. Her discharge dose of Warfarin was 2 mg q.d. On this dose, the patient's INR drifted downward following discharge to 1.8 on [**2176-7-30**], at which time she was referred to [**Hospital6 649**] Emergency Department for management of her anticoagulation. Since her discharge from the hospital on [**2176-7-25**], the patient has experienced no fever or chills, no nausea or vomiting, no shortness of breath. Her only complaint is of some pain in her chest wall near the surgical incision site. PAST MEDICAL HISTORY: 1. History of aortic stenosis (severe) of unknown etiology, status post aortic valve replacement on [**2176-7-17**]; 2. Asthma, no history of systemic steroids, no intubation for asthma; 3. Thyroiditis; 4. Status post right oophorectomy. MEDICATIONS ON ADMISSION: Lasix 40 mg p.o. b.i.d. times two weeks (day 8 of course on admission) Potassium chloride 20 mEq p.o. b.i.d. times two weeks (day 8 of course on admission) Atenolol 75 mg p.o. q.d. Flovent metered dose inhaler, 2 puffs t.i.d. Atrovent 2 puffs b.i.d. Albuterol metered dose inhaler, 2 puffs q. 4-6 hours prn Percocet 5/325 one to two tablets p.o. q. 4 hours prn pain Colace 100 mg p.o. b.i.d. Coumadin (target INR 2.5 to 3) ALLERGIES: Vioxx, rash SOCIAL HISTORY: Widowed, lives with brother and grandson in [**Name (NI) 16174**]. Reports they had been taking care of her "very well" since surgery. Employed as clean-up until late 70s when she became a homemaker. No smoking history. No alcohol. No intravenous drug abuse. FAMILY HISTORY: Two sibling with coronary artery disease. PHYSICAL EXAMINATION: Vital signs, temperature 99.0, pulse 73, blood pressure 134/87, respiratory rate 18, oxygen saturation 98% on room air. General: Lying comfortably, in no apparent distress, alert and oriented times three. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils equal, round and reactive to light, extraocular muscles intact, no jugulovenous distension noted, no lymphadenopathy. Chest: Clear to auscultation and percussion bilaterally, no wheezes, no rales, no rhonchi. Cardiovascular: Regular rate and rhythm, click on S2, particularly along the right upper sternal border. No murmurs, rubs or gallops appreciated. Surgical scar, healing well. Abdomen: Soft, obese, nontender, normoactive bowel sounds. Extremities: No edema bilaterally. No clubbing, no cyanosis. LABORATORY DATA: Pertinent laboratory studies on admission revealed white blood cells 12.6, hematocrit 31.4, platelets 652. PT 17.5, PTT 26.6, INR 2.0. Sodium 137, potassium 4.9, chloride 99, bicarbonate 28, BUN 15, creatinine 0.7, glucose 102. Chest x-ray: Cardiomegaly, no consolidations, no congestive heart failure. HOSPITAL COURSE: 1. Anticoagulation - The patient received a mechanical valve, therefore INR is 2.5 to 3.5. INR measured on admission was 2.0. The patient was given a Warfarin loading dose of 8 mg on the night of admission, and given 4 mg Warfarin per day afterwards. On the morning after admission the patient's INR was 2.5, and stayed within the therapeutic range for 24 hours, so the patient was discharged on [**2176-8-4**]. The patient was discharged on Warfarin 4 mg q.d. and asked to have her INR checked the day after discharge. On admission before the INR was in target range, the heparin intravenous drip was started based on weight-based dosing. The patient reached target PTT between 60 and 80 by the night of admission and stayed within that range until the day of discharge, when heparin drip was discontinued. 2. Pain control - The patient complained of pain in her chest near the surgical incision along the left lower sternal border. Pain appeared to be positional, and was not associated with any symptoms that suggested it was cardiac in origin. There was no erythema, induration, or drainage of the wound. The patient reports that the pain has been slowly decreasing since her surgery. It seemed extremely likely that the pain was normal post surgical pain. For pain control, the patient was given Percocet two tablets q. 4 hours, and Ibuprofen 600 mg q. 6 hours prn. 3. Cardiovascular - During her hospital stay, the patient had no symptoms or signs of cardiac ischemia or failure. She had no shortness of breath, no fevers or chills, no nausea or vomiting. As mentioned earlier, the chest pain that she had did not appear to be cardiac in nature. The patient was maintained on her preadmission cardiac regimen of Lasix, potassium chloride and Atenolol. 4. Asthma - The patient was not wheezing on examination, and did not complain of shortness of breath during her hospital admission. She continued on her preadmission regimen of Flovent, Atrovent and Albuterol. 5. Prophylaxis - The patient was given Colace because of her narcotic pain medications. CONDITION ON DISCHARGE: The patient's condition on discharge was good. She was discharged to home with [**Hospital6 3429**] services. DISCHARGE DIAGNOSIS: 1. Subtherapeutic anticoagulation 2. Status post aortic valve replacement 3. Asthma DISCHARGE MEDICATIONS: 1. Lasix 40 mg p.o. b.i.d. times four days 2. Potassium chloride 8 mEq p.o. b.i.d. times four days 3. Atenolol 75 mg p.o. q.d. 4. Flovent metered dose inhaler 2 puffs b.i.d. 5. Atrovent 2 puffs b.i.d. 6. Albuterol metered dose inhaler 2 puffs q. 4-6 hours prn 7. Percocet 5/325 1 to 2 tablets q. 4 hours prn 8. Colace 100 mg p.o. b.i.d. while on Percocet 9. Coumadin 4 mg p.o. q.d. (target INR 2.5 to 3.5) DISCHARGE INSTRUCTIONS: The patient was discharged to home with [**Hospital6 407**] services. [**Hospital6 1587**] was to check INR the day after discharge, three days after discharge and five days after discharge. The INR results would be monitored by her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13964**]. After one week, the patient was to have her INR checked at [**Hospital 16175**] [**Hospital3 **]. The patient was instructed to make an appointment with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13964**] one week after discharge. DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] 02-248 Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2176-8-3**] 22:48 T: [**2176-8-4**] 07:37 JOB#: [**Job Number 16176**] cc:[**Telephone/Fax (1) 16177**] Admission Date: [**2176-8-2**] Discharge Date: [**2176-8-15**] Date of Birth: [**2124-7-12**] Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a 52 year-old female status post aortic valve replacement on [**2176-7-17**] who presented with subtherapeutic INR of 1.8 to the Medicine Service. The patient had a long standing history of aortic stenosis of uncertain etiology, which became symptomatic for the first time in [**3-7**]. The patient began experiencing dizziness and substernal burning with exercise. An echocardiogram on [**2176-6-13**] showed moderate [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 13385**], moderate left ventricular hypertrophy, EF of 55%, severely thickened/deformed aortic valve leaflets. Cardiac catheterization on [**2176-7-9**] showed severe AS with aortic valve area of .5 cm squared, mean AV gradient of 49 mmHg, moderate pulmonary hypertension with no significant mitral regurgitation and no significant coronary artery disease. Dr. [**Last Name (STitle) 1537**] performed minimally invasive aortic valve replacement on [**2176-7-17**] with 21 mm Carbomedics mechanical valve. The patient tolerated the procedure well and recovery in the hospital was complicated by only some wheezing, mild shortness of breath that improved with aggressive diuresis and bronchodilators. The patient was Coumadinized after surgery with a goal INR of 2.5 to 3. The patient was discharged to home on [**2176-7-25**] with visiting nurse coming on [**7-27**] for INR checks. INR was 3.6 predischarge and drifted to 2.7 on [**7-27**] while the patient was taken 2 mg of Warfarin q.d. Even with increased Warfarin dosage 2 mg to 4 mg alternating the patient's INR drifted down to 1.8 on [**7-30**] at which time she was referred to [**Hospital1 69**] Emergency Department for management. During the time after her discharge from the hospital [**7-25**] the patient reports no nausea, vomiting, fevers or chills, shortness of breath, only some pain in chest near incision that was described as positional. PAST MEDICAL HISTORY: 1. Aortic stenosis (severe), status post AVR [**2176-7-17**]. No documented by tested valve or other congenital malformation. No known history of rheumatic fever RA. 2. Asthma, no systemic steroids, no intubations for asthma in history. 3. Thyroiditis. 4. Status post right oophorectomy. ALLERGIES: Vioxx causes a rash. MEDICATIONS ON ADMISSION: 1. Lasix 40 mg b.i.d. times two weeks, day eight on day of admission. 2. Potassium chloride 20 milliequivalents b.i.d. times two weeks, day eight on admission. 3. Atenolol 75 mg q.d. 4. Flovent MDI two puffs q.d. 5. Atrovent two puffs q.d. 6. Albuterol MDI two puffs. 7. Percocet 5/325 one to two tabs q 4 prn, had been taking about two tabs per day on admission. 8. Colace 100 mg b.i.d. while on Percocet. 9. Coumadin alternating 2 mg and 4 mg. SOCIAL HISTORY: The patient is a widow. She lives with brother and grandfather in [**Location (un) 686**] who have been taking care of her "very well" since surgery. Employed as a cleaning nurse until late 70s when she quit to take care of her children and then grandchildren. No smoking history. No alcohol now, minimal in remote past. FAMILY HISTORY: Two brothers with coronary artery disease. Three other siblings who are healthy. PHYSICAL EXAMINATION ON ADMISSION: Vital signs 99.0, 73, 139/87, 18, 95% on room air. General, she was an obese female lying comfortably in no acute distress, alert and oriented times three. HEENT examination normocephalic, atraumatic female with pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. No JVD. Chest was clear to auscultation and percussion bilaterally. No rales, wheezes or rhonchi. Cardiovascularly the patient had a surgical scar well healing along sternum approximately 12 cm long with regular rate and rhythm. Loud click on S2 especially on right upper sternal border. No murmurs, rubs or gallops. Abdomen was soft, obese, nontender with positive bowel sounds. Extremities showed no edema bilaterally. No clubbing, cyanosis or edema. LABORATORIES ON ADMISSION: White blood cell count of 12.6, hematocrit 31.4 and platelets 652. [**Name (NI) 2591**] PT 17.5, PTT 26.6 and INR of 2.0. Chest x-ray showed cardiomegaly without consolidation without congestive heart failure. HOSPITAL COURSE: The patient was then admitted to the Medicine Service and started on a heparin drip to increase anticoagulation. INR remained around 2 on hospital day one and two, however, after 24 hours the patient was anticoagulated and the patient was complaining of increasing shortness of breath and hypotension on the floor. Primary team performed a transthoracic echocardiogram, which showed well seated and functioning prosthetic valve and tamponade physiology. On conclusion of the echocardiogram the patient became unresponsive and the patient arrested. Cardiopulmonary resuscitation was performed and cardiothoracic surgery was emergently called for pericardiocentesis at the bedside. The patient was resuscitated for PEA arrest after the anterior pericardial hematoma was seen on echocardiogram and cardiothoracic surgery began to make a skin incision in order to perform the pericardiocentesis. Skin incision was made, however, immediately femoral pulses were detected and the patient was then wheeled directly to the Operating Room for emergent pericardial window procedure via subxiphoid approach for pericardia tamponade. The patient tolerated the procedure well. One chest tube was placed postoperatively. The patient did well immediately postoperatively, however, blood work at that time showed increasing liver function tests with transaminases to the 1000 and INR of 66. The liver was deemed to be in shock. Liver function tests began to fall on their own and INR began to normalize spontaneously in the ensuring days postoperatively. By postoperative day three the patient was extubated and INR was down to 30. On postoperative day five the patient went slightly into atrial fibrillation/atrial flutter, however, reverted with beta blockade. By postoperative day seven the patient's INR was down to 2.5 on 3 mg of Coumadin a day and 2.1 on postoperative day eight. Coumadin doses were then adjusted according to INR levels and the patient was continued on 3 mg of Coumadin until postoperative day nine when she was decreased to 2 mg of Coumadin and had INR steady of 2.4 for postoperative days 10 and 11 the day of discharge. The patient did extremely well on the floor and was transferred to the floor earlier on in hospital course on postoperative day seven and was discharged on postoperative day 11 in no acute distress. The patient did have slight wound separation in the subxiphoid pericardial window incision and was placed on Levofloxacin 500 mg q day times six days for this. DISCHARGE MEDICATIONS: 1. Colace 100 mg po b.i.d. 2. Percocet 5/325 mg tablet one to two tabs po q 4 hours prn pain. 3. Fluticasone propionate 110 micrograms areosol with adapter six puff inhalation b.i.d. 4. Ipratropium bromide 18 micrograms areosol with adapter two puffs inhalation q 4 to 6 hours. 5. Albuterol 90 micrograms areosol two puff inhalation q six hours. 6. Warfarin 2 mg one tablet oral one dose, please take in the p.m. of [**8-15**] and the patient was instructed to have INR drawn at [**Hospital3 **] at 10:45 on [**8-16**] and have dose adjusted by then with target INR of 1.8 to 2.5. 7. Lopressor 50 mg 1.5 tablets po b.i.d. 8. Lasix 20 mg tablet one po q 12 hours times ten days. 9. Singulair 10 mg tablet one po q.d. 10. Protonix 40 mg tablet one po q.d. 11. Potassium chloride two capsules po b.i.d. times ten days. 12. Levofloxacin 500 mg tablet one tablet po q day. 13. Coumadin, the patient was instructed to take 2 mg in the p.m. of [**8-15**]. Please keep appointment at [**Hospital 191**] [**Hospital3 **] at 10:25 on [**2176-8-16**] phone number [**Telephone/Fax (1) 2173**]. [**Location (un) 86**] VNA was to check INR Monday, Wednesday and Friday of next week after the week after discharge. She was to follow up in [**Company 191**] anticoagulation service for INR checks. The patient's primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] was notified and was contact[**Name (NI) **] to follow results and then make any needed adjustments for Warfarin doses. Dr. [**Last Name (STitle) 911**] the patient's cardiologist was also notified. DISCHARGE STATUS: Good. Home with [**Location (un) 86**] VNA. DISCHARGE DIAGNOSES: 1. Subtherapeutic INR. 2. Aortic stenosis status post aortic valve replacement. 3. Asthma. 4. Cardiac tamponade with cardiac arrest, emergent pericardial window for evacuation of tamponade and postoperative elevated liver enzymes. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 16178**] MEDQUIST36 D: [**2176-8-15**] 11:29 T: [**2176-8-16**] 07:07 JOB#: [**Job Number 16179**] cc:[**Last Name (NamePattern4) 16180**]

[ "V58.61", "998.32", "427.31", "493.90", "790.92", "570", "423.9", "416.8", "427.5" ]

icd9cm

[ [ [] ] ]

[ "37.12", "99.60" ]

icd9pcs

[ [ [] ] ]

10491, 10594

15897, 16458

14171, 15876

5815, 5903

9675, 10131

11641, 14148

6367, 7361

2442, 3557

7390, 9299

11410, 11623

9321, 9649

10148, 10474

5682, 5794

8,861

109,419

2600

Discharge summary

report

Admission Date: [**2176-2-21**] Discharge Date: [**2176-2-25**] Service: CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old female with limited stage small cell lung cancer who was treated with three cycles of carboplatin/etoposide and concurrent radiation therapy completed in [**10-24**]. Treatment course was complicated by pneumonia and her fourth course of chemotherapy was held. She did relatively well until [**12-24**] when she complained of headache. Temporal artery biopsy was performed and was negative, so she was put on prednisone taper. More recently, she has been complaining of decreased appetite, increased shortness of breath, nausea, and vomiting. Laboratory work included increased LFTs. CT scan torso yesterday revealed a large pericardial effusion from an epi-pericardial mass resulting in right heart failure. She was electively admitted for management of pericardial effusion. PAST MEDICAL HISTORY: 1. Congestive obstructive pulmonary disease. 2. Coronary artery disease status post myocardial infarction and PTCA with stent placement. 3. Chronic lower back pain. 4. Small cell lung cancer. ALLERGIES: She has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Levoxyl 75 mg po q day. 2. Paxil 30 mg po q day. 3. Enalapril 5 mg po q day. 4. Diazepam 3 mg po q day. 5. Zocor 40 mg po q day. 6. Trazodone 50 mg po q day. 7. Roxicet one teaspoon prn. 8. Megace 400 mg po q day. PHYSICAL EXAM ON ADMISSION: Temperature 96.9, blood pressure of 86/palp, heart rate in the 90s, respiratory rate 16, sating well on room air. In general, she is a thin female in bed. HEENT: Oropharynx is clear. Neck is supple. Cardiovascular: Sinus tachycardia, faint S1, S2. Lungs: Coarse breath sounds, otherwise clear. Abdomen is soft with mild tenderness. Extremities: No lower extremity edema. LABORATORY VALUES ON ADMISSION: White blood cell count of 10.6, hematocrit of 38.1, platelets of 310. Sodium of 132, potassium of 4.6, chloride 96, CO2 22, BUN of 27, creatinine 1.1. Glucose 142, INR of 1.4. HOSPITAL COURSE BY SYSTEM: The patient was transferred to the CCU from OMED for elective pericardial centesis. A pericardial centesis was performed by under normal procedures, which removed immediately 600 mL of serosanguinous fluid followed by an additional 4-500 cc over the next 48 hours. The pericardial drain was left in place until drainage was less than 100 cc per day. It was removed, and the patient was transferred to the Medicine Service in good condition. The patient's symptoms improved markedly with drainage of pericardial effusion. She remained in chronic asymptomatic tachycardia, however, even after drainage of the effusion. Oncology: Patient and family decided at this time they did not wish to undergo further chemotherapy and that she would be made DNR/DNI, and brought home as a bridge to hospice. DISCHARGE DIAGNOSES: 1. Small cell lung cancer. 2. Pericardial effusion. 3. Pericardial tamponade. 4. Coronary artery disease. DISCHARGE MEDICATIONS: 1. Diazepam 1 mg po q day. 2. Vitamin D 400 units po q day. 3. Calcium carbonate 500 mg po tid. 4. Prednisone 5 mg po q day. 5. Senna two tablets po q hs. 6. Docusate 100 mg po bid. 7. Lactulose 30 mg po q6 prn. 8. Protonix 40 mg po q day. 9. Aspirin 81 mg po q day. 10. Percocet 1-2 tablets q4-6h prn. 11. Trazodone 50 mg po q hs. 12. Simvastatin 40 mg po q day. 13. Peroxitine 30 mg po q day. 14. Levothyroxine 75 mcg po q day. DISPOSITION: She was discharged in stable condition to home. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13111**] Dictated By:[**Last Name (NamePattern1) 1737**] MEDQUIST36 D: [**2176-2-25**] 10:47 T: [**2176-2-26**] 13:30 JOB#: [**Job Number 13112**]

[ "997.1", "423.9", "198.89", "414.01", "412", "162.8", "427.31", "244.9", "496" ]

icd9cm

[ [ [] ] ]

[ "37.21", "37.0" ]

icd9pcs

[ [ [] ] ]

2943, 3050

3073, 3808

1253, 1485

2121, 2922

100, 122

151, 966

1914, 2093

988, 1227

76,797

191,104

3905

Discharge summary

report

Admission Date: [**2153-8-8**] Discharge Date: [**2153-8-14**] Date of Birth: [**2072-7-6**] Sex: F Service: MEDICINE Allergies: metoprolol / Fosamax Attending:[**First Name3 (LF) 2186**] Chief Complaint: Hypotension, altered mental status Major Surgical or Invasive Procedure: Blood transfusion [**2153-8-8**] L IJ placement History of Present Illness: 81-year-old female with history of atrial fibrillation, CHF s/p mitral and tricuspid annuloplasty [**2-/2153**] c/b ACA infarct and recent resistant proteus mirabilis UTI presenting from rehab with altered mental status and hypotension. Per her husband, patient was in her usual state of health until this morning when she became minimally responsive. En route to the hospital, she became more interactive with EMS, but has remained somnolent and confused. In the ED, triage vital signs were P90 55/36 R30 98%. MAPs remained in the 50s despite 4L NS and levophed was started peripherally. She was also noted to have several episodes of bradycardia to the 30s with spontaneous resolution. A right IJ was attempted but not obtained and a left IJ was placed. VBG 7.31/50/32 on RA, lactate 3.1. UA showed 39 RBC and >189 WBC and ceftriaxone 1g was given based on sensitivities from her prior admission. On arrival to the MICU, patient's VS 97.5 P77 BP 95/63 R 14 97% RA. Past Medical History: - ?Syncope: Admitted to [**Hospital1 18**] [**Date range (3) 16200**] following brief period of unresponsiveness at rehab center. Exam was not suggestive of new stroke, pt was not orthostatic, TTE with EF 50%. Noted to have UTI as below. - Proteus UTI: Urine cultures on last admission grew proteus mirabilis sensitive to ceftriaxone, dc'd to rehab on 5 days ceftriaxone to complete 7 day course - Congestive Heart Failure: secondary to longstanding MVP/MR [**First Name (Titles) **] [**Last Name (Titles) **]R s/p mitral and tricuspid valve annuloplasty [**2153-3-19**]. TTE [**2153-7-25**] showed well seated and normally functinoning mitral and tricuspid annuloplasty rings without regurgitatio, LVEF 50% - CVA: Acute left ACA infarct [**2-/2153**] on POD 1 following valvuloplasty with resulting abulia and right hemiparesis - J-tube: placed [**4-7**] in the setting of left ACA stroke. On tube feeds and daily PO thick nectar at rehab. - Atrial Fibrillation: dx [**2151**], on metoprolol, digoxin. Coumadin was held at last discharge for [**Year (4 digits) 263**] 3.8, currently 1.6 - Sacral decubitus ulcer: noted on discharge summary [**7-25**] - Pulmonary Hypertension - "Patulous" esophagus/Achalasia - s/p botox injections, unable to undergo TEE - History of Aspiration Pneumonia - Osteoporosis - History of Shingles - Leiomyoma, s/p TAH [**2108**] - Cyst on back removed in [**2103**]. - S/P tonsillectomy. - s/p Breast fibroadenoma left aspiration, [**2137**] Social History: Lives with: Husband Occupation: Retired Professor [**First Name (Titles) **] [**Last Name (Titles) 483**] Literature Cigarettes: Quit smoking at 41, approximately 20-25 pk yr hx ETOH: < 1 drink/week Illicit drug use: Denies Family History: Father died of a heart attack in his 70's. Mother died of congestive heart failure at age 88. She is married with three stepchildren and four grandchildren. Physical Exam: Admission: Vitals: 97.5 P77 BP 95/63 R 14 97% RA General: pale appearing, somnolent, opens eyes and squeezes fingers to command HEENT: Sclera anicteric, MMM, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, hypoactive bowel sounds, J tube in place, dressing clean/dry/intact, no organomegaly, no rebound or guarding Skin: stage 2 sacral decubitus ulcer noted, no erythema or exudate GU: foley in place, draining clear yellow urine Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: unable to participate in exam, pupils equal and reactive to light, able to move LUE, LLE and RUE on command, gait deferred. Pertinent Results: [**2153-8-8**] 12:00PM PT-16.8* PTT-29.2 [**Month/Day/Year 263**](PT)-1.6* [**2153-8-8**] 12:00PM PLT COUNT-464* [**2153-8-8**] 12:00PM NEUTS-64.5 LYMPHS-25.5 MONOS-7.4 EOS-1.5 BASOS-1.1 [**2153-8-8**] 12:00PM WBC-6.9 RBC-3.57* HGB-11.3* HCT-35.0* MCV-98 MCH-31.7 MCHC-32.4 RDW-13.3 [**2153-8-8**] 12:00PM GLUCOSE-138* UREA N-29* CREAT-0.7 SODIUM-139 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14 [**2153-8-8**] 12:20PM URINE RBC-39* WBC->182* BACTERIA-MANY YEAST-NONE EPI-12 [**2153-8-8**] 12:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG [**2153-8-8**] 12:29PM LACTATE-3.1* [**2153-8-8**] 03:25PM TYPE-[**Last Name (un) **] PO2-32* PCO2-50* PH-7.31* TOTAL CO2-26 BASE XS--2 [**2153-8-8**] 10:54PM DIGOXIN-0.3* [**2153-8-8**] 10:54PM CK-MB-5 cTropnT-<0.01 [**2153-8-8**] 10:54PM LD(LDH)-215 CK(CPK)-44 Microbiology: Blood cultures 9/12: pending Urine culture [**8-8**]: mixed bacterial [**Month/Year (2) **] Stook [**8-8**]: negative for C. diff Imaging: CXR [**8-8**]: There is interval placement of a left internal jugular catheter with tip terminating in the upper SVC. There is no pneumothorax. Cardiomediastinal and hilar silhouettes are stable. There is stable scarring or atelectasis at the left lung base as well as calcifications at the costochondral junction. The lungs are otherwise clear. IMPRESSION: New left IJ catheter with tip in the upper SVC, no pneumothorax. CT head w/o contrast [**8-8**]: Evolution with encephalomalacia due to a prior left ACA infarction, without evidence of hemorrhage or new infarction. EEG [**2153-8-9**]: This is an abnormal waking EEG because of frequent intermittent left temporal slowing with moderate amplitude polymorphic delta and theta. These findings are indicative of subcortical dysfunction over left temporal region but of non-specific etiology TTE [**2153-8-9**]: The left atrium is dilated. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is mildly depressed (LVEF = 45 %) secondary to ventricular interaction, with a pressure/volume overloaded right ventricle. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. A mitral valve annuloplasty ring is present. The gradients are higher than expected for this type of prosthesis (at heart rates 110-120 beats per minute). The tricuspid valve leaflets are mildly thickened. A tricuspid valve annuloplasty ring is present. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2153-7-25**], the apparent pulmonary artery systolic pressure is significantly increased. Ventricular interaction is more prominent. CXR [**8-9**]: As compared to the previous radiograph, there is no relevant change. There is no right pneumothorax after failed internal jugular vein catheter placement. No evidence of mediastinal widening. No other changes. The previously placed left internal jugular vein catheter has been removed. Brief Hospital Course: 81-year-old female history of atrial fibrillation, CHF s/p mitral and tricuspid annuloplasty [**2-/2153**] c/b ACA infarct presenting from rehab with AMS and hypotension following a syncopal episode, transferred to the ICU for hypotension requiring pressor support. Active Issues: #Hypotension/Shock: Initial SBP 50s was minimally responsive to fluid resuscitation and levophed was started in the ED. Lactate was elevated at 3.1. Initially suspicious for septic shock from presumed urinary source given pyruria/hematuria and recent h/o proteus UTI. She was started on cefepime based on prior sensitivities. However, she did not meet SIRS criteria and WBC normal at 6.9 with normal differential. Her presentation was also concerning for cardiogenic shock given acute onset following presumed syncopal episode. Troponin negative x2. TTE [**2153-8-9**] showed EF 45%, dilated LA, abnormal septal motion/position consistent with right ventricular pressure/volume overload, and increased pulmonary artery systolic pressure compared to prior. Cardiology was consulted and felt her syncopal episode may have been precipitated by a conversion pause (see Syncope below). Patient was quickly weaned off levophed in ICU and remained hemodynamically stable. Continued on abx as below. #Syncope: Differential included syncope secondary to hypotension in the setting of urosepsis vs. cardiogenic shock vs. bradycardia. Cardiology consulted, and felt syncope may have been secondary to conversion pause. Recommended considering amiodarone to keep patient in sinus rhythm, though would defer for now as [**Month/Day/Year 263**] subtherapeutic on admission, and goal would be for therapeutic [**Month/Day/Year 263**] x1 month prior to starting amio. #AMS: Patient p/w somnolence/decreased responsiveness and confusion. CT head neg for acute process. DDx included decreased cerebral perfusion in setting of hypotension, seizures/post-ictal state, toxic-metabolic encephalopathy, recrudesence of prior stroke symptoms and recurrent stroke. No h/o seizures and no involuntary movements per report; EEG obtained and on prelim read showed no e/o seizure activity. Did show focal slowing in left temporal region. Neurology consulted, as patient had recurrent lethargy/decreased responsiveness in context of no longer being hypotension. Felt recurrent CVA unlikely as patient's mental status had improved back to baseline w/o intervetion. #UTI: Hematuria and pyruria on urinalysis in ED. Pt was discharged from [**Hospital1 18**] [**7-25**] on amoxicillin for UTI which was changed to ceftriaxone x 5 days for planned 7 day course the following day when urine culture showed resistant proteus, but it is unclear if patient completed the full course of ceftriaxone based on rehab documentation. Pt received 1g ceftriaxone in the ED. Due to concern for resistance given possible inconsistency in ceftriaxone therapy, started treatment with cefepime to which the prior culture was also sensitive. Repeat urine culture showed only mixed [**Last Name (LF) **], [**First Name3 (LF) **] patient switched back to ceftriaxone [**2153-8-10**] with plans for 4 additional days of abx. #Bradycardia: Unclear etiology. Pt noted to have several episodes of HR in 30s in ED which resolved spontaneously. #CHF: Pt is s/p mitral and tricuspid annuloplasty [**2-/2153**] with recent EF 50% with trivial MR [**First Name (Titles) **] [**Last Name (Titles) 17417**] TR, although presence of acoustic shadowing may have significantly underestimated valvular regurgitation. TEE is contraindicated due to h/o prior failure to pass probe due to resistance in upper esophagous (pt has h/o achalasia). TTE [**2153-8-9**] showed EF 45%, dilated LA, abnormal septal motion/position consistent with right ventricular pressure/volume overload, and increased pulmonary artery systolic pressure compared to prior. No evidence of acute decompensation this admission. #Atrial Fibrillation: Was felt that conversion pauses may have been contributing to syncope as above. Home metoprolol and digoxin initially held given current hypotension and bradycardia, though later restarted. Warfarin intially held, then restarted after CT head neg for bleed. Held again later in admission for supratherapeutic [**Month/Day/Year 263**]. #Anemia: Hct dropped during admission from 35 to 28.9. Tranfused 1 unit pRBCs. [**Month (only) 116**] have been dilutional effect in setting of aggressive volume resuscitation for hypotension. Transitional Issues: -may need further neurologic work-up -restart warfarin once [**Month (only) 263**] no longer supratherapeutic -consider amiodarone in future once [**Month (only) 263**] therapeutic x1 month Medications on Admission: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Digoxin 0.125 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 7. Metoprolol Tartrate 50 mg PO TID 8. Multivitamins 1 TAB PO DAILY 9. Senna 1 TAB PO BID:PRN constipation 10. Albuterol Sulfate (Extended Release) 2.5 mg PO Q4H:PRN SOB 2.5 mg/3 mL (0.083 %) Solution for Nebulization 11. Glycerin Supps 1 SUPP PR PRN constipation 12. Lactulose 30 mL PO DAILY:PRN constipation 13. Mirtazapine 7.5 mg PO HS 14. Amoxicillin 500 mg PO Q8H Duration: 3 Doses Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain 2. Baclofen 5 mg PO TID 3. Digoxin 0.125 mg PO DAILY please hold for HR<50 or SBP<100 4. Metoprolol Tartrate 50 mg PO Q8H please hold for HR<50 or SBP<100 5. traZODONE 25 mg PO HS:PRN insomnia 6. Warfarin 2.5 mg PO DAILY16 Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**] Discharge Diagnosis: - Loss of consciousness - low blood pressure - Recovery from stroke 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 loss of consciousness and low blood pressure. The cause of low blood pressure was considered multifactorial. You had a urinary tract infection, you were dehydrated, and it was possible that you had low heart rate during this episode. You were admitted to the intensive care unit temporarily. After given intravenous fluids and a single unit of red blood cells, your blood pressure and heart rate remained stable. A head CT was done to ensure that there was no extension of stroke and an EEG was done - revealing no seizures. Neuro was involved and felt that there was no new stroke. J-tube was clogged here and was replaced on [**8-13**]. Please continue to flush it regularly with water. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2153-8-20**] at 2:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [**2153-8-30**] at 2:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

13366, 13458

7707, 7974

314, 363

13573, 13573

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391, 1360

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18,648

146,400

4302+55568

Discharge summary

report+addendum

Admission Date: [**2183-11-26**] Discharge Date: [**2183-12-8**] Service: GREEN [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old female who was admitted with one day of abdominal pain. The patient's pain began at 4 a.m. with acute onset and was of a nature that the patient had never experienced before. The pain was diffuse, but otherwise the characteristics were unknown. There was no ever reported radiation of the pain; no nausea, vomiting, fevers or chills. The patient had a bowel movement the prior day. There was no bright red blood per rectum or melena. The patient had had an upper respiratory infection and dry cough for seven days prior to admission. No recent antibiotics, shortness of breath or chest pain. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [**7-/2182**]; status post right coronary artery stent; ejection fraction of 40%. 2. Arthritis. 3. Vertigo. 4. Status post bilateral cataracts. 5. Hypercholesterolemia. 6. NSAIDs gastritis. 7. Depression. 8. Anxiety. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Zoloft 50 mg q. day. 2. Multivitamin. 3. Lasix 20 mg q. day. 4. Calcium. 5. Vitamin D. 6. Lipitor 20 mg q. day. 7. Aspirin 81 mg q. day. 8. FeSO4 325 mg q. day. 9. Potassium chloride 20 mEq four times a day. 10. Tylenol p.r.n. 11. Benicar 20 mg q. day. PHYSICAL EXAMINATION: Temperature 97.0 F.; pulse 83; blood pressure 160/43; respiratory rate 22; 98% on room air. In general, frail elderly female in no apparent distress pulling at her cover, awake, alert and oriented times one. Lungs: Expiratory wheezes, decreased breath sounds at bases bilaterally. Cardiovascular: Regular rate and rhythm; no murmurs, rubs or gallops. Abdomen: Soft, distended, nontender, hypoactive bowel sounds. No rebound, no guarding. Rectal: Normal tone, stool in vault, guaiac negative. LABORATORY: Studies reveal white blood cell count 7.7, hematocrit 37.7, platelets 235; neutrophils 71%, bands zero. Sodium 133, potassium 4.4, chloride 98, bicarbonate 27, BUN 18, creatinine 0.8, glucose 120. Calcium 9.2, magnesium 1.8, phosphorus 3.2. KUB: No free air, single air fluid level in mid abdomen, no evidence of colonic obstruction. Abdominal CT scan reveals multiple dilated loops of small bowel with associated stranding in mesentery and thickening of bowel wall representing a high grade small bowel obstruction with incarcerated internal hernia; small pericardial effusion; ascites. HOSPITAL COURSE: Upon admission, an nasogastric tube was placed with marked improvement in the patient's abdominal distention. The initial plan was to continue the nasogastric tube with intravenous fluids, however, later in the morning of [**2183-11-27**], the patient's abdominal examination worsened with more tenderness in her lower quadrant and a repeat white blood cell count had risen from 7.7 to 12.6. It was therefore decided to take the patient to the Operating Room for exploration of a small bowel obstruction with possible ischemic small bowel. The patient underwent an exploratory laparotomy with small bowel resection and primary anastomosis. There were several adhesive bands noted in the right lower quadrant sidewall that were likely the source of an internal hernia which appeared to have spontaneously reduced, however, there was a 35 centimeter segment of jejunum intussuscepted that had infarcted. This portion of the jejunum was resected. Please see dictated Op Note for further details. Immediately postoperatively, the patient was taken to the Surgical Intensive Care Unit, intubated and sedated. She was medically stable and the plan was to wean the ventilator to extubation. She was on SIMV with 60% FIO2 and a blood gas of 7.38, 32, and 211. The patient was placed on perioperative Kefzol and Flagyl and remained afebrile while in the Intensive Care Unit. On postoperative day one, the patient's blood gas was 7.38, 30, 145, 18, negative five. Because of the acidosis with base deficit, a Renal consultation was obtained. The Renal Team recommended conservative management for what appeared to be a metabolic acidosis with respiratory alkalosis. They expected that it would correct slowly on its own which it did over the course of two days. The patient required a large amount of intraoperative fluids and by postoperative day one was positive 6.5 liters. On postoperative day two, the patient was extubated and had a blood gas of 7.3, 37, 120, 23, minus 2. The patient was positive another 2.2 liters for that day. The patient remained afebrile and the white count rose to 13.6. A chest x-ray was obtained which showed bilateral pleural effusions with atelectasis. On postoperative day three, the nasogastric tube was removed and the patient was okayed for floor status. The patient remained afebrile. Her white blood cell count dropped slightly to 12.9. Her last blood gas was 7.42, 35, 106, 23, zero, showing a resolution of her acid base. At this time, the patient was noted to be somewhat confused and an order was made to minimize the amount of morphine she received. Prior to this time, the patient had been sedated sufficiently to be unable to assess her mental status. The patient ran a 95 cc surplus over the prior day leaving her positive approximately nine liters. She was noted to have coarse breath sounds and aggressive pulmonary toilet was continued from previous days. On postoperative day four at night the patient had a brief run of tachycardia. The rhythm was a junctional rhythm and an EKG was obtained which was unchanged from previous electrocardiograms showing normal sinus rhythm. The patient remained afebrile and heart rate was 72 and blood pressure 120/70. On examination, she was noted to have some moderate right quadrant tenderness with some slight distention. Her lungs were clear and saturations were good at 96% on three liters of O2. The patient nevertheless remained confused and she her morphine dose was decreased to 0.5 q. three hours p.r.n. On postoperative day five, the patient remained afebrile with good heart rate and blood pressure but her saturations dropped to 93% on three liters. She was oriented times three and was noted to have crackles posteriorly. The patient was therefore begun on her Lasix to help with diuresis and she appeared to be mobilizing fluids from the OR. The patient's diet was advanced to sips which she tolerated well. A chest x-ray was also obtained which showed congestive heart failure with worsening effusions bilaterally; however, on the following day, postoperative day six, the patient was saturating at 94% on room air and her lung examination was clear in the posterior bases. She continued to have mild abdominal tenderness but had had three bowel movements. The patient was doing quite well. She was starting to ambulate on her own. Later on, postoperative day six, while the patient was in the bathroom, she experienced a fall while being attended by three other people. The patient fell backwards on her occiput on the bathroom floor. Following the fall, the patient's neurological examination was stable and she had no calvarial step-offs. The patient was put on bed precautions and was only allowed out of bed under supervision. The following morning a CT scan of the head was obtained which showed no acute bleeds and no midline shifts. On postoperative day seven, the patient continued to be poorly oriented as she was prior to her fall. Her neurological examination was stable and her respiratory examination was noted for crackles in the posterior lung fields. The patient continued on a clear liquid diet and had moderate distention. Later on postoperative day seven, the patient was advanced to a full liquid diet which she tolerated well. On postoperative day eight, a Foley catheter was replaced in order to get a better handle on the patient's intakes and outputs. She continued to have crackles posteriorly and was moved to Lasix 40 mg p.o. q. day. The patient's abdominal examination continued to be benign. Her mental status was much improved. On postoperative day ten, the patient's mental status continued to clear. On postoperative day ten the patient's white blood cell count spiked to 14.7, but by postoperative day eleven, the white blood cell count was back down to 9.5. The patient was placed on all of her home p.o. medications except Benicar. She continued to receive metoprolol in its absence. The patient's intravenous was Hep-locked. Her abdominal examination continued to be benign and her Foley was taken out. A chest x-ray showed a decrease in the size of the effusion. The remainder of the [**Hospital 228**] hospital course is to be dictated at a later date. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 14131**] Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. MEDQUIST36 D: [**2183-12-8**] 21:07 T: [**2183-12-8**] 22:57 JOB#: [**Job Number 18634**] Name: [**Known lastname **], [**Known firstname 3038**] Unit No: [**Numeric Identifier 3039**] Admission Date: [**2183-11-26**] Discharge Date: [**2183-12-8**] Date of Birth: [**2087-6-29**] Sex: F Service: CONTINUATION OF HOSPITAL COURSE: On postoperative day 12, the patient's mental status continued to clear and her abdominal examination remained benign. Her staples were removed and the incision was Steri-Stripped. CONDITION ON DISCHARGE: Good. DISPOSITION: To extended care facility. DISCHARGE DIAGNOSES: 1. Small bowel obstruction. 2. Coronary artery disease status post myocardial infarction in [**7-29**], status post right coronary artery stent. 3. Arthritis. 4. Vertigo. 5. Cataracts. 6. Hypercholesterolemia. 7. Depression and anxiety. 8. History of nonsteroidal anti-inflammatory gastritis. DISCHARGE MEDICATIONS: 1. Sertraline 50 mg p.o. q.d. 2. Furosemide 40 mg p.o. q.d. 3. Atorvastatin calcium 20 mg p.o. q.d. 4. Baby aspirin 81 mg p.o. q.d. 5. Potassium chloride 20 mEq p.o. b.i.d. 6. Acetaminophen 325 mg 1-2 tablets p.o. q.4-6h. 7. Metoprolol 50 mg p.o. b.i.d. 8. Famotidine 20 mg p.o. b.i.d. 9. Albuterol one IH q.6h. 10. Ipratropium one nebulizer q.6h. FOLLOW-UP PLANS: 1. Schedule a follow-up appointment from one week from your discharge with Dr. [**Last Name (STitle) 2206**]. 2. An appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3040**] has been made for you to follow your other medical issues. That appointment is for [**12-25**] at 1:15 p.m. 3. The phone numbers for serial geriatricians have been provided to you. Please call and make an appointment with one of them. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**], M.D. [**MD Number(1) 3041**] Dictated By:[**Last Name (NamePattern1) 3042**] MEDQUIST36 D: [**2183-12-22**] 11:35 T: [**2183-12-22**] 12:46 JOB#: [**Job Number 3043**]

[ "560.0", "560.81", "557.0", "272.0", "V45.82", "553.9", "716.90", "412" ]

icd9cm

[ [ [] ] ]

[ "45.62", "45.91", "96.07", "54.59" ]

icd9pcs

[ [ [] ] ]

9692, 9986

10009, 10358

9414, 9597

1449, 2556

10375, 11156

149, 794

816, 1425

9622, 9671

25,634

179,174

24650

Discharge summary

report

Admission Date: [**2133-7-24**] Discharge Date: [**2133-7-30**] Date of Birth: [**2085-6-19**] Sex: M Service: HEPATOBILIARY SURGERY SERVICE DIAGNOSIS: Non-alcoholic steatohepatitis, cirrhosis, liver mass x 2, probable hepatocellular carcinoma. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male who during laparoscopy for planned gastric bypass was noted to have cirrhosis. A liver biopsy was taken. It demonstrated established cirrhosis and steatohepatitis. A mass lesion on the inferior margin of the liver was seen but not biopsied. Mass measures 3.5 x 4 cm. Also of note, elevated alpha fetoprotein of 135. CT of abdomen on [**6-16**] demonstrated a 4.3 x 2.9 exophytic mass within segment V of the liver which enhances slightly compared to the rest of the liver. Also within segment V and to the right of the gallbladder there is a patchy area of arterial-phase enhancement measuring approximately 2 cm x 1.9 cm. The patient underwent an MRI of the abdomen on [**2133-7-15**] demonstrating a large exophytic lesion, 2 lesions adjacent to the gallbladder, and a 4th lesion in the posterior right lobe of the liver. The other 3 lesions are indeterminate but do appear to be slightly hypervascular. The patient was seen by Dr. [**Last Name (STitle) **] for hepatic resection of the exophytic lesion. PAST MEDICAL HISTORY: History of morbid obesity; the current BMI is 43.9; history of hypertension; type 2 diabetes mellitus; sleep apnea. PAST SURGICAL HISTORY: Significant for left knee surgery. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Glipizide 5 mg daily, metformin 1000 mg daily, lisinopril 20 mg daily, hydrochlorothiazide 25 mg daily, nifedipine 30 mg daily, and Reglan 10 mg p.o. p.r.n. SOCIAL HISTORY: He has been married for 19 years; 2 children. He is a psychiatric social worker. [**Name (NI) **] history of alcohol use. No tobacco. No history of IV drug use, marijuana. No history of blood transfusions, tattoos, or piercing. PHYSICAL EXAMINATION: The patient is awake and alert, afebrile, vital signs stable, blood pressure of 136/86, pulse of 72, respirations of 20, a temperature of 99.6. His height is 6 feet 1 inch and weighs 323 pounds. Physical exam reveals he an obese male in no acute distress. HEENT reveals no scleral icterus. The lungs are clear to auscultation. The abdomen is obese. Normal bowel sounds. No hepatomegaly. No masses or tenderness. Extremities reveal no peripheral edema. RADIOLOGIC AND OTHER STUDIES: A preoperative EKG was performed demonstrating a sinus rhythm, rate of 84, normal EKG. A recent chest x-ray on [**2133-7-2**] demonstrated a slightly asymmetrical opacity at the left 1st costochondral junction level, likely due to asymmetric degenerative changes at the site. No pleural effusions. Another preoperative chest x-ray was obtained, an apical lordotic, demonstrating a dense nodular density in the left upper lobe which measured 2.3 x 2 cm in dimension. No evidence of pleural effusion. The heart is not enlarged. PREOPERATIVE LABORATORY DATA: Included a WBC of 5.50, a hematocrit of 38.8, a PT of 15.0, platelets of 122, PTT of 33.0, fibrinogen of 235. Sodium of 142, potassium of 4.5, chloride of 103, bicarbonate of 18, BUN of 11, creatinine of 0.8. ALT of 118, AST of 158, alkaline phosphatase of 59, amylase of 46, total bilirubin of 2.1, with a lipase of 25. HOSPITAL COURSE: On [**2133-7-24**] the patient was operated on by Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**Name5 (PTitle) **] assistant [**First Name8 (NamePattern2) 3825**] [**Last Name (NamePattern1) 3826**]. The patient had a laparoscopic cholecystectomy, laparoscopic intraoperative ultrasound, attempted laparoscopic segment V resection converted to open segment V mass resection adjacent to gallbladder. Please see the operative note for more details; described by Dr. [**First Name (STitle) **]. The patient was transferred to the ICU. While in the ICU the patient had intraoperative bleeding converted to open. Systolic blood pressures in the 50s. Placed on Neo- Synephrine. The patient had an acidosis trough. The patient had a lactate peak of 13.8. Estimated blood loss of 8500; received 13 units of packed red blood cells, 9 units of FFP, 3 units of platelets, 3 units of cryogen, 1 liter of crystalloid, with a urine output of 900 cc. The patient was intubated while in the ICU overnight. The patient was weaned off his vent and was extubated on [**2133-7-26**]. Labs on the 24th revealed a WBC of 11.4, hematocrit of 31.1, platelets of 70. PT of 14.6, PTT of 32.9, INR of 1.4. Sodium of 139, potassium of 4.2, chloride of 108, bicarbonate of 25, BUN of 11, creatinine of 2.6, with a glucose of 181. Also on [**2133-7-26**] ALT of 325, AST of 385, alkaline phosphatase of 79, amylase of 46, total bilirubin of 1.7. On [**2133-7-26**] the patient was transferred to the floor. On postoperative day 5, the patient's Foley was removed, IV was hep-locked, diet was advanced. On the back of his neck he did have a severe abrasion, believed due to positioning in the OR which had been treated with DuoDerm gel applied daily. Physical therapy and occupational therapy were consulted. The patient had a temperature on postoperative day 6 of 101.3; was cultured. Currently, all the blood cultures are pending. The patient had an IJ in place which was removed and sent for culture. The patient's pathology from the wedge resection demonstrated HCC with margins, which means that patient needs to have a liver transplant - which was discussed with him by Dr. [**Last Name (STitle) **]. On postoperative day 7, the patient was doing well. No events overnight, afebrile, vital signs stable. The patient's neck was still irritated but not putting pressure on the area. I's and O's good. Cultures are pending. Labs on the 28th are as follows. WBC of 10.5, hematocrit of 34.0, platelets of 113. Sodium of 133, potassium of 3.4 (which was replaced with 40 mEq of K), chloride of 99, bicarbonate of 27, BUN of 15, creatinine of 0.8, glucose of 106. ALT of 87, AST of 64, albumin of 2.4, AFP of 19.6. Since the patient is a pre transplant candidate, multiple pre transplant labs were sent; including HBsAg, HBsAb, HBcAb, HIV- AB IgM-HIV AFP which we know the results, which is 19.6, and HCV AB pending. HIV also pending. The patient is going to have a TTE this afternoon and then the patient can go home. Wound care nurse did see the patient for his wound and felt that the patient should have VNA and have DuoDerm gel applied daily with a dry gauze applied on top of that without any pressure to the neck. DISCHARGE DISPOSITION: The patient is going to go home today (on [**2133-7-30**]). MEDICATIONS ON DISCHARGE: Tylenol 325/650 p.o. q.4-6h. p.r.n.; glipizide 5 mg daily; hydrochlorothiazide 25 mg daily; Dilaudid 2 mg q.3h. p.r.n.; insulin sliding scale; lisinopril 20 mg daily; metformin 1000 mg daily; Reglan 10 mg q.6h. p.r.n.; nifedipine CR 30 mg daily; Protonix 40 mg q.24. DISCHARGE INSTRUCTIONS: The patient is to call the transplant team at ([**Telephone/Fax (1) 62221**] immediately if any fevers, chills, nausea, vomiting, increased jaundice, excessive dizziness, any changes in his abdominal incision (including redness/discharge); and the VNA nurse or staff should let transplant team know immediately if there is any change in color of the neck wound/any discharge from the neck wound immediately. The patient has a JP drain that the patient is going to be going home with that needs to be emptied every 3 to 4 hours. The record of the amount and color of drainage needs to be brought to his next appointment so that someone from the transplant team can see the record. DISCHARGE FOLLOWUP: The patient needs to follow up with Dr. [**Last Name (STitle) **]. Please call ([**Telephone/Fax (1) 3618**] for an appointment and also will probably need an appointment with one of the liver transplant coordinators. Also, they should be contacting you to make an appointment. The patient also needs to have an endoscopy and colonoscopy as an outpatient as part of the pre transplant workup. When the patient does come for a follow-up appointment, someone from the transplant team needs to see his neck wound to make sure that it is healing. FINAL DIAGNOSIS: Multiple liver masses; pathology demonstrates hepatocellular carcinoma with margins. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2133-7-30**] 14:47:13 T: [**2133-7-30**] 15:54:39 Job#: [**Job Number 62222**]

[ "998.11", "571.5", "155.0", "575.11", "V64.41", "571.8", "401.9", "285.1", "780.57", "278.01", "250.00" ]

icd9cm

[ [ [] ] ]

[ "99.07", "50.22", "99.04", "99.05", "51.23" ]

icd9pcs

[ [ [] ] ]

6666, 6727

6754, 7022

1604, 1762

3415, 6642

8312, 8674

7047, 7728

1503, 1577

2031, 3397

7749, 8294

297, 1339

1362, 1479

1779, 2008

23,588

165,395

14460

Discharge summary

report

Admission Date: [**2184-2-23**] Discharge Date: [**2184-2-25**] Date of Birth: [**2128-10-15**] Sex: F Service: SURGERY Allergies: Demerol Attending:[**First Name3 (LF) 301**] Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: laparoscopic gastric banding History of Present Illness: The pt is a 55-year-old white female complaining of obesity for 20 years. She has a BMI of 44. She has a history of multiple supervised diets with maximum 70-pound weight loss and regain. She denies fevers, chills, or night sweats. No lightheadedness or dizziness. She has shortness of breath when walking stairs and hills and walking on flat ground for any distance. She denies chest pain or paroxysmal nocturnal dyspnea. No abdominal pain, nausea/vomiting. No dysuria or hematuria. She has migraine headaches and numbness/tingling in hands second to carpal tunnel syndrome. Past Medical History: 1. hyperlipidemia 2. hypertension 3. sleep apnea on CPAP 4. asthma 5. emphysema 6. gastroesophageal reflux disease with Barrett's 7. osteoarthritis 8. carpal tunnel disease 9. urinary tract infections and renal stones. PSH: Her surgeries include hysterectomy in [**2153**] at age 25 under general anesthesia, carpal tunnel release in [**2168**] and [**2178**] as well as rotator cuff repair in [**2170**] under general anesthesia. Social History: She smoked one pack per day for 20 years quitting 18 years ago, last used recreational drugs 25 years ago, has glass of wine on rare occasions and drinks can diet soda daily. She is a hair dresser employed in a salon. She is married living with her husband age 59 they have 3 grown children and they live with daughter age 37, son-in-law age 36, granddaughter age 18 and grandson age 11. Family History: Family history is significant for both parents deceased of CA father age 68 of esophageal, mother age 60 also with diabetes and obesity; brother deceased age 52 of esophageal CA and another brother deceased of pancreatic CA; sister living age 50 with hyperlipidemia, another sister age 45 with obesity and asthma. Physical Exam: T 97.7 P 90 BP 143/97 R 20 SaO2 94% RA Gen - nad Heent - Neck is supple Lungs - clear to auscultation without wheezing Heart - regular with no murmurs Abd - soft, nontender, no rebound or guarding. She has no abdominal scars, other than the umbilical site status post tubal. Skin - without rashes. Pertinent Results: [**2184-2-23**] 05:00PM BLOOD WBC-7.9 RBC-4.13* Hgb-11.6* Hct-34.1* MCV-83 MCH-28.1 MCHC-34.0 RDW-14.2 Plt Ct-240 [**2184-2-24**] 02:00AM BLOOD Glucose-107* UreaN-9 Creat-0.8 Na-138 K-3.7 Cl-101 HCO3-31 AnGap-10 [**2184-2-24**] 02:00AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0 Brief Hospital Course: The pt was admitted and had a laparoscopic adjustable gastric band which she tolerated well and was transferred to the PACU in stable condition. The pt remained stable in the PACU and was transferred to the floor. On the floor, the pt triggered for hypotension with a BP of 80/60. During this hypotensive episode, the pt was asymptomatic without lightheadedness, dizziness, chest pain or shortness of breath. Her BP responded to a 1 liter bolus of LR and she was transferred to the ICU for more intensive monitoring. Serial Hcts were checked which remained stable. EKG and cardiac enzymes were also checked which were normal. She remained normotensive and continued to have adequate urine output and was transferred to the floor the following day. She had a barium swallow/upper GI study on post-op day 1 which revealed no evidence of contrast extravasation or obstruction. She was started on a Stage 1 Bariatric diet and was gradually advanced to Stage 3. Her pain was well controlled on oral pain medications. For the pt's history of severe asthma, duoneb treatments were provided as well as albuterol and advair inhalers. She was able to be weaned off supplemental oxygen and had oxygen saturations >93% on room air on discharge. The pt was discharged on post-op day 2 in stable condition. Medications on Admission: Advair, albuterol, DuoNeb, Singulair, Flonase, hydrochlorothiazide, Prilosec, Ativan, Vicodin, and Prozac. Discharge Medications: 1. Ventolin 90 mcg/Actuation Aerosol Sig: One (1) Inhalation three times a day as needed for shortness of breath or wheezing. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 3. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) nebule Inhalation twice a day as needed for shortness of breath or wheezing. 4. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Flonase 50 mcg/Actuation Aerosol, Spray Sig: One (1) spray Nasal once a day as needed for shortness of breath or wheezing. 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*250 ML(s)* Refills:*0* 10. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO qAM: Open capsule and sprinkle on food. 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO qPM: Open capsule and sprinkle on food. 12. Colace 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day as needed for constipation. Disp:*250 * Refills:*0* 13. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: morbid obesity Discharge Condition: good Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay in Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You will be given a prescription for pain medication, which may make you drowsy. Do not drive while taking pain medication. 2. You should begin taking a Flintstones chewable complete multivitamin. No gummy vitamins. 3. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. Activity: No heavy lifting of items [**8-30**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Leave white strips above your incisions in place, allow them to fall off on their own. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Doctor Last Name 28352**], LDN Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2184-3-17**] 12:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2184-3-17**] 1:00

[ "278.01", "327.23", "V85.4", "493.20", "401.9", "530.81" ]

icd9cm

[ [ [] ] ]

[ "44.95" ]

icd9pcs

[ [ [] ] ]

5619, 5625

2752, 4059

282, 313

5684, 5691

2458, 2729

7137, 7427

1805, 2120

4217, 5596

5646, 5663

4085, 4194

5715, 6281

2135, 2439

228, 244

6906, 7114

341, 925

6307, 6894

947, 1380

1396, 1789

22,094

139,704

53524

Discharge summary

report

Admission Date: [**2192-4-15**] Discharge Date: [**2192-5-7**] Date of Birth: [**2124-10-7**] Sex: M Service: MEDICINE Allergies: Albendazole Attending:[**First Name3 (LF) 2181**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a chronically ill 67m with dm2, chf, afib, AVR, cri, gib (PUD s/p billroth, colonic ulcerations), splenic vein thrombosis and gastric varices presents with 1 bloody BM at his rehab. He was recently admitted for draining lue ulcer and is s/p removal of hardware, on IV abx. He was at rehab in his usual state of ill-health when he passed a maroon bowel movement, no associated sx, on the day prior to admission. He has had no BM since, no n/v since, though he does have frequent vomiting when he tries to eat solid food; there's been no hematemesis. Has chronic diarrhea, no recent changes. He denies lightheadedness, chest pain, palpitations, shortness of breath, or dyspnea on exertion, though it should be said, he rarely exerts himself, spending most time in bed, sitting, or in a wheelchair secondary to extensive deconditioning during multiple hospitalizations. The remainder of his ros is positive for a chronic cough with sputum, with no recent change in either; he denies f/c, ha, chest pain, palpitations, back pain, hemoptysis, abd pain, hematuria. He says he's had a bloody bm once before and had a colonoscopy showing "ulcers." However, his PMH is most significant for bleeding PUD ending in a billroth II. In the ED, his G-tube was aspirated, showing occasional blood clots in straw colored fluid, not bilious. He got a unit of pRBCs for a hct of 25, pantoprazole. Past Medical History: -DM2 -CHF -Afib -Bioprosthetic AVR -Gastric ulcer with peforation resulting in billroth II -Splenic vein thrombosis -S/P splenectomy [**5-/2191**] -Gastric varices -CRI -Etoh abuse with recurrent pancreatitis, pseudocysts, pancr insuffc -Peripheral neuropathy -Neurogenic bladder with chronic indwelling foley Social History: Lives at [**Hospital 5279**] health care with wife, recently at [**Name (NI) **]. Former etoh abuse. Family History: Non-contributory. Physical Exam: : t 98.9, bp 122/64, hr 90, rr 18, spo2 99%ra gen- chronically-ill, cachectic appearing male, poor functioning, mustache, non-tox, nad heent- anicteric, op clear but slightly dry neck- no jvd/lad/thyromegaly cv- rrr, s1s2, no m/r/g pul- moves air well, bibasilar rales abd- well healed [**Doctor First Name **] scars, soft, mild rlq pain, no rebound/guarding, no hsm, nabs back- no cva tenderness extrm- no cyanosis/edema, warm/dry nails- mild clubbing, [**Doctor First Name **] nails neuro- a&ox3, no focal cn/motor deficits, though has difficulty moving left arm due to recent procedures Pertinent Results: ECG: sinus tach, nl axis, nl intervals, laa, 1mm st elevation v2 (old) . CXR: Flat diaphragms, bilateral pleural effusions, bilateral lower increased opacification . Notable labs: CK 21/tn 0.11, hct 25 (baseline 27-28), wbc 14.6 (N:39 Band:1 L:19 M:11 E:29 Bas:0 Metas: 1), cr 1.5 (baseline 1.0), alb 2.2 [**2192-5-6**] 03:00AM BLOOD WBC-14.8* RBC-3.10* Hgb-9.9* Hct-29.2* MCV-94 MCH-31.9 MCHC-33.8 RDW-17.2* Plt Ct-443* [**2192-4-15**] 08:25PM BLOOD WBC-14.6* RBC-2.45* Hgb-8.2* Hct-25.0* MCV-102* MCH-33.3* MCHC-32.6 RDW-17.2* Plt Ct-438 [**2192-5-5**] 05:49AM BLOOD Neuts-65 Bands-0 Lymphs-12* Monos-19* Eos-3 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1* [**2192-4-15**] 08:25PM BLOOD Neuts-39* Bands-1 Lymphs-19 Monos-11 Eos-29* Baso-0 Atyps-0 Metas-1* Myelos-0 [**2192-5-6**] 03:00AM BLOOD Plt Ct-443* [**2192-5-6**] 03:00AM BLOOD PT-19.1* PTT-54.3* INR(PT)-1.8* [**2192-4-15**] 08:25PM BLOOD PT-14.9* PTT-36.5* INR(PT)-1.3* [**2192-5-6**] 03:00AM BLOOD Glucose-126* UreaN-49* Creat-4.2* Na-139 K-4.2 Cl-105 HCO3-19* AnGap-19 [**2192-4-15**] 08:25PM BLOOD Glucose-89 UreaN-53* Creat-1.5* Na-132* K-3.9 Cl-100 HCO3-21* AnGap-15 [**2192-5-6**] 03:00AM BLOOD ALT-36 AST-113* LD(LDH)-370* CK(CPK)-1245* AlkPhos-205* TotBili-0.9 [**2192-4-15**] 08:25PM BLOOD CK-MB-1 cTropnT-0.11* [**2192-5-6**] 03:00AM BLOOD CK-MB-11* MB Indx-0.9 cTropnT-2.52* [**2192-5-3**] 05:05AM BLOOD Vanco-18.9* [**2192-4-26**] 05:22AM BLOOD CRP-78.9* [**2192-5-5**] 09:00AM BLOOD Lactate-2.4* . Please see hospital course for reference to important imaging and micro studies. Brief Hospital Course: 1) Respiratory distress: Pt had an episode of respiratory distress on [**4-19**] in the MICU with presumed LLL mucus plugging, with good response to chest PT, nebs, and O2. Also with b/l pleural effusions, as well as sputum growing GNR. He was started on Ceftazidime [**4-19**]. After transfer out of the unit the patient had an episode of tachypnea on [**4-22**] with increasing O2 requirements. CXR showed volume overload and he was diuresed with IV lasix and symptoms improved. He had a known h/o diastolic dysfunction and had received fluids in the MICU, which could have contributed to this. While he was in acute respiratory distress the patient re-affrimed he was DNI, even though he knew that he could potentially die. His son was called and was made aware of the situation. He discussed this with his father and they both re-affirmed he was DNR/DNI. Abx were again started in the setting of respiratory distress and fevers. He had a thoracentesis on [**4-24**] with discovery of transudative R pleural effusion. No evidence of PNA was found, so ceftriaxone dc'd. He recieved PRN lasix. Near the end of his admission the patient was tachypneic for several days. ABGs showed good oxygenation and his sats were stable. EKG showed no changes. This was thought to be [**1-19**] to respiratory compensation from primary metabolic acidosis from uremia. He also had a component of volume overload but we were unable to diurese him [**1-19**] to hypotension. Cardiac enzyems were checked and were elevated, suggesting he had an NSTEMI. This was likely [**1-19**] to hypotension vs. subdendocaridal ishcemia [**1-19**] to volume overload. Aggressive treatment was not pursued during the end of his admission due to the family's wishes. He remained significantly volume overloaded,causing respiratory distress and was unable to be diuresed [**1-19**] to hypotension. After d/w the family it was decided not to send the patient to the unit for pressors, or to dialyze him for his ARF and he was made CMO. He was seen by palliative care and given morphine for [**Month/Day (2) **]. He expired on [**2192-5-7**]. 2)GI bleed: 62 yo male with DM, CHF, afib, AVR, CRI, PUD s/p biliroth, gastric varices and splenic v. thrombosis s/p splenectomy who presented s/p one episode of bloody BM at rehab. On [**2192-4-16**] he had several large maroon bowel movements on the floor. He remained hemodynamically stable with stable hct. Attempted to lavage G tube but were unable to do so. What came back out looked bilious. Pt was sent for tagged RBC which showed only a faint blush in LUQ on 2 hour images (not enough to intervene). He received 2 units of pRBCs and was transferred to the MICU. Colonoscopy was done on [**4-18**] and showed diverticulosis of the sigmoid colon and descending colon and erythema in the descending colon. EGD was also done and was negative. He remained hemodynamically stable with guiac + stool. He was continued on a PPI. hct slowly trended down over his admission and he was transfused another unit of PRBCs. . 3) Acute Renal Failure: At his most recent admission Cr was between 1-1.5 and was most recently 1 on [**4-5**]. At admission Cr was 1.5 thought to be d/t hypovolemia from bleed, dehydration from decreased POs or possibly AIN in the setting of eosinophilia. Nafcillan stopped and patient switched to vancomycin. Urine eos were found to be negative initially. His UOP dropped during his stay and cr trended up from 1.1 to 4.6. Potentially [**1-19**] to contrast nephropathy from imaging studies. Could also have had a component of AIN [**1-19**] to ceftaz, as he had a few eos in his urine. Renal ultrasound was normal. He had HD cath placed by IR and dialysis was initiated. Dialysis was stopped after discussion the the patient and his son and [**Name2 (NI) **] measures were initiated . 4) [**Female First Name (un) 564**] Fungemia: In the MICU the patient was found to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] fungemia from bcx on [**4-15**] and his PICC line was pulled, and he was started on Fluconazole on [**4-18**]. Optho exam was negative and subsequent bcx were negative for [**Female First Name (un) **]. He had a TEE that was negative for endocarditis. . 5) L knee erythema: Pt stated he has had chronic, intermittent stiffness of his left knee. His left knee looked erythematous, and was too painful for him to move. Knee x-ray showed osteopenia and ortho was unable to aspirate much fluid from the joint. He was treated with tylenol for pain b/c narcotics increased his confusion. An MRI of his knee was ordered but was unable to be completed b/c the patient could not straighten his leg. . 6)MSSA osteomyelitis: Patient was found to have MSSA osteomyelitis at last admission. He was on nafcillan as an outpatient but was changed from nafcillan to vancomycin at admission b/c of renal insufficiency. Ortho was consulted, saw the patient and thought his shoulder appeared stable. . 7)Eosinophilia - Had eosinophila at admission. Thought potentially [**1-19**] to naficillin,as he has had no exposures to warrant O&P and has been in NH/hosp/rehab for months/years now. Urine eos were negative but he was changed from naficillan to vancomycin. UPEP was negative for monoclonal Ig / Bence [**Doctor Last Name **] protein and eos trended down. Stool O + P negative x 3 . 8) Atrial fibrillation: hx was unclear. Pt was in NSR during admission. He was followed on tele and atenolol was held in setting of a GI bleed. . 9) Anemia -- Pt had a macrocytic anemia. Labs from one month prior were c/w ACD. Some of the anemia was likely [**1-19**] acute blood loss in setting of GI bleed. Hct bumped appropriately with blood transfusions and he was transfused to keep his hct >27. . 10) HTN/hypotension: SBPs were elevated at the beginning of admission. BB was not increased in the setting of acute CHF. Lisinopril and hydralazine were added to his regimen. Near the end of his admission he had relative hypotension with SBPs in the 90s, so all anti-hypertensives were dc'd. His hct was followed and he was treated for presumed sepsis. An echo was done and showed unchanged cardiac function. . 11) Depression: Patient stated he wanted us to "let him go" during his admssion and had been depressed regarding his medical sturation. Psych was consulted and he was started on Celexa. During his admission he had MS changes and appeared more sedated. Celexa was stopped b/c it was thought to be contributing to his sedation. . 12) Small bowel obstruction: Patient complained of some abdominal pain initially during admission and he continued to have fevers with no source. An abdominal CT done in the middle of his admission showed SBO. During that time the patient was not having abdominal distension or pain, but was more somnolent and spiking temps. Surgery was consulted and recommended stopping tube feeds and placing GJ tube to gravity. His tube feed were re-started when it appeared his ileus was resolving. . 13) Mental stauts changes: Patient became much more somnolent during his stay. His oxycontin and celexa were dc'd and his MS initially improved. Likely [**1-19**] delirium d/t multiple underlying medical issues and also uremia. MRI of the head was attempted but could not be accomplished due to the acuity of his other medical issues. . 14) Fevers: Patient spiked intermittent temps during his stay and had been on fluconazole and vancomycin for much of his hospital course. He finished a 2 week course of fluconazole for [**Female First Name (un) **] bacteremia and vancomycin for MSSA. He was continued on ceftazidime for possible PNA. All blood and urine cultures after [**4-15**] continued to show no growth. CXR was not c/w PNA and left shoulder looked stable. Left knee was likely red [**1-19**] to osteoarthritis but he could have had an underlying osteomyelitis. He was unable to fit in the MRI scanner d/t his knee contracture to further evaluate this. Fevers could have been from SBO, but the exact souce was unknown. Ceftazidime was eventually dc'd d/t concern for AIN. he was also started on flagyl for potential c. diff, though he was not having any BMs. . 15) DM2: He was followed with a RISS and given standing lantus. Medications on Admission: -Glargine 18units qHS -RISS -Pantoprazole 40mg daily -Folate 1mg daily -Tamsulosin 0.4mg qHS -Simvastatin 20mg daily -Furosemide 20mg daily -Thiamine 100mg daily -Atenolol 25mg daily -Vit C 2000mg [**Hospital1 **] -Amylase-lipase-protease tid with meals -Temazepam 30mg qHS -Citalopram 20mg daily -Oxybutynin 5mg tid -Iron 325mg daily -Docusate 100mg [**Hospital1 **] -Nafcillin 2gm q4` ongoing from last admission -Oxycodone 5mg prn Discharge Medications: expired Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 1110**] Discharge Diagnosis: GI bleed CHF Fungemia Discharge Condition: expired

[ "285.1", "V45.3", "427.31", "584.5", "303.93", "996.62", "730.12", "578.9", "585.6", "403.91", "428.0", "511.9", "560.9", "596.54", "117.9", "571.2", "V42.2", "250.80", "293.0", "707.03", "286.7", "518.82", "719.06" ]

icd9cm

[ [ [] ] ]

[ "96.6", "81.91", "39.95", "45.13", "38.95", "96.36", "38.93", "34.91", "88.72", "45.23", "99.04" ]

icd9pcs

[ [ [] ] ]

13150, 13237

4387, 12633

278, 284

13303, 13313

2814, 4364

2167, 2187

13118, 13127

13258, 13282

12659, 13095

2203, 2794

232, 240

312, 1697

1719, 2031

2048, 2151

26,391

178,671

4229

Discharge summary

report

Admission Date: [**2191-2-21**] Discharge Date: [**2191-3-5**] Date of Birth: [**2107-11-7**] Sex: M Service: MEDICINE Allergies: Keflex / Avandia / Aldactone / Levofloxacin Attending:[**First Name3 (LF) 4760**] Chief Complaint: hypoxia at rehab Major Surgical or Invasive Procedure: bronchoscopy and [**First Name3 (LF) **] [**2191-3-3**] History of Present Illness: This is a 83 year-old male with MMP including afib on coumadin, CAD, cardiomyopathy s/p ICD/pacer, T2DM, HTN, hyperlipidemia, and CKD who presents to the ED from rehab with weakness and hypoxia. Pt was recently admitted to [**Hospital1 18**] [**Location (un) 620**] from [**2191-2-2**] to [**2191-2-8**] for weakness and was found to have multifocal PNA. He was initially treated with azithromycin and ceftriaxone. He worsened clinically and continued to have fevers and he was switched to vancomycin and zosyn. He was discharged to rehab to complete his course of ABx. Hospital course was c/b rhabdomyolysis, supratherapeutic INR, transaminitis, and ARF on CRI. . In the ED, vitals on presentation were T 100.6 HR 74 BP 143/74 RR 18 89%2L NC. He was given 1L of NS. He was given levofloxacin 750 mg IV x 1, vancomycin 1 gram IV x 1, and ceftriaxone 1 gram IV x 1. In addition, he was given Tylenol 1 gram PO x 1 and an amp of D50 for a BG of 44. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: CAD, s/p MI, s/p PTCA to the LAD in [**2178**] Cardiomyopathy with ventricular tachycardia, status post ICD placement in [**2185**], status post VT ablation of VT foci in [**2185**] (inferior scarring). History of biventricular bigeminy. Status post CVA in [**2178**] without residual effect Transient Ischemic Attacks Diabetes mellitus type 2, insulin dependent. Obesity. Hypertension. Hypercholesterolemia. Status post right hip replacement in [**2188**]. C-Diff colitis. Status post cholecystectomy. Asthma. AFib - on Coumadin CHF (EF of 35%-40%) Chronic kidney disease, Stage III, with baseline creatinine of 1.9 Question of a TIA in [**2190-4-10**] Early vascular dementia Social History: The patient lives at home. The patient quit smoking 50 years ago. The patient is dependent for his ADLs and walks with a walker. He denied any alcohol or illicit drug use. Family History: Father with coronary disease and diabetes mellitus. Physical Exam: Vitals: T:96.7 BP:145/57 HR:73 RR:28 O2Sat:93% GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2191-2-21**] 08:55PM WBC-12.2* RBC-3.79* HGB-11.3* HCT-33.2* MCV-88 MCH-29.9 MCHC-34.1 RDW-14.2 [**2191-2-21**] 08:55PM NEUTS-70.2* LYMPHS-17.4* MONOS-3.7 EOS-8.2* BASOS-0.5 [**2191-2-21**] 08:55PM PLT COUNT-670*# [**2191-2-21**] 08:55PM PT-20.9* PTT-29.2 INR(PT)-2.0* [**2191-2-21**] 08:55PM GLUCOSE-43* UREA N-20 CREAT-1.6* SODIUM-138 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 [**2191-2-21**] 09:20PM GLUCOSE-44* UREA N-20 CREAT-1.6* SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 [**2191-2-21**] 09:20PM CK(CPK)-51 [**2191-2-21**] 09:20PM CK-MB-NotDone [**2191-2-21**] 10:59PM cTropnT-0.02* [**2191-2-21**] 10:34PM PT-21.7* PTT-32.3 INR(PT)-2.1* Portable CXR, [**2191-2-21**]: The study is limited secondary to profoundly diminished lung volumes and patient positioning. Despite these limitations, there is significant opacification and a patchy distribution throughout the aerated right lung. The findings are most compatible with a pneumonia likely involving the right lower lobe. There is a more hazy linear opacity at the left lung base, likely atelectasis. The remaining left lung is clear. A dual-lead pacemaker is stable in course and position. There is atherosclerotic disease of the aorta again identified. The cardiac silhouette is difficult to assess, but grossly stable. Degenerative changes are noted throughout the thoracic spine. IMPRESSION: Patchy opacities throughout the right lung, presumably the right lower lobe, most compatible with pneumonia. If clinically feasible, consider PA and lateral views to establish a baseline early in treatment. CT CHEST W/O CONTRAST [**2191-2-22**]: COMPARISON: CT of the chest obtained on [**2191-2-7**] in [**Location (un) 620**] and chest radiograph obtained on [**2191-2-21**]. TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to upper abdomen with subsequent 1.25- and 5-mm collimation axial images reviewed in conjunction with coronal and sagittal reformats. FINDINGS: Compared to the prior chest CT obtained two weeks ago, there is interval worsening of the involvement of the right upper lobe and right middle lobe extensive areas of consolidation containing air bronchogram with some slight interval improvement of the right lower lobe consolidations. There is also increase in size of the left lower lobe consolidations with interval development of bilateral small pleural effusions. Several mediastinal lymph nodes are enlarged including right paraesophageal lymph node, 2:32, measuring 13 mm; right lower paratracheal lymph node measuring 14 mm as well as several scattered mediastinal lymph nodes, not pathologically enlarged. Compared to the prior study, this lymph nodes have increased in size in the interval, most likely being reactive. There is no pericardial effusion. The heart size is increased. The position of the pacemaker lead terminating in the right ventricle is unchanged. The imaged portion of the upper abdomen is unremarkable except for calcified splenic artery. There are no bone lesions worrisome for malignancy. Several healed anterior fractures of the lower left rib are noted, unchanged. IMPRESSION: 1. Interval worsening of the multifocal pneumonia, in particular in the right upper and left lower lobes. 2. Small bilateral pleural effusion. 3. Interval additional increase in mediastinal lymphadenopathy, most likely reactive, but should be evaluated with subsequent following study after injection of IV contrast. 4. Status post cholecystectomy. ECHO [**2191-2-23**]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is probably moderately depressed (LVEF= 35-40 %) with inferior and infero-lateral akinesis. There is no ventricular septal defect. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CT Chest [**2191-2-28**]:FINDINGS: Extensive parenchymal abnormality in the contracted right lung, characterized by widespread ground-glass opacification and multiple areas of peribronchial infiltration and septal thickening predominantly in the lower lung is very little changed since [**2-22**]. In the anterior segment of the right upper lobe there is less peribronchial infiltration. More focal regions of consolidation in the left lung predominantly in the lower lobe have improved a little but not resolved, but the left lung is free of the generalized ground- glass opacification. Moderate narrowing of the basal trunk of the right lower lobe bronchus and secretions at the origin of the superior segment are new, but I doubt that they are contributing to respiratory insufficiency. Small nonhemorrhagic bilateral pleural effusions layering posteriorly have decreased. There is no pericardial effusion. Moderate multi-chamber cardiomegaly is stable; marked enlargement of the pulmonary arteries (intrapericardial right PA) measures 30 mm and is unchanged. Atherosclerotic calcification is heavy in the proximal head and neck vessels, all major coronary branches and the descending thoracic aorta but there is no aneurysm. Borderline enlarged central lymph nodes in the right lower paratracheal station at 11 mm were 14.1 mm on [**2-22**]; in the right paraesophageal station nodes have increased to 16 mm from 11 mm at one location, and remain stable at 20 mm in another( 2:26). IMPRESSION: 1. Very little change since [**2-22**] aside from minimal improvement in small peribronchial component of the diffuse infiltrative abnormality in the right lung, and some improvement in more focal consolidation at the left lung base. Findings are not consistent with pulmonary edema, instead suggest organizing pneumonia, either postinfectious or cryptogenic. Since patient has a pacer defibrillator system in place this raises the question of amiodarone toxicity, which can produce widespread pulmonary abnormality, but I do not see the increased attenuation in the liver generally seen with amiodarone administration. 2. Severe atherosclerotic calcification, particularly in the coronary arteries. Stable global cardiomegaly and pulmonary hypertension. . [**2191-3-3**] 8:30 am BRONCHOALVEOLAR LAVAGE RML. GRAM STAIN (Final [**2191-3-3**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. ACID FAST SMEAR (Final [**2191-3-4**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2191-3-3**]): NEGATIVE for Pneumocystis jirovecii (carinii).. . [**2191-3-3**] 8:30 am BRONCHOALVEOLAR LAVAGE HSV AND VZV DFA NOT PERFORMED ON BRONCH LAVAGE. CMV VIRAL LOAD NOT PERFORMED ON BRONCH LAVAGE.. Rapid Respiratory Viral Antigen Test (Final [**2191-3-3**]): Respiratory viral antigens not detected. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. This kit is not FDA approved for the direct detection of respiratory viruses in specimens; interpret negative result with caution.. Refer to respiratory viral culture for further information. Respiratory Viral Culture (Preliminary): VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Virus isolated so far. VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Virus isolated so far. VARICELLA-ZOSTER CULTURE (Preliminary): No Virus isolated so far. Brief Hospital Course: 83 year-old male with MMP including afib on coumadin, CAD, cardiomyopathy s/p ICD/pacer, T2DM, HTN, hyperlipidemia, and CKD who presents to the ED from rehab with weakness and hypoxia. Pt was found to have interstitial lung disease, likely due to amiodarone toxicity. . # Hypoxia/Interstitial Lung Disease/Amiodarone Toxicity: Initially, it was unclear if the patient had truly failed treatment of his prior multifocal pneumonia diagnosed at [**Hospital1 18**] [**Location (un) 620**] and from where he was discharged on [**2191-2-8**] on a total 10 day course of vanc and zosyn or if there was another process occurring. WBC was elevated at 12.8 on admission however the patient was afebrile with a cough without sputum production. Other possible etiologies for the patient's hypoxemia in the setting of his chest CT findings included post-pneumonic inflammatory changes/scar, BOOP. Of note, the pt required 2 L NC prior to admission here. On admission, the patient's acid-base status on ABG looked good 7.43/42/73 on NRB. Although the patient did receive vanc, CTZ, and levo in ED, he was s/p 10 day course of vanc and zosyn and afebrile, without substantial change in radiographic (CT images reviewed with ICU attending Dr [**Last Name (STitle) **] appearance of multifocal opacities, so no antibiotics were administered after the ED doses. The MICU team felt that diuresis initially improved hypoxia somewhat, even though CXR/CT did not look grossly volume overloaded and the patient went into subsequent mild acute on chronic renal failure. On the medicine floor, the patient still required 4 liters O2 by nasal cannula. The patient was not volume overloaded and was not diuresed. He received nebs given history of asthma and noted wheeziness at times. Given possible chronic aspiration ( bilateral lower lobe infilrations), speech and swallow evaluation was obtained which did not show any clear evidence of aspiration. Video swallow eval showed no silent aspiration either. A repeat CT of his chest on [**2191-2-28**] was done (performed due to persistent 4 L O2 requirement). This showed continued multilobular opacities, diffuse ground glass opacities with peribronchial nodular opacities, somewhat more peirpherally based, sparing LUL, with posterior RUL confluence. There was concern for COP or amiodarone toxicity. Pulmonary was consulted and it was felt that the leading diagnostic possibility was BOOP/COP either idiopathic or due to amio. With elevated INR, alveoloar hemorrhage also in differential. Infection and malignancy were felt to be less likely. Felt unlikely that all of his parenchymal opacities, some peripheral and upper zone, were due to aspiration. His eosinophilia was felt to be more c/w drug toxicity or hypersensitivity process. [**Date Range **] was recommended to rule out infection and hemorrhage and assess for pulmonary eosinophilia or lymphocytosis. Amiodarone was stopped due to potential toxicity. This was discusssed with pts cardiologist, Dr. [**Last Name (STitle) **]. Bronchoscopy with [**Last Name (STitle) **] was performed on [**2191-3-3**] and this showed no evidence of [**First Name8 (NamePattern2) 691**] [**Last Name (un) **] or infection. Following bronchoscopy the patient had mild hypotension (requiring 250 cc NS bolus) and mild increase in hypoxia (needing 6 L NC) which resolved after 24 hours (back to 4 LNC). [**Last Name (un) **] sent for for cell count and diff, gram stain and culture, fungal stain and Cx, AFB, mycobacterial Cx, PCP stain, cytology. PCP smear was negative, and fungal stain neg. Rapid respiratory viral antigen test was negative. He had only 15% eosinophils, so not indicative of eosinophilic PNA. Given that staph aureus (sensitivities not yet back) grew out from the bronch, we decided to treat the patient with an 8 day course of Vancomycin (although the staph may just be a colonizer or from subtle aspiration). Vancomycin was started on [**3-4**]. In addition, we started the pt on prednisone 40 mg daily (to be given for 2 weeks and then tapered to 30 mg daily for another 2 weeks until follow up with Dr. [**Last Name (STitle) 575**] of pulmonary in 1 month) to treat for amiodarone toxicity. The pt will need his Vancomycin trough checked on [**3-6**] and redosing of his vancomycin if trough<15. The patient was also started on Ca, VIt D, and prophylactic bactrim theraphy while on steroids. He will need to follow up with Dr. [**Last Name (STitle) 575**] of pulmonary in 1 month from now with a CT scan of the lungs prior to his appointment. . # Weakness/Lethargy: Unclear etiology, likely related to COP/amiodarone toxicity. TSH/CK normal. UA negative for infection. PT and rehab recommended. . # Afib on coumadin: rate controlled. He was on amiodarone for both atrial and ventricular arrhythmias, started in [**11-16**] for PAF. INR therapeutic 2.1 on admission, but after pt had 1-2 days of diarrhea, INR up to 8. He was given 5 mg of Vitamin K on [**2-28**] and again on [**3-1**]. Coumadin was held in setting of need for bronch/[**Last Name (LF) **], [**First Name3 (LF) **] pt was bridged with Lovenox once subtherapeutic (after bronch) given his high risk (h/o TIA, DM, HTN, age). As per above, the pts amiodarone was stopped due to potential toxicity. Case discussed with pts cardiologist Dr. [**Last Name (STitle) **], and per notes it seems pt had been started on amio in [**11-16**] for PAF. INR was 2.2 at discharge, so lovenox was stopped. Pt should have his INR checked at least weekly. . # CAD/Chronic Systolic CHF (EF 35-40%): Continued home regimen of metoprolol and isosorbide; had not been on standing diuretics since recent PNA, but we did diurese total ~2L negative (net) over 2 consecutive days for clinical volume overload, at which point Cr bumped to 2.3; Creatinine trended down to 1.8. Baseline creatinine is documented at 1.9. Given his poor po intake, his home dose of lasix (held since last admission) was not resumed. Given his supratherapeutic INR, his ASA and Plavix were held until his INR trended down. His [**Last Name (un) **] was restarted when his creatinine stabilized, but stopped again when creatinine trended back up to 2.2. Would hold [**Last Name (un) **] currently in setting of poor po intake. . # Delirium on early vascular dementia: Pt with new onset delirium following bronchoscopy on [**3-3**]. He became sleepier and more confused. Suspect this was due to sedation received. At baseline pt knows the year and where he is, but he did not at this time. 24 hours later the pt was still sleepy but able to answer questions appropriately. B12, TSH, and folate were normal. UA was normal. Pt currently is closer to his baseline (less sleepy although still very fatigued, did state year was [**2181**] prior to discharge but able to correct himself, knew he was in the hospital), but with initiation of his steroids his delirium may worsen. . # Type II Diabetes Mellitus, controlled/Hypoglycemia: Had low fs at 44 in ED here, got 1 amp D50. Likely [**3-14**] to poor po intake and continued home insulin dosing. Pt was noted to have poor po intake, so his 70/30 was decreased from 42 U in the AM and 27 U at night to 22 U in the AM and 14 U at night which resulted in hyperglycemia. Ultimately he was placed on 70/30 40 U units in AM and 40 U in PM. Given initiation of steroids, his 70/30 will need to be titrated further. . # Eosinophilia: Pt had an absolute eosinophilia here up to [**2182**]. Felt to be likely due to amiodarone toxicity. Amiodarone was stopped. O and P was negative x1. Differential for his eosinophilia included eosinophilic PNA, drug toxicity (ie amiodarone), Churg [**Doctor Last Name 3532**]. ABPA unlikely given no bronchiectasis. No known malignancy. [**Doctor Last Name **] showed only 15% eos, so not diagnostic for eosinophilic PNA. ANCA was negative. Should continue to trend eosinophils as outpatient. . # Acute Kidney Failure on CKD, Stage III: Cr 1.6, near baseline, on admission. However, his creatinine rose up to 2.3 after diuresis. His creatinine improved to 1.7 after cessation of lasix. Cozaar was reinitiated and creatinine again bumped to 2.2. He was given further IVF and cozaar again held with creatinine trending back down to 2.0 prior to discharge. . # Recent rhabdomyolysis: Off statin and zetia after last hospitalization. CK normal on admission here. . # Hyperlipidemia: Off statin/zetia due to recent rhabdo.His LFTs and CK was normal here. His LDL was 99 (goal less than 70 given his h/o CAD), with HDL of 23. He was started on pravastatin 20 mg daily, and his LFTs/CK should be rechecked in 1 month. . # FULL CODE: Discussed with pt and his family . # ACCESS: Midline placed [**3-5**] prior to discharge (L arm) Medications on Admission: Amiodarone 100 mg PO daily Aspirin 81 mg PO daily Plavix 75 mg PO daily Imdur 20 mg PO daily Cozaar 100 mg PO daily Metoprolol 25 mg PO TID MVI Coumadin 5 mg PO QHS Novolin 70/30 42 units in am and 27 units in pm Vancomycin 1 gm UV q24 hours x 9 days, Zosyn 3.378 gram q6h x 9 days (completed [**2-20**]) Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheeze. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous as directed: For FS of: 150-199 give 2U, 200-249 give 4 U, 250-299 give 6 U, 300-349 give 8 U, 350-400 give 10 U. 15. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 16. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO Monday, Wednesday, Friday. 17. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous q48 hr for 8 days: First dose was evening of [**3-4**]. 18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO as directed: Take 40 mg daily (4 tablets) for 2 weeks, then take 30 mg daily (3 weeks) until you follow up with pulmonary in a month from now. 19. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 20. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Forty (40) units Subcutaneous qam and qpm. 21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Interstitial Lung Disease Amiodarone Toxicity Eosinophilia Hypoxemia Generalized Weakness Delirium Supratherapeutic INR Acute on Chronic Kidney Failure Discharge Condition: stable, satting 95% 4 L NC Discharge Instructions: You were admitted with shortness of breath and weakness. You were noted to have continued changes on your chest imaging which we feel is consistent with an interstitial lung disease. You underwent a bronchoscopy while you were here. We have stopped your amiodarone due to concern that this could be causing some of your symptoms. You were started on steroids, and you will be on these for a long time. Steroids can cause worsening of your diabetes/sugar control, confusion, agitation, and other symptoms. You were also started on an antibiotic called bactrim because steroids can predispose to infections. Due to a bacteria growing from your bronchoscopy, we will treat you with a 8 day course of Vancomycin again. . You were treated with lasix while here to try to remove fluid from your lungs. This resulted in acute kidney failure. Your kidney function has now returned to baseline. . You were also noted to have a high INR. Your coumadin, plavix, and aspirin were held. You were treated with Vitamin K to try to lower your coumadin levels in order to decrease your risk of bleeding. Your coumadin, plavix, and aspirin have all been restarted. . Your cozaar was stopped as you have intermittently had acute renal failure. . Call your doctor or go to the ER for any worsening shortness of breath, wheezing, increased sputum production, fever, chest pain, confusion, dehydration, bleeding, or any other concerning symptoms. Followup Instructions: 1. You need to have a repeat CT scan in 4 weeks from now and follow up with pulmonologist Dr. [**Last Name (STitle) 575**]. Please call his office at ([**Telephone/Fax (1) 513**] to make sure that these are arranged. You should have a CT scan prior to your appointment with Dr. [**Last Name (STitle) 575**] earlier on the same day. If you have any difficulty, please ask to speak with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11622**]. I have already emailed her in advance to try to arrange for these appointments. . 2. [**Hospital **] clinic: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2191-3-15**] 2:30 PM, [**Hospital1 18**] [**Hospital Ward Name 5074**], [**Hospital Ward Name 23**] Building [**Location (un) 436**], [**Telephone/Fax (1) 62**] . 3. Please call Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] to arrange for follow up after your discharge from rehab . 4. Please call Dr. [**Last Name (STitle) **], your cardiologist, after your discharge from rehab to arrange for follow up.

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Discharge summary

report

Admission Date: [**2114-4-22**] Discharge Date: [**2114-5-2**] Date of Birth: [**2038-8-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: Fall Major Surgical or Invasive Procedure: Right Hip Hemiarthroplasty Upper Endoscopy History of Present Illness: 75 yo F with a past medical history of hypertension, hypothyroidism, low back pain, and possible osteoperosis presents s/p fall. Patient was in her USOH when she tripped getting out of the car after dinner with her sister. Of note, she had 2 glasses of wine at dinner. She landed on her right hip, which initially was not uncomfortable. She denies chest pain, LOC, head trauma, dizziness and syncope. She crawled to the stairs of her house but could not get inside. [**Name (NI) **] sister usually calls her after dinner to make sure she arrived home, and she sent her nephew to check on her who found her in the driveway. Patient was initially brought to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. There a CXR was read as consistent with COPD and plain films of the hip and pelvis on the right revealed femoral neck fracture. She was transferred to [**Hospital1 18**] for further care. On ride to ED, patient noted acute onset nausea and vomitted once, which was coffee ground. She was also noted to have tachycardia and received 1.6 L fluids in the ED. She was guaiac negative and found to have a Hct of 32 with no known baseline. She received Dilaudid 1 mg IV x1 and Pantoprazole 40 mg IV x1. She vomitted a total of 3 times. EKG showed sinus tachycardia. Orthopedics evaluated here and advised admit to MICU. On transfer VS were 98.4, 100, 115/60, 16, 94% RA. In the ICU, patient reports [**9-4**] Right hip pain but otherwise feels well. Of note, patient has had chronic low back pain worked up by her PCP and recently had an outpatient MRI last week but she has not received the results of this. She also completed a 10 day prednisone course for her "low back pain", which consisted of 40 mg tablets and completed last Tuesday. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies 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: # Osteopenia vs. osteoperosis # HTN, # Hypothyroid # Low back pain # Dyslipidemia # History of C diff # Right sided inguinal hernia # S/p hysterectomy, # S/p tonsillectomy, # S/p vein ligations Social History: Less than 5 glasses of wine per week; quit tobac 5 years ago (prior 25 pack-year history). Denies illicits or IV drug use. Lives alone in [**Location (un) **]. Not married. No children. Family History: No history of DM, CAD, or osteoperosis Physical Exam: Vitals: T: 97.6 BP: 146/66 P: 110 R: 20 O2: 95% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: easily reducible right inguinal hernia, 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, mild erythema at right hip 6 x6 cm, TTP over femoral neck Pertinent Results: Labs on admission: [**2114-4-22**] 04:00AM PT-12.2 PTT-27.0 INR(PT)-1.0 [**2114-4-22**] 04:00AM PLT SMR-HIGH PLT COUNT-455* [**2114-4-22**] 04:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2114-4-22**] 04:00AM NEUTS-88* BANDS-2 LYMPHS-5* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2114-4-22**] 04:00AM WBC-23.1* RBC-3.74* HGB-10.5* HCT-32.4* MCV-87 MCH-28.0 MCHC-32.3 RDW-13.9 [**2114-4-22**] 04:00AM CALCIUM-7.8* PHOSPHATE-3.0 MAGNESIUM-1.4* [**2114-4-22**] 04:00AM CK-MB-4 cTropnT-<0.01 [**2114-4-22**] 04:00AM LIPASE-59 [**2114-4-22**] 04:00AM ALT(SGPT)-24 AST(SGOT)-24 CK(CPK)-309* ALK PHOS-88 TOT BILI-0.3 [**2114-4-22**] 04:00AM GLUCOSE-98 UREA N-19 CREAT-0.8 SODIUM-125* POTASSIUM-3.8 CHLORIDE-89* TOTAL CO2-24 ANION GAP-16 [**2114-4-22**] 04:55AM URINE GRANULAR-0-2 [**2114-4-22**] 04:55AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2114-4-22**] 04:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [**2114-4-22**] 04:55AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020 IMAGES/STUDIES: ECG [**2114-4-22**]: Sinus tachycardia. Normal tracing except for rate. No previous tracing available for comparison. RIGHT FEMUR AP & LATERAL [**2114-4-22**]: COMPARISON: Reference radiograph of pelvis ([**Hospital1 **] ER; 4 hrs prior). FOUR VIEWS OF THE RIGHT FEMUR: There is a transversely oriented right femoral neck fracture, with overriding of the distal fracture fragment. there is no distal femoral fracture, but there is severe tricompartmental degenerative change in the right knee. At the superolateral aspect of the patella, round, nearly confluent soft tissue calcifications are seen. IMPRESSION: 1. Transversely oriented impacted fracture of the right femoral neck with overriding of fracture fragments. 2. Possibly intra-articular soft tissue calcification which may represent synovial osteochondromatosis, loose bodies, or less likely tumoral calcinosis. Consider MRI for further characterization on a non-emergent, outpatient basis following treatment of the acute hip fracture. SINGLE PORTABLE SUPINE VIEW OF THE CHEST [**2114-4-22**]: The cardiomediastinal contour is normal. The heart is not enlarged. However, the aortic arch is calcified. The lungs demonstrate no focal consolidation or evidence of congestive heart failure. Osseous structures and soft tissues are unremarkable except for moderate degenerative change in the upper lumbar spine, partially imaged. IMPRESSION: No evidence of acute process. URINE CULTURE (Preliminary): ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=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 Brief Hospital Course: 75 y/o F with hx of HTN, hypothyroidism and c.diff colitis who presented with hip fracture and coffee ground emesis. GI bleeding resolved and she had an uncomplicated ORIF of R femur. Recent presented to the ICU with afib with RVR and fevers. Afib resolved. . # Upper GI bleed. Patient was evaluated by the GI and underwent an EGD that did not show any signs of active bleeding. Subsequently she underwent hemiarthroplasty of the right hip and received 1 unit of pRBC intraoperatively. Patient was tachycardic post-operatively and went into afib w/ RVR, however hct remained stable throughout this time. Patient discharged with outpatient GI follow up. - Outpatient follow up . # Right hip fracture: Pain was controlled with standing acetaminophen, lyrica, morphine and lidocaine patch for pain control with good effect. She was evaluated by the orthopedic service who recommended surgical correction once hemodynamically stable and ruled out for active UGIB. After EGD, patient underwent right hip hemiarthroplasty. She was started on lovenox ppx. - Continue PT - [**Name (NI) **] bearing activity as tolerated . # Tachycardia/Atrial fibrillation: While on the medicine floor, the patient was working with physical therapy and developed a HR in the 160s-200s. Per report it was sinus tach, although it was difficult to tell on telemetry. She stopped PT and went back to bed. She continued to be tachycardic around that time and EKG was consistent with sinus tach with Hr 113. On telemetry, her HR went to the 170s again and EKG showed afib with RVR to 180s with SBPs in the 100s. She received 5 mg IV metoprolol and her HR did not respond and her SBPs dropped to the 60s-70s. She was asymptomatic and mentating throughout this episode. After the beta blocker, she pharmacologically cardioverted back to normal sinus rhythm. Her afib was postulated to be due to her diarrhea/dehydration. Subsequently, she was rehydrated and remained in normal sinus rhythm. She further underwent LENIs/CTA of her chest to rule out PE as a cause of her AF. . #Diarrhea: Upon return to the medical ICU, she was found to have diarrhea. Based upon her history of clostridium difficile infection, she was empirically started on vancomycin PO. Cultures were negative for c diff; however, given her c diff history she was continued on po vanc. - Continue po vanc until [**2114-4-18**] - Consider adding flagyl showed diarrhea persists . # UTI: Patient developed UTI started on a 7 day course of bactrim. Urine cx grew ENTEROBACTER sensitive to bactrim. - Continue bactrim until [**2114-4-4**] . # Hyponatremia: Cortisol was normal at 22 at 4:00 am. HCTZ/triamterene was held and pt free water restricted. - Please check Na on [**2114-5-5**] - Holding dyazide - Free water restrict . # Intra-articular soft tissue calcification noted on hip x-ray. Differential includes synovial osteochondromatosis, loose bodies, or less likely tumoral calcinosis. Radiology recommendations are to consider MRI for further characterization on a non-emergent, outpatient basis following treatment of the acute hip fracture as above. - Outpatient follow up . # Hypothyroidism: TSH was low at 0.35. Patient's synthroid was reduced from 70mcg to 50mcg daily, particularly in the setting of tachycardia and atrial fibrillation. . # Dyslipidemia: Continued on home statin. . # Hypertension: Dyazide and ACE inhibitor initially held. Ace-i restarted after EGD and hemiarthroplasty. Dyazide held for hyponatremia Medications on Admission: # triamterene/hydrochlorothiazide 1 tab daily, # simvastatin 40 daily, # levothyroxine 75mcg daily, # alendronate 70 mg weekly, # mvi, # albuterol prn, # lyrica 50 mg daily, # lisinopril 20 mg daily Discharge Medications: 1. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) Subcutaneous DAILY (Daily). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 6. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): To be completed [**2114-5-7**]. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): To be completed [**2114-5-5**]. 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 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. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 16. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing Rehab Center Discharge Diagnosis: Primary: Hip fracture Atrial Fibrillation C diff infection Urinary Tract infection Hypothyroidism Discharge Condition: Weight bearing as tolerated Discharge Instructions: We had the pleasure of taking care of you while you were admitted to [**Hospital1 18**]. You were admitted for hip fracture and underwent surgical repair. While you were here we also did an endoscopy because of concern for vomiting blood, however you endoscopy did not show sign of bleeding. After your surgical procedure you developed an arrythmia called atrial fibrillation which resolved with fluids and treating your c diff infection. We have made the following changes to your medications: 1. We have started you on Lovenox to prevent deep vein thrombosis 2. We have started you on Pantoprazole for reflux 3. We have changed your Synthroid dose from 75mcg daily to 50mcg daily 4. We have started you on folic acid, thiamin, calcium, and vitamin D supplements 5. We have held your alendronate, please follow up with your PCP and [**Name9 (PRE) **] [**Name9 (PRE) 86190**] before restarting this 6. We have started you on oxycodone and tylenol for pain relief. 7. We have started you on senna/colace as stool softners 8. We have started bactrim for a urinary tract infection to end [**2114-5-5**] 9. We have started you on vancomycin for c diff to end [**2114-5-7**] 10. We have started you on albuterol for wheezing or shortness of breath Followup Instructions: Appointment #1 MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Gastroenterology Date/ Time: Tuesday, [**6-5**], 12pm Location: [**Location (un) **], [**Location (un) 86**]. [**Hospital Ward Name 1950**] Building, [**Location (un) **] Phone number: [**Telephone/Fax (1) 463**] Special instructions for patient: You will receive prep information in the mail. Appointment #2 MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Orthopedics Date/ Time: Thursday, [**5-10**], 9:20 Location: [**Hospital Ward Name 23**] Building, [**Location (un) **] Phone number: [**Telephone/Fax (1) 1228**] Special instructions for patient: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2114-5-3**]

[ "041.85", "338.29", "496", "793.7", "578.9", "820.8", "599.0", "427.31", "E824.0", "553.3", "276.50", "733.00", "276.1", "724.2", "E849.0", "550.90", "272.4", "458.9", "244.9", "008.45" ]

icd9cm

[ [ [] ] ]

[ "81.52", "45.13" ]

icd9pcs

[ [ [] ] ]

12645, 12732

7448, 10931

318, 363

12874, 12904

3736, 3741

14198, 15054

3044, 3084

11183, 12622

12753, 12853

10957, 11158

12928, 13397

3099, 3717

13426, 14175

2177, 2606

274, 280

6377, 7425

391, 2158

3755, 6342

2628, 2824

2840, 3028

14,316

183,110

19516

Discharge summary

report

Admission Date: [**2148-7-4**] Discharge Date: [**2148-7-13**] Date of Birth: [**2103-7-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Severe epigastric and L flank pain after ERCP Major Surgical or Invasive Procedure: Ttube cholangiogram [**2148-7-11**] Transjugular liver biopsy [**2148-7-12**] History of Present Illness: ERCP for Bile stricture on [**7-4**], after which he developed severe epigastric pain and L flank pain. Pt. was admitted to [**Hospital Ward Name 26179**]. Past Medical History: 1. Cirrhosis (Hep C/etOH) 2. hepatoma -s/p ablation now on transplant list/evaluation 3. Esophageal varices 4. s/p femur/tibia/fib fx 5. h/o polysubstance abuse Social History: 44 yo man, currently unemployed who lives with girlfriend. h/o alcohol use remission for 5 years tobacco-1ppd X22 yrs h/o cocaine, heroine, amphetamine abuse - none since [**2138**] Family History: mother died of MI at 65 yo Physical Exam: Gen: Alert, oriented, appropriate HEENT: oropharynx without erythema, PERRL, neck supple without masses CV: RRR, no m/r/g Lungs: CTA bilaterally, no crackles/wheezes Abd: soft, nontender to direct palpation, nondistended, +BS, PTC tube in place Ext: 2+ pulses bilaterally, no edema/clubbing/cyanosis Brief Hospital Course: Patient was admitted with severe abdominal pain and significantly elevated LFTs as well as amylase and lipase. He was given liberal iv fluids and pain medication via a PCA. Soon after, pt developed tachycardia into the 100's, hypotension and decreasing urine output. At that time, an ABG was performed and revealed a metabolic acidosis for which the patient was transferred to the SICU for more aggressive fluid resuscitation and monitoring. Throughout this event, the patient was asymptomatic and denied any chest pain/SOB/dizziness. Pt responded well to ivf and was transferred back to the floor the next day. Supportive care was continued although the patient continued to complain of vague abdominal pain waxing and [**Doctor Last Name 688**] throughout the day. A T tube cholangiogram was performed which demonstrated free flow through the bile duct into the duodenum. Subsequently, the patient demonstrated elevated liver function tests for which a transjugular liver biopsy was performed. Medications on Admission: Nadolol 60mg qd, Lactulose 2 tbsp [**Hospital1 **], Carafate Discharge Disposition: Home Discharge Diagnosis: post-ERCP pancreatitis Discharge Condition: Stable Discharge Instructions: Call if fevers, chills, nausea/vomiting, abdominal pain, redness/bleeding from incision. No driving while taking pain medications, may shower. Activity as tolerated, no heavy lifting. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-7-18**] 11:20 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: LM [**Hospital Unit Name 45464**] Phone:[**Telephone/Fax (1) 3681**] Date/Time:[**2148-7-18**] 11:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-7-25**] 9:00 Completed by:[**2148-7-13**]

[ "E879.8", "458.29", "997.5", "070.70", "577.0", "251.8", "276.2", "785.0", "576.2", "997.4", "996.82", "284.8", "794.4" ]

icd9cm

[ [ [] ] ]

[ "50.11", "99.04", "51.87", "38.91", "87.54" ]

icd9pcs

[ [ [] ] ]

2498, 2504

1390, 2387

358, 437

2571, 2579

2811, 3423

1022, 1050

2525, 2550

2413, 2475

2603, 2788

1065, 1367

273, 320

465, 622

644, 806

822, 1006

50,520

167,360

44997

Discharge summary

report

Admission Date: [**2110-1-22**] Discharge Date: [**2110-2-1**] Date of Birth: [**2026-5-8**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: hypernatremia Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Mrs. [**Known lastname **] is an 83 yo female with dementia and B12 deficiency who presented to her PCP's office today for an epi visit with her son who described the patient as having worsening mental status and increased lethargy for the past 1.5 weeks, being difficult to arouse and eating and drinking less. Her son also reported a nonhealing sacral decubitus ulcer that keeps opening and draining; has been followed by VNA as outpatient. The patient is nonverbal at baseline, but normally eats when prompted to do so. Son does not think she's had a fever, no obvious changes in bowel or bladder pattern (is incontinenet of urine, has to have bowel clean out with weekly). Vital signs at PCP's office were: rectal temp 98.7 BP faint at 84/54 (verified systolic by palp)RR 12. Concern existed at that time for sepsis, and the PCP recommended [**Name9 (PRE) **] evaluation and admit. . In the ED, initial vs were: T96.6 84 106/69 16 96% on ?4L NC. Labs drawn were notable for a sodium of 169, chloride of 130 and BUN/Cr of 29/1.2 (BL 17/1.0). Patient was given 2L NS and started on 1/2NS. Initially to be admitted to floor but was thought to require too much nursing care and changed to MICU admission. . On the floor, patient very lethargic, responds to voice but nonverbal, inconsistently following simple commands. . Review of sytems: (+) Per HPI (-) unable to obtain currently. Past Medical History: Alzheimer's Dementia B12 Deficiency Anemia Depression Sacral decubitus ulcers h/o urinary incontinence Social History: Lives at home with 24 hr care and VNA for decubitus ulcer care. Son, [**Name (NI) **], who is HCP is nearby and very attentive to patient. Family History: unable to obtain Physical Exam: Gen: Thin, cachectic appearing elderly female, difficult to arouse, follows some commands, but not able to cooperate with majority of exam. HEENT: Per ED: pupils unequal, left pinpoint, with lid lag, right 4mm and nonreactive, but cataract overlying. Here: R minimal reactive and sluggish (3.5->3), unable to visualize L pupil due to patient resistance (also resists opening of R eye). Neck: Flat jugular veins. COR: RRR, soft SM at LUSB. LUNG: unable to cooperate with exam, generally quite decreased with rhonchi at RLL ABD: soft, patient winces to palpation diffusely, no masses appreciated, no r/g. RECTAL/BACK: 2-3 cm stage 2 decubitus sacral ulcer, does not appear infected, clean base. duoderm dressing in place. Neuro: able to open eyes with prompting, squeezes hand lightly to verbal command, does not follow command to move toes/LEs. Pertinent Results: CXR [**2110-1-22**]: IMPRESSION: 1. No focal consolidation. 2. Dilated loops of bowel. 3. Possible chronic interstitial lung disease. KUB [**2110-1-23**]: PENDING [**2110-1-22**] 05:55PM BLOOD WBC-8.8 RBC-4.69 Hgb-14.3 Hct-43.5 MCV-93 MCH-30.4 MCHC-32.8 RDW-15.1 Plt Ct-132* [**2110-1-23**] 04:15AM BLOOD WBC-9.8 RBC-4.05* Hgb-12.4 Hct-38.5 MCV-95 MCH-30.6 MCHC-32.1 RDW-14.8 Plt Ct-119* [**2110-1-22**] 05:55PM BLOOD Neuts-86.6* Lymphs-10.5* Monos-2.2 Eos-0.6 Baso-0.2 [**2110-1-23**] 04:15AM BLOOD Neuts-87.7* Lymphs-8.3* Monos-2.5 Eos-1.4 Baso-0.1 [**2110-1-22**] 05:55PM BLOOD PT-12.2 PTT-24.9 INR(PT)-1.0 [**2110-1-22**] 05:55PM BLOOD Glucose-130* UreaN-29* Creat-1.2* Na-169* K-3.9 Cl-130* HCO3-30 AnGap-13 [**2110-1-22**] 08:40PM BLOOD Glucose-107* UreaN-27* Creat-1.0 Na-169* K-3.5 Cl-131* HCO3-29 AnGap-13 [**2110-1-23**] 04:15AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-159* K-3.3 Cl-126* HCO3-25 AnGap-11 [**2110-1-22**] 09:00PM BLOOD CK(CPK)-216* [**2110-1-22**] 09:00PM BLOOD CK-MB-5 cTropnT-0.11* [**2110-1-22**] 05:55PM BLOOD Calcium-9.7 Phos-2.7 Mg-2.9* [**2110-1-23**] 04:15AM BLOOD Albumin-3.0* Calcium-7.9* Phos-2.2* Mg-2.1 [**2110-1-23**] 04:15AM BLOOD TSH-1.4 [**2110-1-22**] 05:53PM BLOOD Glucose-126* Lactate-2.6* Na-171* K-4.0 Cl-120* calHCO3-28 [**2110-1-29**] 07:01AM BLOOD WBC-9.4 RBC-3.20* Hgb-9.7* Hct-28.2* MCV-88 MCH-30.3 MCHC-34.4 RDW-15.0 Plt Ct-202 [**2110-1-29**] 07:01AM BLOOD Plt Ct-202 [**2110-1-29**] 07:01AM BLOOD Glucose-67* UreaN-13 Creat-0.7 Na-138 K-3.6 Cl-107 HCO3-27 AnGap-8 [**2110-1-25**] 05:41AM BLOOD TSH-1.9 . .. . URINE ADD ON @1446 CHEM# [**Serial Number 96186**]D. **FINAL REPORT [**2110-1-27**]** URINE CULTURE (Final [**2110-1-27**]): KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. KLEBSIELLA OXYTOCA. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | KLEBSIELLA OXYTOCA | | AMPICILLIN/SULBACTAM-- 4 S 4 S CEFAZOLIN------------- 8 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R . . . CXR Final Report AP CHEST, 7:33 P.M., [**1-26**] HISTORY: Dementia and fever. IMPRESSION: AP chest compared to [**1-22**] and 4: Peripheral opacity at the base of the right lung has increased in size in radiodensity over the past three days. This has been ascribed to surgery in the breast, but could be a small mass or infection in the lung and warrants conventional radiographs including obliques when feasible. Lungs are otherwise clear, mildly hyperinflated. Heart is mildly enlarged, but there is no pulmonary vascular engorgement, edema or effusion. In the upper abdomen, the colon is moderately distended. Left PIC catheter ends in the mid-to-upper SVC and a nasogastric tube ends in the upper stomach. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] LI DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: MON [**2110-1-27**] 12:55 PM . . Brief Hospital Course: --- pt could not leave earlier as she had to complete her antibiotic course. -- 83F with dementia and b12 deficiency anemia who presented with worsening functioning, decreased po intake, now admitted with hypernatremia which is resolving. . # Dementia: appears to be subacute on chronic due to alzheier's/B12. unclear etiology. head CT shows slight increase in ventriculomegaly from [**2106**] which can be seen in NPH. spoke with neuro who feels that NPH is unlikely given her ambulation cannot be assessed. also notes that clinical resolution of hypernatremia can trail lab resolution by weeks to months. may also be due to UTI. TSH, B12, folate wnl. pt did not pass S+S, had palliative care involved with family mtg where it was determined that the pt would be [**Year (4 digits) 3225**]. NG tube and meds d/c'd, she is to have PO diet (thin liquids) as she wishes for comfort. she was sent home with hospice with morphine and tylenol for comfort. . # Low grade temps: Patient p/w with worsened mental status, poor po intake, rectal temp 98.7, and initial hypotension. Has sacral decub. Initially oncerning for infectious process. No signs of sepsis or hypothermia since admission. UCx with >100K GNRs, Klebsiella, cipro sensitive, which she completed treatment for. The pt also subsequently developed a RLL/RML infiltrate concern for aspiration from her tube feeds. she received levo/flagyl for 4 days, however, pt was made [**Year (4 digits) 3225**] so we d/c'd NG tube and meds. . #. Dilated loops of bowel: at baseline, per [**Name (NI) **], pt only has approx one BM per week with laxative use. Could be due to chronic constipation, but wished to rule out obstruction, ileus, or pseudo-obstruction. KUB no e/o obstruction. had good relief with colace, senna, bisacodyl and soap suds enema. now d/c'd for comfort measures and pt not eating much. . # Hypernatremia: Na 169 initially, 149 on xfer. Given dementia and low baseline functional status, likely secondary to impaired access to free water, but also another contributing etiology such as infection/sepsis, impaired PO intake from bowel obstruction or pseudoobstruction, MI must be considered. No medications other than B12 to explain increase in serum Na, also son does not report recent diarrhea, polyuria, or fever to suggest extra-renal losses or DI. Calculated Free H20 deficit estimated at 4.70L based on 100 kg (likely less than this). Uosm not consistent with DI. Corrected hypovolemia with NS 1L bolus. Sodium improved to normal range after receiving 75 cc/hr of D5W (total amt IVFinfused: ~4L). . # Decubitus ulcer. stage II, no evidence of superinfection initially. recent concern for prurulent drainage. can image with MRI if concern for early osteo. wound care RN followed and was not concerned for infx. . # Anemia: has h/o B12 def. HCT stable at 43.5. Last Vit B12 and folate levels normal on [**2110-1-3**] at 850 and 7.2. Last injection on [**2109-12-24**], per [**Date Range **]. B12 levels 1800 this admission. gave monthly B12 dose. Fe studies c/w anemia of chr disease. . # Hyperglycemia: noted to have blood glucose greater than 500s after D5 1/2NS during this admission. pt does not have apparent h/o DM appears to be new onset DM. RISS d/c'd now that pt is [**Name (NI) 3225**]. . # Pulmonary nodules: seen in RLL of lung on KUB (not seen on chest films); will not pursue as pt is now [**Name (NI) 3225**]. . # ARF. Likely hypovolemia/prerenal. resolved after volume resuscitation. . FEN: po diet with thin liqs as tolerated for comfort . Prophylaxis: none now that pt is [**Name (NI) 3225**] . Access: none now that pt is [**Name (NI) 3225**]. . Code: DNR/DNI // [**Name (NI) 3225**] . Communication: son and HCP, [**Name (NI) **] [**Name (NI) **], cell: [**Telephone/Fax (1) 96187**] Medications on Admission: Cyanocobalamin 1,000 IM monthly Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 1-20 mg PO q1h as needed for pain or respiratory distress. Disp:*90 ml* Refills:*0* 2. Acetaminophen 160 mg/5 mL Solution Sig: Four (4) PO Q6H (every 6 hours) as needed for pain or comfort. Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 9995**] Discharge Diagnosis: Primary: end stage dementia (alzheimer's and B12 related) hypernatremia UTI aspiration pneumonia due to tube feeds acute renal failure . Secondary: chronic sacral decubitus ulcer constipation Discharge Condition: Mental Status: Confused - always Level of Consciousness: Lethargic but arousable Activity Status: Bedbound Discharge Instructions: You were admitted due to a high sodium level and urinary tract infection. You were treated with both effectively; however, your mental status and alertness did not improve. You were started on tube feeds temporarily; however, given that you did not improve there was concern that the tube feeds would not provide you with ultimate comfort and benefit as you already had developed a likely aspiration event (pneumonia). It was ultimately determined that you would be made comfort measures only and sent home with hospice. We discontinued your IV lines and feeding tube. Please eat and take medications that will optimize your comfort. . Please take all medications as prescribed. Please do not hesitate to return to the hospital for any concerning symtoms at all. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2110-3-25**] 12:10 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2110-6-24**] 11:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2110-12-30**] 11:30

[ "276.0", "294.10", "287.5", "041.3", "584.9", "707.22", "707.03", "311", "331.0", "507.0", "281.1", "599.0", "294.8", "564.00" ]

icd9cm

[ [ [] ] ]

[ "96.07", "38.93" ]

icd9pcs

[ [ [] ] ]

10730, 10808

6609, 10385

328, 350

11044, 11044

2962, 6586

11968, 12375

2063, 2081

10467, 10707

10829, 11023

10411, 10444

11177, 11945

2096, 2943

275, 290

1718, 1764

378, 1700

11059, 11153

1786, 1891

1907, 2047

47,967

175,890

38534

Discharge summary

report

Admission Date: [**2194-7-4**] Discharge Date: [**2194-7-11**] Date of Birth: [**2122-2-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 72 year old spanish speaking woman with a history of a hemorrhagic CVA in [**2164**] s/p craniotomy, hypertension, hyperlipidemia, admitted to [**Hospital3 **] on [**7-1**] with two weeks of increased confusion at home, slurred speech and conversation not making any sense, unsteady gait, weakness, and substernal chest pain. . First presented to LGH [**2194-6-30**] where she was 141/80 p82 rr18 98%RA. She had a positive UA for infxn (Proteus Vulgaris, per report) and she was given either Levaquin, Rocephin, or [**Name (NI) **] (unclear). CK was 123, MB 2.3, and TropI 0.03, subsequently "negative x3." Other labs significant for hypercalcemia at 10.4, WBC 7.9, Hct 30.8 (normocytic), Plts 425k. Chemistry unremarkable, Cr 1.1. EKG was non specific with some ST changes in II. CT of head negative x2 for acute process with post-operative changes, chronic ischemic changes. Carotid duplex study pending. . Stress test positive for inferior ischemia (? unclear if pt got the stress test, reports indicate that she was too agitated to sit still for it). Cathed today and found to have a tight proximal 90% PDA lesion. 5 French sheath in RFA. On aspirin only, has not been prescribed plavix. Daughter speaks english and has signed consent, will come with patient. Past Medical History: Cerebral aneurysm s/p cerebral (MCA) hemorrhage in [**2164**], s/p craniotomy and repair (clip placement) --> anterior temporal frontal encephalomalacia Patchy white matter disease changes in the periventricular and subcortical white matter HTN HL Social History: lives with her daughter. non-[**Name2 (NI) 1818**] non-drinker Family History: N/C Physical Exam: On admission to ICU: 97.5 183/83 p98 19 98%RA Large hispanic woman in no distress but with eyes closed and moaning. Opens her eyes to voice and follows simple commands but moans or says nonsensical things and dozes back off if not stimulated. Not in respiratory distress. Corneas with bilateral cataracts, pupils are constricted, but EOMI are grossly intact and sclera normal appearing No jugular distention noted. CTAB no w/c/r/r noted anteriorly, good air movement Regular rhythm but tachycardic, no murmurs or gallops are heard. Bilateral radial and DP's pulses palpable Abd soft, NT ND, BS hyperactive No BLE edema No rashes noted Pt responsive but not coherently. Opens eyes to commands but doesn't answer questions appropriately. Pupils constricted to 1-2mm, EOMI grossly intact. No facial droop noted. Dysarthria unable to be appropriately tested. Spontaneously moving all four extremities, with normal tone, not rigid. Pertinent Results: OSH: - UA/UCx: >100k Proteus Vulgaris: resistant--amp, nitrofurantoin, tetracycline, cefuroxime, cefazolin sensitive--ceftazadime, ceftriaxone, gent, levaquin, pip-tazo, tobra, bactrim, cefoxitin, [**Name2 (NI) 9847**] -CARDIAC CATH performed at OSH demonstrated: 90% PDA stenosis AO 148/76 (106) LV 156/4,11 AO 157/71 (107) LV 161/3,10 . [**2194-7-8**] 3:06 pm URINE Source: Catheter. **FINAL REPORT [**2194-7-9**]** URINE CULTURE (Final [**2194-7-9**]): NO GROWTH. Brief Hospital Course: # Coronary Artery Disease: The patient was transfered for cardiac catheterization. Although the patient was found to have 90% PDA lesion, her symptoms and stress test were unclear. It was thought that the patient could benefit from medication managment of CAD with ASA, increased statin and addition of betablocker. Therefore, she did not undergo repeat cardiac catheterization. Plavix was stopped. If she does develop more chest pain in the future, she could have further optimization of anti-anginal medications and then undergo repeat stress testing. . # Agitation/Altered Mental Status: Patient became agitated in the pre cath area and was given multiple doses of haldol. This agitation was attributed to delirium [**3-11**] UTI. She was transferred from the CCU to the medicine service on [**2194-7-5**]. She did well with the resolution of her UTI. . She was started on nighttime Zyprexa which we should be stopped in two weeks. . #HCT Drop: Thought to be [**3-11**] Groin oozing into her leg. Bedside doppler was negative for pseudoanneurysm and there were no bruits on exam. Her HCT stabilized. This was complicated by iron deficiency anemia, for which she was started on iron with vitamin C. . # Urinary Tract Infection: At the outside hospital prior to transfer, she was noted to have a Proteus UTI, and was started on levofloxacin on [**2194-6-30**], switched to ceftriaxone on [**7-1**], then to ciprofloxacin on [**7-3**], based on culture data. While here she was treated with ciprofloxacin, initially IV due to agitation, and later with PO. She completed her course in house . # s/p Arthroscopy: Patient had R knee arthroscopy at [**Hospital3 12748**] in [**4-16**] per her daughters. [**Name (NI) **] right knee was initially noted to be more swollen than the left, but with no obvious effusion. She was given one dose of vancomycin, ultimately, her right knee did not appear infected w/o small amount of suprapatellar swelling but no effusion, warmth or pain on movement. Vancomycin was discontinued. Medications on Admission: Home medications: Multivitamin ASA Lovaza (omega 3 fish oils) . MEDICATIONS ON TRANSFER: Simvastatin asa 81mg Plavix 600mg prior to cardiac catheterization seroquel Ancef 1g given at 8am ([**7-4**]?) vs Ciprofloxacin Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*15 Tablet(s)* Refills:*2* 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) for 2 weeks. Disp:*7 Tablet, Rapid Dissolve(s)* Refills:*0* 10. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of greater [**Location (un) **] Discharge Diagnosis: Urinary Tract Infection Coronary Artery Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for chest pain, and for possible coronary catheterization. While here you were noted to be confused. You were found to have a urinary tract infection, and were treated with the antibiotic ciprofloxacin. Followup Instructions: Please arrange to see your primary care doctor within one week of discharge. . PCP [**Name Initial (PRE) 648**]: Tuesday, [**2194-7-15**] @4:15pm With: Dr. [**First Name8 (NamePattern2) 1399**] [**Last Name (NamePattern1) **] Location: [**Location (un) 85714**], #204-[**Hospital1 487**] [**Numeric Identifier 85352**] Phone: ([**2194**] Department: GASTROENTEROLOGY When: FRIDAY [**2194-7-25**] at 1:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2194-7-11**]

[ "E879.0", "285.1", "401.9", "583.9", "272.4", "998.12", "E947.8", "584.9", "434.90", "041.6", "599.0", "414.01", "293.0", "V12.54" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7147, 7222

3512, 4090

336, 342

7314, 7314

2979, 3489

7714, 8386

2004, 2009

5810, 7124

7243, 7293

5568, 5568

7467, 7691

2024, 2960

5586, 5632

275, 298

370, 1637

7329, 7443

5657, 5787

1659, 1908

1924, 1988

7,386

105,665

24388

Discharge summary

report

Admission Date: [**2109-6-13**] Discharge Date: [**2109-6-20**] Date of Birth: [**2039-12-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: hypotension s/p BiV-ICD placement in OR Major Surgical or Invasive Procedure: Surgical epicardial lead placement of BiV pacemaker Placement of BiV pacemaker. Central line placement. History of Present Illness: 69M with DM, non-ischemic CM (EF 20-25%)s/p bivi/ICD placement in OR with hypotension/decreased urine output. Clean coronaries on cath 4/[**2108**]. Attempt at BiVi implant in [**Country 11150**] unsuccessful. Transfer to [**Hospital1 18**] [**6-12**] for re-attempt. RV lead placed OK but could not place CS lead. To OR [**6-14**] for epicardial LV lead. Tolerated procedure well. Post op, SBP down to 80s from baseline 110-120, UOP down to 9cc/hr. Pt has received 3L IVF since OR. Past Medical History: CM (EF 20-25%) LBBB DM CRI Enlarged prostate Social History: pt traveled from [**Country 11150**] for BiV-ICD placement. Nephew is radiologist here at [**Hospital1 18**] Physical Exam: T: 101.8/100.8 P: 100-110 BP:99-110/57-63 RR: 18-27 )2: 98-99% I/O: 4610/1050 (630ccUOP, 350 cc CT (dark serosanguinous drainage) CT no longer on wall suction Gen: pt sitting up in bed, appears uncomfortable, but NAD HEENT: PERRL, sclerae anicteric, mm-dry; no JVP appreciated Cardiac: rrr; +SEM, ? diastolic murmur lungs: cta ant abd: soft, + distention, no suprapubic pain but diffuse upper epigastric pain on palpation (LUQ most signficant pain per pt) ext: warm/dry; +DP pulses Pertinent Results: [**2109-6-13**] 10:00AM GLUCOSE-124* UREA N-21* CREAT-1.2 SODIUM-140 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14 [**2109-6-13**] 10:00AM CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-2.0 [**2109-6-13**] 10:00AM WBC-7.7 RBC-5.36 HGB-13.5* HCT-42.5 MCV-79* MCH-25.1* MCHC-31.7 RDW-18.1* [**2109-6-13**] 10:00AM PLT COUNT-280 [**2109-6-13**] 10:00AM PT-11.7 PTT-20.4* INR(PT)-0.9 Brief Hospital Course: Mr. [**Known lastname 1603**] is a 69M who is s/p operative BiV/ICD placement c/b hypotension and decreased urine output. In particular, after placement of BiV pacemaker/ICD, the patient developed hypotension. He was placed on Neosynephrine for a short period of time and responded well with MAPs >65. Initially the differential of the hypotension included sepsis, cardiogenic shock, tamponade, and dehydration. However, 2 ECHO's did not show evidence of tamponade, and the swan catheter did not support cardiogenic shock. The fever and elevated white count was consistent with sepsis, especially in the setting of presumed PNA and lung infiltration. Zosyn and vanco were started for presumed nosocomial infection or infection d/t surgery. BB, ACE, and lasix, and aldactone were initially held, but losartan waw restarted and titrated up to home dose, and [**Last Name (un) 61755**] was started and kept at 1/2 home dose. Lasix IV was subsequently used when patient demonstrated fluid overload, improving the patient's breathing and clinical status. After pacemaker/ICD placement on [**6-13**], the patient was started on Vanc per recommendations of CSurg. He was atrial-sensed and v-paced. On [**6-16**] he was found to be in a-fib and intermittent VT. Initially the plan was to wait until [**6-17**] for DCCV and load the patient with ibutilide and lidocaine and start him on amio on [**6-16**]. However, the patient was hypotensive and concern there was concern that was causing this hypotenion. The patient was cardioverted on [**6-16**] and returned to sinus rhythm (V paced). In regards to ID, the Pt spiked a fever to 101.8 post-op. Pneumonia was considered as a cause of the fever and hypotension for several reasons, including complicated OR course of intubation and adjusting lung volumes as needed for placement of leads of pacemaker, developing a new productive cough, and having infiltrates on CXR. Pt was started on vancomycin per protocol of pacemaker placement and given dose of levofloxacin in PACU for fever. However, in the CCU levo was changed to zosyn due to concern for nocosomial infection and to avoid prolongued QT interval, and this was continued until discharge. Laboratory data did not definitively confirm the source of infection, as sputum cultures revealed only moderate growth of oropharyngeal flora ([**6-17**], after antibiotics had already begun), urine cultures were negative, and blood cultures did not demonstrate growth. In regards to his CHF and cardiac status, digoxin was held d/t dig toxicity (level 1.3), while ASA and zocor were continued. As hypotension improved metoprolol was added, as well as losartan and coreg. BP tolerated these medication additions well Patient has underlying diabetes and was placed on an insulin sliding scale while in the hospital. He also received SQ heparin and protonix as prophylactic measures for DVT and gastric bleed, respectively. The patient remained full code during this hospitalization. Medications on Admission: losartan 100 lasix 40 aldactone 25 digoxin 0.25 M-F, hold S and Sun Coreg 12.5 [**Hospital1 **] Ticlid (held 4d PTA) ASA 325 (held 2d PTA) MVI Terazosin 2 protonix 40 amaryl 2 zocor 5 Insulin H. Actrapid 20-20-0, H. Mixtard 0-0-26 Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take a total of 400 mg (2 tablets) [**Hospital1 **] for 2 days (until [**6-23**]), then take 200 mg (1 tablet) [**Hospital1 **] for 7 days, then take 200 mg (1 tablet) qD from then on. Disp:*120 Tablet(s)* Refills:*0* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 9. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig: One (1) ML Injection ONCE (once) for 1 doses. 10. Please return to your normal insulin regimen. Discharge Disposition: Home Discharge Diagnosis: Non-ischemic cardiomyopathy Type 2 Diabetes Hypertension Cardiac Arrhythmia Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 1.5 liters per day. Take your medications as instructed. Please follow up with electrophysiology on [**6-28**]. Followup Instructions: DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2109-6-28**] 1:30pm. You will have an appointment with Dr. [**Last Name (STitle) **] after your device clinic appointment.

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icd9cm

[ [ [] ] ]

[ "38.93", "99.62", "00.53", "37.26", "00.52" ]

icd9pcs

[ [ [] ] ]

6565, 6571

2105, 5099

355, 461

6690, 6698

1695, 2082

6979, 7209

5380, 6542

6592, 6669

5125, 5357

6722, 6956

1191, 1676

276, 317

490, 982

1004, 1050

1066, 1176

31,136

148,910

9057

Discharge summary

report

Admission Date: [**2131-4-10**] Discharge Date: [**2131-4-20**] Date of Birth: [**2065-10-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Bronchoscopy Lumbar Puncture History of Present Illness: 65 year old female with hx of CLL with c/o fever x 2 days up to 101.9. She is currently day 23 s/p second cycle of FCR (Fludarabine, Cytoxan and Rituxan). She was referred to the ED given concern for potential febrile neutopenia. She does c/o some lightheadedness and nausea as well as poor appetite. She is without cough or diarrhea, CP, SOB, n/v, dysuria, change in bowel or bladder habits. In the Ed Tmax 100.1, received cefepime 2gm IV. Then SBP dropped to 80s, at which point vancomycin was added. She was given roughly 3.5L NS and her SBP improved to 90-100's and remained stable for several hours prior to transfer. Currently, pt feels well. No specific complaints other than decreased appetite. Denies LH/dizziness, cp, sob, n/v, abd pain, diarrhea, dysuria. Past Medical History: 1. CLL. Please refer to OMR note [**2131-4-4**] for extensive details. 2. Extrapulmonary TB s/p 6 months of 4-drug therapy with rifampin, INH, ethambutol, and pyrazinamide. 3. Hypothyroidism 4. OA Social History: From [**Country 27587**]. Tobacco: [**1-5**] PPD x 45 years, no alcohol, other drugs. Lives at home with her husband, daughter, and grandson. Owns and works at her own business "Helping hands" as a home health aide. Family History: NC Physical Exam: VITALS: T 99.8, hr 98, bp 104/53, rr 16, sat 100%ra GENERAL: Pleasant woman, comfortable, D HEENT: Oropharynx is clear, without any erythema, lesions, or thrush. NECK: Supple, no JVD CHEST: Clear to auscultation. HEART: Regular rate and rhythm, S1, S2, no clicks, murmurs, or rubs. ABDOMEN: Normal bowel sounds, soft and nontender with a mild distention without hepatomegaly. EXTREMITIES: Without edema, clubbing, or cyanosis. SKIN: Warm, dry, and intact without any rashes. Neuro: AAOx3 Pertinent Results: [**2131-4-10**] 05:15PM WBC-3.1*# RBC-3.05* HGB-9.6* HCT-27.2* MCV-89 MCH-31.6 MCHC-35.4* RDW-19.1* [**2131-4-10**] 05:15PM NEUTS-30* BANDS-0 LYMPHS-59* MONOS-5 EOS-1 BASOS-0 ATYPS-5* METAS-0 MYELOS-0 [**2131-4-10**] 05:15PM PLT SMR-VERY LOW PLT COUNT-76* [**2131-4-10**] 05:15PM GLUCOSE-124* UREA N-15 CREAT-0.9 SODIUM-135 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-15 [**2131-4-10**] 05:34PM LACTATE-1.9 [**2131-4-10**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2131-4-10**] 09:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004 [**2131-4-10**] 05:15PM BLOOD WBC-3.1*# RBC-3.05* Hgb-9.6* Hct-27.2* MCV-89 MCH-31.6 MCHC-35.4* RDW-19.1* Plt Ct-76* [**2131-4-12**] 07:55AM BLOOD WBC-2.0* RBC-2.61* Hgb-8.3* Hct-23.6* MCV-90 MCH-31.8 MCHC-35.3* RDW-18.4* Plt Ct-58* [**2131-4-13**] 09:20AM BLOOD WBC-1.9* RBC-3.01* Hgb-9.6* Hct-26.8* MCV-89 MCH-31.8 MCHC-35.7* RDW-17.4* Plt Ct-51* [**2131-4-14**] 05:11AM BLOOD WBC-1.6* RBC-3.15* Hgb-9.9* Hct-28.7* MCV-91 MCH-31.5 MCHC-34.6 RDW-17.8* Plt Ct-52* [**2131-4-19**] 07:25AM BLOOD WBC-3.6* RBC-3.25* Hgb-10.1* Hct-29.3* MCV-90 MCH-31.0 MCHC-34.4 RDW-17.2* Plt Ct-64* [**2131-4-20**] 07:25AM BLOOD WBC-5.3 RBC-3.37* Hgb-10.6* Hct-30.3* MCV-90 MCH-31.6 MCHC-35.2* RDW-17.3* Plt Ct-66* [**2131-4-10**] 05:15PM BLOOD Neuts-30* Bands-0 Lymphs-59* Monos-5 Eos-1 Baso-0 Atyps-5* Metas-0 Myelos-0 [**2131-4-19**] 07:25AM BLOOD Neuts-34* Bands-0 Lymphs-52* Monos-4 Eos-2 Baso-1 Atyps-6* Metas-1* Myelos-0 [**2131-4-20**] 07:25AM BLOOD Neuts-31* Bands-0 Lymphs-59* Monos-6 Eos-1 Baso-0 Atyps-3* Metas-0 Myelos-0 [**2131-4-11**] 07:05AM BLOOD Gran Ct-600* [**2131-4-12**] 07:55AM BLOOD Gran Ct-560* [**2131-4-13**] 09:20AM BLOOD Gran Ct-740* [**2131-4-14**] 05:11AM BLOOD Gran Ct-560* [**2131-4-15**] 12:37AM BLOOD Gran Ct-580* [**2131-4-15**] 11:04PM BLOOD Gran Ct-1010* [**2131-4-17**] 07:35AM BLOOD Gran Ct-1170* [**2131-4-18**] 07:30AM BLOOD Gran Ct-1130* [**2131-4-19**] 07:25AM BLOOD Gran Ct-1260* [**2131-4-20**] 07:25AM BLOOD Gran Ct-1130* [**2131-4-10**] 05:15PM BLOOD Glucose-124* UreaN-15 Creat-0.9 Na-135 K-4.1 Cl-102 HCO3-22 AnGap-15 [**2131-4-11**] 07:05AM BLOOD Glucose-118* UreaN-9 Creat-0.7 Na-136 K-3.8 Cl-106 HCO3-21* AnGap-13 [**2131-4-12**] 07:55AM BLOOD Glucose-114* UreaN-9 Creat-0.6 Na-134 K-4.2 Cl-108 HCO3-19* AnGap-11 [**2131-4-20**] 07:25AM BLOOD Glucose-120* UreaN-9 Creat-0.6 Na-138 K-3.9 Cl-105 HCO3-27 AnGap-10 [**2131-4-11**] 07:05AM BLOOD ALT-12 AST-26 LD(LDH)-255* AlkPhos-79 TotBili-0.4 [**2131-4-13**] 09:20AM BLOOD ALT-13 AST-27 LD(LDH)-281* AlkPhos-83 TotBili-0.5 [**2131-4-18**] 07:30AM BLOOD ALT-9 AST-25 LD(LDH)-223 AlkPhos-141* TotBili-0.4 [**2131-4-20**] 07:25AM BLOOD ALT-15 AST-32 LD(LDH)-232 AlkPhos-123* TotBili-0.4 [**2131-4-13**] 03:24PM BLOOD proBNP-4610* [**2131-4-11**] 07:05AM BLOOD Albumin-3.3* Calcium-7.4* Phos-2.5* Mg-1.7 [**2131-4-13**] 09:20AM BLOOD Albumin-2.9* Calcium-7.6* Phos-2.4* Mg-2.1 UricAcd-3.6 [**2131-4-15**] 12:37AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.8 [**2131-4-17**] 07:35AM BLOOD Albumin-2.7* Calcium-7.5* Phos-1.8* Mg-2.0 [**2131-4-19**] 07:25AM BLOOD Albumin-2.9* Calcium-8.0* Phos-2.3* Mg-2.0 [**2131-4-20**] 07:25AM BLOOD Albumin-3.2* Calcium-8.4 Phos-2.1* Mg-2.1 [**2131-4-13**] 09:20AM BLOOD Cortsol-21.0* [**2131-4-12**] 07:55AM BLOOD Hapto-53 [**2131-4-13**] 12:19PM BLOOD Type-ART pO2-61* pCO2-30* pH-7.42 calTCO2-20* Base XS--3 Intubat-NOT INTUBA [**2131-4-10**] 05:34PM BLOOD Lactate-1.9 [**2131-4-15**] 12:44AM BLOOD Lactate-1.0 [**2131-4-13**] 09:20AM BLOOD ADENOVIRUS PCR-Test Name [**2131-4-13**] 01:20PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- TEST CXR - no acute cardiopulmonary process. BCx - sent. Radiology: CT Chest/Abd/Pelvis [**2131-4-11**] IMPRESSION: 1. No significant interval change in nodal size and massive splenomegaly. 2. Increasing opacification in the right lower lobe may have an infectious etiology. . CT Chest/Abd/Pelvis [**2131-4-17**] IMPRESSION: 1. No pathology is identified to explain the patient's source of fever. 2. Unchanged size and appearance of multiple mesenteric and retroperitoneal nodes. Unchanged massive splenomegaly. 3. Interval development of moderate right and small left pleural effusion and interval development of ascites. . Ultrasound of RUE: IMPRESSION: 1. No evidence of right upper extremity DVT. 2. Subcutaneous edema in the area of swelling in the right forearm. . ----------------- Cardiology: EKG [**2131-4-14**]: Sinus tachycardia. There is a late transition which is probably normal. Low voltage. Compared to the previous tracing low voltage is new. . Echo [**4-15**] The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2130-8-8**], the findings are similar with limited views except for mild mitral regurgitation and mild pulmonary artery systolic hypertension. No pericardial effusion. Normal biventricular systolic function. . ------------------- Lumbar Puncture - NEGATIVE FOR MALIGNANT CELLS. Bronchoscopy - NEGATIVE FOR MALIGNANT CELLS. . -------------- Brief Hospital Course: 65 year old female with hx of CLL who presented to the ED with fever x 2 days up to 101.9 day 23 s/p second cycle of FCR (Fludarabine, Cytoxan and Rituxan). In the ED, she was not neutropenic but did have an episode of hypotension that responded to IVF. Currently looks well and remains hemodynamically stable. Patient admitted to the BMT service for management. . #Febrile Neutropenia/ID: Patient was continued on broad neutropenic coverage with cefepime and vancomycin on admission given hypotension in ED and counts < 1000 and decreasing on admission. CT torso was performed for evaluation for a source for fever. A small RLL infiltate was identified concerning for pneumonia. In patient with history of TB there was concern for reactivation of prior infection in setting of neutropenia and patient was placed in respiratory isolation. On Hospital day 2 patient complained of headache, neck pain and nausea. Concern for infectious process in CNS and patient had stat head CT to r/o bleed. LP was deferred given thrombocytopenia. Abx broadened to include fungal coverage and anaerobes at that time. On morning of Hospital day 3 patient became hypotensive w/ SBP in upper 70's, low 80's requiring IV fluid boluses, mild tachycardia, and increasing tachypnea. With IVF's patient's pressures normalized, but she became hypoxic. Started on azithromycin for atypical coverage. Impression was for sepsis and she was transferred to the ICU for monitoring. In ICU LP was performed that showed no evidence of significant CNS infection. Bronchoscopy exluced TB or other fungal processes. Patient's pressures stabilized but she required intermittent IVF boluses for support. After [**2-4**] day ICU stay she was called out to the floor. On floor she was monitored while counts recovered. Repeat CT scan of the chest demonstrated a new pleural effusion concerning for a para-pneumonic effusion. However, patient remained afebrile and so decision was made to monitor her and to perform thoracentesis only if patient's fevers returned. Antibiotics were peeled off as possible and patient completed full course of azithromycin for atypicals and cefepime 2mg IV q8 days for regular pneumonia coverage. She remained afebrile and she autodiuresed on arrival to the floor much of the fluid she had retained earlier. Ultrasound of her R-uppper extremity was negative for any DVT. Patient discharged to home with plan for outpatient follow-up with Dr. [**Last Name (STitle) **] early the following week and further discussion of her plan for chemotherapy at that time. . #Cardiac: Echo demonstrated no new wall motion abnormalities, depressed EF of infectious lesions. Small pericardial effusion noted on CT scan not reported on Echo. Patient without pulsus on exam, but with low voltage on EKG not noted previously. . #Leukemia: counts recovered with recovery from infection. Further treatment to be discussed as an outpatien with Dr. [**Last Name (STitle) **]. Patient to remain on acyclovir, fluconazole, and bactrim PPx on discharge. . #Hypertension: Not-hypertensive during this stay. HCTZ held and advised not to restart until seen as an outpatient. #Gout: stable. Continue on allopurinol #Hypothyroidism: Stable. Continued on levothyroxine. Medications on Admission: Acyclovir - 400 mg three times a day Allopurinol - 300 mg once a day Fluconazole [Diflucan] - 200 mg once a day Hydrochlorothiazide - 12.5 mg once a day Levothyroxine - 150 mcg eight times weekly Lorazepam [Ativan] - 0.5 mg Tablet - [**1-3**] Tablet(s) by mouth q4-6 hours as needed for nausea, anxiety, insomnia Trimethoprim-Sulfamethoxazole [Bactrim] - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*30 Capsule(s)* Refills:*0* 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety/nausea. Disp:*10 Tablet(s)* Refills:*0* 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: Pneumonia Febrile Neutropenia Pleural Effusion Pericardial Effusion CLL Hypothyroidism Discharge Condition: Good, ambulating without need of assitance and cleared for home by PT Discharge Instructions: You were admitted to the hospital for treatment of fevers and a low white blood cell count. You were treated with antibiotics for your infection, and your fevers improved. It was found that you had a pneumonia in your lungs. While in the hospital you completed a full course of antibiotics. . Please call your oncologist or your primary doctor IMMEDIATELY if you have any fever (Temperature > 100.3), chest pain, shortness of breath, increasing cough or other complaints that are concerning to you. . Please follow-up with Dr. [**Last Name (STitle) **] as directed below. . The following changes were made to your medications: 1. Hydrochlorothiazide 12.5mg - please do not resume taking this medication until you are seen by your primary doctor. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Wednesday [**2131-4-25**] at 9:00am, ([**Telephone/Fax (2) 31301**], [**Hospital Ward Name 23**] [**Location (un) **], please call with any questions or concerns. . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 31302**], please call for an appointment in the next 2-3 weeks. . Previously Scheduled Appointments: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2131-11-26**] 8:00 .

[ "274.9", "V12.01", "458.9", "486", "204.10", "244.9", "799.02", "511.9", "423.9", "287.5" ]

icd9cm

[ [ [] ] ]

[ "33.24", "03.31" ]

icd9pcs

[ [ [] ] ]

12272, 12316

7663, 10922

322, 353

12447, 12519

2152, 7640

13317, 13918

1625, 1629

11383, 12249

12337, 12426

10948, 11360

12543, 13294

1644, 2133

277, 284

381, 1155

1177, 1375

1391, 1609

7,624

127,944

23981

Discharge summary

report

Admission Date: [**2200-2-20**] Discharge Date: [**2200-3-10**] Date of Birth: [**2143-6-22**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 759**] Chief Complaint: obtunded Major Surgical or Invasive Procedure: Lumbar Punctures x 4 Left frontal sinus drainage History of Present Illness: 57F H/O Hypothyroidism who presented with unresponsiveness and meningitis. The patient was feeling well, but then developed URI symptoms (fevers, headache, ear pain) four day prior to admission. She then had persistent myalgias and nausea with worsening headaches over one to two days PTA> She felt very "cold" the night PTA when she asked her husband to turn up the heat. On the AM of admission, he tried to wake her up when leaving for work and she was unresponsive, barely opening her eyes to voice and not following commands. He called EMS and she was brought to [**Hospital1 18**]. The patient had no previous HIB or Pneumococcal vaccination. There was no rash, bruising, or mouth sores. Her husband had a mild "cold" a few days before her. ROS: Two months of intermittent headaches. ED: Received Ceftriaxone 2 grams IV, Vanco 1 gram IV, Acyclovir 800 mg IV and Ativan/Tylenol. Past Medical History: Hypothyroidism, Osteoporosis, Childhood Right Retinoblastoma S/P Enucliation (At Age 1.5) Social History: lives at home w/ husband, no hx EtOH, tobacco, IVDU Family History: no Fx seizures, migraines Physical Exam: PE: 103.8 137/60 123 23 96%RA Gen: cauc W lying in stretcher w/ eyes closed, hands wrapped around head, opens eyes to name. HEENT: R PRRL, L prosthesis; + photophobia Neck: + neck stiffness Heart: RRR, S1, S2, no m/r/g LUngs; CTBLA, no rales or wheezing ABd: S/NT/ND/no masses Ext: no edema Derm: no rash Neuro: R PRRL, uncooperative, opens L eye to command, moves feet to command to move feet or arms, nonverbal, flipped over in the prone position during examination. Brief Hospital Course: Mrs [**Last Name (STitle) 61064**] presented to [**Hospital1 18**] with obtundation after several days of URI symptoms - she was admitted to the [**Hospital Unit Name 153**]. A CSF examination revealed Hemophilus influenza meningitis and she was cotniued on Ceftriaxone, after Vancomycin and Acyclovir were discontinued. Her neurologic status improved dramatically and she recovered full function. However, her course was complicated by persistent fatigue, hyponatremia (deemed secondary to meningitis-related SIADH), fever, leukocytosis and an inflammatory CSF. Follow-up head imaging showed a right frontal sinus opacification with possible right frontal osteomyeltis. Her right frontal sinus was surgically evaluated and drained. Her fevers persisted and no clear alternate source of infection was found - in her liver, blood, urine (although she had urine with yeast and no signs of inflammation), or chest. 1. Bacterial Meningitis/Fever: Again, the patient presented with obtundation and an inflammatory CSF after URI symptoms. She was admitted to the [**Hospital Unit Name 153**] for a short course and improved dramatically on Ceftriaxone, Vancomycin and Acyclovir. Once Hemophilus influenza was cultured from her admission CSF and BCXRs, Vancomycin and Acyclovir were discontinued. Although she improved neurologically, she had persistent fever and increased serum WBCs. Repeat-LPs showed increased CSF WBCs (to 2500). She also had persistent tachycardia, presumed secondary to fever. Her antibiotics were changed to Meropenem, Levofloxacin and then empiric Vancomycin. Head and spine imaging showed opacification of the left frontal sinus, possible frontal osteomyelitis and possible underlying meningeal enhancement, but no abscesses. Her distal thecal sac and cauda equina were markedly enhancing and her cauda equina nerve roots were markedly thickened. These findings were consistent with meningitis. Her right frontal sinus was surgically evaluated by ENT and drains were placed. Of note, no purulent material drained from her sinus; she had only marked mucosal edema. A repeat CSF cytology showed decreasing WBC and increasing glucose, indicating overall improving meningitis. Her persistent fever was thought to be [**1-8**] drug fever from meropenem, as a screen for other sources of infection (UA/UCXR/BCXR/CXR/Liver CT) was negative. Given signs of improving meningitis by CSF studies and likely drug fever from meropenem, meropenem was d/c and the pt was placed back on levoflox with good effect. Fever resolved after 48 hours off meropenem, and there no signs of active infection after starting levoflox. At the time of d/c, the pt has been afebrile > 48 hours and is near her neurologic baseline on levoflox. She will continue levofloxacin after d/c until f/u with [**Hospital **] clinic. 2. Hyponatremia: She was euvolemic to hypovolemic and had a hypotonic serum. Her sodim levels downtrended intiailly with normal saline hydration and she nadired at 123. Her clinical picture and urine electrolytes were consitent with SIADH in setting of meningitis. She improved slightly with fluid restriction but also required small boluses of hypertonic saline. Renal service was consulted and recommended salt tablets. She was treated w/ NaCl 3gm PO TID, resulting in marked improvement in hyponatremia. At d/c, she is asymptomatic w/ stable sodium. She will need to continue fluid restriction to < 1 L per day after d/c, and will also continue NaCl tablets until f/u with her PCP. 3. LDH/ALK PHOS/AST Elevation: She had an incidental rise in these values in the middle of her course. They were checked as a screen given her persistent fever. It was possibly related to high-dose Levofloxacin liver toxicity. An abdominal CT was negative for abscess. After levoflox was resumed towards the end of her hospital course, LFTs were followed and were stable. She will require ongoing monitoring of LFTs while taking levoflox. 4. Left Diagphragmatic Hernia: This was discovered incidentally on chest x-ray. She was seen by surgery and a likely congenital (Bochdalek) diaphragatic hernia was diagnosed, without obvious lung aplasia or dysfunction. She was slotted for follow-up with surgery as an outpatient for possible elective correction. 5. Hearing loss: she has bilateral hearing loss at the time of d/c, likely [**1-8**] meningitis. ENT recommends audiological evaluation after d/c, w/ close follow-up for 6 months after resolution of meningitis. She will f/u in [**Hospital **] clinic after d/c for ongoing evaluation. 6. Hypothyroidism: controlled w/ her outpt dose of levoxyl during her admission. 7. Code status was full code during this admission. Medications on Admission: levoxyl ? dose fosamax ? dose Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. Tablet(s) 2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Alendronate Sodium 70 mg Tablet Sig: 0.5 Tablet PO QMON (every Monday). 4. Sodium Chloride 1 g Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* 5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-8**] Sprays Nasal QID (4 times a day) as needed. 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1) H. influenza meningitis Secondary: 2) SIADH 3) H. influenza bacteremia 4) Thrombocytopenia - resolved 5) Anemia - prob secondary to acute illness. Discharge Condition: Stable Discharge Instructions: 1) Please take your temperature twice daily (morning and early evening) and record on a piece of paper. Please take this with you to your appointment with Dr. [**Last Name (STitle) 17444**] on Monday. 2) Call Dr.[**Name (NI) 61065**] office on Tuesday to schedule a blood draw to check your serum sodium level. 3) Return to the Emergency Department immediately if you develop confusion, trouble breathing, chest pain or severe headache. Call your doctor if you have a temperature higher than 101 degrees F. Followup Instructions: Audiology (Hearing) testing - [**4-1**], 1:45 pm at Dr. [**Name (NI) 61066**] office, [**Hospital **] Medical Building, [**Location (un) 61067**]. Follow-up appointment for frontal sinus drain with Dr. [**Last Name (STitle) **] to follow at 2:30 pm, same location. Please arrive around 15 min before your first appointment. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 59700**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-3-17**] 1:00 Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] general surgery [**Telephone/Fax (1) 6439**] regarding thoracic hernia repair (repair would potentially prevent hernia from causing obstruction). Repair could potentially be performed laproscopically, call the office to come discuss the surgical options in an office visit.

[ "790.4", "473.1", "790.7", "320.0", "553.3", "730.28", "244.9", "253.6", "309.0", "E930.8", "780.6", "276.5", "287.5" ]

icd9cm

[ [ [] ] ]

[ "22.19", "22.41", "03.31" ]

icd9pcs

[ [ [] ] ]

7350, 7356

1979, 6665

280, 331

7560, 7568

8126, 9005

1444, 1471

6745, 7327

7377, 7539

6691, 6722

7592, 8103

1486, 1956

232, 242

359, 1245

1267, 1358

1374, 1428

16,187

147,570

49122

Discharge summary

report

Admission Date: [**2187-8-14**] Discharge Date: [**2187-8-20**] Date of Birth: [**2130-12-20**] Sex: F Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 56-year-old black female with a history of benign metastasizing leiomyoma found on CT scan in the right lower lobe with some involvement of the right middle lobe. The patient was symptomatic for baseline shortness of breath with cough, mostly exertional, after one block of ambulation or one to two flights of stairs. VQ scan done showed approximately 80% ventilation perfusion from the left lung and approximately 12% ventilation perfusion performed by the right lung. CT scan also showed that the mass had increased in size occupying the entire right lower lung with significant shift of the diaphragm and mediastinum. The patient had also undergone attempted embolization of the mass due to suspected bleeding; however this was not performed since there were no vessels identified. PAST MEDICAL HISTORY: The past medical history revealed metastasizing benign leiomyoma of the right lung, benign left breast cyst, G6PD deficiency, history of ventricular premature beats, and status post total abdominal hysterectomy with bilateral salpingo-oophorectomy and left pelvic mass resection with rising CA-125. ALLERGIES: Penicillin, aspirin, sulfa. MEDICATIONS ON ADMISSION: Atenolol 12.5 mg q.d., ibuprofen, multivitamin, Levofloxacin. PHYSICAL EXAMINATION: On initial physical examination, the patient was in no apparent distress. Temperature was 97, heart rate 128, respiratory rate 20, blood pressure 148/85, O2 saturation 96% on room air. The patient was in no apparent distress. In general, she was alert and oriented times three. The neck was supple. The chest revealed decreased breath sounds over the right lower lobe. Cardiovascular examination revealed regular rate and rhythm. Neurologically, the patient was grossly intact. LABORATORY DATA: Hematocrit was 29, white blood cell count 8.8, PT 12, INR 1.0, PTT 30, sodium 139, potassium 4.0, chloride 103, CO2 22, BUN 10, creatinine 0.6, glucose 97. Electrocardiogram showed normal sinus rhythm. Studies were as per the history of present illness. BRIEF HOSPITAL COURSE: The patient was admitted with a diagnosis of right lower lobe benign metastasizing leiomyomas. She was taken to the Operating Room on [**2187-8-14**] where she underwent right pneumonectomy with bovine pericardial patch. The patient tolerated the procedure well and there were no intraoperative complications. She was taken to the Recovery Room in stable condition having been extubated with an epidural catheter in place and bilateral chest tubes. The patient's right chest tube was removed on postoperative day #1 and the left was removed on postoperative day #2 without incident. The patient had had no air leaks. Of note, she had some postoperative elevation of her CKs to 1,011 which subsequently decreased. Troponin was mildly elevated to 5.8 and decreased to 1.4. However her EKG changes were suggestive of pericardial involvement and she was ruled out for myocardial infarction with the elevation in CKs and troponin thought to be secondary to intraoperative cardiac manipulation. Of note, the patient had some intraoperative arrhythmias for which she was started on Amiodarone intravenous load and switched to p.o. postoperatively. She remained in normal sinus rhythm for the rest of her postoperative course. From a respiratory standpoint, the patient improved to her baseline oxygenation. Of note she had some postoperative leukocytosis with white blood cell count to 27,000; however her white blood cell count continued to decrease over the next few days and was 12.6 on discharge. She remained otherwise stable and was ready for discharge on postoperative day #6. She was ambulating, was tolerating a regular diet, was in normal sinus rhythm, and was saturating well on room air. DISCHARGE STATUS: The patient is to be discharged home. DISCHARGE DIAGNOSES: Status post right pneumonectomy, leiomyosarcoma with negative nodes and negative margins, G6PD deficiency, benign left breast cyst. DISCHARGE MEDICATIONS: Atenolol 12.5 mg q.a.m., Amiodarone 400 mg t.i.d. x 2 days then Amiodarone 400 mg b.i.d. x 7 days then Amiodarone 400 mg q.d. x 7 days, Tylenol 650 mg p.o. p.r.n. pain, ibuprofen 400 mg p.o. q. 6 hours p.r.n. pain. DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr. [**Last Name (STitle) 175**] on [**2187-8-23**]. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Last Name (NamePattern1) 2682**] MEDQUIST36 D: [**2187-9-12**] 16:18 T: [**2187-9-12**] 19:33 JOB#: [**Job Number **]

[ "171.8", "197.0" ]

icd9cm

[ [ [] ] ]

[ "32.5", "37.4" ]

icd9pcs

[ [ [] ] ]

2244, 4009

4031, 4164

4188, 4404

1376, 1439

4429, 4793

1462, 2220

185, 985

1008, 1349

63,572

132,398

37151

Discharge summary

report

Admission Date: [**2175-1-16**] Discharge Date: [**2175-1-20**] Date of Birth: [**2112-9-26**] Sex: M Service: CARDIOTHORACIC Allergies: Simvastatin / Penicillins / Iodine / Aspirin / Toprol Xl Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Coronary artery bypass grafting x 3 (left internal mammary artery grafted to left anterior descending artery/saphenous vein grafted to first obtuse marginal /posterior descending artery)-[**2175-1-16**] History of Present Illness: 62 yo M with history of hypertension,hyperlipidemia, and known CAD s/p PTCA in [**2159**] with dyspnea on exertion x1 year and abnormal stress test referred for cardiac catheterization. Asked to evaluate for surgical revascularization. Past Medical History: Past Medical History: Hypertension Hyperlipidemia Coronary Artery Disease s/p MI s/p PTCA [**2159**] Obesity h/o H.Pylori 25 years ago Past Surgical History: s/p removal of nasal polyps x2 s/p tonsillectomy s/p right Rotator cuff repair s/p Right thumb surgery Social History: Race:Caucasian Last Dental Exam:4 weeks ago Lives with:Wife Occupation:Machine shop Tobacco:1ppd x 35+years ETOH:rare Family History: Family History:Father s/p CABG age 62 Physical Exam: Physical Exam Pulse:71 Resp:14 O2 sat: 98% RA B/P Right: 143/94 Left: 143/92 Height: 6'0" Weight:233 lbs 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 Abdomen: Soft [] non-distended [] non-tender [] bowel sounds + [] obese, firm, non-tender Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: dressed s/p cath Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: dressed s/p radial cath Left: 2+ Carotid Bruit Right: 2+ Left: 2+ no carotid bruits Pertinent Results: [**2175-1-17**] 02:30AM BLOOD WBC-10.5 RBC-3.65* Hgb-10.7* Hct-32.7* MCV-89 MCH-29.4 MCHC-32.9 RDW-13.8 Plt Ct-198 [**2175-1-16**] 04:15PM BLOOD WBC-8.1 RBC-3.61*# Hgb-10.4*# Hct-31.6*# MCV-88 MCH-28.8 MCHC-32.9 RDW-13.7 Plt Ct-171 [**2175-1-16**] 04:15PM BLOOD PT-13.5* PTT-28.7 INR(PT)-1.2* [**2175-1-16**] 02:30PM BLOOD PT-14.0* PTT-24.6 INR(PT)-1.2* [**2175-1-17**] 02:30AM BLOOD UreaN-18 Creat-0.8 Na-140 Cl-108 HCO3-25 [**2175-1-16**] 04:15PM BLOOD UreaN-18 Creat-0.8 Cl-108 HCO3-26 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 83703**], [**Known firstname 251**] [**Hospital1 18**] [**Numeric Identifier 83704**] (Complete) Done [**2175-1-16**] at 12:19:15 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2112-9-26**] Age (years): 62 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: CABG ICD-9 Codes: 786.05, 786.51, 424.0 Test Information Date/Time: [**2175-1-16**] at 12:19 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW1-: Machine: aw3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aortic Valve - LVOT diam: 2.1 cm Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is normal in size. No spontaneous echo contrast is seen in the left atrial appendage. 2. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6. There is no pericardial effusion. Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] were notified in person of the results. POST-CPB: On infusion of phenylephrine. A pacing. Preserved biventricular systolic function with LVEF now 50%. Mild MR. [**First Name (Titles) **] aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician ?????? [**2168**] CareGroup IS. All rights reserved. Brief Hospital Course: [**2175-1-16**] Mr.[**Known lastname **] was taken to the operating room and underwent coronary artery bypass grafting x 3 (left internal mammary artery grafted to left anterior descending artery/saphenous vein grafted to first obtuse marginal /posterior descending artery)by Dr.[**Last Name (STitle) **]. Cross clamp time was 42 minutes. Cardiopulmonary Bypass time was 56 minutes. Please refer to Dr[**Last Name (STitle) **] operative report for further details. He tolerated the procedure well and was transferred to the CVICU in critical but stable condition, intubated and sedated, requiring pressors to optimize hemodynamic stability. Postoperative night he awoke neurologically intact and was extubated without difficulty. All drains and lines were discontinued in a timely fashion. He weaned off Phenylephrine, and aspirin, beta-blocker, statin, and diuresis were initiated. Mr.[**Known lastname **] continued to progress and on post-operative day one he was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation of strength and mobility. The remainder of his postoperative course was essentially uncomplicated and he was cleared by Dr.[**Last Name (STitle) **] for discharge to home with VNA on post-operative four. All follow up appointments were advised. Medications on Admission: BUDESONIDE 0.5 mg/2 mL Suspension for Nebulization - 2 inhaled [**Hospital1 **] NITROGLYCERIN 0.4 mg SL PRN:chest pain PRAVASTATIN 40 mg po daily PREDNISONE 40 mg po BID (take two days before procedure and morning of and two days after procedure for IVP dye allergy). VERAPAMIL 240 mg po daily ZILEUTON [ZYFLO CR] 1200mg po BID ZOLPIDEM 5 mg po qHS PRN: insomnia ASPIRIN 325 mg po dialy CETIRIZINE 10 mg po daily DIPHENHYDRAMINE HCL [BENADRYL]- 25 mg po TID Capsule dye allergy medication pre-cardiac catheterization Discharge Medications: 1. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. 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* 4. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp:*14 Tablet(s)* Refills:*2* 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 6. Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) Inhalation twice a day. 7. Zileuton 600 mg Tablet Sig: Two (2) Tablet PO twice a day. 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 10. 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* Discharge Disposition: Home With Service Facility: [**Hospital3 6011**] Care Discharge Diagnosis: 3 vessel coronary artery disease Hypertension Hyperlipidemia Coronary Artery Disease s/p MI s/p PTCA [**2159**] Obesity h/o H.Pylori 25 years ago Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Primary Care Dr.[**Last Name (STitle) 39676**],RULA [**Telephone/Fax (1) 83705**] in [**1-14**] weeks Cardiologist Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5424**] in [**1-14**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2175-2-23**] 1:00 Completed by:[**2175-1-20**]

[ "414.01", "V45.82", "518.0", "278.00", "401.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.72", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

8684, 8740

5619, 6938

344, 549

8930, 9026

2056, 4411

9651, 10191

1268, 1293

7506, 8661

8761, 8909

6964, 7483

9050, 9628

996, 1101

4460, 5596

1308, 2037

284, 306

577, 815

859, 973

1117, 1237

2,881

190,994

25509

Discharge summary

report

Admission Date: [**2119-8-7**] Discharge Date: [**2119-8-18**] Date of Birth: [**2099-1-20**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: 1. Irrigation and debridement left open calcaneus fracture. 2. Closed treatment right calcaneus fracture. 3. Open reduction and internal fixation of left distal radius fracture. History of Present Illness: This is a 20 year-old female who was intoxicated (alcohol and cocaine) at the Rolling Stones concert and fell >30 feet after climbing onto the rafters. Past Medical History: Substance abuse/ETOH abuse Irritable Bowel Syndrome (per father report) Social History: +ETOH +Cocaine Family History: Noncontributory Physical Exam: VS on admission to trauma bay: T 101.4 HR 115 BP 82/27 RR 25 room air sats 98% Gen: lethargic, GCS 14 HEENT: face stable, PERRL; TM's clear; blood in nares Neck: trachea midline Chest: CTA bilat; left breast abrasion; tender sternum Cor: tachy S1 S2 Abd: soft, NT, ND FAST negative Rectum: decreased tone; guaiac positive Pelvis: Stable Back: NT Ext: left wrist swelling; bilat ankle ecchymosis; laceration left ankle; 2+DP pulses bilat Pertinent Results: [**2119-8-7**] 12:35PM HCT-29.9* [**2119-8-7**] 05:19AM LACTATE-0.9 [**2119-8-7**] 04:38AM GLUCOSE-91 UREA N-11 CREAT-0.8 SODIUM-140 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 [**2119-8-7**] 04:38AM PHOSPHATE-4.0 MAGNESIUM-1.3* [**2119-8-7**] 04:38AM WBC-12.5* HCT-30.6* [**2119-8-7**] 04:38AM PLT COUNT-220 [**2119-8-7**] 04:38AM PT-13.8* PTT-24.9 INR(PT)-1.3 [**2119-8-7**] 01:36AM HGB-11.3* calcHCT-34 [**2119-8-6**] 10:35PM ASA-NEG ETHANOL-103* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2119-8-6**] 10:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG FOREARM (AP & LAT) RIGHT [**2119-8-7**] 5:05 AM FOREARM (AP & LAT) RIGHT Reason: assess for fx [**Hospital 93**] MEDICAL CONDITION: 20 year old woman with s/p fall w/ mult fx REASON FOR THIS EXAMINATION: assess for fx CLINICAL HISTORY: Assess for fracture. LEFT FOREARM AP & LATERAL: The lateral image does not include elbow. Compared to prior examination of 2:09 a.m., re-identified is an impacted comminuted fracture of the distal radial metaphysis with medial and dorsal displacement of the distal radial fracture fragment, unchanged. There is ulnar positive variance. Ulnar styloid fracture is re- identified. The forearm is in a fiberglass cast which limits fine bony detail. CT LOW EXT W/O C BILAT [**2119-8-7**] 8:07 AM CT LOW EXT W/O C BILAT; CT RECONSTRUCTION Reason: assess for fx [**Hospital 93**] MEDICAL CONDITION: 20 year old woman with s/p fall w/ bilat calcaneus fx REASON FOR THIS EXAMINATION: assess for fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 20-year-old woman with bilateral calcaneus fractures status post fall. TECHNIQUE: Non-contrast MDCT of the bilateral ankles acquired in the axial plane and reconstructed in the sagittal and coronal planes. COMPARISON: No prior CT. Ankle radiographs dated [**2119-8-6**]. CT BILATERAL FEET: On the right, a comminuted fracture of the distal fibula extends as far superiorly as approximately the tibiotalar joint. There is mild displacement of the fracture fragments. Markedly comminuted fracture of the calcaneus extends to the subtalar and calcaneocuboid joints. The posterior subtalar joint is particularly widened and disrupted. The sustentaculum tali is comminuted. There is narrowing of the sinus tarsi. Fragments also project to the tarsal tunnel. There is a generalized flattening to the configuration of the calcaneal fragments. The ankle mortise remains relatively congruent. On the left, a tiny osseous fragment projects posterolaterally from the distal fibula at the expected level of the superior peroneal retinaculum, likely representing an avulsion. A comminuted fracture of the calcaneus extends to the subtalar and calcaneocuboid joints. There is widening of the posterior subtalar joint, less pronounced than on the contralateral side. The sustentaculum tali is separated as primarily one fragment. The sinus tarsi is not particularly narrowed. The calcaneal fragments have a generalized flattened configuration. The ankle mortise remains relatively congruent. Limited assessment of tendons crossing the ankle joints is grossly unremarkable. Diffuse soft tissue edema is more pronounced on the right than the left. Casts have been placed on both lower extremities. CT RECONSTRUCTIONS: Coronal and sagittal reformatted images were useful in delineating the extent of the severely comminuted bilateral calcaneal fractures. IMPRESSION: 1. Comminuted bilateral calcaneal fractures, with disrupted subtalar joints, as above. 2. Comminuted distal right fibula fracture. 3. Calcific [**Doctor Last Name **] adjacent to left distal fibula suggestive fo avulsion fracture at the insertion site of the superior peroneal retinaculum. CT C-SPINE W/O CONTRAST [**2119-8-6**] 10:47 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: fracture? [**Hospital 93**] MEDICAL CONDITION: 20 year old woman s/p [**2119**]5 feet REASON FOR THIS EXAMINATION: fracture? CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Status post fall from 20 feet. COMPARISON: No previous studies. TECHNIQUE: Axial noncontrast multidetector CT images of the cervical spine were obtained. Sagittal and coronal reconstructions were performed. FINDINGS: There is no fracture or malalignment. At C5/6, there is a small disc protrusion with associated mild uncovertebral spurring, suggesting that this is degenerative in nature. However, a traumatic component cannot be excluded. There is no prevertebral soft tissue swelling. IMPRESSION: 1. No fracture or malalignment. 2. Small disc protrusion at C5/6, which may be degenerative in nature, but a traumatic component cannot be excluded. Brief Hospital Course: On arrival she was hemodynamically unstable and was admitted to the Trauma ICU. She was awake and complained of head, abdominal and extremity pain. Orthopedics was consulted immediately for her extremity fractures. She was taken to the operating room on [**2119-8-7**] for repair of her injuries. Ophthalmology and Plastic Surgery were consulted for her right orbital floor and nasal fractures; no surgical intervention at this time for these injuries. She will need to follow up with Ophthalmology and Plastic Surgery after discharge. Orthopedic Spine service was consulted for the disc protrusion noted on CT imaging of her cervical spine; no fractures or ligamentous injuries identified. Recommendations for soft cervical collar for comfort and flexion extension films if patients developed any neck discomfort. Physical and Occupational therapy were consulted; patient is strict NWB bilat LE's and LUE at this time. Social work was also consulted for patient's ETOH/Substance abuse issues. Her pain is being managed with Oxycodone prn with fairly good response; she does experience intermittent anxiety and has required prn Ativan. Her bowel regimen was increased because of constipation secondary to immobility and narcotics. On HD #10 patient with fever spike 101.8; urine and blood cultures obtained and sent; CXR ordered. CXR revealed no active lung processes; Sinus CT scan obtained because of patent's facial fractures; abscess was ruled out. Her operative wounds were also assessed and showed no signs of infectious process at this time. Results of both urine and blood cultures pending at time of this summary. Medications on Admission: None Discharge Medications: 1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 tablets* Refills:*0* 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: not to exceed 12 in 24 hours. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: s/p Fall from ~30 ft Left inferior pubic ramus fracture Right maxillary fracture Right inferior orbit fracture Left iliac fracture extending to SI joint Bilateral calcaneus fractures Right fibula fracture Left distal radius/ulna fracture Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedics on date scheduled. You will need to continue with your Lovenox injections until stopped by Dr. [**Last Name (STitle) 1005**]. Followup Instructions: 1.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2119-8-22**] 1:20 2. Call [**Telephone/Fax (1) 274**], Plastic Surgery CLinic to schedule a follow up appointment in 1 week 3. Call [**Telephone/Fax (1) 13471**] to schedule an appointment in the Eye Clinic in 2 weeks.

[ "305.60", "839.05", "802.6", "824.8", "825.1", "850.11", "825.0", "868.03", "802.4", "780.6", "808.43", "E882", "305.00", "813.44", "802.0" ]

icd9cm

[ [ [] ] ]

[ "79.37", "79.02", "79.67", "79.32" ]

icd9pcs

[ [ [] ] ]

8710, 8787

6053, 7677

321, 504

9069, 9078

1321, 2057

9279, 9675

828, 845

7732, 8687

5245, 5284

8808, 9048

7703, 7709

9102, 9256

860, 1302

273, 283

5313, 6030

532, 685

707, 780

796, 812

10,235

103,676

15057+15058

Discharge summary

report+report

Admission Date: [**2179-8-11**] Discharge Date: [**2179-8-19**] Date of Birth: [**2104-8-10**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old gentleman with longstanding paraplegia for fifty years reportedly self inflicted injury. He came from an outside hospital after a fall from a wheelchair, striking the right loss of consciousness. He stated that he was being transported by wheelchair, when the [**Doctor Last Name **] took a sharp turn and he tipped over in the wheelchair hitting his head on the side wall or floor of the [**Doctor Last Name **]. He was taken to the outside emergency room, where head CT was negative and neck CT with limited recon showed a positive C2 fracture of the left lateral mass through the left foramen. C2 fracture of the with slight displacement and fracture at the base of the odontoid. He remained neurologically stable without changes from the longstanding paraplegia and he also has a colostomy and urostomy. PAST MEDICAL HISTORY: The patient has had multiple surgeries. The patient is status post open reduction and internal fixation of the left femur and hip fracture. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Zoloft 10 mg PO q.d. 2. Roxicet 4 mg to 6 mg PO q.4h.p.r.n. PHYSICAL EXAMINATION: On examination, the patient is afebrile. Blood pressure 188/58, heart rate 83, respiratory rate 20, saturations 94% on room air. He was awake, alert, oriented times three. He was pleasant and conversant. He had a 2 cm right parietal scalp laceration. Neck was in rigid C collar with mild-to-moderate tenderness posteriorly. Pupils equal, round, and reactive to light; extraocular muscles full. Mouth: Symmetrical. Tongue: Midline. Face: Symmetrical. LUNGS: Clear. HEART: Regular rate and rhythm. ABDOMEN: Multiple surgeries, positive colostomy in the left lower quadrant and urostomy in the right lower quadrant. EXTREMITIES: No clubbing, cyanosis or edema. There was minimal movement given left quadriceps. Otherwise, essentially flaccid paraplegia with mild awareness of left lower extremity more than the right lower extremity. Sensory level was at the right iliac crest and left proximal thigh. Strength in bilateral upper extremities was [**4-4**]. Deep tendon reflexes are 2+ in the upper extremities. He has had no clonus. Head CT: No acute hemorrhage. Ventricles and sulci: [**Doctor Last Name **]-white differentiation, appropriate for age. Cervical spinal film showed a positive fracture at the base of the odontoid with fracture through the lateral mass foramen transversarium. There was slight displacement on the left. The patient was admitted to the Trauma Intensive Care Unit with close monitoring. He was placed in a hard collar. The patient underwent a four-vessel angiogram to rule out dissection, which was ruled out. Angiogram was unsuccessful because of bilateral common femoral artery stenosis. The patient required no further imaging. The patient was transferred to the regular floor on [**2179-8-13**]. On [**2179-8-14**] and [**2179-8-15**] the patient complained of severe right shoulder and arm pain. Shoulder x-rays were performed, which were negative. The patient also had right upper extremity Doppler to rule out DVT due to edema in the right upper extremity, which was also negative. The patient also underwent lower extremity Dopplers, which again were negative. The patient had a chest x-ray on [**2179-8-16**], which showed left lung pneumonic consolidation. The patient's pain improved. The patient was seen by the Department of Physical Therapy and the Department of Occupational Therapy. The patient was found to be below baseline and requiring rehabilitation. MEDICATIONS ON DISCHARGE: 1. Metoprolol 100 mg PO b.i.d. for hypertension; hold for systolic blood pressure less than 120, heart rate less than 60. 2. Colace 100 mg PO b.i.d. 3. Milk of Magnesia 30 cc PO q.6h.p.r.n. 4. Percocet elixir 5 cc to 10 cc PO q.4h.p.r.n. 5. Zantac 150 PO elixir b.i.d. 6. Tylenol 650 PO q.4h.p.r.n. 7. Zolpidem tartrate 5 mg PO q.h.s.p.r.n. 8. Heparin 5000 units subcutaneously q.12h. 9. Zoloft 50 mg PO q.d. CONDITION ON DISCHARGE: Stable. The patient will remain in the hard collar for twelve weeks and follow up with Dr. [**Last Name (STitle) 1132**] in one month. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2179-8-19**] 13:25 T: [**2179-8-19**] 13:37 JOB#: [**Job Number 44007**] Admission Date: [**2153-1-29**] Discharge Date: [**2179-8-24**] Date of Birth: Sex: M Service: ADDENDUM: The patient's discharge was delayed until [**2179-8-24**] secondary to lack of rehabilitation bed. The patient's condition was stable at the time of discharge and he was discharged to rehabilitation at that point. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-349 Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2179-9-29**] 10:34 T: [**2179-9-29**] 10:41 JOB#: [**Job Number 44008**]

[ "344.1", "E884.3", "V45.73", "V55.3", "873.0", "V55.6", "805.02", "790.92" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3777, 4206

1311, 2364

2374, 3751

1029, 1288

4231, 5209

15,057

113,790

47559

Discharge summary

report

Admission Date: [**2124-6-29**] Discharge Date: [**2124-7-1**] Date of Birth: [**2064-3-13**] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Demerol / Ambien Attending:[**First Name3 (LF) 1436**] Chief Complaint: CC: SOB Major Surgical or Invasive Procedure: Intubation History of Present Illness: . 58 M with CAD s/p CABG, CHF EF 20%, s/p BiV/ICD, OSA, DM2, htn presents with SOB. The pt developed a relatively sudden onset of SOB while sleeping. The family called EMS(arrived 0400 on [**6-29**]) who found the pt acutely SOB, using accessory muscles, vitals were p 100 bp 220/110 rr 24 83% RA. He was given [**Month/Year (2) **] 100 IV and ntg SL x3. Of note, the pt denies any chest pain, no fevers, chills or coughing. On arrival to OSH, remained SOB with sats in 80s on NRB and was intubated nasotracheally since he was a difficult intubation. bp was better controlled to 150/90, he was breifly on nitro gtt which was stopped when he was becoming hypotensive. The pt was then transferred to [**Hospital1 18**] for further management. . Allergies: demerol, hctz, ambien, aldactone, strawberries. . ECG: regular paced rhythm at 64, QT wnl, no over signs of ischemia . CXR at [**Hospital1 18**]: 1. Satisfactory endotracheal tube position. 2. Mild cardiac decompensation with small bilateral pleural effusions, but no pulmonary edema. . Past Medical History: PMHx: 1. CAD, s/p recent CABG as above; TTE [**3-5**] showing dilated LA/LAV, 1+ MR, EF=20-30%, with BiV pacer for ventricular arrhythmias 2. Prostatitis 3. Melanoma s/p excisions 4. DM x 2 years 5. Recurrent PNA 6. GERD 7. gout 8. Sleep apnea 9. s/p hemorrhoidectomy 10. bilateral Iliac artery anneurysm s/p repair 11. Hypertensive cardiomyopathy 12. Hypercholesterolemia 13. Cervical radiculopathy Echo [**2123-4-13**]: LV EF severely depressed, severely dilated, global HK TR gradient 31, mild RV free wall HK 1+MR, Tr AR . Stress [**2123-6-9**]: no anginal sx with uninterpretable ECG . Cath [**2123-4-12**]: 1. Three vessel coronary artery disease. 2. Patent LIMA to LAD. 3. Three patent vein grafts. 4. Marked elevation of right and left heart filling pressures and moderate pulmonary hypertension. Social History: Ex-smoker, with 40 pack-year smoking history. He quit in [**2106**]. He lives with his wife. [**Name (NI) **] history of EtOH consumption. Family History: Father with MI in 50s Physical Exam: p62 bp 144/72 18 96% on CPAP 50% Gen: nasotracheally intubated, though awakem alert, in no resp distress on PSV HEENT: PERRL, OP clear Lungs: crackes at bases, mostly clear CV: RRR, nl s1/s2, no m/r/g Abd: soft, nt/nd, nabs, no masses Extr: trace edema, DP 2+ bilat Pertinent Results: [**2124-6-29**] WBC-9.7# RBC-5.47# Hgb-14.5# Hct-44.6# Plt Ct-189 [**2124-6-29**] PT-11.9 PTT-21.2* INR(PT)-1.0 [**2124-6-29**] Glucose-186* UreaN-30* Creat-2.1* Na-143 K-5.4* Cl-105 HCO3-25 AnGap-18 [**2124-6-29**] Type-[**Last Name (un) **] Rates-/18 PEEP-10 FiO2-50 pO2-70* pCO2-55* pH-7.29* calTCO2-28 Base XS-0 Intubat-INTUBATED Brief Hospital Course: Mr. [**Known lastname **] is a 58yo M well known to Dr. [**Last Name (STitle) **], with CAD s/p CABG, CHF EF 20%, s/p BiV/ICD, OSA, DM2, obesity and htn presents with acute SOB requiring intubation s/s flash pulmonary edema after missing his [**Last Name (STitle) **] dose x 2 days, with subsequent extubation 2 hours later and 2 days of aggressive diuresis. . 1 Resp Distress: Given the history of CHF, acute decomensation of CHF with flash pulmonary edema was the likely etiology. The patient can have sudden onset respiratory decompensation s/s to both high salt meals and/or anxiety and in this case missed his [**Last Name (STitle) **] dose for 2 days prior to onset of symptoms. Patient was extubated soon after intubation and with diuresis, had an accelerated resolution of his symptoms. . 2. Cardiac a. pump: on admission, patient was volume overloaded but is now better maintained after diuresis. Patient should be continued on coreg, lisinopril, aldactone, digoxin on pre-admission [**Last Name (STitle) 4319**] and should not miss [**First Name (Titles) **] [**Last Name (Titles) 4319**]. . b. coronaries: no evidence of active ischemia, though the patient has a history of CAD s/p CABG. mild troponin leak to 0.06 at peak in setting of CHF likely represented demand ischemia. There were no dynamic ECG changes. . c. Rhythm: Mr. [**Known lastname **] is s/p BiV/ICD, with stable rhythm. Appears AS-VP on ECG. Continue Amiodorone at pre-admission [**Known lastname 4319**]. . 3. Dm2: Was maintained on lantus 20 [**Hospital1 **] during admission as sugars have been in the 150-200 range. His home dose is 70 [**Hospital1 **] and he should return to this regimen upon discharge. . 4. CRI: Mr. [**Known lastname **] baseline Creatinine was 1.2-1.5 in [**4-5**]. He should have his creatinine followed by his PCP and should avoid nephrotoxic medications. . 5. Gout: Allopurinol and colchicine were held during this admission will being diuresed to avoid nephrotoxic medications. Can be restarted on discharge. . Medications on Admission: Coreg 12.5 mg b.i.d. Digoxin 0.125 mg q.o.d., [**Month/Day (1) 11573**] 40 mg qd Lisinopril 20 mg qd Zetia 10 mg qd Lantus 70U [**Hospital1 **] Lipitor 80 mg qd Lexapro 20 mg qd, Folic Acid qd Amiodarone 200 mg qd Protonix 40 mg qd ASA 81 mg qd [**Doctor First Name **] 180 mg qd Klonopin 0.5 mg up to b.i.d. Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amiodarone 200 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 Q24H (every 24 hours). 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO QDAY (). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Congestive Heart Failure Discharge Condition: Stable vital signs, afebrile, ambulating. Discharge Instructions: Please note that none of your medications have been changed during this admission. Please return to the hospital if you become short of breath, experience chest pain or severe headache. Please make sure to take all of your medications, including your diuretic, [**Doctor First Name 11573**]. Please contact your primary care physician if your weight goes up by 3 pounds, or if you notice your legs becoming swollen. Please note that one of your lab values, the Creatinine, which is a measure of your kidney function, was slightly elevated on this admission. Please have your primary care physician recheck this value within 1-2 weeks of discharge from the hospital. Followup Instructions: Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], within 1 week of discharge. Please follow up with your primary care physician [**Name Initial (PRE) 176**] [**1-3**] weeks of discharge.

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

6669, 6675

3090, 5111

306, 318

6743, 6786

2732, 3067

7503, 7715

2407, 2430

5470, 6646

6696, 6722

5137, 5447

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259, 268

346, 1392

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2251, 2391

60,600

193,602

36883

Discharge summary

report

Admission Date: [**2162-7-29**] Discharge Date: [**2162-8-7**] Date of Birth: [**2105-1-7**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 5547**] Chief Complaint: large right sided adrenal mass Major Surgical or Invasive Procedure: 7/24/9: 1. Exploratory laparotomy. 2. R2 resection of large right adrenocortical carcinoma with en bloc right adrenalectomy. 3. Total right nephrectomy. 4. Placement of abdominal packing with abdomen left open. 7/25/9: 1. Exploratory laparotomy and removal of intraabdominal packs and closure of abdomen. History of Present Illness: 57F with large right sided adrenal mass. The patient was seen by Dr. [**Last Name (STitle) 1924**] on [**2162-7-6**]. Dr. [**Last Name (STitle) 1924**] reviewed all the labs and imaging with the patient during this visit. Given her findings, the mass is concerning for an adrenocortical carcinoma based on its size and imaging. The patient was scheduled to undergo an open right adrenalectomy on [**7-30**] AM. She was admitted the night before and undergo a triple phase CT. Of note, patient recently had episode of bronchitis. Seen at OSH and started on prednisone and Zithromax on Sunday. No recentl f/c. No SOB. Past Medical History: Elevated cholesterol, Bronchitis, Gastroesophageal reflux disease, Status post excision of a lipoma from the right abdomen. Social History: Patient is a school bus driver. She lives alone but has a local friend who can take care of her postoperatively. She has never smoked tobacco and does not drink alcohol. Family History: lung cancer in her mother, who died at the age of 55, and throat cancer in her brother, who died at the age of 57. She also has a sister who is alive with bladder cancer. Physical Exam: NAD, A+OX3, supine on bed RRR Scattered wheezes b/l, good inspiratory effort Soft, ND, tenderness felt RUQ, fullness felt RUQ but no distinct mass, no erythema or crepitus no c/c/e Left eye - scleral injected Pertinent Results: [**2162-7-29**] 08:05PM WBC-11.3* RBC-4.33 HGB-12.2 HCT-38.3 MCV-88 MCH-28.2 MCHC-31.9 RDW-13.6 [**2162-7-29**] 08:05PM PLT COUNT-214 [**2162-7-29**] 08:05PM GLUCOSE-78 UREA N-15 CREAT-1.0 SODIUM-141 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11 [**2162-7-29**] 08:05PM PT-11.3 PTT-24.1 INR(PT)-0.9 Imaging: [**2162-6-9**]: 10.7 x 11.9 x 11.5 cm, well-circumscribed, heterogeneously-enhancing mass within the right adrenal gland and invaginating the inferomedial aspect of the right lobe of the liver and possibly the caudate lobe of the liver. Several small regional mesenteric lymph nodes were also noted in the right upper quadrant. [**7-29**] CT Abd/Pelvis: 13.2 X 12.0 X 12.9 heterogenous, well circumscribed, ? invasion to caudate of liver (no clear border seen), no involvement of IVC, rest of liver WNL, left adrenal gland WNL, right kidney is displaced but fills symetrically, LAD seen, no evidence of mets Brief Hospital Course: Patient was admitted the day prior to surgery and underwent a CT angiogram of the abdomen and pelvis that demonstrated slight enlargement of the adrenal mass to just over 13 cm. There was no evidence of obvious metastatic disease. Patient .underwent a radical resection of a large hemorrhagic right adrenocortical carcinoma on [**7-30**]/9. The operation was accompanied by extraordinary blood loss which required a massive transfusion of blood products. At the conclusion of the case, she had diffuse oozing from multiple sites which was felt to be related to her hypothermia and coagulopathy. Accordingly, her right upper quadrant was packed and she was returned to the intensive care unit with an open abdomen. Overnight, her temperature normalized and her coagulation parameters were normalized with blood product. She was brought back to the OR on [**7-31**]/9 for removal of her packs, and abdominal closure. After her second operation she went back to the ICU. Her postoperative course was relatively uneventful in her recover after her surgeries, being extubated on [**8-3**]/9 and starting to advance her diet on [**8-4**]/9. She was transfered to the floor on [**8-4**]/9 and started to ambulate. There was a question of a right hemiparesia, as she felt weakness on her right leg and arm, so a Head CT was performed and there was no evidence of hemorrhage, edema, masses or infaction. Clinically she improved and her weakness resolved. Her foley catheter was taken out, making adequate amounts or urine, and she started tolerating regular food. Due to baseline history of chronic bronchitis, on [**8-6**] her sats were in the high 80s - low 90s, so she was started on O2 at 1-2lt/min. Today patient was weaned from the oxygen with PO2 > 95% on room air. Chest X Ray was ordered and showed no evidence of acute pulmonary process. Patient will be discharged home with services and PT until for further return to her baseline activities. Medications on Admission: ProAir and Advair inhalers p.r.n. She also takes calcium and multivitamins. Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze/SOB/cough. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheeze/SOB/cough. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Southern Main VNA Discharge Diagnosis: Large right adrenocortical carcinoma. Discharge Condition: stable tolerating regular diet pain well controlled with oral medications Discharge Instructions: Please call your doctor or return to the ER for 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. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * 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. * Continue to ambulate several times per day. . Incision Care: -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Please call Dr.[**Name (NI) 12822**] office, [**Telephone/Fax (1) 7508**], to make a follow up appointment in [**1-8**] weeks. Completed by:[**2162-8-7**]

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icd9cm

[ [ [] ] ]

[ "54.62", "03.90", "07.29", "55.51" ]

icd9pcs

[ [ [] ] ]

5795, 5843

2990, 4936

300, 608

5925, 6001

2031, 2967

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1613, 1787

5064, 5772

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1802, 2012

230, 262

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50,495

102,738

7734

Discharge summary

report

Admission Date: [**2152-4-20**] Discharge Date: [**2152-4-23**] Date of Birth: [**2069-4-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9824**] Chief Complaint: Tachypnea Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 82F with hx COPD on 4 L NC at baseline. Patient had been having increased difficulty breathing for the past few days, then developed cough today with brown sputum 9no hemoptysis). She has not had any fevers or chills, and her oxygen saturation had remained greater than 90% on her usual 4L of oxygen. Yesterday patient's son [**Name (NI) 653**] her PCP to inform him of this change, and prescription for Z pack and prednisone 40 was started (on chronic prednisone 5 qd). Patient took one dose of these but overnight was noted to have increasing work of breathing and to be breathing more rapidly so presented to ED. Last hospitalization in [**1-2**] for SVT, on Dilt [**Hospital1 **] for rate control. In the ED, initial vs were: 99.7, 180/90, 118, 26, 96% on 4 L NC. She received Levaquin 750, Solumedrol 125, nebs, ASA, and ativan 1.5 mg total. On arrival to the ICU, pt and family note breathing is better. Pt is claustrophobic and would likely not tolerate BiPAP. Past Medical History: - AVNRT - COPD, on home O2 4L at baseline - Diabetes mellitus, type 2 - Hypothyroidism - Psoriasis - Osteoarthritis - Hyperlipidemia - Anxiety - Atypical chest pain - Obesity - Anemia Social History: Does not currently smoke or drink. Smoked 1 to 1-1/2 packs per day, quit in [**2133**]. Family History: Noncontributory Physical Exam: ADMISSION Vitals: 97.8 110 118/94 22 100% 4 L NC General: Alert, oriented, tachypneic, speaking in short sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Scattered wheezes and rhonchi bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&O x3, MAE, nonfocal Pertinent Results: ADMISSION [**2152-4-20**] 08:00AM WBC-13.5* RBC-4.82 HGB-10.3* HCT-33.8* MCV-70* MCH-21.3* MCHC-30.3* RDW-16.4* [**2152-4-20**] 08:00AM NEUTS-82.7* LYMPHS-12.6* MONOS-4.1 EOS-0.5 BASOS-0.2 [**2152-4-20**] 08:00AM GLUCOSE-158* UREA N-10 CREAT-0.6 SODIUM-138 POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-36* ANION GAP-14 [**2152-4-20**] 08:00AM TOT PROT-7.7 PHOSPHATE-4.5 MAGNESIUM-1.8 [**2152-4-20**] 08:00AM CK(CPK)-46 [**2152-4-20**] 08:00AM CK-MB-NotDone [**2152-4-20**] 09:45AM TYPE-ART O2 FLOW-4 PO2-87 PCO2-67* PH-7.38 TOTAL CO2-41* BASE XS-10 INTUBATED-NOT INTUBA COMMENTS-NC CHEST (PORTABLE AP) Study Date of [**2152-4-20**] 8:00 AM The cardiac, mediastinal and hilar contours are unchanged. The cardiac silhouette is not enlarged. Prominent left epicardial fat pad is present. The lungs are hyperinflated with flattening of the diaphragms re-demonstrated compatible with patient's history of COPD. Pulmonary vascularity is within normal limits without evidence of pulmonary edema. Minimal bibasilar atelectasis is demonstrated. No pleural effusion or pneumothorax is present. The osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary abnormality. COPD. Brief Hospital Course: Ms [**Known lastname 28070**] is an 82 year old woman with history of severe COPD (on 4L NC at home), diabetes, obesity, presenting with respiratory distress consistent with COPD exacerbation, in fair condition. #. COPD EXACERBATION: Patient with well known COPD and poor functional reserve with decreased FEV1 and FEV1/FVC ratios. Infection appears most likely diagnosis for etiology of exacerbation. She was most recently treated in [**Month (only) **] with Avelox and steroids, improved. She also has a history of pseudomonas infection in [**2147**]. Baseline sats 92 per pt. Initial chest x-ray as above without evidence of infiltrate. Most likely this represents worsening bronchitis causing inflammatory response. Started on IV Solumedrol for flair and she was started on Levofloxacin and Vancomycin empirically until culture data returned. Sputum culture grew out coag+ staph on [**4-22**]. Given her improvement, the lack of infiltrate on CXR, lack of findings consistent with an aggressive pneumonia such as one would find with MRSA, this was felt to be a contaminant. She was then transferred out of the ICU for further monitoring. On the floor, her vancomycin was discontinued and she was transitioned to oral steroids. She was discharged on 1 more day of levofloxacin to finish 5 day course. She was also given a 2 wk steroid taper and instructions to follow up with her PCP. [**Name10 (NameIs) **] the time of discharge, she was on her home requirement of 4L NC. #. DIABETES: Glucophage was initially held in case of need for contrast. Once more stable, her Glucophage was restarted. She was also on an insulin sliding scale for supplemental glucose control given her steroids as above. #. SUPRAVENTRICULAR TACHYCARDIA / AVNRT: Well controlled on Verapamil, has not had any symptomatic episodes or procedures for this. Was initially on short acting until it was clear she was hemodynamically stable. She was then continued on her home dose of Verapimil 180mg SR [**Hospital1 **]. # ANXIETY: On ativan daily at home, 0.5mg TID. While inpatient, continued to have significant anxiety and this was increased to 0.5mg QID PRN. #. HYPOTHYROIDISM: Continued hormone replacement at her regular dose of Levothyroxine 100mcg daily. Medications on Admission: ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - 1 (One) Tablet(s) by mouth up to four times a day as needed for pain ALENDRONATE - 35 mg Tablet - 1 Tablet(s) by mouth q week BETAMETHASONE-CALCIPOTRIENE [TACLONEX SCALP] - 0.05 % (0.064 %)-0.005 % Suspension - apply qd to scalp BETAMETHASONE-CALCIPOTRIENE [TACLONEX] - 0.05 % (0.064 %)-0.005 % Ointment - apply once a day BUDESONIDE [PULMICORT] - 0.5 mg/2 mL Suspension for Nebulization - 1 (One) vial inhaled via nebulizaiton twice a day (this dose covered by medicare) FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each nostril once a day FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 2 puffs twice a day when out of the house HUMIDIFIER FOR HOME O2 DELIVERY SYSTEM - use whenever using O2 IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90mcg)/Actuation Aerosol - 3 puffs 3 -4 times day when out of the house IPRATROPIUM-ALBUTEROL [DUONEB] - 2.5 mg-0.5 mg/3 mL Solution for Nebulization - 1 (One) vial inhaled via nebulizaiton up to four times a day as needed for and as needed for wheezing and shortness of breath LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM [ATIVAN] - 0.5 mg Tablet - 1 (One) Tablet(s) by mouth 2-3 times daily METFORMIN [GLUCOPHAGE] - 850 mg Tablet - 1 Tablet(s) by mouth twice a day OXYGEN -4 Liters/min continuous flow 02 24 hrs daily and 5 by pulse dose 02 PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day PREDNISONE - 10 mg Tablet - 4 (Four) Tablet(s) by mouth once a day Taper as directed over 10 days SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth qpm VERAPAMIL - (Prescribed by Other Provider) - 180 mg Cap,24 hr Sust Release Pellets - 1 Cap(s) by mouth twice a day CALCIUM CARBONATE-VITAMIN D3 600mg-400 unit Tablet - [**Hospital1 **] GUAIFENESIN [MUCINEX] - 600 mg Tablet Sustained Release - 1 (One) Tablet(s) by mouth once or twice a day as needed for thick mucus POLYSACCHARIDE IRON COMPLEX [NIFEREX] - 60 mg Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Disp:*1 Tablet(s)* Refills:*0* 3. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 4. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week. 5. Taclonex 0.05-0.005 % Ointment Sig: One (1) application Topical once a day. 6. Taclonex Scalp 0.05-0.005 % Suspension Sig: One (1) application to scalp Topical once a day. 7. Pulmicort 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) neb Inhalation twice a day. 8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 9. Flovent HFA 220 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 10. Combivent 18-103 mcg/Actuation Aerosol Sig: Three (3) puffs Inhalation 3-4 times daily. 11. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebulizer Inhalation four times a day as needed for shortness of breath or wheezing. 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO 2-3 times daily as needed for anxiety. 13. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 16. Prednisone 20 mg Tablet Sig: One (1) taper PO DAILY (Daily): Take 3 tablets daily for 3 days. Then 2 tabs daily for 4 days. Then 1 tab daily for 4 days. Then half tab daily for 4 days. Then resume prednisone 5 mg daily. . Disp:*23 tabs* Refills:*0* 17. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO twice a day. 18. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day as needed for thick mucus. 19. Niferex 60 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: COPD exacerbation Secondary diagnoses: Severe COPD Diabetes Mellitus type 2 Anxiety Hypothyroidism Discharge Condition: Good. Stable with O2 sats in mid 90's on 4L NC. Discharge Instructions: You were admitted with shortness of breath. We think this was due to an exacerbation of your COPD. We also treated you with antibiotics for a possible pneumonia. You are being discharged home on your baseline amount of oxygen. . We are putting you on a taper of prednisone over the next 2 weeks. We are giving you 1 more day of the antibiotic Levaquin. Please be careful when taking this medication as it can cause tendon problems. Report any joint, muscle, ankle or other unusual pain to your doctor immediately or go to the emergency room. . Please follow up as below. . Please call your doctor or return to the ED if you have any chest pain, increasing shortness of breath, lightheadedness, headache, worstening cough, nausea, vomitting, fever or any other concerning symptoms. Followup Instructions: Please call Dr. [**First Name (STitle) **] on Monday morning at [**Telephone/Fax (1) 1247**] to arrange follow up within 1 week. . Please call Dr. [**Last Name (STitle) 575**] at [**Telephone/Fax (1) 612**] to arrange follow up within 1 month. Completed by:[**2152-4-25**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9715, 9772

3479, 5734

326, 332

9934, 9984

2260, 3456

10813, 11089

1674, 1691

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276, 288

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1367, 1553

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27,172

166,580

49075+59139

Discharge summary

report+addendum

Admission Date: [**2109-1-10**] Discharge Date: [**2109-2-14**] Date of Birth: [**2055-11-20**] Sex: M Service: MEDICINE Allergies: Heparin Agents / Penicillins / Aspirin / Ibuprofen Attending:[**First Name3 (LF) 1493**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: central line tunneled line paracentesis hemodialysis History of Present Illness: Mr. [**Known lastname 102989**] is a 53 yo M with PMH of ETOH cirrhosis, colon ca s/p colectomy on [**2108-12-18**], course c/b post-op c diff, currently on po vanco, admitted with abdominal pain. Patient reports that he had been doing well at rehab but developed sharp intermittent left sided abdominal pain 3 days prior to admission while at rehab. He had KUB x2 at rehab that was reportedly unrevealing, then spiked temp to 101 so was transferred for further eval. He usually gets his care and recent surgery at [**Hospital1 2025**] however was transferred here as [**Hospital1 2025**] on diversion. He reports that the pain is worse with movement and with eating, also has noticed increased bloating with eating lately. He also reports loose stools. He denies nausea, vomiting, chest pain, shortness of breath, dysuria, hematuria, dysuria. . He denies prior h/o SBP but does report taking ofloxacin prophylactically prior when he was having frequent paracenteses. . In ED T101 116/67 HR 70 RR 18 96%RA. Had CT abdomen which was unremarkable, intact colectomy anastomosis, no obstruction. He also had paracentesis c/w SBP. He was treated with levo/flagyl/vanc IV. For pain he has been given oxycodone 10mg x2, tylenol 1g, morphine 4mg x3, zofran 4mg x1. . Past Medical History: -ETOH cirrhosis - has h/o ascites,pleural effusions, multiple prior taps, had been on prophylactic ofloxacin -colon cancer s/p colectomy last month -C. diff infection (still on po vanc) -HTN -hypercholesterolemia -esophageal varices -cervical stenosis - s/p several vertebral fracture after a fall Social History: Lives with wife and daughter in [**Name2 (NI) **], denies ETOH for past 4 years, Tobacco: [**Date range (1) 61126**] PPD x 30 years, denies h/o IVDA; not currently working as disabled, used to work as construction worker. Family History: Denies fhx of early MI, stroke, cancer Physical Exam: VS: T99.3 112/72 HR 68 RR 16 93%RA Gen: awake, alert, no acute distress, appropriate with conversation HEENT: dry mucousa Neck: no lymphadenopathy Lungs: bibasilar crackles, no wheezing Abd: distended, midline incision with steristrips in place, well healing incision, no erythema or exudate, +BS, tenderness to percussion Ext: no pedal edema, DP's 2+ bilaterally NO asterixis Pertinent Results: [**2109-1-10**] 07:00AM ASCITES TOT PROT-1.6 GLUCOSE-125 LD(LDH)-100 ALBUMIN-<1.0 [**2109-1-10**] 07:00AM ASCITES WBC-[**2100**]* RBC-3250* POLYS-71* LYMPHS-11* MONOS-0 ATYPS-1* MESOTHELI-1* MACROPHAG-16* [**2109-1-10**] 12:45AM LACTATE-1.4 [**2109-1-9**] 07:10PM GLUCOSE-135* UREA N-22* CREAT-1.2 SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11 [**2109-1-9**] 07:10PM estGFR-Using this [**2109-1-9**] 07:10PM ALT(SGPT)-26 AST(SGOT)-45* ALK PHOS-187* [**2109-1-9**] 07:10PM LIPASE-42 [**2109-1-9**] 07:10PM ALBUMIN-2.4* CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-1.7 [**2109-1-9**] 07:10PM WBC-6.6 RBC-3.36* HGB-10.5* HCT-32.0* MCV-95 MCH-31.4 MCHC-33.0 RDW-13.8 [**2109-1-9**] 07:10PM NEUTS-75.7* LYMPHS-15.6* MONOS-7.5 EOS-1.1 BASOS-0.1 [**2109-1-9**] 07:10PM PLT SMR-VERY LOW PLT COUNT-69* LPLT-2+ Brief Hospital Course: A/P: 53M w/ ETOH cirrhosis, colon ca s/p colectomy on [**2108-12-18**] (c/b post-op c-diff) admitted on [**1-10**] with abdominal pain, initial tap revealed greater than 1000WBC in peritoneal fluid, only growth from any of the peritoneal samples grew fluc sensitive [**Female First Name (un) **] albicans. Pt was briefly in the MICU for hypotension and hypoxia. He was initially on CVVH for acute renal failure and completed a course of vancomycin for presumed pneumonia and was transferred back to the floor for further management. On the floor: #)Peritonitis. Finished course of Cefepime on [**2-8**] for presumed bacterial peritonitis (WBC of 1000) in post operative setting. Fluconazole to continue until [**2-22**] (4week course) for fungal peritonitis in post-op setting (fluconazole sensitive [**Female First Name (un) **] albicans). Repeat tap 2 weeks into the course of treatment showed clearance of bacterial and fungal infection and repeat tap on the day of discharge remains negative for infection (100 WBC). Needs to continue Flagyl until one week after cefepime is finished for c-diff prophylaxis (last day [**2109-2-15**]). . #)Acute renal failure - Presumed due to hepatorenal syndrome and ATN. Seen by renal service and initially on CVVH and then intermittent dialysis 1-2 times per week, with stable creatinine no at 3 to 3.3. Pt's creatinine has plateaued on dialysis, with approximate crcl of 25. UOP 350 to 450 cc per day. Will most likely need intermittent HD, and follow up of renal function at rehab center. Tunneled line placed on [**2109-2-12**] by IR today. Continued to hold diuretics due to renal failure. Will need to continue midodrine 15 mg TID, octreotide 200mcg TID and daily albumin 25 gram per renal and hepatology for HRS. In case renal function remains impaired and does not resolve, early decision needs to be made with regard of indication for renal co-transplantation. . #)C.diff - patient with documented severe C.diff infection at [**Hospital1 2025**] postoperatively after colectomy. Will continue course of PO Flagyl until [**2-15**] for prophylaxis as recommended by ID service. C.diff stool toxin A and B, so far negative. . #)ETOH cirrhosis/ESLD - h/o ascites, pleural effusion, esophageal varices; per patient not on lactulose at home, has been receiving in house. No asterixis, but pt seems intermittently confused, per wife he "waxes and wanes." Continued bowel regiment with lactulose (sometimes refuses -it has to be reinforced), continued rifaximin. Patient refuses repeatedly his medication, reporting he is "off this medicine" or "Dr. [**Last Name (STitle) **] I should not take it", however all his medications have to be reinforced and compliant has to be supervised. . #)Cervical stenosis - s/p fall and cervical vertebral fracture requiring surgical repair/stabilization with chronic neuropathic pain. Low dose Dilaudid given liver and renal failure. . #)Depression - continued sertraline . #)Pain: prefer Dilaudid to morphine given impaired renal function . #)FEN low sodium, high caloric intake, calorie count suboptimal but improves with encouragement. . #)Prophylaxis - pantoprazole, pneumoboots (no heparin for HIT), bowel regimen . #)Code status: full . #) Dispo - screen for rehab, PT/OT. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. MD ([**Telephone/Fax (1) 33431**]) WIFE: [**Telephone/Fax (1) 102990**] Medications on Admission: -KCL 10meq daily -amiloride 5mg daily -omeprazole 20mg [**Hospital1 **] -furosemide 40mg [**Hospital1 **] -nystatin powder -nadolol 10mg daily -oxycodone 10mg q4 prn -albuterol sulfate nebs -sertraline 100mg daily -pregabalin 300mg [**Hospital1 **] -folic acid 1mg daily -MTV -Vancomycin 250mg po Q6h Discharge Medications: 1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): titrate to [**1-29**] bowel movements per day. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: not more than 2 grams per day. 11. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 12. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): hold for systolic blood pressure >160. 14. Octreotide Acetate 500 mcg/mL Solution Sig: Two Hundred (200) mcg Injection Q8H (every 8 hours). 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): to continue until [**2-15**] (which is one week after cefepime course has been finished) . 16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours): Give med after dialysis on hemodialysis days. to continue until [**2-22**] for [**Female First Name (un) **] peritonitis . 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 18. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed. 19. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): SBP prophylaxis . 20. Albumin, Human 25 % 25 % Parenteral Solution Sig: Twenty Five (25) gram Intravenous DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Bacterial and fungul peritonitis 2. Acute renal failure 3. Hepatorenal syndrome secodary: 1)ETOH cirrhosis - has h/o ascites, pleural effusions, multiple prior taps, had been on prophylactic ofloxacin 2)Colon cancer s/p colectomy last month at [**Hospital1 2025**] 3)C. diff infection s/p colectomy 4)Hypertension 5)Hypercholesterolemia 6)Esophageal varices 7)Cervical stenosis - s/p several vertebral fracture after a fall 8)s/p subtotal colectomy and ileal proctotomy 9)surgical repair of vertebral fx Discharge Condition: Good. Discharge Instructions: You were admitted with mental status changes, renal failure and peritonitis (infection of the fluid in your belly) . You were treated with antibiotics, and you have to continue taking them as instructed. You also were treated for renal failure and have been dialysed. . Please follow up with your appointments as instructed. Call your doctor or 911 if any confusion, fever, abdominal pain or any other health concern Followup Instructions: PLEASE CALL THE LIVER CENTER TOMORROW [**2109-2-15**] TO SET UP AN FOLLOW UP APPOINTMENT Department: Medicine Division: Gastroenterology Operating Unit: [**Hospital1 18**] Office Location: [**Last Name (NamePattern1) 13209**], [**Location (un) 86**], [**Numeric Identifier 718**] Office Phone: ([**Telephone/Fax (1) 3618**] Office Fax: ([**Telephone/Fax (1) 4409**] Patient Location: [**Last Name (NamePattern1) **], [**Location (un) 86**], [**Numeric Identifier 16457**] Patient Phone: ([**Telephone/Fax (1) 1582**] Patient Fax: ([**Telephone/Fax (1) 12173**] Name: [**Known lastname 16638**],[**Known firstname **] Unit No: [**Numeric Identifier 16639**] Admission Date: [**2109-1-10**] Discharge Date: [**2109-2-14**] Date of Birth: [**2055-11-20**] Sex: M Service: MEDICINE Allergies: Heparin Agents / Penicillins / Aspirin / Ibuprofen Attending:[**First Name3 (LF) 12135**] Addendum: THIS IS AN ADDENDUM TO PATIENTS RECENT HOSPITALIZATION FROM [**2109-1-10**] TO [**2109-2-14**]. IT INCLUDES THE FOLLOWING INFORMATION: Labs upon discharge Radiological studies MELD score Follow up appointments Labs upon discharge: 146 / 108 / 40 / 97 AGap=15 --------------- 3.4 \ 26 \ 3.3 Ca: 9.0 Mg: 1.7 P: 4.2 ALT: 12 AP: 60 Tbili: 3.6 Alb: 4.0 AST: 29 107 3.9 \ 9.8 / 83 ------- / 30.4 \ PT: 26.7 PTT: 47.4 INR: 2.7 Radiological studies ================================================================ RADIOLOGY Final Report CT PELVIS W/O CONTRAST [**2109-1-29**] 3:38 AM CT PELVIS W/O CONTRAST Reason: anastomotic leak - Please use PO and RECTAL contrast Field of view: 36 [**Hospital 5**] MEDICAL CONDITION: 53 year old man with h/o semi-colectomy for rectal ca, cirrhosis, ascites, recent SBP, fungal infection of peritoneum, GI source REASON FOR THIS EXAMINATION: anastomotic leak - Please use PO and RECTAL contrast CONTRAINDICATIONS for IV CONTRAST: on HD CLINICAL INDICATION: History of partial colectomy for rectal cancer with fungal infection of peritoneum, evaluate for an anastomotic leak. Technique: 0.625-mm helically acquired images are obtained through the pelvis without intravenous contrast. Multiplanar reformations are provided for interpretation. FINDINGS: Direct comparison is made to prior exam dated [**2109-1-13**]. Again, there is a large amount of ascites within the peritoneal cavity. There is no evidence of anastomotic leak. Orally administered contrast is identified extending to the level of the rectum. Pelvic structures are grossly unremarkable. No suspicious lytic or blastic bony lesions are identified. IMPRESSION: Large ascites. No evidence of anastomotic leak. ================================================================ RADIOLOGY Final Report CT ABDOMEN W/CONTRAST [**2109-1-10**] 3:48 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: eval for cause of L abd pain; obstruction, abscess, anastamo Field of view: 42 Contrast: OPTIRAY [**Hospital 5**] MEDICAL CONDITION: M from [**Hospital3 **], colon ca s/p subtotal colectomy w/ileoproctostomy [**12-18**] at [**Hospital1 2239**] by Dr. [**Last Name (STitle) 11634**], now with fever, increased abd dist, LUQ/LLQ pain, diarrhea, nausea. No vomiting, tolerating po. On vanc for cdiff. Tenderness diffusely, most significant in L mid abd. REASON FOR THIS EXAMINATION: eval for cause of L abd pain; obstruction, abscess, anastamotic leak. Thanks. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 53-year-old man from [**Hospital3 **] with a history of colon cancer, status post subtotal colectomy on [**12-18**] at [**Hospital1 2239**]; now presents with fever, increased abdominal distention and left-sided abdominal pain as well, nausea and diarrhea. On vancomycin for C. Difficile. Here has no leukocytosis. COMPARISON: None. The patient apparently gets his care at [**Hospital6 2241**]. TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis was performed after oral and intravenous contrast. Coronal and sagittal reformations were obtained. CT OF THE ABDOMEN: There are small bilateral pleural effusions with associated lower lobe atelectasis. The heart and pericardium are unremarkable. The liver is shrunken and nodular, consistent with cirrhosis. There are multiple calcified gallstones within a nondistended gallbladder. The adrenal glands, spleen, pancreas, and kidneys appear unremarkable. Loops of small bowel are normal in caliber. There is an anastomosis in the left abdomen between the small bowel and sigmoid, which appears unremarkable. Contrast extendeds into the colon. There is no colonic inflammation. There is a large amount of simple fluid (ascites) within the abdomen. There is splenomegaly with two splenules. There is midline stranding in the anterior abdominal wall consistent with recent surgery. The caliber of the abdominal aorta is normal with mild atherosclerotic calcification infra- renally. No residual free intraperitoneal air is identified. Few borderline celiac lymph nodes are noted. CT OF THE PELVIS: The bladder, prostate, seminal vesicles and rectum are unremarkable. A linear density within the rectum may represent ingested material. A large amount of free fluid tracts into the pelvis. There is no definite lymphadenopathy. OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic lesions. Bilateral SI joint anterior fusion is noted. IMPRESSION: 1. No evidence of bowel pathology. Intact anastomosis without obstruction. 2. Shrunken nodular liver and splenomegaly, suggestive of underlying cirrhosis. Large amount of ascites. 3. Small bilateral pleural effusions and associated atelectasis. 4. Cholelithiasis without findings suggestive of cholecystitis. ================================================================ [**Hospital1 8**] ECHOCARDIOGRAPHY REPORT [**Known lastname 16638**], [**Known firstname **] [**Hospital1 8**] [**Numeric Identifier 16640**]Portable Stress Echo (Pharmacologic) Done [**2109-1-25**] at 2:53:05 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) 3731**], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], Critical Care & [**Last Name (un) **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Location (un) 6736**], E/KS-B23 [**Location (un) 42**], [**Numeric Identifier 5891**] Status: Inpatient DOB: [**2055-11-20**] Age (years): 53 M Hgt (in): BP (mm Hg): 98/56 Wgt (lb): 186 HR (bpm): 74 BSA (m2): Indication: Preoperative assessment. ICD-9 Codes: 414.8 Test Information Date/Time: [**2109-1-25**] at 14:53 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Test Type: Portable Stress Echo (Pharmacologic) Son[**Name (NI) 5895**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16641**], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2008W008-0:56 Machine: Vivid [**6-4**] Echocardiographic Measurements Results Measurements Normal Range Findings AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no pericardial effusion. The patient received intravenous dobutamine beginning at a dose of 15 mcg/kg/min for 3 minutes. The test was stopped because of a hypotensive response. The exercise ECG tracings are unavailable for review. The blood pressure response to stress was abnormal/hypotensive. Resting images were acquired at a heart rate of 60 bpm and a blood pressure of 98/56 mmHg. These demonstrated normal regional and global left ventricular systolic function. Right ventricular free wall motion is normal. At peak dobutamine stress [15 mcg/kg/min; heart rate 118 bpm, blood pressure 76/48 mmHg), there was appropriate augmentation of systolic function of all segments with decrease in cavity size. ================================================================ MELD score upon discharge: 36, actively listed on transplant list Follow up appointments: With transplant center on [**2109-2-27**] 11:00a Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**Name6 (MD) **] [**Last Name (NamePattern4) 12140**] MD [**MD Number(2) 12141**] Completed by:[**2109-2-26**]

[ "567.29", "401.9", "572.4", "272.0", "572.2", "008.45", "486", "571.2", "584.9", "567.89", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95", "54.91", "96.6", "38.95" ]

icd9pcs

[ [ [] ] ]

18749, 18956

3557, 6972

327, 382

9951, 9959

2703, 3534

10424, 11599

2250, 2290

7324, 9311

9421, 9930

6998, 7301

9983, 10401

2305, 2684

273, 289

13787, 18595

18675, 18726

13440, 13758

18611, 18651

410, 1672

1694, 1995

2011, 2234

79,015

155,865

27680

Discharge summary

report

Admission Date: [**2194-1-25**] Discharge Date: [**2194-2-19**] Date of Birth: [**2157-2-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1390**] Chief Complaint: Polytrauma s/p pedestrian struck by a vehicle Major Surgical or Invasive Procedure: RLE ExFix,Tracheostomy,VAC placement/IM nailing, PEG, s/p trach revision, ORIF mandible, attempted IVC filter, s/p IVC filter placement and removal of CI filter. History of Present Illness: 37M hit by car thrown 20 feet, found unresponsive, agonal breathing, intubated at scene. B/l CTs placed in ED. R PTX initially needled, then CT placed; decreased BS noted on L and CT placed w/clinical suspicion of PTX. + ETOH. Past Medical History: PMH: Bipolar d/o, Klinefelter's, Raynaud's, Systemic sclerosis (extent uncertain, recent dx), ^chol, Prostatitis Obesity Social History: +EtOH, +Tob Family History: NC Physical Exam: PHYSICAL EXAM on Admission: T: 98.5 BP:110 / 55 HR:123-133 R 30 O2Sats 92% Vented Gen: Intubated and sedated on propofol, patient examined when off of propofol for 5 min. HEENT: Pupils: right 4.5 to 3.5, left 3 to 2.5 Neck: Trauma collar Lungs: Bilateral chest tubes Cardiac: Tachy Abd: Distended Extrem: Right open tib fib fracture, fingers and toes cyanotic Neuro: Mental status: No eye opening to voice and or painful stimuli. Cranial Nerves: Positive corneals Positive cough Motor: Moves bilaterl lower extremities to lightening of sedation, localizes to nox with left upper extremity Pertinent Results: MICRO: [**1-26**] MRSA: positive [**1-27**] R BAL: coag + staph aureus ([**Last Name (un) 36**] to vanc) 12/28 L BAL: coag + staph aureus [**1-27**] Blood Cx: P [**1-27**] Blood Cx: P [**1-27**] Urine Cx: neg [**1-27**] Aline tip Cx: neg [**1-28**] Epidural tip Cx: neg [**1-29**] BAL RLL: NG [**1-29**] BAL LLL: Sparse staph a [**1-30**] Sputum: Sparse staph a [**1-30**] Blood Cx: P [**2-1**] Bl cx x 2: P [**2-1**] Urine Cx: P [**2-1**] BAL: NG [**2-5**] Bl cx x 2:P [**2-5**] UCx:GPB <[**Numeric Identifier 4856**] [**2-5**] Sputum: Staph [**2184**] [**2-5**] nasal swab: GPC, GNR- STAPH AUREUS COAG + [**2-5**] BAL: STAPH AUREUS COAG +. ~[**2184**]/ML. [**2-6**] Ucx:NG [**2-6**] sputum: Staph coag + sparse [**2-6**] Bl Cx: Klebsiella PNA Pan [**Last Name (un) 36**] [**2-6**] Cath: Coag neg staph [**2-6**] Cath: Coag neg staph [**2-7**] Bl Cx: NG [**2-9**] C diff NG [**2-13**] Swab: NG [**2-13**] Bl cx x 2: P . IMAGING: [**2194-1-25**] CT Head: 5-mm L frontal lobe parenchymal contusion. Small linear R frontal SAH w/possible parenchymal component. R frontal subgaleal hematoma and laceration . [**2194-1-25**] CT cspine: No acute cervical fx or malalignment. [**2194-1-25**] CT Torso: Multiple b/l displaced, comminuted rib fx(Rt [**3-11**] ant rib fx, Lt [**2-5**] ant rib fx). Tiny residual [**Hospital1 **]-basilar PTX. Lower lung collapse b/l. Possible contusion. High density structures in RLL segmental bronchus &in esophagus, most likely representing aspirated &swallowed teeth, respective. Subtle ant mediastinal haziness=small hematoma, w/o acute aortic injury or sternal fx. No intra-abdominal or pelvic injury. [**2194-1-25**] CT Face: Multiple b/l mandibular fx w/dislocation of R TMJ; Rt [**Last Name (un) **] neck fx/dislocation, b/l ramus fx, b/l symph fx. Hyperdense structures in the soft tissue lat to L alveolar process of maxilla and w/in oral cavity ?dislodged teeth or tooth fragments. [**2194-1-25**] CT RLE: Comminuted, displaced mid tib fx. Oblique fx of fib diaphysis. Min displaced fibular head fx. Possible peroneus tendon injury. [**1-26**] CT Head: very slight incr in visibility of a minimal degree of SAH w/in multiple cerebral sulci [**1-26**] CXR: Improvement in multifocal pulmonary opacities [**1-27**] TTE: Mild right ventricular cavity dilation with free wall hypokinesis [**1-28**] CT Head: No new hemorrhage. Expected interval evolution SAH. No sig change L frontal contusion. [**1-28**] RUE Xrays: Questionable malalignment radial head articulation w/ capitellum. No evid acute traumatic injury R shoulder/wrist. [**1-29**] CXR: Worsening bibasilar atelectasis [**1-30**] CXR: Increased R PTX [**1-31**] CXR: Unchanged [**2-1**] CXR: BL pl eff, collapse of lung bases. effusions. [**2-1**] CXR: tracheostomy has been advanced several centimeters with the distal tip now 2.5 cm above the carina [**2-2**] CXR: Unchanged [**2-3**] CXR: Unchanged, trach in place [**2-4**] CXR: Stable s/p CT removal [**2-5**] LENIs: clot in R greater saphenous, close to CFV. fever 102.2 O/N [**2-6**] RUQ U/S: Limited study but likely neg for cholecystitis [**2-8**] CXR: Bilateral pleural effusions [**2-10**] CXR: Improved aeration of bases, Stable R infrahilar consolidation. [**2-12**] CXR: interval increase in pleural effusions and atelectasis. [**2-13**] CXR: Previous pleural effusions have decreased substantially, small if any on the right Brief Hospital Course: EVENTS: [**1-25**]: Admit to TSICU. 4L resusitation in ER plus 500 bolus. D50/insulin, kayexalate given for K 5.8. [**1-26**]: Bronch, retrieval of tooth in RLL. Bolused 1L NS for low urine output x2. Ex fix, fasciotomies, OMFS cleaned, debrided fx & removed loose teeth. T7-8 epidural (10/14 cm) placed in OR, APS following. TTE ordered. Desats w/turning. FENA prerenal, increased IVF and multiple boluses for uop <100 [**1-27**]: desat with turning, paO2 66; increased FiO2 to 50%, suctioned mucous plugs. Combivent for wheeze. s/p Trach. TTE with dilated RV and hypokinesis. Ophtho c/s rec'd -> E-mycin bilateral eyes [**Hospital1 **] and eyes taped shut at all times. Acute hypoxia after returning from OR -likely derecruitment. Started empiric VAP tx [**1-27**]. [**1-28**]: Repeat head CT for decreased mvmt RUE -> stable. Cuff leak with movement. Astromorph instilled through epidural, and d/c'd [**3-4**] concern for abcess. Started cisatt gtt. Lasix 20 IV x1 @1500. 1PRBC for Hct 21.6. [**1-29**]: Transfused another untit of PRBC for hct 21.7. Lasix increased to TID. Bronch and BAL performed. Vanc increased to 1.5 TID. PEG placed at bedside. Plan for OMFS and ORTHO @ 0730 [**1-30**]. Ax a-line placed [**1-30**]: OR. Revision of tracheostomy/Multiple tooth extractions/ maxillary fixation/ORIF of symphysis/Closure of chin wound. Lasix diuresis. TFs started. [**1-31**]: attempted to wean Fi02. Decr paO2, tried recruitment. Re-bolused cis. Diamox x3. Started Lovenox in place of heparin for DVT prophylaxis. Cipro d/c. Insulin gtt started. Diuresed. HCT down to 22.4. [**2-1**]: Dcd cefepime. Transfused 1 unit. Acute inability to ventilate pormptin trach repositioning under bronch. Mild desats overnight. Ct back to suction. Diuresed overnight. Diamoc for met alkalosis. Continued paralysis given poor oxygenation. [**2-2**]: transfused 1 unit, CT to water seal, wean FiO2 [**2-3**]: Trasfused 2 units (22.1 -> 27.0), Dilantin reloaded. Off of Cis, had acute episode of hypoxia likely [**3-4**] mucous plug, placed back on Cis and changed to PCV. CTs back on suction. Developed severe respiratory acidosis - switched back to CMV to achieve better MV (only 6.5-7.0 on PCV with high pressures). Switched Dilantin to IV from PO [**3-4**] poor absorption. [**2-4**]: Changed to PC ventilation. Decreased peep to 16. Esophageal balloon placment. Removed R CT. Dilantin dcd. 101.4 ax temp- pancultured. [**2-5**]: Bronch and BAL. Increased Peep to 18. Unasyn for Sinusitis started. Dcd Cisatracuronium paralysis. [**2-6**]: Decreased peep to 15, decreased RR to 12, Ti to 1.9 with improved O2. Started Vanc/Zosyn for gram neg rods in blood cx. Dc'd R axillary and R subclavian line (cultured). Placed L axillary and L femoral lines. RUQ U/S likely neg for cholecystitis (possible source of gram neg bacteremia), LFTs nml. [**2-7**]: Placement of U/s guided IVC, Placement of RIJ. Decresed FIO2 to 50%. Acetazolamide for diuresis. [**2-8**]: Decreased Peep from 15 to 12. not tolerated, returned to Peep 15. Fio2 decreased to 45% 1/10: Continued Acetazolamide and Lasix diuresis. [**2-10**]: Increased lasix to 60mg [**Hospital1 **], Cont acetazolamide, Decreased fio2 to 40% with peep 13, Pins 23, IT 1.6. [**2-11**]: decreased peep 12 [**2-12**]: Did not go to the OR. Restarted TF at goal of 60cc because discontinued propofol. Tachy and htn, thought [**3-4**] agitation, trial of zyprexa with minimal results, continued to increase fentanyl gtt and give boluses of ativan [**2-13**]: to or for removal of common iliac IVC and washout of RLE with closure of lateral wound. New left CVL placed 16 cm wire. [**2-14**]: Changed vent to PS. [**2-15**]: Decreased repiratory drive s/p methadone. [**2-16**]: Decreased PS 8, PEEP to 5. Decreased methadone dosing. Decreased lasix to 10 [**Hospital1 **]. [**2-17**]: on trach collar, lasix stopped, to OR for STSG tomorrow [**2-18**]: Vac change in OR [**2-19**]: No acute events overnight. Patient stable for discharge. Medications on Admission: [**Last Name (un) 1724**]: Abilify 5mg', Zoloft 250mg', Trileptal 200mg, Seroquel 750mg, Zolpidem 1mg, Lipitor, Protonix, Nifedipine, Androderm Soc: Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day). 2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**7-8**] Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 3. Acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for fever. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Sertraline 50 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 7. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous Q12H (every 12 hours). 12. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain. 13. Methadone 10 mg Tablet Sig: 1.5 tablets PO BID (2 times a day). 14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO DAILY (Daily). 15. Methadone 10 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Acute Respiratory Distress Syndrome Bilateral frontal subarachnoid hemmorhages/contusions bilateral basilar lung collapse Right mandibular neck, bilateral ramus, bilateral symph fxs Right [**3-11**] anterior rib fractures, Left [**2-5**] anterior rib fractures, and Bilateral Pneumothoraces Right fibular head fracture, comminuted Right tibial fracture Right temporal laceration Right talus fracture Right Lower extremity Deep Venous Thrombosis Right peroneus tendon injury. . Discharge Condition: Activity Status:Out of Bed with assistance to chair or wheelchair Mental Status:Confused - always intermittently follows commands Level of Consciousness: arousable Discharge Instructions: Please call if patient develops fevers to greater than 101.4 any worsening ventilator requirments or any redness or selling around wound sites. Followup Instructions: Please call Dr. [**Last Name (STitle) **], Trauma Surgery at [**Telephone/Fax (1) 600**] for a follow up appointment in [**2-1**] weeks. Please call the Orthopedic Surgery Clinic at [**Telephone/Fax (1) 1228**] for a follow up appointment in [**2-1**] weeks. Please call the Vascular Surgery Clinic at [**Telephone/Fax (1) 1237**] for a follow up appointmment in 2 weeks. Please call the Plastic [**Hospital 37176**] Clinic at [**Telephone/Fax (1) 67594**] ffor a follow up appointment on Friday [**2194-2-28**]. Please call the [**Hospital 40530**] Clinic at [**Telephone/Fax (1) 55393**] for a follow up appointment with Dr. [**First Name (STitle) **] on [**2194-2-28**]. Completed by:[**2194-4-7**]

[ "823.32", "997.31", "802.29", "453.6", "296.80", "807.4", "728.88", "041.19", "860.0", "790.7", "873.0", "851.80", "825.21", "E814.7", "958.92", "278.00", "518.81", "802.36", "461.9", "934.8" ]

icd9cm

[ [ [] ] ]

[ "83.39", "76.76", "88.51", "23.19", "38.7", "34.04", "39.99", "96.6", "83.65", "83.14", "31.1", "33.24", "78.67", "88.65", "79.36", "76.2", "79.66", "96.72", "78.17", "43.11" ]

icd9pcs

[ [ [] ] ]

10546, 10617

5025, 9002

359, 523

11138, 11204

1616, 2562

11496, 12204

969, 973

9202, 10523

10638, 11117

9028, 9179

11328, 11473

988, 1002

274, 321

551, 779

1451, 1597

3957, 5002

1017, 1371

11218, 11304

801, 924

940, 953

31,962

152,298

31956

Discharge summary

report

Admission Date: [**2136-11-13**] Discharge Date: [**2136-11-27**] Date of Birth: [**2056-4-15**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: Ms. [**Known lastname 74903**] is an 80-year-old woman who had had metal tracheal stents for tracheal stenosis. These were removed the previous day and she needs a tracheostomy tube for longer term airway management. Major Surgical or Invasive Procedure: [**2136-11-14**] - Flexible and rigid bronchoscopy for metal and silicone stent removal [**2136-11-16**] - Flexible and rigid bronchoscopy for removal of remaining metal stent fragments and open tracheostomy History of Present Illness: Mrs. [**Known lastname 74903**] has a high-grade airway obstruction due to fractured metal stents in her trachea that covered the entire length from her subglottic space to her main carina. Originally, an Ultraflex stent was placed on the outside for tracheal stenosis, and after fracturing, silicone stent was placed inside the metal stent. The patient was admitted from OSH for removal of stents and definitive airway. She was transferred on linezolid for MRSA PNA. Past Medical History: MRSA pneumonia tracheal stenosis arthriti Hiatal hernia HTN COPD CCY '[**88**] Hysterectomy '[**94**] laminectomy [**11/2134**] Social History: 30 pack year history, quit smoking [**2108**] Lives with family Family History: non contributory Physical Exam: Vitals 98.0 HR 59, BP 134/50, RR 20, 96% RA Gen- in NAD Card- regular rate and rhythm, S1, S2 Pulm- # 8 portex trach in place, breathing comfortably Abd- soft, non tender, non distended Extrem; No c/c/e Neuro; intact, mouths words around trach Pertinent Results: [**2136-11-18**] 2:23 pm URINE Source: Catheter. URINE CULTURE (Final [**2136-11-20**]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- 2 S MEROPENEM------------- 0.5 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S VIDEO OROPHARYNGEAL SWALLOW Clip # [**Clip Number (Radiology) 74904**] Reason: Evaluate for aspiration [**Hospital 93**] MEDICAL CONDITION: 80 year old woman with new trach/swelling REASON FOR THIS EXAMINATION: Evaluate for aspiration Final Report CLINICAL HISTORY: 80-year-old female with new tracheostomy and swelling. Evaluate for aspiration. VIDEO OROPHARYNGEAL SWALLOW: Study done in conjunction with speech and swallow division. Multiple consistencies of barium were administered to the patient under constant video fluoroscopy. Oral phase showed mild impairments in bolus control and formation. Pharyngeal phase showed normal palatal elevation, laryngeal elevation and valve closure. Note was made of consistent penetration with thin liquids secondary to delay in initiation of swallow. No aspiration was detected. IMPRESSION: Penetration without evidence of aspiration. Brief Hospital Course: The patient was admitted from OSH on [**2136-11-13**] on linezolid for MRSA PNA detected at OSH. She was admitted to the ICU for close monitoring and CPAP therapy. [**2136-11-14**] the patient underwent a flexible and rigid bronchoscopy for removal of silicone and fractured metal stent. The patient remained intubated following the procedure d/t trauma to the airway from removal of metal stent which was imbeded in the airway. On [**2136-11-16**] the patient underwent flexible and rigid bronchoscopy for removal of remaining metal fragments and for a definitive airway. A #8 portex trach was placed. She weaned readily from the vent to trach mask and was transfered to the floor. She passed her swallow eval w/o evidence of aspiration and was [**Last Name (un) 1815**] reg diet thin liquids and soft solids. She progressed well w/ PT and was ambulatory in the [**Doctor Last Name **] w/ O2 and assist. Her linezolid was changed to vanco and her course will be completed on [**11-30**]. Her pseudomonas UTI was treated w/ a full course of cipro. Her trach sutures should be removed on [**11-30**]. Medications on Admission: prevacid, norvasc, diovan, lopressor, lasix, k-dur, singulari, xopenex, vsicare, klonipin, [**Doctor Last Name **], mucinex, nasocort, advair, celebrex, paxil, zyvox Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor Last Name **]: One (1) Injection TID (3 times a day). 2. Amlodipine 5 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily). 3. Valsartan 80 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily). 4. Montelukast 10 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily). 5. Clonazepam 0.5 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Doctor Last Name **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: Four (4) Tablet PO DAILY (Daily). 8. Diphenoxylate-Atropine 2.5-0.025 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours) as needed. 9. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs PO Q6H (every 6 hours) as needed. 15. Lidocaine HCl 2 % Solution [**Hospital1 **]: Ten (10) ML Mucous membrane TID (3 times a day) as needed. 16. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO QOD (). 17. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 19. Hydralazine 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q3H (every 3 hours) as needed for SBP > 150 . 20. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1) gm Intravenous Q 24H (Every 24 Hours) for 3 days. 21. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Four (4) mg Injection Q8H (every 8 hours) as needed. 22. regular insulin per sliding scale finger stick Discharge Disposition: Extended Care Facility: good [**Hospital **] specialty hospital Discharge Diagnosis: Tracheal stenosis s/p metal and silicone stent removal and open trach Discharge Condition: good Discharge Instructions: Please call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10084**] if you have any questions re: airway status. Followup Instructions: Please call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10084**] to schedule a follow up appointment in 6 weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2136-11-27**]

[ "041.11", "599.0", "490", "041.7", "496", "285.9", "E878.1", "553.3", "519.19", "996.69", "996.59", "V09.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "33.22", "31.1", "00.14", "33.78", "96.6" ]

icd9pcs

[ [ [] ] ]

7088, 7154

3362, 4464

540, 750

7268, 7275

1793, 2545

7440, 7683

1496, 1514

4680, 7065

2582, 2627

7175, 7247

4490, 4657

7299, 7417

1529, 1774

284, 502

2656, 3339

778, 1248

1270, 1399

1415, 1480

6,365

106,689

10662

Discharge summary

report

Admission Date: [**2201-4-12**] Discharge Date: [**2201-4-20**] Date of Birth: [**2129-2-20**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4111**] Chief Complaint: Fever and Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname **] is a patient well-known to our service who has had a long and complicated history originating with his pancreatic pseudocyst, gallstone pancreatitis, and a challenging post-operative course therein. After an arduous recovery, Mr [**Known lastname **] was discharged to the [**Hospital6 **] under the expert care of Uri [**Doctor Last Name **]. He was eventually weaned from ventilatory support and his tracheostomy was removed. He complained on [**4-9**] of Fever to 103 and hypotension. He subsequently developed respiratory distress and had to be re-trached and placed on a ventilator. He denies nausea/vomiting, or other constitutional signs. He presents for evaluation and management of fever and respiratory distress. Past Medical History: HTN CAD, s/p angioplasty s/p AVR [**7-6**] Respiratory failure tracheostomy Failure to thrive s/p R knee surgery ventilator associated pneumonia pancreatic pseudocyst Atrial fibrilation galstone pancreatitis picc line placement cholelithiasis COPD CHF sepsisq Social History: lives with his wifeformer tobacco use Physical Exam: Physical exam on discharge: Lungs CTA B bs Herat rrr nm ng Abd soft nt nd Cns awake, alet MAE FC ext + edema pos pulses Pertinent Results: [**2201-4-12**] 05:15PM BLOOD WBC-13.1* RBC-3.08* Hgb-9.7* Hct-29.6* [**2201-4-19**] 04:29AM BLOOD WBC-8.1 RBC-3.13* Hgb-9.2* Hct-29.1* Brief Hospital Course: Pt admitted through ER for fever and hypotension. Admitted to SICU for ventilatory management. His indwelling PICC line was removed. Cultures drawn and pt continued on meropenem and zyvox as [**First Name8 (NamePattern2) **] [**Hospital1 **]. Resp: He was placed on assist-control mode ventilation with a PEEP of 10. A speech and swallow eval was reluctant to advance his po's as at that high of PEEP his ability to swallow would be impaired. Throughout his hospital course his PEEP was gradually reduced. This was not pursued aggressively, as it was felt that [**Hospital1 **] was well-suited to do a long, gradual [**Hospital1 **] wean that would be ideal for this patient, and the acute hospital issue was the infection. He was discharged on the [**Hospital1 **] with a PEEP of 5 on assist-control, with the understanding that [**Hospital1 **] would resume his [**Hospital1 **] wean. GI: As he had no active GI issues, his tubefeeds were rapidly increased to his goal rate. He tolerated this well, as would be expected. No other acute GI issues. ID: Although pt arrived with high fevers and likely infection, his cultures were negative except for a positive MRSA screen, which was unsurprising as the pt is known to be MRSA-positive. Pt continued to be afebrile throughout hospital course on meropenem and linezolid. Neuro: Pt has been on long-term [**Last Name (LF) **], [**First Name3 (LF) **] no significant sedation was needed for [**First Name3 (LF) **] tolerance. No other active issues. GU: Although a UTI was suspected as an infectious source, urine culture was negative. Medications on Admission: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) susp PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 12. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous every eight (8) hours Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) susp PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 12. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous every eight (8) hours for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Fever of likely respiratory origin Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. [**Location (un) 5442**] wean as per Sapulding protocols. If pt experiences return of fevers, chills, rigors, respiratory difficulty, or other concerning symptoms, please contact our office or the [**Hospital1 18**] Emergency dept. Followup Instructions: Please contact [**Name (NI) 20112**] office to arrange follow up. Completed by:[**2201-4-20**]

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icd9cm

[ [ [] ] ]

[ "00.14", "96.72" ]

icd9pcs

[ [ [] ] ]

5313, 5383

1774, 3363

336, 342

5462, 5470

1614, 1751

5786, 5883

4339, 5290

5404, 5441

3389, 4316

5494, 5763

1473, 1473

1501, 1595

275, 298

370, 1119

1141, 1402

1418, 1458

43,112

136,852

47666

Discharge summary

report

Admission Date: [**2158-2-12**] Discharge Date: [**2158-3-1**] Date of Birth: [**2087-5-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: Tracheostomy Percutaneous Endogastric tube Intubation and extubation History of Present Illness: 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred in from rehab due to increased SOB over the prior 3-4 days. This am, she was noted to have low sats in 70% which did not respond to nebs. Her sats came up with high flow O2 in the EMS. Pt denied any cough, increased sputum, chest pain or pedal edema. She was notably wheezey on presentation and was initially treated as COPD exacerbation. . In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL infiltrate seen on CXR. On re-evaluation, pt was lethargic and desatting into the 70s. Pt was intubated for respiratory failure and received ceftriaxone and vancomycin for presumed PNA. Pt was noted to have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt was transferred to the ICU on versed/fentanyl and dopamine to maintain SBPs. . On arrival, pt was intubated and sedated though following commands. She reported some chest pain but was otherwise comfortable and sating 100% on the vent. Past Medical History: COPD HTN Carotid Stenosis PVD: aortoileac disease, followed by Dr. [**Last Name (STitle) **] Osteoporosis CAD s/p NSTEMI Depression/Anxiety Social History: previously lived alone, works in publishing, ETOH: one drink [**3-8**] days per week, nonsmoker, quit smoking 15 yrs ago, smoked for about 30 years. Former VP of Celtics Business Operations. Niece involved in care. Family History: non contributory Physical Exam: Vitals: T: 97.5 BP: 103/51 P: 99 R: 14 Sats 100% on AC 500/5/14/100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2158-2-12**] 10:00AM BLOOD WBC-17.0* RBC-3.66* Hgb-11.2* Hct-34.8* MCV-95 MCH-30.5 MCHC-32.1 RDW-15.4 Plt Ct-425# [**2158-2-13**] 03:20AM BLOOD WBC-15.8* RBC-2.64* Hgb-8.0* Hct-25.1* MCV-95 MCH-30.4 MCHC-31.9 RDW-15.5 Plt Ct-288 [**2158-2-14**] 03:59AM BLOOD WBC-24.4* RBC-2.82* Hgb-8.6* Hct-26.7* MCV-95 MCH-30.6 MCHC-32.3 RDW-15.6* Plt Ct-306 [**2158-2-19**] 03:01AM BLOOD WBC-16.7* RBC-2.81* Hgb-8.5* Hct-26.2* MCV-93 MCH-30.2 MCHC-32.4 RDW-16.0* Plt Ct-251 [**2158-2-23**] 03:16AM BLOOD WBC-41.1*# RBC-3.03* Hgb-9.2* Hct-28.0* MCV-92 MCH-30.5 MCHC-33.0 RDW-15.5 Plt Ct-349 [**2158-2-25**] 03:10AM BLOOD WBC-25.0* RBC-2.82* Hgb-8.4* Hct-25.6* MCV-91 MCH-29.9 MCHC-33.0 RDW-15.3 Plt Ct-301 [**2158-2-27**] 03:56AM BLOOD WBC-15.9* RBC-3.29* Hgb-9.6* Hct-30.0* MCV-91 MCH-29.2 MCHC-32.0 RDW-15.1 Plt Ct-391 [**2158-3-1**] 03:05AM BLOOD WBC-15.3* RBC-3.43* Hgb-10.3* Hct-31.1* MCV-91 MCH-30.0 MCHC-33.1 RDW-15.1 Plt Ct-422 [**2158-2-12**] 10:00AM BLOOD PT-13.6* PTT-24.4 INR(PT)-1.2* [**2158-2-13**] 03:20AM BLOOD PT-14.8* PTT-30.2 INR(PT)-1.3* [**2158-2-21**] 04:31AM BLOOD PT-13.1 PTT-38.5* INR(PT)-1.1 [**2158-3-1**] 03:05AM BLOOD PT-13.8* PTT-35.1* INR(PT)-1.2* [**2158-2-12**] 10:00AM BLOOD Glucose-188* UreaN-16 Creat-0.5 Na-138 K-4.5 Cl-93* HCO3-37* AnGap-13 [**2158-2-14**] 03:59AM BLOOD Glucose-121* UreaN-16 Creat-1.0 Na-140 K-4.0 Cl-108 HCO3-26 AnGap-10 [**2158-2-16**] 02:05AM BLOOD Glucose-107* UreaN-30* Creat-1.2* Na-146* K-3.1* Cl-106 HCO3-32 AnGap-11 [**2158-2-26**] 03:54AM BLOOD Glucose-90 UreaN-14 Creat-0.5 Na-138 K-3.9 Cl-102 HCO3-32 AnGap-8 [**2158-3-1**] 03:05AM BLOOD Glucose-95 UreaN-15 Creat-0.5 Na-139 K-3.7 Cl-92* HCO3-40* AnGap-11 [**2158-2-12**] 04:47PM BLOOD ALT-71* AST-113* LD(LDH)-294* CK(CPK)-27 AlkPhos-102 TotBili-0.4 [**2158-2-12**] 10:00AM BLOOD cTropnT-0.01 [**2158-2-12**] 04:47PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2158-2-13**] 03:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 ----------------- Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2158-3-1**] 03:05AM 15.3* 3.43* 10.3* 31.1* 91 30.0 33.1 15.1 422 . INR 1.2 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2158-3-1**] 03:05AM 95 15 0.5 139 3.7 92* 40* 11 . CXR: [**2158-2-12**] IMPRESSION: Focal consolidation in the left peripheral mid lung superimposed on changes of emphysema. This is consistent with pneumonia. . CXR: [**2158-2-25**] IMPRESSION: AP chest compared to 7:12 p.m. Nasogastric tube ends in the upper portion of a nondistended stomach. Although the tip of the ET tube is less than 2 cm from the carina and the chin is down, this is only 1 cm below optimal placement. Right PIC line ends at the junction of the brachiocephalic veins. Residual of pneumonia in the left mid lung has been stable for several days. Small bilateral pleural effusion has increased slightly since earlier in the day, and there is pulmonary vascular redistribution but no edema. Heart size is normal. Thoracic configuration indicates COPD. . A region of scar-like opacity in the axillary portion of the right mid lung is more radiodense than it was earlier in [**2157**] and largely new since [**2156-10-4**]. This could also be post-inflammatory, but is concerning for possible malignancy. Followup is advised clinically indicated, with chest CT, which can be compared to the CTPA on [**2157-11-19**]. Dr. [**Last Name (STitle) 40583**] and I discussed these findings at the time of dictation. . IMPRESSION: Little overall change. . CXR: [**2158-2-27**]: FINDINGS: In comparison with the study of [**2-27**], the tracheostomy tube and PICC line remain in place. Hyperinflation of the lungs is again seen consistent with chronic pulmonary disease. Extensive areas of scarring persist. More focal opacifications laterally in the mid lung zone on both the right and left are again seen. No evidence of pneumothorax. . Echo: [**2158-2-27**]: Conclusions The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2157-11-21**], regional and global left ventricular systolic function are improved. The estimated pulmonary artery systolic pressure is now slightly higher. Based on [**2156**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . ECG: Sinus rhythm. Left bundle-branch block with secondary repolarization abnormaliites. Compared to the previous tracing of [**2158-2-19**] no diagnostic change. . Microbiology: Blood Culture, Now Growth from [**2158-2-12**] and [**2158-2-23**] UCx: now growth from [**2158-2-12**] UCx: [**2158-2-23**] + Yeast Urine Legionella Ag: Negative Sputum Cx [**2158-2-12**]: GRAM STAIN (Final [**2158-2-12**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): TINY PLEOMORPHIC GRAM NEGATIVE COCCOBACILLI. RESPIRATORY CULTURE (Final [**2158-2-14**]): SPARSE GROWTH OROPHARYNGEAL FLORA. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. . Sputum Cx: [**2158-2-23**] 9:32 am Mini-BAL **FINAL REPORT [**2158-2-25**]** GRAM STAIN (Final [**2158-2-23**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2158-2-25**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 8 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 1 S PIPERACILLIN---------- 32 S PIPERACILLIN/TAZO----- 32 S TOBRAMYCIN------------ =>16 R . C. Diff: Toxin Negative [**2158-2-23**] ------ [**2-2**], pt had sputum performed at [**Hospital3 **]: 2 different pseudomonas 1st strain pan resistant except amikacin & imipenem 2nd strain sensitive to Zosyn/Ceftaz/cefepime Brief Hospital Course: 70 y/o F with severe COPD who presents with hypoxia and respiratory failure, now intubated. . # Resp failure: Patient was intubated on presentation for severe respiratory distress. Was empirically treated for COPD exacerbation and given CXR findings was treated for pneumonia as well. Sputum cultures subsequently grew haemophilus which was treated with a course of ceftriaxone. Patient had difficulty weaning from the vent but was given a trial of extubation after several days of slow improvement. She managed approximately 12-18 hours extubated before she needed to be reintubated for respiratory distress. Following her second intubation patient developed elevated WBC count to 40. Was pan cultured and empirically treated for C. Diff infection. Data subsequently revealed a GNR in the sputum and diagnosis of VAP was made. She was started on doripenem given a history of meropenem resistant isolates in the past. Sensitivities on GNR subsequently revealed a meropenem GNR and after discussion it was determined that patient could be treated with a course of meropenem. Lastly, patient was more than 20L positive on day prior to discharge, but diuresing well. - Meropenem to complete on [**2158-3-8**] - Continue to diurese as tolerated with goal 2L negative per day to facilitate weaning from the trach. - If patient not responding clinically to meropenem may require doripenem for coverage. - At time of discharge, tolerating trach collar w/o difficulty. - Tapered steroids down to 10mg prednisone which was pre-admission dose - Continue PCP prophylaxis given steroids . # Hypotension: Likely septic physiology on admission. Treated with stress dose steroids given h/o long standing steroid use, and tapered back to preadmission baseline prior to discharge. Subsequently started on anti-hypertensive regimen of lisinopril and diltiazem. . # CAD/Chest pain: Pt with recent NSTEMI who presented with hypoxia and was denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific changes from baseline. Patient did not rule in during hospital stay. Echocardiogram results did no demonstrate significant cardiac pathology. Was restarted on ASA, lipitor, ACE-I. Transiently with atrial fibrillation. Not restarted on anti-coagulation on discharge given acute medical issues and that episode of A. fib was in setting of substantial acute lung pathology. Would reassess need for anticoagulation given episode of a. fib as an outpatient. Continue diltiazem. - Uptitirate lisinopril as tolerated - Recommend repeating electrolytes while actively diuresing patient with lasix and uptitrating lisinopril would follow creatinine regularly. . # Hct drop: Thought to be dilutional. No major bleeding source identified. Patient received 2 units PRBC's during her hospital stay and was trace guaiac positive. - consider outpatient colonoscopy when able. . # Anxiety: started on clonazepam prior to discharge for treatment of anxiety. To use ativan PRN. . # ?Lung Mass: Irregular opacity in R-mid lung noted on chest films that was new from [**2157**]. Recommend obtaining a CT scan of her chest for further evaluation. This was not done during this hospitalization given her other acute medical conditions. . # FEN: PEG placed prior to discharge and started on tube feeds. . # Prophylaxis: heparin sc tid, bowel regimen, PPI . # Access: PICC line placed . # Code: FULL . # Disposition: to rehab for trach care. . # Communication: Niece, patient, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 100698**] (PA) who has been caring for Ms. [**Known lastname 30984**] in her current rehab setting. (Her phone number is [**Telephone/Fax (1) 100699**]). The patient's niece became involved and visited often. We had several end of life discussions with the patient and she agreed to trach and full code while hospitalized. Medications on Admission: Aspirin 81mg Atorvastatin 40mg Xopenex prn Tiotropium Daily Advair [**Hospital1 **] Alendronate 70mg weekly Colace [**Hospital1 **] Senna [**Hospital1 **] prn Mucomyst inhaled Vitamin B12 diltiazem 120mg daily Prednisone 10mg daily Ativan prn Robitussin prn Discharge Medications: 1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]: 0.63mg/3ml ML Inhalation q4hr (). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation Q6H (every 6 hours). 6. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection [**Hospital1 **] (2 times a day). 8. Zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime) as needed. 9. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 11. Citalopram 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 12. Clonazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. 14. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 15. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 16. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily (). 17. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 18. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1) injection Injection Q8H (every 8 hours) as needed for nausea. 19. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 20. Diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 21. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: as per sliding scale as per sliding scale Subcutaneous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Community Acquired Pneumonia Ventilator Associate Pneumonia Respiratory Failure status post tracheostomy placement Chronic Obstructive Pulmonary Disease Chronic steroid use Osteoporosis Depression/Anxiety Discharge Condition: Stable. Afebrile. Patient is doing daytime trach mask, interchanged with pressure support mechanical ventilation at night. Discharge Instructions: You were admitted with an pneumonia. For this you were intubated. You had difficulty weaning from the ventilator, but were given a trial of extubation. You had difficulty breathing on your own during this trial and were reintubated to protect you. As a result, you had a tracehostomy placed to allow you to wean from the vent slowly over time. You were treated for two pneumonias during your hospital stay, and have been steadily improving prior to discharge. Followup Instructions: Please f/u with doctors at Rehab. Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2158-4-14**] 8:00 Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time:[**2158-3-10**] 9:50 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2158-7-7**]

[ "518.81", "486", "491.21", "410.72", "599.0", "733.00", "997.31", "300.4", "041.7", "416.9", "276.52" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.24", "96.04", "31.1", "96.6", "96.72", "43.11", "33.22" ]

icd9pcs

[ [ [] ] ]

15872, 15957

9497, 13353

329, 400

16208, 16335

2546, 4481

16848, 17380

1971, 1989

13662, 15849

15978, 16185

13379, 13639

16359, 16825

4497, 9474

2004, 2527

282, 291

428, 1557

1579, 1721

1737, 1955

82,898

170,418

31358

Discharge summary

report

Admission Date: [**2100-12-13**] Discharge Date: [**2100-12-20**] Date of Birth: [**2023-4-21**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Amiodarone / Dofetilide Attending:[**First Name3 (LF) 1505**] Chief Complaint: fatigue/DOE Major Surgical or Invasive Procedure: [**2100-12-14**] MV repair (28mm [**Doctor Last Name **] ring)/ TV repair ( 28 mm [**Company 1543**] Contour 3D ring)/ res. L atrial appendage History of Present Illness: 77 year old female who has been followed for several years for atrial fibrillation and mitral regurgitation. She has undergone PVI in [**2098**] with atrial fibrillation recurrence in [**2099**] requiring DC cardioversion. In addition, she required a pacemaker in [**1-7**] for symptomatic bradycardia. Most recent echocariogram showed worsening mitral regurgitation, now moderate to severe. In addition, she had markedly increased tricuspid regurgitation, now 3+. Referred for surgery. Past Medical History: mitral regurgitation s/p MV repair/TV repair/res. Left atrial appendage tricuspid regurgitation - Paroxysmal atrial fibrillation status post cardioversion in [**2096**], pulmonary vein isolation on [**2098-3-11**]. Recurrent atrial fibrillation post PVI requiring DC cardioversion, [**2099-7-31**] - Prior antiarrhythmic therapy with amiodarone discontinued due to lung toxicity (increased DLCO) - Prior antiarrhythmic therapy with dofetilide discontinued due to QT prolongation - Coronary Artery Disease s/p prior MI [**2076**], - Hypertension - Hyperlipidemia - Congestive Heart Failure - Cardiomyopathy - Mild emphysema/COPD - Hypothyroidism - Anxiety Past Surgical History: - St. [**Hospital 923**] medical dual-chamber pacemaker on [**2099-1-21**], [**Hospital3 **], for symptomatic bradycardia. - s/p Back surgery - s/p Tonsillectomy - Left breast biopsy - (Benign) Social History: Lives with: Husband Contact: Phone # Occupation: Retired Cigarettes: Smoked no [] yes [X] Hx: quit [**2076**] 35 pack-years Other Tobacco use: ETOH: < 1 drink/week [X] [**3-8**] drinks/week [] >8 drinks/week [] Illicit drug use: None Family History: Denies premature coronary artery disease Father died of CAD in 70's Physical Exam: Pulse: 70 Paced Resp: 16 O2 sat: 96% B/P Right: 131/77 Left: 140/86 Height: 65" Weight: 127lb General: WDWN in NAD Skin: Warm, Dry, intact. Right upper chest pacer pocket. HEENT: NCAT, PERRLA, EOMI, sclera anicteric sclera. OP benign. Full dentures. Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: AF with V-Pacing. III/VI Pansystolic blowing murmur. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: Right anterior varicosity over knee but GSV appears suitable on standing Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Question faint left vs. transmitted Pertinent Results: TEE [**2100-12-14**] Intra-op Conclusions PRE-BYPASS: -The left atrium is markedly dilated though not entirely seen. -The coronary sinus is dilated. -Mild spontaneous echo contrast is present in the left atrial appendage. -The right atrium is dilated though not entirely seen. -No atrial septal defect is seen by 2D or color Doppler. -The left ventricle is not well seen in transgastric midpapillary short- axis view. Overall left ventricular systolic function appears low normal (LVEF 50-55%) with normal free wall contractility. -There are simple atheroma in the aortic arch. There are complex (>4mm) and simple atheroma in the descending thoracic aorta. -The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. -The mitral valve leaflets are mildly thickened. There is moderate/severe anterior leaflet mitral valve prolapse. There is a cleft in the anterior mitral leaflet at A2.The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). -The tricuspid valve leaflets are moderately thickened. Severe [4+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. -There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at the time of the study. POSTBYPASS: The patient is AV paced on low dose epinephrine and phenylephrine infusions. There is a well seated annuloplasty ring in the mitral position. There is trace mitral regurgitation. There is no mitral stenosis. There is a well seated annuloplasty ring in the tricuspid position. There is trace tricuspid regurgitation. There is no tricuspid stenosis. The Left ventricular function remains unchanged. During the initial separation from bypass, the right ventricular function was mildly depressed, but improved to normal function with time on epinephrine infusion. The aorta remains intact. I certify that I was present for this procedure in compliance with HCFA regulations. . [**2100-12-17**] 07:25PM BLOOD WBC-12.5* RBC-3.98* Hgb-10.9* Hct-33.1* MCV-83 MCH-27.4 MCHC-32.9 RDW-17.2* Plt Ct-203 [**2100-12-17**] 03:23AM BLOOD WBC-12.7* RBC-3.77* Hgb-10.5* Hct-30.9* MCV-82 MCH-27.8 MCHC-34.0 RDW-17.2* Plt Ct-159 [**2100-12-20**] 05:30AM BLOOD UreaN-23* Creat-1.1 Na-141 K-4.3 Cl-104 [**2100-12-17**] 07:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-140 K-4.2 Cl-102 HCO3-28 AnGap-14 [**2100-12-20**] 05:30AM BLOOD PT-29.3* INR(PT)-2.8* [**2100-12-19**] 05:05PM BLOOD PT-29.5* INR(PT)-2.9* [**2100-12-18**] 10:40AM BLOOD PT-24.5* INR(PT)-2.3* [**2100-12-17**] 03:23AM BLOOD PT-19.6* PTT-33.2 INR(PT)-1.8* [**2100-12-16**] 02:22AM BLOOD PT-13.5* PTT-30.8 INR(PT)-1.2* [**2100-12-15**] 02:05AM BLOOD PT-13.5* PTT-33.4 INR(PT)-1.2* [**2100-12-14**] 01:47PM BLOOD PT-14.4* PTT-44.1* INR(PT)-1.2* [**2100-12-14**] 12:10PM BLOOD PT-17.6* PTT-55.4* INR(PT)-1.6* [**2100-12-13**] 07:19PM BLOOD PT-14.4* PTT-28.2 INR(PT)-1.2* [**2100-12-13**] 10:30AM BLOOD PT-15.5* INR(PT)-1.4* Brief Hospital Course: Admitted [**12-13**] to complete preop w/u while off coumadin. Underwent Mitral Valve repair (28mm [**Doctor Last Name **] ring), Tricuspid Valve repair (28mm Contour ring) and Left Atrial Appendage resection with Dr. [**Last Name (STitle) **] [**12-14**]. Transferred to the CVICU in stable condition on titrated epinephrine, propofol, and phenylephrine drips. Extubated that evening after waking neurologically intact. Transferred to the floor on POD #3 to begin increasing her activity level. Gently diuresed toward her preop weight. Beta blockade and BP meds titrated. Chest tubes removed per protocol. Coumadin restarted for A Fib. Permanent pacemaker was interrogated and temporary pacing wires discontinued. Home meds were slowly resumed for hypertension with good effect. The patient does have a history of COPD and took some extra time to wean from oxygen. She was weaned and stable with room air saturations in the high 80s to low 90s. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA and home PT in good condition with appropriate follow up instructions. Medications on Admission: ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet - 1.5 Tablet(s) by mouth daily AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day AZITHROMYCIN - 500 mg Tablet - 1 Tablet(s) by mouth 1 hour prior to the dental procedure as needed BUMETANIDE - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth once a day CLONIDINE - (Prescribed by Other Provider) - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once daily PRAVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth once a day ***WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth once a day- LAST DOSE 11/10 ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*1* 6. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 9. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 11. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*1* 12. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Dr. [**Last Name (STitle) **] to manage for goal INR 2-2.5 dx: AFib. Disp:*60 Tablet(s)* Refills:*2* 13. clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 14. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication A Fib Goal INR 2.0-2.5 First draw Monday [**12-21**] Results to Dr. [**Last Name (STitle) **] phone [**Telephone/Fax (1) 22166**] fax [**Telephone/Fax (1) 73915**] 15. bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: mitral regurgitation s/p MV repair/TV repair/res. L atrial appendage tricuspid regurgitation - Paroxysmal atrial fibrillation status post cardioversion in [**2096**], pulmonary vein isolation on [**2098-3-11**]. Recurrent atrial fibrillation post PVI requiring DC cardioversion, [**2099-7-31**] - Prior antiarrhythmic therapy with amiodarone discontinued due to lung toxicity (increased DLCO) - Prior antiarrhythmic therapy with dofetilide discontinued due to QT prolongation - Coronary Artery Disease s/p prior MI [**2076**], - Hypertension - Hyperlipidemia - Congestive Heart Failure - Cardiomyopathy - Mild emphysema/COPD - Hypothyroidism - Anxiety Past Surgical History: - St. [**Hospital 923**] medical dual-chamber pacemaker on [**2099-1-21**], [**Hospital3 **], for symptomatic bradycardia. - s/p Back surgery - s/p Tonsillectomy - Left breast biopsy - (Benign) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema trace 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**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **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) **] [**Name (STitle) **] [**Hospital Unit Name **] [**1-19**] at 1:30pm Wound check on [**12-30**] at 10:00am, [**Hospital Ward Name **] [**Hospital Unit Name **] Cardiologist:Dr. [**Last Name (STitle) **] on [**1-12**] at 9:00am (patient will see Dr[**Name (NI) 73916**] nurse practitioner that day) Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**5-4**] weeks [**Telephone/Fax (1) 22166**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication A Fib Goal INR 2.0-2.5 First draw Monday [**12-21**] Results to Dr. [**Last Name (STitle) **] phone [**Telephone/Fax (1) 22166**] fax [**Telephone/Fax (1) 73915**] Completed by:[**2100-12-20**]

[ "276.2", "300.00", "285.9", "428.0", "414.01", "412", "424.2", "427.31", "401.9", "V53.31", "492.8", "V58.61", "425.4", "V12.04", "424.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "35.33", "39.61", "88.53", "37.36", "37.23" ]

icd9pcs

[ [ [] ] ]

10591, 10646

6268, 7571

318, 463

11559, 11736

3082, 6245

12660, 13595

2165, 2235

8712, 10568

10667, 11319

7597, 8689

11760, 12637

11342, 11538

2250, 3063

267, 280

491, 979

1001, 1656

1891, 2149

32,195

198,333

31289

Discharge summary

report

Admission Date: [**2158-7-20**] Discharge Date: [**2158-8-7**] Date of Birth: [**2129-7-21**] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 613**] Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: A-line placement History of Present Illness: 29 yo F h/o DM1, ESRD on PD, HTN, hypercholesterolemia p/w persistent hyperglycemia. FSBG have been elevated the 5 days prior to admisison associated with fatigue, increased thirst and frequency in urination. She reports compliance with her insulin regimen. She denies fevers/chills, no cough, dysuria/hematuria, abdominal pain/nausea/vomiting/diarrhea. She further denies sick contacts. She denies ever having been hospitalized for DKA/poorly controlled BS except for when she was initially diagnosed with DM 15 years ago in [**Male First Name (un) 1056**]. . She initially presented to [**Hospital1 2025**] 3 days prior to her admission to [**Hospital1 18**] however left AMA because her roommate was too annoying/loud and trouble w/ her nurse so came to [**Hospital1 18**] for further care. In the ED at [**Hospital1 18**], she reported SSCP x1 hour duration. EKG was without ischemic changes and CP resolved with SL nitro, ASA, beta-blocker. Initial chemistries showed a glucose in the 300s without AG and she was admitted to the [**Doctor Last Name **]-[**Doctor Last Name **] service to improve her BS management. . In the setting of her hyperglycemia and chest pain, she was ruled out for MI x 3 sets of negative cardiac enzymes. Additionally, urine HCG was negative as was serum confirmation. Blood cultures were sent and have shown NGTD. Peritoneal fluid was sent on [**7-23**] and revealed 1 WBC; gram stain was negative however culture grew sparse GNRs. A repeat peritoneal specimen was sent on [**7-24**] without any WBCS again with negative gram stain and cultures are outstanding. She received 1 dose of IP ceftazidime in the setting of the initial fluid specimen. She did endorse mild sinus tenderness, however CT sinus was negative for acute sinusitis. She was initially started on novolog/humalog standing in addition to humalog SS however BS continued to climb into the 500s range and she transiently developed an AG. In this setting, she was started on insulin gtt on the floor. Although her AG closed with the initiation of insulin gtt, she was requiring up to 430units/hour with serum glucose ranging 300-500s. . In review of her I/Os, it appears that she received 1L NS in the ED and then received approximately 2.5L while on the floor in the form of unconcentrated insulin gtt. Given concern for volume overload due to volume from insulin gtt, she was not further fluid resuscitated and is now being transferred to the ICU for concentrated insulin gtt. Past Medical History: -DM1 (last A1c 10.7%) c/b neuropathy, nephropathy, retinopathy w/ left eye blindness (followed by Dr. [**Last Name (STitle) **] at [**Last Name (un) **]) -ESRD on PD (seen by Dr. [**Last Name (STitle) **] *** Transplant w/u per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - Her pretransplant workup is complete. She is O positive. CMV and EBV positive, hepatitis A, B, C and HIV are negative. She has 0% PRA. She had a normal Pap, normal EKG. Stress test with no reperfusion. Cardiac echo demonstrated normal EF of 50-60% with some diastolic dysfunction in left ventricle with no valvular disease. -Hypertension -Hyperlipidemia; TG in the 4000s -Depression Social History: Initially from [**Male First Name (un) 1056**], moved to US 12 years ago. She lives with boyfriend and her 9-year-old daughter. She does not work outside the house. She quit smoking over a year ago but has restarted and is smoking [**2-8**] ppd. She and denies alcohol or drug use. Family History: Her parents are both alive and have diabetes and hypertension. She has one sister who is obese and has hypertension. Her 9-year-old girl is healthy. Physical Exam: T 98.63 HR 116 BP 128/84 RR 24 SaO2 94-96% RA General: Sitting up in bed, awake, alert, NAD HEENT: PERRL, EOMI, anicteric sclera, conjunctivae pink, round face Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: Sinus tachy, no mrg appreciated Pulmonary: fine rales left lung base, no wheezes/rhonchi Abdomen: +BS, soft, nontender, distended with PD fluid, PD tube site looks clean Extremities: warm, 2+ DP pulses, trace b/l LE edema, extremities without significant subcutaneous fat Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves all extremities Pertinent Results: Studies: [**2158-7-24**] CT sinus: Minimal mucosal thickening of the bilateral maxillary sinuses. No air-fluid levels to suggest acute sinusitis. . [**2158-7-20**] CXR: PA and lateral chest radiographs are reviewed without comparison. Allowing for low lung volumes and body habitus, cardiomediastinal contours are within normal limits. Pulmonary vascularity is normal. Lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. . [**2158-8-2**] CXR: In comparison with the study of [**8-1**], there has been some decrease in the diffuse bilateral pulmonary opacifications, though a substantial residual persists. Enlargement of the cardiac silhouette is again seen. The radiographic findings are most consistent with improving pulmonary edema, though this pattern could also be a manifestation of ARDS. . [**2158-7-31**] Echo: The left atrium and right atrium are normal in cavity size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The estimated cardiac index is normal(>=2.5L/min/m2). Right ventricular chamber size and free wall motion arenormal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved regional and low normal global systolic function. No intracardiac shunt identified. . [**2158-7-30**] V/Q scan: Normal study without evidence of pulmonary embolism. Labs: [**2158-7-20**] 08:20PM WBC-4.7 HCT-31.0* [**2158-7-20**] 08:20PM NEUTS-53.9 BANDS-0 LYMPHS-36.7 MONOS-5.0 EOS-3.8 BASOS-0.6 [**2158-7-20**] 08:20PM ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.1 [**2158-7-20**] 08:20PM CK-MB-5 cTropnT-0.02* [**2158-7-20**] 08:20PM GLUCOSE-361* UREA N-46* CREAT-3.6* SODIUM-135 POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-29 ANION GAP-14 [**2158-7-20**] 08:20PM ALT(SGPT)-45* AST(SGOT)-34 LD(LDH)-257* CK(CPK)-137 ALK PHOS-71 AMYLASE-25 TOT BILI-0.2 [**2158-7-20**] 11:00PM URINE RBC-[**4-12**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-[**7-18**] [**2158-7-20**] 11:00PM URINE UCG-NEGATIVE Brief Hospital Course: # DM: On the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service, the patient received her outpatient insulin regimen, but her FS continued to climb into the 500s and [**Last Name (un) **] was consulted. She only briefly developed an AG which seemed less related to her BG as it was in the 200s at that time. Insulin gtt was started, and she was requiring 400-500 U/h. Given the concern for development of volume overload with such large amounts of fluid with insulin gtt, she was transferred to the ICU for further monitoring and for management of much concentrated insulin gtt. Despite insulin gtt rates of up to 550 units/hour, her glucose remained elevated initially to the 400-500 range despite uptitration. Given lack of BS response to escalating doses of insulin gtt, it was held at a stable dose and her BS began to fall into the 200s. The insulin gtt was then decreased and, because her BS was stable in the 200s with decrease, she was transitioned back to SC insulin at [**Last Name (un) **] recommendation. She tolerated this transition well without further rise in her BS. Addtionally throughout her MICU stay, regular insulin was added to her PD fluid given the dextrose contented and was uptitrated to 30 Units with each dwell. Actos was briefly held in the setting of volume overload, however was restarted prior to transfer to the floor. She was transferred to the floor on stable SC insulin regimen and PD insulin dose with stable finger sticks in the low 200s. There her SS was changed to humalog, SS and lantus were adjusted upward, and her PD insulin DCed. Upon discharge her FS were in the upper 200s on this regimen. Of note, the etiology of the acute worsening of insulin resistance was not determined. Although she did have enterobacter in her peritoneal fluid, subsequent sample even prior to antibiotics was negative and, thus, unlikely precipitant. No other infective source was found, she was ruled out for MI on admission, and HCG was negative. Insulin antibodies were sent and were negative. Leptin level was sent and is outstanding at the time of discharge. She was discharged with [**Last Name (un) **] following. . # Hypoxia/ARDS: Developed after nearly 1 week in the ICU. BNP and troponin were both elevated, so fluid overload was thought to be contributing. In addition, pt was found to be bacteremic, so an ARDS component was thought likely; CXR consistent. TTE was performed and showed EF 50-55% and mild LVH and was without intracardiac shunt. Actos and CCB were held in this setting, and pt was given supplemental O2 by facemask. Additional fluid was removed via PD by alternating 1.5% and 2.5% dextrose solution, and bacteremia was treated. Pt was slowly weaned from O2 and left the ICU on 5 L NC, quickly tapered over 2 days to room air with O2 sats >95% . # Bacteremia: Blood cx grew [**5-12**] MRSE, source thought to be A-line which was removed. Vancomycin was continued for a total of 7 days. Follow-up surveillance ultures were persistently negative. . # Elevated troponin/EKG changes: Pt was initially r/o for MI by EKG and enzymes, given her chest pain in the ED. Amidst her decompensation and hypoxia in the MICU, troponin was stably elevated 0.16 with elevated BNP thought to be [**3-11**] fluid overload. Initial review of EKG was concerning for lateral STD, but further review showed that they were present on admission. . # Sinus tach: .Pt with pulse 100-130 in the setting of fever/bacteremia. Fevers controlled with Tylenol (NSAIDS avoided). Beta blockade was continued, tachycardia resolved with treatment of infection. . # Dyslipidemia: Pt. with lipodystrophy. TGs weremarkedly elevated to 7000s,, and plans were made for pheresis if necessary. Pt was given a zero fat diet, and TGs came down to ~1000 without the need for pheresis. Statin and Tricor were continued, omega-3 fatty acids added. . # ESRD on PD: PD was continued (CAPD), pt followed by the renal team throughout her stay. Cultures of PD fluid grew enterobacter, and pt received 12 days of IP ceftazidime. Sevelamer was discontinued while PO intake was poor, restarted on discharge. Calcitriol and aranesp were continued. NSAIDS were avoided given residual renal function. Pt was instructed to return to home PD cycler on discharge, with follow-up with her PD nurse. . # Anemia/Thrombocytopenia: Thought to be [**3-11**] underlying renal dz, no evidence of bleeding. Pt received 1 U PRBC. Iron/aranesp were continued. . # HTN: Metoprolol was continued, CCB held in setting of fluid overload. . # Hyponatremia: Normalized with improved BS control. Pseudohyponatremia in the setting of both marked hyperglycemia as well as elevated TGs. . # Probable OSA: Pt had witnessed apneic episodes while sleeping with mild desats. Will need outpatient sleep study. . # Yeast infection: >100K yeast on urine cx with negative UA, pt endorsed vaginal itching and was given fluconazole x 3 days. . # Seborrheic dermatisi: Pt endorsed scalp itching and was noted to have erythematous, flaky scalp. Ketoconazole shampoo applied. . # Neuropathy: Lyrica and nortriptyline were continued. Medications on Admission: Nortriptyline 10mg [**Hospital1 **], 30 mg qhs Iron 325 mg tid Lasix 40mg [**Hospital1 **] Calcitriol 0.5mcg qam Renagel 400mg tid Crestor 20mg qhs Colace 100mg [**Hospital1 **] Lyrica 150mg tid Trazadone 100mg qhs prn Zofran 8mg po q8h prn Atenolol 12.5mg qam Humalog R U500 24 units sc lunch and qhs Novolog 12 units sc breakfast and dinner Actos 30mg qam Reglan 5mg qid prn Percocet 5-325 q3h prn Peritoneal dialysis 4-6x/day Gentamycin cream 0.1% prn Discharge Medications: 1. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Nortriptyline 10 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 6. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 7. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO tid (). Capsule(s) 8. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 13. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day as needed for fluid overload. Disp:*60 Tablet(s)* Refills:*0* 16. Renagel 400 mg Tablet Sig: One (1) Tablet PO three times a day. 17. Insulin Glargine 100 unit/mL Cartridge Sig: Forty (40) units Subcutaneous twice a day. Disp:*30 cartridge* Refills:*2* 18. Insulin Lispro 100 unit/mL Cartridge Sig: sliding scale Subcutaneous qachs. Disp:*50 cartridges* Refills:*2* 19. Ketoconazole 2 % Shampoo Sig: One (1) Appl Topical ASDIR (AS DIRECTED) for 1 months. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Health Systems Discharge Diagnosis: primary: diabetes mellitus type I vs II, uncontrolled with complications chronic kidney disease stage V on peritoneal dialysis secondary peritonitis MRSE line infection secondary: hypertension, hyperlipidemia, depression Discharge Condition: stable Discharge Instructions: You were admitted to the hospital because you had very high blood sugars. You were transferred to the intensive care unit so that you could receive IV insulin. While there you developed an infection in your blood and in your abdomen. You were treated with antibiotics for both infections. You also had difficulty breathing because of the infection and were given oxygen to help. You are being discharged now that you are able to breathe well without oxygen. While in the hospital, your peritoneal dialysis was continued. When you go home, you should return to your previous PD cycler schedule. You should also contact your PD nurse, [**Name (NI) 3040**], at ([**Telephone/Fax (1) 12088**] to arrange for follow-up. You should also follow-up at the [**Last Name (un) **] Diabetes Center. You should follow a very low fat and very low salt, and low carbohydrate diet when you leave. If you eat too much salt, you may become fluid overloaded. We have given you a prescription for lasix that you may use to alleviate some of the overload if needed. While in the hospital, it was noted that you sometimes have trouble breathing while you are sleeping. Because of this, you need a formal sleep evaluation. We have made an appointment with a new primary care physician for you, and he will help you arrange this. Please return to the emergency room or call your doctor if you have fingersticks persistently above 400 or if you experience fevers >102, shaking chills, or severe abdominal pain. Followup Instructions: Patient should call [**Doctor First Name 3040**], the peritoneal dialysis nurse, at ([**Telephone/Fax (1) 12088**] for follow up on her dialysis. Dr. [**Last Name (STitle) **], [**Last Name (un) **] Diabetes Center: [**8-14**], 9 AM Dr. [**Last Name (STitle) **], Primary Care, [**Hospital1 18**] [**Hospital Ward Name 516**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2158-8-16**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2158-8-8**]

[ "567.29", "250.62", "272.6", "996.62", "250.52", "518.81", "038.19", "287.5", "327.23", "357.2", "250.42", "276.1", "112.1", "362.01", "995.92" ]

icd9cm

[ [ [] ] ]

[ "54.98", "99.04", "38.91" ]

icd9pcs

[ [ [] ] ]

14696, 14757

7187, 12339

280, 298

15024, 15033

4600, 7164

16582, 17127

3828, 3978

12845, 14673

14778, 15003

12365, 12822

15057, 16559

3993, 4581

227, 242

326, 2804

2826, 3511

3527, 3812

27,179

194,513

8148

Discharge summary

report

Admission Date: [**2163-2-27**] Discharge Date: [**2163-3-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Confusion, shortness of breath, cough Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 6352**] is an 89 YO male with HTN and mild dementia at baseline, who presented with delirium, shortness of breath, and cough. His cough was present for one week prior to presentation and was productive of a clear sputum. At home his temperature was 102.2 degrees F on the morning of admission, according to his home health aide. He also complained of generalized weakness. His home health aide reported that he had not been himself for the several days PTA as he has been increasingly confused and not able to complete his ADLs. At baseline, he pays his own bills and keeps up with the daily stock report. In the ED T 98.1, HR 86, BP 120/84, RR 28-30, O2 Sat 97% 2L NC. He received tylenol 650 mg PO at 6 AM. Levofloxacin 750 mg IV was given in the ED for a presumed PNA and blood cultures were sent. He was stable and tranferred to the floor. Past Medical History: BPH HTN Social History: Patient lives at home with his wife. A nurse [**First Name (Titles) **] [**Last Name (Titles) 29028**] Alliance sees the couple twice a week on Mondays and Wednesdays. He denies tobacco use and drug use, but does drink [**2-6**] glasses of wine/day. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 101.2/101.2, BP 4133/63, P 91, RR 18,O2 sat97-100%3Lnc General: Pleasant, elderly male sitting comfortably HEENT: NCAT, PERRL, EOMI, no cervical LAD, neck supple Chest/CV: RRR, Nl s1/s2, no M/R/G Lungs: course rhonchi b/l Back/CVA,Flank: No CVA tenderness, kyphosis Abd: NTND, + BS Ext: warm, 2+ pulses, no c/c/e Neuro: Alert, not oriented to date/place CN 2-12 intact; [**5-9**] bilateral strength Skin: no rashes, skin damage Pertinent Results: ADMISSION LABS: [**2163-2-27**] 12:00PM BLOOD WBC-5.4 RBC-3.92* Hgb-12.4* Hct-35.4* MCV-90# MCH-31.6 MCHC-34.9 RDW-12.5 Plt Ct-317 [**2163-2-27**] 12:00PM BLOOD Neuts-71.9* Lymphs-15.7* Monos-11.7* Eos-0.4 Baso-0.3 [**2163-3-2**] 05:30PM BLOOD PT-13.9* PTT-31.9 INR(PT)-1.2* [**2163-2-27**] 12:00PM BLOOD Glucose-110* UreaN-19 Creat-0.9 Na-132* K-3.9 Cl-97 HCO3-25 AnGap-14 [**2163-2-28**] 06:15AM BLOOD Calcium-8.1* Phos-3.8# Mg-1.8 CARDIAC MARKERS: [**2163-3-2**] 05:30PM BLOOD CK(CPK)-76 [**2163-3-3**] 02:49AM BLOOD CK(CPK)-101 [**2163-3-2**] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2163-3-3**] 02:49AM BLOOD CK-MB-5 cTropnT-0.12* [**2163-3-5**] 12:27AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2163-3-4**] 05:48AM BLOOD proBNP-[**Numeric Identifier 26263**]* ANEMIA STUDIES: [**2163-3-10**] 02:12AM BLOOD calTIBC-122* VitB12-835 Folate-17.1 Ferritn-1020* TRF-94* URINE STUDIES: [**2163-2-27**] 01:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024 [**2163-2-27**] 01:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2163-2-27**] 01:30PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 MICROBIOLOGY: [**2-27**], [**3-2**], [**3-3**], [**3-5**] Blood Cultures: negative [**3-3**] Urine cultures: negative [**3-3**] Urine Legionella: positive [**3-2**] Influenza DFA: A-positive; B-negative [**2-/2084**] Sputum Culture: >25 PMNs and <10 epithelial cells/100X field; sparse growth of oropharyngeal flora; sparse growth of yeast. IMAGING: [**2-27**] CT Head: No evidence of infarction or hemorrhage. [**2-27**] CXR PA and lateral: No focal consolidation to suggest pneumonia. [**3-2**] CXR Portable: In comparison with the study of [**2-28**], focal areas of opacification adjacent to the aortic arch, in the left lower lung zone and at the right base. This raises the possibility of multiple areas of pneumonia, though some of this apparent change may reflect differences in technique. The possibility of a central source of infection must be considered and echocardiography could be helpful. [**2163-3-7**] TTE: The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild-moderate regional dysfunction with focal hypokinesis of the apical half of the septum, anterior, apical and lateral walls. Basal segments contract best (LVEF = 40-45%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mitral regurgitation is present but cannot be quantified. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2162-7-15**], regional left ventricular hypokinesis is now identified (and the severity of mitral regurgitation is not as well characterized). [**3-9**] CTA Chest: 1. No central pulmonary embolism. Evaluation of distal pulmonary artery branches is limited by respiratory motion artifact. 2. Findings suggestive of CHF versus fluid overload. 3. Extensive peripheral ground-glass opacities, most prominent in the upper lobes with areas of honeycombing. These findings may be related to chronic interstitial process/pulmonary fibrosis. However, a more acute superimposed process such as viral or atypical pneumonia cannot be excluded. 4. Nodular opacities in the right middle lobe which may be infectious in etiology. 5. Pleural calcifications suggesting asbestos-related pleural disease. 6. Subacute rib fractures involving multiple posterior ribs. Additional old healed fractures of several right lateral ribs. 7. Several thoracic compression fractures of indeterminate age. 8. Cardiomegaly. Reflux of contrast into the hepatic veins suggestive of right- sided heart failure. 9. Small pericardial effusion. EKG:Resting sinus tachycardia. Left atrial abnormality. Possible left ventricular hypertrophy. Borderline intraventricular conduction delay. Non-specific ST-T wave changes. P-R interval at the upper limits of normal. Compared to the previous tracing of [**2162-7-13**] heart rate is faster. Brief Hospital Course: INFLUENZA A and PNEUMONIA: The patient was intially on the [**Hospital1 139**] service, as an admission for influenza A and pneumonia. In the ED, he was evaluated with EKG, CXR, CT head, and labs. He was initially treated with levaquin and standing nebulizer treatments, and was sent to the floor for management and observation. He also received a five day course of Tamiflu 75 mg PO BID. On [**3-2**] a floor trigger was called for SOB, hypoxia and increased work of breathing. He O2 sat was found to be in the mid 80s on room air and he was tachypneic to the mid 30's; oxygenation improved to 96% on NRB with abg of 7.38/45/81. CXR from [**3-2**] was not significantly different from admission with fluffy basilar predominant infiltrates. He was transferred to the MICU. On [**3-3**], he had been improving with stable sats; he was afebrile and had a decreased WBC, so he was transferred out to the floor again. His influenza course was thought to be superimposed with a bacterial pneumonia, as he had persistent temperatures, respiratory distress and worsening infiltrates on CXR . He also had worsening secretions, which he had difficulty clearing without aggressive suctioning, causing occasional hypoxia. He was started on vancomycin and zosyn on [**3-5**], and was completed on a 10 day course to treat the pneumonia. At the time of discharge, he was afebrile, but had persistent secretions that needed to be managed with frequent suctioning. Mr. [**Known lastname 6352**] was noted to have an elevated troponin and BNP in the setting of acute lung injury. He had frequent ectopy; aspirin was started and he was maintained on is home dose of metoprolol 25 mg PO BID. SPEECH and SWALLOW EVALUATION: Although he was admitted on a regular PO diet, Mr. [**Known lastname 6352**] failed a speech and swallow evaluation and was made NPO. A Dobhoff tube was placed and he was started on tube feeds. It is hoped that after he recovers from his acute illness, he will return to his baseline function and be able to take in a PO diet again. He should be re-evaluated at the rehabilitation facility. HYPONATREMIA: Mr. [**Known lastname 6352**] was noted to have hyponatremia, thought to be secondary to SIADH given the urine lytes and lung disease (pneumonia). This may have played a role in his delirium on presentation and throughout the hospital stay. The hyponatremia resolved with 1.5 L fluid restriction and concurrently with clearance of his delirium. DELIRIUM: Likely secondary to the influenza and then pneumonia given compromised mental reserve in the setting of mild baseline dementia. Head CT on admission was negative for an acute process. He had no meningeal signs on exam or headache/photophia/neck stiffness to suggest meningitis; no LP was performed. By the end of his hospital stay, his mental status had improved and was near baseline. Medications on Admission: Lopressor 50 mg [**Hospital1 **] Tylenol Dulcolax Calcium Carbonate Colace Senna Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. 3. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 12H (Every 12 Hours): Please give through [**2163-3-15**]. 4. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours): Please give through [**2163-3-15**]. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. Senna Oral 7. Colace Oral 8. Dulcolax Oral 9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain, fever. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnoses: Influenza Pneumonia Secondary Diagnoses: Hypertension Discharge Condition: Stable-- satting in the mid- to upper 90's on 3 - 4 L NC; breathing comfortably; has an NG tube for feeding. Discharge Instructions: You were evaluated for your symptoms, and treated for influenza and a post-influenze pneumonia. During your hospital stay, you were taken care of in the intensive care unit and then transitioned to the general medicine floor. You responded well to the medications and respiratory treatements Please continue your previous medicine regimen. Vancomycin and zosyn should be taken through [**2163-3-15**]. Please call your doctor or return to the ED if you experience any of the following: Fever, chills, difficulty breathing, chest pain, nausea, vomiting or any other symptoms that are worrisome to you. Followup Instructions: 1. Please make an appointment to see your primary care doctor in 2 - 3 weeks for follow-up care. Their number is [**Telephone/Fax (1) 3329**] (Dr. [**First Name8 (NamePattern2) 29029**] [**Last Name (NamePattern1) 1968**]) 2. Please keep your previously scheduled appointments: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2163-4-26**] 9:55 Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2163-4-26**] 10:15

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

9909, 9988

6215, 9091

299, 306

10106, 10217

2042, 2042

10869, 11394

1524, 1542

9222, 9886

10009, 10049

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1582, 2023

10070, 10085

222, 261

334, 1207

3592, 6192

2058, 3583

1229, 1238

1254, 1508

82,139

134,607

13052

Discharge summary

report

Admission Date: [**2159-7-22**] Discharge Date: [**2159-7-31**] Date of Birth: [**2080-12-25**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: nausea, vomiting, headache, mental status changes. Found to have large cerebellar hemorrhage. Major Surgical or Invasive Procedure: You were evaluated by neurosurgery, however, decision was made to manage medically given the risks of surgical intervention. History of Present Illness: 80 y/o RHM with h/o HTN, CAD s/p CABG and A-fib on coumadin (full PMH and meds not known on transfer; OSH records and meds request) presented to an OSH with nausea and headache. GCS 15 upon arrival to OSH. The patient describes acute onset of dizziness w/o exertion followed by [**4-2**] frontal midline headache and nausea/vomiting. He also noted difficulty walking straight and describes veering to the left, spinning in a circle to the left when walking. His son witnessed the event and called an ambulance and he was brought to the hospital. The patient denies trauma, vision changes, LOC, or difficulty speaking at the time. A similar episode of acute dizziness without nausea/vomiting, but with so much spinning to the left that he had to put himself into a corner, occurred 6 months ago but resolved within 30 minutes and no medical attention was sought. At the OSH, he had persistent hypertension with BP of 190/110. Head CT showed L cerebellar hemorrhage and the patient was given 10mg of vitamin K for an INR of 1.9. He was medflighted to [**Hospital1 18**] and while on route to [**Hospital1 **] the patient deteriorated with a GCS of 7. He was intubated and given fentanyl, succinylcholine, etomidate and ativan. On admission he had an elevated Troponin of 0.3 which has been trending down, likely due to demand ischemia. His a-fib has been successfully rate controlled with metoprolol. He was successfully extubated. Clinical exam has been stable and no hematoma expansion or transtentorial herniation was seen on repeat head CT. Patient was transferred to Stroke service for further neurological monitoring. Past Medical History: CAD s/p CABG, HTN, atrial fibrillation, HLD, prostate CA s/p radical prostatectomy, s/p bilateral cateract surgery, presbycusis Social History: Patient has been retired for the last 10 years; previously involved in "adapting machinery to be automated." Currently lives in [**Location (un) 5503**], MA by himself. He has a son and daughter who live nearby and visit him once a week. He denies tobacco and illicits. Has occasional EtOH. Family History: Father died of prostate cancer. No siblings. Physical Exam: Exam: T 97.3 BP160/80 HR 90 RR 20 O2Sat 97% 3L NC Gen: Sitting in chair, NAD HEENT: Soft, well circumscribed mass 3x3 cm at base of the occiput, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid bruits, no LAD Back: No point tenderness or erythema CV: Normal rate, irregularly irregular rhythm, nl S1 and S2, [**1-27**] holosystolic mumur greatest at the apex, [**12-30**] decrescendo murmur greatest in the aortic area Lung: Clear to auscultation bilaterally Abd: +BS soft, nontender, nondistended Skin: Actinic keratosis on face and seborrheic keratosis on face and back. ext: 1+ non-pitting edema in LE bilaterally, 1+ DP pulses bilaterally Neurologic examination: Mental status: General: Alert, normal affect Orientation: Oriented to person, place (hospital "[**Country **]"), date, situation; however waxes and wanes occasionally thinks he is at home. Attention: Able to spell "world" backwards, unable to go backwards with DOW/[**Doctor Last Name 1841**] Memory: Registration [**12-27**], recall 0/3. Recalls where he grew up and the current president. Speech/Language: some disarthria is present, follows simple commands, unable to repeat full phrase "no ifs and buts." Prosody is normal. Cranial Nerves: II: Right pupil 3mm left 2mm, with normal reaction to light. Visual fields are full to confrontation. III, IV, VI: Extraocular movements are intact, without nystagmus. V1-3: Sensation intact V1-V3. VII: Facial movement symmetric. VIII: Hearing diminished equally to finger rub bilaterally. IX & X: Palate elevation symmetric. Uvula not visualized. Gives a good cough. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally. XII: Tongue is midline. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor Delt; C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 5 5 5 5 5 Right 5 5 5 5 5 Deep tendon Reflexes: [**12-28**] bilateraly , there is a decrese of the left biceps and triceps reflexes. Coordination: finger-nose-finger dysmetria L>R; heel to shin mild dysmetria on L, nl on the right. Gait: wide-based stance, unsteady. Pertinent Results: Laboratory Evaluation: [**2159-7-22**] 04:52PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2159-7-22**] 04:52PM WBC-11.5* RBC-4.63 HGB-15.9 HCT-46.6 MCV-101* MCH-34.3* MCHC-34.1 RDW-13.3 [**2159-7-22**] 04:52PM PT-24.0* PTT-34.6 INR(PT)-2.3* [**2159-7-31**] 07:55AM BLOOD Plt Ct-199 [**2159-7-31**] 07:55AM BLOOD PT-14.7* PTT-33.1 INR(PT)-1.3* [**2159-7-22**] 04:52PM BLOOD Fibrino-269 [**2159-7-31**] 07:55AM BLOOD Glucose-104* UreaN-21* Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-30 AnGap-10 [**2159-7-26**] 11:09PM BLOOD CK(CPK)-112 [**2159-7-23**] 09:31PM BLOOD CK(CPK)-448* [**2159-7-24**] 02:33AM BLOOD CK(CPK)-412* [**2159-7-23**] 03:33AM BLOOD CK-MB-17* MB Indx-9.3* cTropnT-0.30* [**2159-7-23**] 11:58AM BLOOD CK-MB-11* MB Indx-3.8 cTropnT-0.21* [**2159-7-23**] 09:31PM BLOOD CK-MB-8 cTropnT-0.16* [**2159-7-24**] 02:33AM BLOOD CK-MB-7 cTropnT-0.17* [**2159-7-26**] 11:09PM BLOOD CK-MB-4 cTropnT-0.18* [**2159-7-31**] 07:55AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.8 [**2159-7-25**] 06:10PM BLOOD VitB12-540 Folate-12.4 [**2159-7-26**] 05:15AM BLOOD Triglyc-61 HDL-41 CHOL/HD-2.7 LDLcalc-56 [**2159-7-22**] 04:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2159-7-23**] 04:29AM BLOOD Type-ART pO2-173* pCO2-51* pH-7.40 calTCO2-33* Base XS-5 Head CT [**2159-7-22**]: IMPRESSION: Large left cerebellar hematoma with mild effacement of the left aspect of the quadrigeminal cistern. No significant transtentorial or tonsillar herniation is seen. Head Ct [**2159-7-24**]: IMPRESSION: Stable appearance of large cerebellar hemorrhage with surrounding edema and mass effect on the pons. Head CT [**2159-7-26**]: IMPRESSION: 1. Though measurements of the cerebellar hemorrhage are slightly greater than prior, this may be due to slice selection; if there is continued concern, interval continued followup is recommended. Echo Conclusions The left atrium is markedly dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with akinetic septum, anterior hypokinesis and basal inferior akinesis. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %). The right ventricular cavity is moderately dilated with mild hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is moderately dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. IMPRESSION: Severely dilated left ventricle with severe regional left ventricular dysfunction. Moderate to severe mitral regurgitation. Moderate aortic stenosis (low gradient). Severe pulmonary artery systolic hypertension. Brief Hospital Course: [**Hospital 39928**] Hospital Course: Mr [**Known lastname **] was initially admitted to the neurosurgery service on [**7-22**] and had a poor exam on admission. He intially made DNR/DNI by his family. His exam improved on his first hospital day to following commands and was able to be successfully extubated. On admission he had an elevated Troponin of 0.3 which has been trending down, likely due to demand ischemia. His initial INR was 2.3 which was reversed with vitamin K, FFP, and Factor VII. His Coumadin was discontinued. His a-fib was successfully rate controlled with metoprolol. He continued to have waxing / [**Doctor Last Name 688**] confusion, but neurologic examination was essentially stable. He was transferred to the floor neuromedicine service for management. Initially floor stay was complicated by difficult to control blood pressure with systolic blood pressures greater than 160 and intermittent worsening mental status, and new nystagmus, so he was transferred back to the ICU where he was placed on a Nicardipine drip. Blood pressure medications were titrated. Repeat head CT was stable, so he returned to the neuromedicine floor where he remained stable. To further evaluate waxing and [**Doctor Last Name 688**] mental status, chest X-ray and urine cultures were obtained with no sign of acute infection. (Urine culture from indwelling foley likely contaminated, however repeat urine testing is pending.) Echocardiogram in the hospital revealed poor ejection fraction of 25-30% and severely dilated left veintricle. He also had moderate to severe mitral regurgitation, moderate aortic stenosis, and severe pulmonary artery systolic hypertension. During his hospitalization he had serial no[**Serial Number 39929**]. At the time of discharge to rehabilitation, he has been cleared by speech and swallow evaluation and is tolerating oral diet. His current blood pressure regimen is Spironolactone 12.5mg daily, Carvedilol 12.5mg every 6 hours, Lisinopril 40mg daily, and Norvasc 5mg nightly. The most recent changes include increased Lisinopril, and addition of the Norvasc. His Lasix 20mg daily has been held secondary to hypovolemia, and can be re-started when clinically appropriate. Medications on Admission: Lasix 40mg daily Quinopril 20mg [**Hospital1 **] Lipitor 5mg daily Digoxin 250mcg daily Metoprolol 100mg [**Hospital1 **] Warfarin 7.5mg MWF, 5mg T/TH/S/S Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hypertension. 10. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) MG Injection Q8H (every 8 hours) as needed for n/v. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: L cerebellar hemorrhage Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were transferred to [**Hospital1 18**] after you had nausea and headache and had a CT scan which showed a large bleeding stroke in your brain, in the cerebellum. You were also found to have a heart arrhythmia (atrial fibrillation). Your coumadin was discontinued in the hospital because of your bleed. You should not restart this unless directed by your cardiologist and neurologist. You were started on new medicines to control your blood pressure. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 548**] of Neurosurgery in 4 weeks with a Head CT w/o contrast. Please call [**Doctor First Name **] at [**Telephone/Fax (1) 2992**] to make this appointment. Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] (Office Phone: ([**Telephone/Fax (1) 19129**]) after you are discharged from rehab. Please call to follow up with your cardiologist upon discharge from rehab. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

11869, 11966

8606, 8627

411, 538

12034, 12034

4974, 8583

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2670, 2717

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3437, 3437

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60,579

135,143

5188

Discharge summary

report

Admission Date: [**2188-11-26**] Discharge Date: [**2188-12-2**] Date of Birth: [**2112-8-8**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 64**] Chief Complaint: Total right hip revision after septic arthritis . Reason for MICU transfer: Acute blood loss, hypotension Major Surgical or Invasive Procedure: [**2188-11-26**]: s/p COMPLEX revision right total hip replacement (all components) with proximal femoral tumor replacement prosthesis, revision acetabulum component with constrained liner, excision of massive heterotopic ossification. History of Present Illness: 76 year old male with past medical history of osteoarthritis s/p right total hip arthroplasty in [**5-/2185**] complicated by Salmonella septic joint requiring multiple wash outs and antibiotic spacer placement [**2188-8-2**] who presented for total right hip revision after completion of antibiotic courses. The surgery had been planned for mid-[**Month (only) 1096**] but he was experiencing hemoptysis and presumptive pneumonia (was seen by [**Hospital1 18**] Pulmonary) and treated with Azithromycin; the surgery was deferred. . The patient's OR course today was complicated by profuse bleeding (EBL 3000cc+) requiring 12L lactated ringers, 1.4L normal saline, 4 units pRBC, two units FFP and 2100cc of cell [**Doctor Last Name 10105**]. The patient was given 8.46mcg levophed and 31.48mg phenylephrine. He also received his first doses of Cipro 400mg IV and Cefazolin 4 grams peri-operatively and had samples of granulation tissue, heterotopic bone and acetabular reamings sent for pathology/micro. Because of the significant bleeding, Vascular Surgery was consulted intra-operatively to evaluate for vessel injury. No obvious vessel injury was seen on exploration and dopplerable pulses were noted in bilateral DP/PT in the PACU. Upon transfer for to the [**Hospital Unit Name 153**], the patient's vital signs were: T96.2, HR93, BP130/87 --> 94/71, 100% on PSV PEEP 5, PSV 5, FiO2 50%, RR15. He remained intubated and comfortable with midazolam boluses. . Of note, the patient's [**2188-8-23**] admission for hip wash out was complicated by a hematocrit drop from 28.7 to 19.9. Medicine was consulted at that time and it was felt that his anemia was due to acute blood loss. Stool guaiacs and hemolysis labs were negative although outpatient colonoscopy screening was recommended. . Review of systems: (+) Per HPI (-) Unable to fully assess but patient denies fevers/chills, chest pain, general pain, nausea/vomiting, diarrhea Past Medical History: Right Hip OA s/p THA w/ subsequent infection, washout and antibiotic spacer placement Social History: Married, with three children in good health. Retired iron worker. Denies tobacco, or tobacco exposure. Previously consumed alcohol socially (2 drinks/night, 2-4 days/week); quit in [**Month (only) **] in preparation for surgical procedures. Family History: No known coronary artery disease, strokes, prostate or colon cancer Physical Exam: Vitals: T: 96.2 BP: 130/87 --> 94/71 P: 93 R: 15 O2: 100% on PSV [**3-28**], FiO2 50% General: Alert, arousable with loud verbal stimuli, no acute distress, following commands HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Soft, supple, no JVP 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 GU: Voiding independently Ext: Warm, well perfused upper extremities; cold but not mottle lower extremities, dopplerable DP/PT pulses, no clubbing, cyanosis or edema. Pressure dressing across right hip surgical incision, two circular JP drains in place to gravity Pertinent Results: [**2188-12-2**] 06:47AM BLOOD WBC-10.6 RBC-3.46* Hgb-10.1* Hct-29.9* MCV-86 MCH-29.2 MCHC-33.7 RDW-15.4 Plt Ct-265 [**2188-12-1**] 06:50AM BLOOD WBC-9.6 RBC-3.59* Hgb-10.4* Hct-31.2* MCV-87 MCH-29.0 MCHC-33.4 RDW-15.2 Plt Ct-220 [**2188-11-30**] 08:40AM BLOOD WBC-10.8 RBC-3.70* Hgb-10.7* Hct-31.5* MCV-85 MCH-28.8 MCHC-33.9 RDW-15.1 Plt Ct-167 [**2188-11-30**] 04:55AM BLOOD WBC-9.5 RBC-3.49* Hgb-10.2* Hct-28.9* MCV-83 MCH-29.3 MCHC-35.4* RDW-14.9 Plt Ct-153 [**2188-11-29**] 05:21AM BLOOD WBC-10.9 RBC-3.39* Hgb-9.9* Hct-27.8* MCV-82 MCH-29.2 MCHC-35.5* RDW-14.8 Plt Ct-107* [**2188-11-28**] 04:10AM BLOOD WBC-13.7* RBC-3.30* Hgb-9.3* Hct-26.9* MCV-82 MCH-28.2 MCHC-34.6 RDW-14.5 Plt Ct-90* [**2188-11-27**] 09:01PM BLOOD WBC-15.7* RBC-3.05*# Hgb-8.8*# Hct-25.4* MCV-83 MCH-29.0 MCHC-34.8 RDW-14.6 Plt Ct-101* [**2188-11-27**] 04:24AM BLOOD WBC-20.6* RBC-4.52* Hgb-12.9* Hct-38.0* MCV-84 MCH-28.5 MCHC-33.9 RDW-14.3 Plt Ct-127* [**2188-11-26**] 05:27PM BLOOD WBC-19.3*# RBC-5.09 Hgb-14.9 Hct-44.2 MCV-87 MCH-29.3 MCHC-33.7 RDW-14.2 Plt Ct-129*# [**2188-12-1**] 06:50AM BLOOD Neuts-73.9* Lymphs-14.7* Monos-6.1 Eos-5.1* Baso-0.3 [**2188-11-29**] 05:21AM BLOOD Neuts-81.9* Lymphs-10.9* Monos-6.3 Eos-0.8 Baso-0 [**2188-11-27**] 04:24AM BLOOD Neuts-86.0* Lymphs-5.3* Monos-8.6 Eos-0 Baso-0.1 [**2188-12-2**] 06:47AM BLOOD PT-38.3* PTT-36.9* INR(PT)-3.7* [**2188-12-1**] 01:30PM BLOOD PT-48.0* INR(PT)-4.7* [**2188-12-1**] 06:50AM BLOOD PT-38.3* PTT-32.8 INR(PT)-3.7* [**2188-11-30**] 08:40AM BLOOD PT-13.9* PTT-27.3 INR(PT)-1.3* [**2188-11-30**] 04:55AM BLOOD PT-12.0 PTT-25.7 INR(PT)-1.1 [**2188-12-2**] 06:47AM BLOOD Glucose-103* UreaN-12 Creat-0.7 Na-141 K-3.8 Cl-106 HCO3-30 AnGap-9 [**2188-12-1**] 06:50AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-141 K-4.0 Cl-105 HCO3-31 AnGap-9 [**2188-11-30**] 08:40AM BLOOD Glucose-161* UreaN-10 Creat-0.7 Na-138 K-3.5 Cl-102 HCO3-29 AnGap-11 [**2188-11-28**] 04:10AM BLOOD ALT-10 AST-19 LD(LDH)-155 AlkPhos-39* TotBili-0.8 [**2188-11-26**] 10:45PM BLOOD ALT-22 AST-33 LD(LDH)-314* AlkPhos-47 TotBili-1.9* [**2188-12-1**] 06:50AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2 [**2188-11-27**] 04:41AM BLOOD freeCa-1.24 Brief Hospital Course: 76 year old male with past medical history of osteoarthritis s/p right total hip arthroplasty in [**5-/2185**] complicated by Salmonella septic joint requiring multiple wash outs and antibiotic spacer placement [**2188-8-2**] who presented for total right hip revision with significant intra-operative bleeding and DIC requiring ICU transfer. ICU COURSE: # Hypotension: Shock most likely due to hypovolemia/hemorrhage given visible, significant bleeding in the OR. Patient was complicated by DIC and profuse bleeding (EBL 3000cc+) requiring 12L lactated ringers, 1.4L normal saline, 4 units pRBC, two units FFP and 2100cc of cell [**Doctor Last Name 10105**]. Phenylephrine was started, but was weaned off within a day of the operation with stable BPs. Also on the differential were sepsis and cardiogenic process, both less likely. The patient has recent history of hip joint infection but presumably adequately treated; likewise, he had hemoptysis and cough in [**2188-10-23**] for which he was evaluated by pulmonary and treated with Z-pack. CXR currently possibly concerning for developing retrocardiac/right middle lobe infiltrate but not overwhelming. He was instrumented, though, today with new leukocytosis. Given empiric vancmycin, cefepime and ciprofloxacin, however changed to ciprofloxacin and cefazolin POD #2. Blood, urine and tissue cultures without growth. For cardiogenic processes, the patient has no known cardiac disease and good functional capacity previously. EKG also unchanged from prior. Coagulopathy management as below. Once stabilized, without further evidence of bleeding, patient was transferred to orthopedic surgery. # Coagulopathy: Given difficult to control bleeding intra-operatively and anemia as well as relative thrombocytopenia. Differential includes DIC, hemolysis, TTP. The latter is less likely, especially in setting without fevers, confusion, renal failure. Patient was determined to be in DIC intraoperatively, given his low fibrinogen at 88, increasing INR/PT/PTT. Also with increasing D-dimer, LDH, and decreasing platelets. Unclear if infectious etiology precipitating this, however patient was covered with antibiotics as above; possibly stress of surgery, age contributory. Elevated Tbili, decreased haptoglobin, increased LDH suggestive of hemolysis which can be seen in DIC. Patient was given additional blood, cryoprecipitate and vitamin K initially in the ICU. Within several days s/p OR, labs normalized with the exception of hct, which took time to recuperate. # Total right hip revision: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for hip revision. Please see separately dictated operative report for details. The surgery was complicated by DIC and profuse bleeding (EBL 3000cc+) requiring 12L lactated ringers, 1.4L normal saline, 4 units pRBC, two units FFP and 2100cc of cell [**Doctor Last Name 10105**]. 2 JP drains left in place, initially draining blood. Transferred to ICU for monitoring. Patient received perioperative IV antibiotics. Post op pain managed with oxycodone. # Respiratory status: Intubated for operation and remained on the ventilator given plan for volume resuscitation overnight and some hypoxia/hypervolemia. Patient was extubated the following morning without issues. # Hyponatremia: Mild, possibly in setting of hypovolemia vs. euvolemia (SIADH) given his surgery, recent painful right hip. Resolved within 2 days or surgery, with Na+ 138. # Hyperglycemia: A1c 5.7%. Managed on ISS. [**2188-11-30**]. He was transferred to the floor POD4 in stable condition. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received Coumadin for DVT prophylaxis starting on the morning of POD#4. The foley was removed on POD#5 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. His INR increased from 1.3 to 4.7 on POD 5 for unknown reasons. His coumadin was held at this point. Repeat check POD 6 showed a level of 3.7. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior precautions. Mr [**Known lastname **] is discharged to rehab in stable condition. Medications on Admission: * Aspirin 325mg daily * Ferrous sulfate dose unknown * Multivitamin daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q8H (every 8 hours). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*1* 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed for constipation. 11. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day for 6 weeks: Goal INR [**12-26**]. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living Discharge Diagnosis: infected right hip Post-op anemua due to blood loss 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse (VNA) or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please take coumadin daily with an INR goal of [**12-26**] for 6 weeks. After this time you do not need to continue the coumadin. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior precautions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: WBAT ROM - posterior precautions Mobilize frequently Treatments Frequency: dry, sterile dressing changes daily and as needed for drainage wound checks ice staple removal and replace with steri strips on POD20 TEDs Followup Instructions: Provider: [**Name10 (NameIs) 14621**] [**Last Name (NamePattern4) 14622**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-12-22**] 9:30 Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2188-12-19**]. Please call [**Telephone/Fax (1) 1228**] to confirm time of appointment. Provider: [**Name10 (NameIs) 326**] SPECIAL FLUORO (TCC) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2189-10-29**] 2:15 Completed by:[**2188-12-2**]

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icd9cm

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6028, 10826

414, 652

12343, 12343

3857, 6005

15620, 16201

3000, 3070

10951, 12084

12269, 12322

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12526, 14574

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15457, 15597

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267, 376

14586, 15364

680, 2470

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21,450

181,562

26688+26689

Discharge summary

report+report

Admission Date: [**2197-3-27**] Discharge Date: [**2197-3-31**] Date of Birth: [**2123-7-16**] Sex: F Service: MEDICINE Allergies: Tetanus Attending:[**First Name3 (LF) 2159**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo F who was recently admitted for abdominal pain returns with same complaint. The pt has a history of CVA, PVD, and HTN and was initially seen in OSH on [**2197-3-16**] with complaints of constant lower abdominal pain and several bloody stools. She was transferred to [**Hospital1 18**] for concern for SMA embolus. A mesenteric angiogram revealed patent SMA/[**Female First Name (un) 899**] but a high grade celiac stenosis. She was taken to the OR by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for an ex-lap where she was found to have transverse colitis but no obvious ischemia. She was given a unit of PRBC in the OR as well as 1300 crysatalloid with minimal EBL. During hospital course, she was noted to have sinus tachycardia and HTN which was treated with metoprolol. The pt was transiently on TPN and started on levo/flagyl empirically for cultures. Rectal swab later revealed VRE. GI was consulted for continuing abdominal pain and guaiac positivel stool during the last admission and recommended colonoscopy as an outpatient to r/o cancer and IBD. The pt was discharged to [**Location (un) 582**] NH on [**2197-3-25**] after tolerating full POs and having regular BMs. . Since her discharge, the pt reports [**6-24**] bilateral LQ pain as well as RUQ pain with +N/V. The abd pain is unchanged from last admission. The pt is unable to describe the pain, however it occurs in a band like manner across the abdomen without significant radiation. The pain is unrelated to food. It is a [**6-24**]. The pt never saw her own vomitus. However she reports she had one episode yesterday and two episodes today. Initially the vomitus was described as projectile, green in color without food. Since then it has become yellow in color but again without food. The vomiting is unrelated to food. The pt also reports +BM x2 described as loose, non-bloody stool. The pt denies any f/c/r. She is still tolerating POs through these episodes. . In the ED, the pt received Anzmet x1 for nausea as well as 1L of NS with significant improvement in pain. She had a CT Abd/Pelvis which demonstrated improvements in transverse colon wall thickening and post op changes but no acute pathologic changes. The pt was seen by surgery in the ED who believed the pt was able to be discharged back to [**Location (un) 582**], however she was admitted to Medicine for pain control. Past Medical History: 1. Idiopathic colitis 2. Bladder CA s/p neo bladder 3. CVA with L paralysis on [**9-19**] 4. PVD 5. HTN 6. COPD 7. GERD 8. UTI Social History: From [**Location (un) 582**] NH Divorced Family History: Sister: endometrial CA Physical Exam: VS: T: 97.5 -> 98.2, HR: 111 -> 102, BP: 86/49 -> 143/56, RR: 18 -> 16, SaO2: 97% on 2L ->95% on 2L GEN: well nutritioned well appearing female in NAD, conversing fluently in full sentences. No accessory muscle use HEENT: pupils 3mm and minimally reactive but equal bilaterally CV: tachy, no m/r/g CHEST: min crackles bilaterally ABD: obese, distended abd with intact staple, no obvious erythema. soft, obese, diffusely tender but without rebound, guarding, no drainaged expressed from wound. RECTAL: guaiac neg brown stool as per ED. EXT: trace bilateral LE edema. SKIN: Erythematous patches over face, chest. Pertinent Results: STUDIES: [**2197-3-27**]: CT Abd/Pelvis: 1. Interval improvement in transverse colon wall thickening. 2. Postoperative changes in the anterior peritoneal cavity and subcutaneous tissues at the midline. 3. No evidence of small-bowel obstruction. 4. Air within the bladder, presumably secondary to recent Foley catheterization. . CXR [**2197-3-27**] IMPRESSION: No focal infiltrate or evidence of aspiration. Persistent opacity in the right paratracheal region suggestive of volume loss in an azygos lobe. . [**2197-3-23**]: stool cultures, O&P, Cdiff, ALL NEGATIVE. . [**2197-3-27**] 10:30PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2197-3-27**] 10:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016 [**2197-3-28**] 09:15PM URINE Blood-TR Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [**2197-3-28**] 09:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019 [**2197-3-27**] 10:30PM URINE RBC-0-2 WBC-[**12-4**]* Bacteri-FEW Yeast-FEW Epi->50 [**2197-3-28**] 09:15PM URINE RBC-0-2 WBC-[**12-4**]* Bacteri-MOD Yeast-OCC Epi-0 . Urine culture [**2197-3-28**]: E coli >100,000, resistant to levofloxacin, bactrim, sensitive to nitrofurantoin . [**2197-3-27**] WBC-11.9* RBC-3.42* Hgb-10.3* Hct-30.1* MCV-88 MCH-30.1 MCHC-34.3 RDW-15.9* Plt Ct-611*, Neuts-65 Bands-1 Lymphs-8* Monos-4 Eos-11* Baso-0 Atyps-7* Metas-3* Myelos-1* [**2197-3-31**] WBC-10.1 RBC-3.50* Hgb-10.5* Hct-31.4* MCV-90 MCH-30.1 MCHC-33.6 RDW-16.1* Plt Ct-615* [**2197-3-28**] ESR-121*, CRP-16.3* [**2197-3-31**] Glucose-93 UreaN-17 Creat-1.0 Na-138 K-4.5 Cl-103 HCO3-22 AnGap-18 [**2197-3-27**] ALT-10 AST-17 AlkPhos-66 TotBili-0.2 [**2197-3-30**] Neuts-70.6* Lymphs-14.8* Monos-4.3 Eos-9.2* Baso-1.1 Brief Hospital Course: A/P: 73yo F with idiopathic colitis and hx of CVA, PVD, HTN who was recently admitted to surgery s/p ex lap, with persistent abd pain, unchanged, nausea, vomiting and loose stools with unclear etiology, sent stool for cultures/cdiff/etc, and given symptomatic relief. . 1. Abd pain, nausea, vomiting, 2 loose bm: The etiology of the abd pain is unclear at this point, however she has known transverse colitis indicating some pathology. Prior admission and work up has been unrevealing. Admission WBC count was 11 but pt did not have a left shift and lactate is low making acute infection less likely. Incisional pain is also in ddx. Surgery eval in ED recommended outpt follow up and GI had previously seen her in house and recommended colonoscopy as an outpt as well. -Surgery consulted in ED and recommended outpt fololow up in Dr. [**Name (NI) 32606**] clinic ([**Location (un) 65777**] of [**Hospital Unit Name **]). The pt will see Dr. [**First Name (STitle) **] on Monday. -Symptomatic pain control and nausea control - anzemet and percocet with neurontin. Pt appears to be improving. -She tolerated po well thoughout her stay, with no nausea or vomiting for several days prior to discharge. We ordered for stool studies such as Cdiff, cx, O&P, giardia/crypto to be done, however, the stool sample was not collected and was accidentally discarded. The pt's prior stool studies from [**2197-3-23**] were completely negative. -She has a follow up appointment with GI on Monday, [**2197-4-3**] for eval for outpt colonoscopy. -Her abdominal pain continued to improve this admission on supportive care. . 2. HTN: The pt has a hx of HTN, however she was infact slightly hypotensive in the ED prior to IVF. This may have been due to her decreased PO intake from n/v. BP trended up after IVF, and currently stable. We restarted her beta blocker. . 3. UTI- with evidence of UTI on resent UA, urine cx from [**3-27**] showing mixed flora, from skin/genital contamination. Her culture from [**3-28**] demonstrated resistant E coli, and her bactrim was changed to Macrodantin, which the pt will receive for a 7 day course. Of note, surgery had previously discharged the pt on levofloxacin, however, this was discontinued this admission, as the pt had already received >10 days. Her E coli was resistant to both levoflox and bactrim. . 4. Cardiovascular: A. CAD: Given her hx of PVD, the pt most likely has CAD as well. She may not be on ASA due to her proximity with her surgery. ASA likely held in setting of her recent surgery, however, it was restarted on [**2197-3-30**]. We continued her statin at outpatient dose, 20mg po qd. We restarted her beta blocker and she should continue this med. . b. Rhythm: currently NSR. . c. Pump: some evidence of lower extremity edema but no JVD. Her CXR showing no vol overload. . 5. Surgical wound: The pt was discharged on two weeks of abx - levo/flagyl by the surgical team on her prior admission. As she had received >10 days of levo/flagyl, this was discontinued this admission. The surgical site is without drainage, pus. There is minimal erythema. The wound is approximating nicely, healing well. . 6. Eosinophilia: Felt most likely secondary to allergic reaction to her levofloxacin, which was discontinued. She demonstrated a pink macular eruption on the upper chest and bilateral arms, which improved after levoflox was discontinued. We did not suspect parasitic infection, as pt without appropriate history, travel. No further episodes of diarrhea. . 5. Pulm: The pt has a hx of COPD and is on spiriva, alb and advair at baseline. We continued these medications. CXR showing no infiltrate, possible volume loss in azygos lobe, no evid for aspiration. She was satting well on nasal cannula, and weaned as tolerated. . 6. FEN: cardiac/heart healthy diet, replete electrolytes to keep k>4 and Mg>2 . 7. PPx: heparin sub Q TID, bowel regimen. . 8. Communication: HCP: Sister. [**Telephone/Fax (1) 65778**] Medications on Admission: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **]. 2. Tiotropium Bromide 18 mcg Daily. 3. Albuterol every 4 hours. 4. Levofloxacin 500 mg PO Q24H. 5. Metronidazole 500 mg PO TID. 6. Metoprolol Tartrate 50 mg PO BID. 7. Atorvastatin 20 mg PO DAILY. 8. Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4-6H as needed for pain. 9. Nystatin 100,000 unit/g Cream [**Hospital1 **]. 10. Gabapentin 100 mg TID 11. Zolpidem 5 mg at bedtime prn 12. Insulin SS 13. Docusate Sodium 100 mg PO BID. 14. Heparin 5,000 unit/mL [**Hospital1 **]. 15. Lidocaine HCl 2 % Gel as needed for foley placement. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*2* 4. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. Disp:*30 Tablet(s)* Refills:*2* 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed. Disp:*qs nebulizer treatment* Refills:*2* 8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs largest stock powder* Refills:*2* 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 14. Nitrofurantoin 100 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours for 7 days. Disp:*14 Capsule(s)* Refills:*0* 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: 1. Idiopathic transverse colitis, status post exploratory laparotomy on a prior admission 2. Urinary Tract Infection 3. Hypertension 4. History of Bladder Cancer 5. History of CVA 6. Peripheral vascular disease 7. Chronic Obstructive Pulmonary Disease 8. Gastroesophageal Reflux Disease Discharge Condition: Stable Discharge Instructions: If you experience any worsening of your symptoms, please report to the emergency room immediately. Please take all of your medications as directed. Please follow up with your doctors (see information below). Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time: Monday [**2197-4-3**] 9:30am, you will need your sutures removed. 2. You will need to follow up with the GI specialists for a colonoscopy. Your appointment is set for: Monday, [**2197-4-3**] at 3pm with Dr. [**Last Name (STitle) 21140**] on [**Hospital Ward Name 23**] 7, [**Hospital1 18**] [**Hospital Ward Name 516**]. their office number is: [**Telephone/Fax (1) 1954**] if you need directions. 3. You have an appointment with Dr. [**Last Name (STitle) 65779**], your Primary Care Physician, [**Name10 (NameIs) **] [**2197-4-7**] at 10am. Her office number is: [**Telephone/Fax (1) 65780**]. Completed by:[**2197-3-31**] Admission Date: [**2197-4-1**] Discharge Date: [**2197-4-8**] Date of Birth: [**2123-7-16**] Sex: F Service: MEDICINE Allergies: Tetanus Attending:[**First Name3 (LF) 2159**] Chief Complaint: hypotension and fever Major Surgical or Invasive Procedure: central venous line History of Present Illness: 73 yo F with CVA, HTN, bladder ca s/p neobladder, who was recently d/c from [**Hospital1 18**] morning prior to admission. In brief, pt was eval for bloody stools and abd pain and found to have an SMA embolus. She was taken to the OR with Dr [**First Name (STitle) **] for [**MD Number(4) 65781**] who found transverse colitis, no mesenteric ischemia. She was on TPN, levo/flagyl during that admission. GI consulted who rec. outpt c-scope; pt improved and d/c to NH on [**3-25**] tolerating POs. . Pt returned to [**Hospital1 18**] with similar lower abd bandlike pain, N/V. She was admitted, negative GI infectious w/u of her pain. She was briefly hypotensive during this admission which improved with IVFs. UA/u cx showed E Coli, bactrim switched to nitrofurantoin, pt d/c'd with this med. . Pt presents to [**Last Name (un) 4068**] with 98.1, 100, 33, 182/121, 100% NRB (68% RA). CTA neg for PE and CT abd neg for infection. She recieved ntg gtt, flagyl, levofloxacin, vanco, lasix 40 mg IV x 1, fentanyl 50 mcg x 1. Transferred to [**Hospital1 18**] for further mgmt. . In the ED, 103.8, 122, 94/33, 100% NRB. Pt was given levofloxacin, flagyl; BP's decreased to SBP 70's. Given IVFs without improvement. Femoral line placed. Levophed started at currently at 0.05 mcg/kg/hr. Her breathing worsened; CXR with mild CHF, lasix 40 mg IV given. Trop also noted to be 0.2, EKG with some [**Street Address(2) 4793**] dep in v3-6. [**Name8 (MD) **] RN report, pt received 5500 with resucitation. . On eval, pt c/o of some SOB, no cough. She denies CP, pressure or other sx. Her only complaint is that she is hungry. . Admitted to MICU for sepsis and resp failure. Past Medical History: 1. Idiopathic colitis 2. Bladder CA s/p neo bladder 3. CVA with L paralysis on [**9-19**] 4. PVD 5. HTN 6. COPD 7. GERD 8. UTI Social History: From [**Location (un) 582**] NH Divorced Family History: Sister: endometrial CA Physical Exam: Temp 103.8 BP 122/54 (0.05 mcg/kg/hr on levophed) Pulse 122 Resp 19 O2 sat 97% 100 % NRB Gen - alert, tired, able to speak in full sentences HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes dry Neck - JVP to angle of jaw, no cervical lymphadenopathy Chest - poor air mvmt, diffuse wheezes, ? crackles at bases CV - tachycardia Abd - Soft, nontender, min distended, surgical midline scar C/D/I w/ staples Extr - trace edema. 1+ DP pulses bilaterally; right leg with femoral line Neuro - Alert and oriented x 3, cranial nerves [**2-26**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rash Brief Hospital Course: MICU COURSE: The patient was admitted to the MICU service. She was covered with linezolid for h/o VRE, and zosyn for the E. Coli UTI/urosepsis. The patient was weaned off pressors, restarted when SBP decreased to 70s, then weaned off. She maintained good UOP. Briefly on steriods for a quetion of COPD exacerbation but this was discontinued by HD 2. On HD 3 the patient had her femoral line removed and was transferred to the floor in stable condition for futher monitoring and treatment of her E. coli UTI. . A/P: 73yo F with idiopathic colitis and hx of CVA, PVD, HTN who was recently admitted to surgery s/p ex lap, s/p E coli urosepsis vs. colitis and covered with Zosyn/Linezolid (w/ Linezolid d/c'd) s/p MICU from [**Date range (1) 65782**], stabilized, now transferred to Medicine service. . # Abd pain, Idiopathic colitis: On exam, pt with diffuse abd pain, worse at suture line. Pt felt to have resolved sepsis [**2-16**] colitis vs. urosepsis. Repeat CT Abd showing no evid colitis, findings c/w cystitis, and pt being treated with Zosyn day [**8-28**] of therapy. Transplant surgery evaluated pt, felt that mesenteric ischemia unlikely, and that her abdominal pain is c/w post op pain. He noted that she had normal flow on angio [**2197-3-17**]. We continued w/ oxycodone prn and followed her abd exam closely, which went unchanged since transfer to medical floor. Her stool cx sent and were all negative, O&P negative, Cdiff negative. We checked her TSH, and it was slightly elevated at 4.6, but checked free T4 and this was found to be normal. She is [**Doctor First Name **], ANCA negative (elev CRP, ESR). She has follow up in [**Hospital **] clinic to evaluate her transverse colitis, and then should be scheduled for outpatient colonoscopy. . # UTI s/p ?Urosepsis in MICU, resistant E coli [**Last Name (un) 36**] to Zosyn, nitrofurantoin, cefazolin, ctx. Pt is on day [**8-28**] of Zosyn therapy, which should cover her broadly for urinary tract pathogens. She had a PICC line placed on [**2197-4-6**] for expected total of 2 weeks of Zosyn. She continues to be afebrile, with WBC reflecting eosinophilia recently, most likely secondary to Zosyn. Her repeat UA was negative X 2, [**2197-4-6**] urine cx negative. Her foley catheter was changed [**4-5**] and irrigated. Urine cytology was sent given her distant history of bladder cancer, and is pending at discharge. This can be followed up at her PCP [**Name Initial (PRE) 648**]. . # Leukocytosis: Pt is being broadly covered with IV Zosyn, which may be causing the elevated WBC count, which is predominately eosinophilia most likely [**2-16**] antibiotics. Her UA and urine cx negative, blood cx negative, and stool is negative for bacterial, parasitic, Giardia/Cryptosporidium, and C diff negative. . # Hct drop/Anemia, stable now. Her hemolysis labs are negative. Her ferritin is normal. Her B12 and folate are WNL. Her iron was sent and is pending at discharge. RN reports the pt's stool is guiaic negative. She is to undergo outpatient colonoscopy. . 2. HTN: BP well controlled. We restarted lopressor 12.5mg po bid w/ hold parameters. . 3. CV: A. CAD: Pt w/ risk factors for CAD. H/o PVD. -cont ASA, statin, BB . b. Rhythm: currently NSR. Has been tachycardic to 100s. . c. Pump: some evidence of lower extremity edema but no JVD. -CXR showing no vol overload. -cont BB . 4. h/o CVA -cont ASA, statin . 5. Surgical wound: appears to be healing very well -removed staples [**4-7**], with good cosmetic result. . 5. Pulm: The pt has a hx of COPD and is on spiriva, alb and advair at baseline. Her most recent CXR shows mild interstitial pulm edema, resolving, and small b/l pleural effusions. We continued her outpatient regimen of spiriva, alb and advair. Her sats continue to be stable on room air. . 6. PPx: heparin sub Q TID, bowel regimen. . 7. Communication: HCP: Sister [**Name (NI) **]. [**Telephone/Fax (1) 65778**] Medications on Admission: flovent 250/50 IH [**Hospital1 **] tiotporium 1 cap qd albuterol sulfate neb q 6 neurontin 100 mg tid lipitor 20 mg qd metoprolol 50 mg [**Hospital1 **] oxycodone 5 mg q 4-6 prn nitrofurantoin 1 cap [**Hospital1 **] ASA Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*2* 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer treatment Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of breath or wheezing. Disp:*qs nebulizer treatment* Refills:*2* 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 13. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 7 days: apply to groin areas bilaterally until redness diminishes. Disp:*1 largest stock tube* Refills:*0* 14. Piperacillin-Tazobactam Na 2.25 gm IV Q6H 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*100 Tablet(s)* Refills:*0* 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) sq Injection TID (3 times a day). Disp:*90 sq* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. Sepsis secondary to urosepsis vs. idiopathic colitis 2. Urinary tract infection 3. Transverse colitis secondary 4. Hypertension 5. Peripheral vascular disease 6. Chronic Obstructive pulmonary disease 7. Gastroesophageal reflux disease 8. Hyperlipidemia Discharge Condition: Stable, good Discharge Instructions: If you experience any worsening of your symptoms, please report to the emergency room immediately. Please take all of your medications as directed. Please follow up with your doctors (see information below). Followup Instructions: 1. You will need to follow up with Gastroenterology for an outpatient colonoscopy. You have an appointment set for [**4-14**], [**2197**] at 9:30am (Friday) with Dr. [**Last Name (STitle) **]. Located in [**Last Name (NamePattern1) **]. [**Location (un) **], [**Hospital Ward Name 517**] [**Hospital Unit Name **], [**Hospital1 18**]. Their office [**Telephone/Fax (1) 1983**]. 2. Please follow up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 35403**] [**Last Name (NamePattern1) 65779**] on Friday, [**2197-4-14**] at 12 noon. Her office number is: [**Telephone/Fax (1) 65780**]. Completed by:[**2197-4-8**]

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Discharge summary

report

Admission Date: [**2179-3-11**] Discharge Date: [**2179-3-22**] Date of Birth: [**2098-8-2**] Sex: M Service: MEDICINE Allergies: Benzodiazepines / Terazosin Hcl / Iodine Attending:[**First Name3 (LF) 3283**] Chief Complaint: Lethargy, fever, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: 80M h/o CHF, DM2, GERD, CRI, and dementia presented from his nursing home with lethargy, fever, vomiting, and diarrhea. . ED course: # VS: T oral 101.6, T rectal 103.8, HR 99, BP 133/66, O2 sat 99% on NRB # PE: Dry MM, diffusely tender but soft abdomen, guaiac-negative diarrhea, lungs CTAB with mild crackles at left base. # Labs: INR 9.5. # Imaging: --CT abdomen: Left hydronephrosis and hydroureter with perinephric inflammatory fat stranding with a mildly thickened bladder wall. Differential includes recently passed stone with superimposed cystitis or another obstructive process such as neoplasm. --CXR: Negative for acute process. --CT head: Negative for ICH # Meds/IVF: 1L NS, ceftriaxone, vancomycine, metronidazole; vit K 10mg SC # Treatment: Chronic indwelling Foley found in urethra, replaced. Past Medical History: Atrial fibrillation, on warfarin and metoprolol HTN CAD CHF (EF 75-80%) CRI (baseline Cr 3.5) BPH DM2 (diet-controlled) OSA Anemia (baseline Hct 26) Social History: # Personal: Lives in [**Hospital3 2558**]. # Professional: Retired ship captain. # Tobacco: Heavy past smoking history. # Alcohol: No current use. # Recreational drugs: None. Family History: Noncontributory Physical Exam: VS: T 96.3, BP 102/54, RR 21, O2 93% on 5LNC Gen: Increased work of breathing using abdominal accessory muscles on exhalation, responds to commands and moves all 4 extremities. HEENT: PERRLA, NCAT, MM dry Neck: Unable to assess JVP, supple CV: Irreg irreg, S1 S2, no m/r/g Pulm: Bilateral wheezes, no crackles Abd: Obese, ND, NT, decreased BS Ext: BLE pitting 2+ edema [**Date range (1) 8642**] up calves, w/w/p, weak DP +1 pulses bilaterally Skin: Venous stasis changes in BLE, no rashes Pertinent Results: Admission labs: . [**2179-3-10**] 03:00PM WBC-9.4 RBC-3.71*# HGB-11.9*# HCT-35.2*# MCV-95 MCH-31.9 MCHC-33.7 RDW-15.6* [**2179-3-10**] 03:00PM PT-76.1* PTT-48.8* INR(PT)-9.5* [**2179-3-10**] 03:08PM LACTATE-1.4 . Microbiology: . [**2179-3-10**] 04:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2179-3-10**] 04:20PM URINE RBC->50 WBC->1000 BACTERIA-MANY YEAST-NONE EPI-0 . # URINE CULTURE (Final [**2179-3-13**]): KLEBSIELLA PNEUMONIAE, GRAM POSITIVE RODS. Pansens . # [**2179-3-11**] 1:00 am STOOL (FINAL [**2179-3-13**]): NO SALMONELLA OR SHIGELLA FOUND; NO CAMPYLOBACTER FOUND. . # [**2179-3-18**]: CDiff positive . Imaging: . --CT abdomen: Left hydronephrosis and hydroureter with perinephric inflammatory fat stranding with a mildly thickened bladder wall. Differential includes recently passed stone with superimposed cystitis or another obstructive process such as neoplasm. --CXR: Negative for acute process. --CT head: Negative for ICH Brief Hospital Course: 79M (Polish speaking) h/o CHF, CAD, OSA, atrial fibrillation, presented with lethargy, fever, vomiting, and diarrhea, and was found to have urinary tract infection and hypernatremia. Pt was intially admitted to the MICU given possible urosepsis, but he remained stable and was transferred to the floor the following day. . # UTI: Pt had chronic indwelling foley for BPH, with urinalysis consistent with UTI on admission, and urine culture growing pansensitive Klebsiella. Pt was initially treated with vancomycin and ceftriaxone, with the vancomycin later stopped given speciation of his urine culture. Urology changed his Foley catheter. Follow-up urine culture demonstrated no growth. Pt was discharged to complete a 14 day course of cefpodoxime. . # C. Diff: Pt had loose stool so stool cx were sent which returned CDiff pos. He was started on metronidazole 500mg PO TID, to be continued for 14d after completing cefpodoxime course. . # ?Cellulitis: Pt developed erythematous, mildly indurated areas at the bilateral upper arms, at pressure points where his arms rested on pillows. While it was considered unlikely cellulitis, pt was prescribed mupirocin topical antibiotic. . # Altered mental status: Pt's lethargy was considered likely secondary to UTI and hypernatremia. His symptoms improved as his infection was treated with antibiotics and as his hypernatremia was treated with free water repletion. TSH demonstrated slight hypothyroidism which was considered likely secondary to sick euthyroid. . # Hypernatremia: Serum sodium reached a maximum of 151 during admission, and pt was treated with IVF with improvement. . # Afib with RVR: Pt was noted to have a rate in 120s, likely due to metoprolol being initially held. Pt was restarted on his metoprolol with good subsequent rate control. Metoprolol was ultimately reduced to 12.5mg [**Hospital1 **] from 25mg [**Hospital1 **] given frequent asymptomatic pauses of up to almost 3 seconds. . # Elevated INR: Pt's elevated INR on admission was considered most likely due to nutritional deficiency v. possible recent levofloxacin. Pt received vitamin K 10mg SC in the ED, and his warfarin was held on admission. Pt's INR trended down to less than 2, and he was restarted on warfarin with a heparin bridge. On discharge, his INR was 1.5 on warfarin 3mg QHS. Given the relative low daily risk of stroke [**2-20**] afib, pt was transferred to his [**Hospital1 1501**] with instructions to recheck INR in two days and to adjust his warfarin dosage accordingly. . # Chronic diastolic CHF: Pt received an echocardiogram revealing a hyperdynamic EF of 80% with severe symmetric LVH. Pt did not demonstrate signs of heart failure and was not started on any new medications. . # Acute on chronic renal insufficiency: Creatinine on admission was elevated at 3.1 above his baseline of 2.4. He was treated with IVF and his creatinine improved. # Anemia: Pt's hematocrit was stable during this admission, with no evidence of bleeding. Pt was continued on ferrous sulfate PO as per outpatient regimen. . # BPH: Pt's chronic indwelling foley was changed by urology during this admission, and pt was continued on finasteride. . # Depression: Pt's fluoxetine was discontinued, given his altered mental status, and pt was changed to citalopram. . # Aspiration: Pt was evaluated by speech and swallow who recommended a soft dysphagia diet, thin liquids, pills administered whole with purees, and sitting upright for 30 min after meals. . # Full code Medications on Admission: AMOXICILLIN 500 MG--4 tabs by mouth one hour prior to procedure ASPIRIN E.C. 325 MG--One tablet by mouth every day FLUOXETINE 10 MG--One tablet by mouth every day FUROSEMIDE 80 mg--1 tablet(s) by mouth 1 in the morning NITROGLYCERIN 0.3MG--One under the tongue as needed for chest pain, may repeat times 2 PROTONIX 40 mg--one tablet(s) by mouth once a day TOPROL XL 50 mg--3 tablet(s) by mouth once a day ?coumadin dose finasteride 5mg po qday fluoxetine20mg, 10mg renal caps vit C 500mg SR cap calcium carbonate cp;ace 100 flovent fleet enema bisacodyl PR genasyme 80mg q day guiatuss tylenol albuterol duoneb singulair Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Inhalation every six (6) hours. 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 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. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once Daily at 16): adjust for goal INR [**2-21**]. 15. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical TID (3 times a day): Apply to bilateral upper arms until erythema resolves. 16. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*16 Tablet(s)* Refills:*0* 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 18 days. 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for Groin rash. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary Diagnoses: Urinary tract infection Hypernatremia: resolved after IV fluid Clostridium difficile infection . Secondary Diagnoses: Atrial fibrillation CAD Diastolic CHF Chronic renal insufficiency BPH with indwelling foley HTN Diabetes mellitus type 2 Obstructive sleep apnea Anemia Discharge Condition: Stable. Tolerating POs. On RA. Discharge Instructions: You were admitted to the hospital because you had a fever and were confused. You were found to have a urinary tract infection. You were treated with antibiotics and also intravenous fluids. Your foley catheter was changed by the urology doctors. Later, we discovered you had a gastrointestinal infection (Clostridium difficile). We treated you for that. In addition, we were concerned that you had developed a skin infection, and we gave you topical antibiotics. . We have given you NEW medications. Please consult the discharge medication list. . # For your urinary tract infection: Continue to take cefpodoxime 200mg by mouth every 12 hours until [**3-26**]. . # For your gastrointestinal infection: Continue to take metronidazole 500mg by mouth three times daily until [**4-9**]. . # For your skin infection: Continue to apply mupirocin to your upper arms three times daily for 10 days, or until the redness in your arms has subsided. . # For your depression: We have discontinued your past medications and started you on citalopram. . Because of your diastolic congestive heart failure, you should weigh yourself every morning, and call your [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] MD if your weight increases by 3 lbs. You should also eat a 2 gm sodium diet daily. . If you have any severely concerning symptoms, please call Dr. [**Last Name (STitle) 2450**] and go to the emergency room. Followup Instructions: Please call Dr.[**Name (NI) 10427**] office at [**Telephone/Fax (1) 250**] and schedule an appointment to follow up within 2 weeks of discharge. Please also arrange for transportation to his office. Completed by:[**2179-3-22**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9026, 9122

3138, 4335

336, 342

9455, 9490

2101, 2101

11005, 11236

1560, 1577

7318, 9003

9143, 9259

6671, 7295

9514, 10982

1592, 2082

9280, 9434

261, 298

370, 1012

3097, 3115

2117, 3088

4350, 6645

1201, 1352

1368, 1544

17,436

103,268

17165

Discharge summary

report

Admission Date: [**2156-8-7**] Discharge Date: [**2156-8-29**] Date of Birth: [**2109-2-24**] Sex: Service: REASON FOR ADMISSION: Hypotension, hypoxia, sepsis, complicated by multisystem organ failure, pneumonia, acidosis. The patient is a 47 year old female with a history of multiple myeloma refractory to treatment who presents with hypotension, respiratory failure, septicemia, pneumonia. She was transferred from [**Hospital3 3583**] to [**Hospital6 649**] on [**2156-8-7**]. She developed a cough several days prior to admission, according to her fiance on [**2156-8-5**]. She was seen in the oncology clinic and complained of progressive headache that had begun on [**2156-8-4**], which she described as a band encompassing the perimeter of her scalp. She had a history of hyperviscosity syndrome secondary to her uncontrolled myeloma. She denied visual changes, nausea or vomiting, or other symptoms at that time. The patient had recently had plasmapheresis for hyperviscosity/high IgG. That procedure was on [**2156-8-5**]. At the end of the procedure, she had shaking chills but no fever and she was hemodynamically stable. On [**2156-8-6**] at 5:00 am, she had an unwitnessed fall and her fiance found her nearly unresponsive and brought her to the [**Hospital1 46**] E.R. She had temperature of 104 and was hypotensive. She received I.V. fluids, four units of packed red blood cells, four units of platelets, four units of FFP. Levophed and Neo-Synephrine were started. She was intubated for acidosis. Antibiotics were changed to Zosyn, sparfloxacin, vancomycin, and Levaquin. She was dialyzed times two for acidemia. Vasopressor was added. She was paralyzed and MedFlighted to [**Hospital1 18**] for continued dialysis. Blood cultures were drawn and grew out Gram-negative rods. Chest x-ray at [**Hospital1 46**] showed right pneumonia. Later the blood cultures were to reveal Pseudomonas. PAST MEDICAL HISTORY: Notable for multiple myeloma diagnosed in [**2156-2-14**], treated with thalidomide, prednisone, Decadron and Cytoxan with refractory disease and continued myeloma. The patient was found during this admission to have up to 22 percent of her peripheral blood smear to contain plasma cells. The patient was also on Procrit and Lupron. She received intermittent transfusions as an outpatient. She also received plasmapheresis, the last time being on [**2156-8-5**], the day prior to her collapse. Also she has history of asthma. ALLERGIES: No known drug allergies. MEDICATIONS: Prior to massive septic shock included: Metoprolol 150 mg b.i.d. Nifedipine CR 30 q.day. Allopurinol 100 mg q.day Procrit 40,000 q.week. Albuterol p.r.n. Oxycodone p.r.n. Her medications on transfer were: Neo-Synephrine drip. Levophed drip. Ativan/fentanyl drips. Vasopressin. Sparfloxacin. Zosyn. PHYSICAL EXAMINATION: On the day of admission, her vital signs at [**Hospital1 46**] revealed temperature 104, blood pressure 84/32 on Neo-Synephrine, breathing 25, 100 percent on AC 700, 14.5, FIO2 100 percent. On arrival at [**Hospital6 649**], her temperature was 98, her blood pressure was 70/59, went up to 93/68, heart rate 110 on Levophed, Neo- Synephrine and Vasopressin. Her vent settings were AC 500/26/5/1. Her gases on those settings were 7.19, 41, and 289 upon arrival. At [**Hospital3 3583**], she had 7 liters in and 500 cc out. The patient was cyanotic, intubated, anasarcic and non-responsive. Her pupils were equal, minimally reactive at 3 mm to 2 mm. There was bleeding from the oral and nasal mucosa. The patient had a right IJ placed. She had bronchial breath sounds. She was tachycardic, S1 and S2. No murmurs, rubs or gallops. She had hypoactive bowel sounds. She is anasarcic. She had diffuse mild erythroderma and she was unresponsive. LABORATORY DATA: Laboratory values at [**Hospital3 3583**] presentation: white count 3, hematocrit 27, platelets 134. Chem-7: sodium 136, potassium 3.9, chloride 103, bicarb 20, anion gap 13, BUN 24, creatinine 2.8. At [**Hospital1 **] on [**2156-8-7**], the patient's bicarb was 11 with an anion gap of 27. Platelets were 64, INR was 6, with picture being compatible with DIC. PTT was 72.5, albumin 2.5, ALT 1719, AST 3421, compatible with shock liver. LDH 4350. Her total bilirubin was 2.5, troponin 0.25, MB CK 467, MB 10, consistent with a non-ST elevation MI. Her lactate was 12.3. ASSESSMENT: 47 year old woman with multiple myeloma, presented with pneumonia, Pseudomonas septic shock, with multisystem failure, profound acidemia, anuria, shock liver, myocardial infarction, DIC, and hypocalcemia. Her calcium was 5.9. HOSPITAL COURSE: HYPOTENSION SECONDARY TO GRAM-NEGATIVE SEPTIC SHOCK: The patient was continued on pressors and given many liters of I.V. fluids with a goal of MAP of 60. CVPs were followed. An arterial line was placed and followed as well for titration of pressors. She was initially started on cefepime and vancomycin. When the Pseudomonas was identified, she was treated with Zosyn and ciprofloxacin. She completed a full course. Her pressors were eventually weaned off and she completed a course of antibiotics for her sepsis. OTHER INFECTIOUS DISEASE ISSUES: The patient developed fungemia secondary to central line, broad-spectrum antibiotics and TPN. All her lines were removed and peripheral IVs were placed. Cultures were drawn. The patient was started on ampicillin. Ophthalmology consult was done to rule out endophthalmitis. She had TEE with no evidence of vegetations. After sterile blood cultures, she had replacement of a central line. Fungus was identified as [**Female First Name (un) 564**] albicans. The patient developed herpes, crusted lesions in her oropharynx and nasopharynx and on her nose. Derm was consulted. DFA's were sent. Herpes virus grew out of them. She was started on acyclovir. Encephalitis doses were used due to the fact that the patient was unresponsive for the length of her hospital course and it was impossible to know whether she was suffering from encephalitis or not. RESPIRATORY FAILURE: The patient was intubated. She remained intubated throughout the course of her stay. She remained on AC mode, unable to breathe herself. The ventilator was used often to help blow off the metabolic acidosis the patient had. METABOLIC ACIDOSIS FROM LACTATE AND RENAL FAILURE: The patient had CVVH and that was eventually titrated to regular dialysis and patient was off of pressors. CVVH was done to correct her acidemia. The patient also received liters of bicarb drip in the acute episode to address her acidosis that was not compatible with life. HYPOTHERMIA: The patient had a temperature of the low 90s. Bear hugger and warmed I..V. fluids were used to support her and get her through her hypothermia. ANEMIA: The patient had evidence of DIC at presentation, also in conjunction with besides her septic shock her myeloma, resulting in decreased production. The patient had also oozing of blood from her mouth and from her lines and from other sites during her stay secondary to DIC. She was supported with FFP, platelet transfusions and red blood cell transfusions. She had greater than 20 each of platelet and red blood cell transfusions during the course of her stay in the FI CU. ELEVATED LFTS SECONDARY TO SHOCK LIVER COAGULOPATHY SECONDARY TO DIC: The patient received, as mentioned before, FFP, multiple units, throughout her stay both for procedures as well as to prevent the oozing that she had from multiple sites in her body, especially her oropharynx. HYPOCALCEMIA: The patient was on a calcium drip. This was maintained especially during the CCVH where her hypocalcemia became acutely worse. This also worsened her hypothermia. MYELOMA: Dr. [**First Name (STitle) 1557**] followed the patient regarding her myeloma, spoke to the family on multiple episodes saying that there was no treatment that could be offered to the patient, given the fact that she had already had multiple treatments without response and that she presented with multi-system organ failure with peripheral plasma cells and was deemed not a candidate for further treatment of myeloma. Dr. [**First Name (STitle) 1557**] played a further role in helping to talk to the patient's family, her fiance, and close relatives at the end of the patient's life. FEN: The patient was NPO. She was on TPN, which led to fungemia. The patient was a full code. The patient's fiance served as healthcare proxy for the patient. OTHER EVENTS: The patient had an intracranial bleed, hyperintensity, small, on CAT scan done to evaluate the lack of interaction that the patient had with the outside throughout her hospital stay. She was not responsive to voice or followed any commands. This bleed was stable throughout her stay. Multiple CAT scans confirmed this and she was supported with FFP and platelets to prevent further bleeding. She had atrial fibrillation during her episode, most likely in the context of volume overload and pressors. She was hypotensive and had adenosine push once for what was believed to be an early SVT, then was shocked and came out of the atrial fibrillation. She remained in normal sinus rhythm throughout the rest of her stay. The patient received stress dose of steroids for her sepsis, as she did not have an appropriate stress response. Thrombocytopenia, as mentioned before, the patient had DIC and was supported with platelets to prevent bleeding. The patient during her stay was made cardiopulmonary resuscitation not indicated, after a month in the hospital with no improvement in her condition. On [**2156-8-28**], the patient's condition began to worsen. After two units of packed red blood cells, the patient began to become more tachycardic, sinus tach at 150 - 160. She dropped her blood pressure to the 80s, receiving boluses of fluid that brought it back up to the mid-90s. The patient was sent for a pulmonary CT to rule out pulmonary embolus that showed diffuse patchy severe air-space disease consistent with ARDS, pus, blood or capillary leak, with an PA:FIO2 ratio of less than 200. Blood cultures were drawn on that day which eventually grew out Pseudomonas aeruginosa in two out of four bottles. The patient also had respiratory washings from that day which also grew out Pseudomonas on her sputum. Due to the patient's deterioration, a family meeting was held by the author and the healthcare proxy, [**Name (NI) **] [**Name (NI) 6692**], who is the patient's fiance. The patient's condition was explained to the family and that the patient had gotten worse. Reference was made to previous conversations with Dr. [**First Name (STitle) 1557**] and Dr. [**Last Name (STitle) **], and decision was made to make the patient comfort measures only. Drs. [**First Name (STitle) 1557**] and [**Name5 (PTitle) **] were notified via e-mail and Dr. [**First Name (STitle) 1557**] was also called. The patient passed away at 6:00 am with no spontaneous pulse or respirations and was pronounced at that time. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981 Dictated By:[**Doctor Last Name 11627**] MEDQUIST36 D: [**2157-5-19**] 18:37:44 T: [**2157-5-19**] 22:43:02 Job#: [**Job Number 48155**]

[ "584.5", "038.43", "785.59", "585", "203.00", "410.71", "482.1", "518.81", "570" ]

icd9cm

[ [ [] ] ]

[ "99.61", "38.95", "38.93", "96.72", "86.11", "99.15", "39.95", "38.91", "33.22" ]

icd9pcs

[ [ [] ] ]

4680, 11314

2871, 4662

1965, 2848

63,628

192,804

37161

Discharge summary

report

Admission Date: [**2176-7-2**] Discharge Date: [**2176-8-8**] Date of Birth: [**2118-4-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5141**] Chief Complaint: Lung carcinoma Major Surgical or Invasive Procedure: chest tube and pericardial tube placement Pericardial Window Bilateral Chest Tube Placement Abdominal port placement Thoracenteses L pleurex History of Present Illness: Briefly, this is a 58 y/o Vietnamese male with history of GERD and recently diagnosed mixed small cell/non-small cell lung cancer, complicated by recurrent pericardial effusions, being transferred from CCU to [**Hospital Unit Name 153**] for initiation of chemotherapy. . His workup started on [**6-10**], after his PCP ordered [**Name Initial (PRE) **] CXR for chronic cough, weight loss, chest burning and dyspnea. The CXR showed left hilar mass and left upper lobe consolidations, and the patient was referred to the ED. CT chest revealed a large spiculated left lung mass, bulky necrotic mediastinal and left hilar lymphadenopathy, bilateral pulmonary nodules, pericardial effusion and pericardial mass. He was subsequently admitted for one week, during which time he underwent pericardiocentesis for effusion with tamponade physiology, and bronchoscopy with biopsy revealing a mix of small cell and non-small cell lung carcinoma. He was ultimately discharged with PCP and thoracic oncology follow up. . On [**7-2**], the patient re-presented with ongoing dry cough, chest pain, dyspnea, weight loss, and swelling of his left arm, neck and face. Pulsus was measured at 10, and bedside echo showed recurrent effusion. He was taken to the cath lab for urgent pericardiocentesis and drain placement. Pericardial fluid grew gram positive cocci, and vancomycin was started. The drain was pulled, and the patient subsequently underwent pericardial window placement and bilateral chest tube placement by thoracics in the OR yesterday. Following the procedures, he self-extubated and was weaned off pressors entirely. Prior to transfer today, he had a PICC line placed. Vancomycin was discontinued after his pericardial fluid grew out coagulase negative staph. Labs this morning were notable for increase in creatinine from 0.9 to 1.3. Urine lytes were consistent with perfusion-related kidney injury. The patient has not been given IV fluid boluses given SVC syndrome, but is taking consistent oral intake. Oncology has been consulted and has been planning on starting chemotherapy with etoposide and carboplatin when the patient is hemodynamically stable. Prior to transfer from the CCU, vital signs were 97.9, 113, 94/76, 18, 95% 3L NC. . On arrival to the [**Hospital Unit Name 153**], the patient does not appear to have significant discomfort or distress. His ability to communicate is limited by language barrier. Past Medical History: Lung cancer as above -Prior gastro-esophageal reflux disorder -Prior history of H. Pylori status post therapy Social History: Vietnamese, immigated in [**2173**]. No travel outside US since. Current smoker 10 cig/day x 30 years. No ETOH, no illicits. Family History: Noncontributory Physical Exam: Admission PE: Vitals: T:96.8 BP:99/51 P:112 R:36 O2:96% 3LNC Pulsus: 4 General: Alert, no acute distress, sitting upright in bed, eating dinner HEENT: MMM, oropharynx clear, no conjunctival injection or icterus. No sinus tenderness. No acromegaly. 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: VS: 96.4 tmax 98.4 110/58 (109-132) 97 16 97%RA, pulsus 5 (via thigh measurement) General: Comfortable, thin male, NAD, lying in bed, hair on pillow Neck: supple, no LAD Lungs: scattered mild crackles at bases b/l, L sided chest tube in place w/ clean/dry bandage in place, no erythema, no dullness to percussion appreciated CV: regular rate and rhythm, normal S1S2, no mrg Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, port site c/d/i Ext: warm, well perfused, 2+ DP/PT/radial pulses, no clubbing, cyanosis or edema in LE. b/l upper extremity edema w/ evident engorged veins b/l. Pertinent Results: Adm labs: [**2176-7-2**] 11:45AM BLOOD WBC-5.7 RBC-4.24* Hgb-12.9* Hct-38.5* MCV-91 MCH-30.4 MCHC-33.5 RDW-13.4 Plt Ct-512* [**2176-7-2**] 11:45AM BLOOD PT-12.6 PTT-30.9 INR(PT)-1.1 [**2176-7-2**] 11:45AM BLOOD Gran Ct-3780 [**2176-7-2**] 11:45AM BLOOD UreaN-13 Creat-0.8 Na-134 K-4.6 Cl-99 HCO3-26 AnGap-14 [**2176-7-2**] 11:45AM BLOOD ALT-14 AST-22 LD(LDH)-262* AlkPhos-182* TotBili-0.2 [**2176-7-2**] 11:45AM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.2 Mg-2.2 [**2176-7-6**] 04:12AM BLOOD Osmolal-270* Micro: [**7-31**] Pleural fluid: no growth [**7-29**] Stool: no growth for C. diff, o/p, shigella, campylobacter [**7-23**] Pleural fluid: no growth [**7-22**] Pleural fluid: no growth [**7-16**] Sputum: no growth [**7-15**] Urinary legionella Ag: negative [**7-15**] BCx: no growth [**7-15**] UCx: yeast [**7-4**] Pericardial fluid: PMNs, no growth [**7-4**] Pleural fluid: no growth [**7-4**] Urine culture: no growth [**7-3**] BCx: No growth at time of transfer [**7-4**] BCx: No growth at time of transfer Pertinent Interval Labs: [**2176-7-27**] 06:00AM BLOOD WBC-15.4* RBC-3.09* Hgb-9.2* Hct-27.7* MCV-90 MCH-29.7 MCHC-33.0 RDW-14.4 Plt Ct-1039* [**2176-7-2**] 11:45AM BLOOD Gran Ct-3780 [**2176-7-23**] 05:18AM BLOOD Ret Aut-0.5* [**2176-7-28**] 06:00AM BLOOD ALT-15 AST-25 LD(LDH)-292* AlkPhos-173* TotBili-0.2 [**2176-7-15**] 06:00AM BLOOD CK-MB-5 cTropnT-<0.01 [**2176-7-15**] 12:01AM BLOOD CK-MB-5 cTropnT-<0.01 [**2176-7-23**] 05:18AM BLOOD Hapto-215* [**2176-7-11**] 06:10AM BLOOD calTIBC-208* VitB12-1276* Folate-11.6 Ferritn-418* TRF-160* [**2176-7-6**] 04:12AM BLOOD Osmolal-270* [**2176-7-19**] 06:08AM BLOOD Vanco-4.5* [**2176-7-15**] 11:52AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2176-7-6**] 08:52AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2176-7-4**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2176-7-15**] 11:52AM URINE RBC-36* WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 [**2176-7-6**] 08:52AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [**2176-7-11**] 06:46PM URINE Hours-RANDOM Na-28 K-97 Cl-75 [**2176-7-6**] 08:52AM URINE Hours-RANDOM Creat-139 Na-28 K-74 Cl-80 [**2176-7-5**] 09:32AM URINE Hours-RANDOM UreaN-436 Creat-241 Na-18 K-71 Cl-21 [**2176-7-11**] 06:46PM URINE Osmolal-855 [**2176-7-6**] 08:52AM URINE Osmolal-764 [**2176-7-31**] 04:08PM PLEURAL WBC-18* RBC-4038* Polys-7* Lymphs-88* Monos-5* [**2176-7-23**] 08:21AM PLEURAL WBC-333* RBC-1000* Polys-40* Lymphs-37* Monos-3* Atyps-1* Meso-3* Macro-13* Other-3* [**2176-7-22**] 01:18PM PLEURAL WBC-390* RBC-565* Polys-17* Lymphs-63* Monos-0 Atyps-4* Meso-1* Macro-13* Other-2* [**2176-7-31**] 04:08PM PLEURAL LD(LDH)-216 Amylase-32 [**2176-7-23**] 08:21AM PLEURAL TotProt-0.9 Glucose-78 LD(LDH)-165 Cholest-19 [**2176-7-22**] 01:18PM PLEURAL TotProt-1.0 Glucose-155 Creat-0.4 LD(LDH)-181 Amylase-28 Albumin-LESS THAN [**2176-7-2**] 07:00PM OTHER BODY FLUID WBC-700* Hct,Fl-14.5* Polys-24* Lymphs-38* Monos-16* Eos-5* Mesothe-11* Macro-6* [**2176-7-2**] 07:00PM OTHER BODY FLUID TotProt-4.2 Glucose-92 LD(LDH)-441 Amylase-31 Albumin-2.7 Discharge Labs: [**2176-8-8**] 06:05AM BLOOD WBC-4.1 RBC-3.21* Hgb-10.0* Hct-28.9* MCV-90 MCH-31.2 MCHC-34.6 RDW-17.4* Plt Ct-405 [**2176-8-8**] 06:05AM BLOOD Glucose-86 UreaN-18 Creat-0.5 Na-137 K-4.3 Cl-102 HCO3-29 AnGap-10 [**2176-8-8**] 06:05AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.1 Rads: [**7-2**] CTA chest:1. Near complete attenuation of the SVC by a large (4.7 x 3.0 cm) necrotic right precarinal lymph node conglomerate. SVC appears to reconstitute distal to this mass. 2. Extensive mediastinal and left hilar necrotic lymphadenopathy. Large left hilar/mediastinal necrotic nodal conglomerate (6.1 x 5 cm) markedly attenuates the left main pulmonary artery. Left upper lobe necrotic mass stable to slightly increased in size. 3. Moderate right and small left pleural effusions are increased. 4. Unchanged pericardial lesion with moderate pericardial effusion, stable to slightly increased from PET-CT from five days prior. 5. Right mainstem endobronchial filling defect could reflect aspirated secretions or tumoral involvement. [**7-2**] Echo: There is a moderate to large sized pericardial effusion. There is left atrial diastolic collapse. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. [**7-2**] Cath:1. Pericardial tamponade. 2. Successful pericardiocentesis with 400cc bloody fluid removed and sent for pathological analysis. 3. Drainage overnight with repeat echocardiogram tomorrow morning. [**7-4**] CXR: In comparison with the next preceding portable chest examination of [**2176-6-17**], the patient is now intubated and has bilateral chest tubes as described without evidence of pneumothorax. Hilar mass appears unchanged. ============ [**7-29**] echo: Overall left ventricular systolic function is normal (LVEF>55%). RV with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a moderate sized pericardial effusion. The effusion appears loculated. Stranding is visualized within the pericardial space c/w organization. There are no overt echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2176-7-19**], the pericardial effusion has increased in size. [**8-5**] CT Chest: IMPRESSION: 1. Decrease in size of spiculated left lung nodule and decreased size of conglomerate necrotic lymph nodes throughout the mediastinum as compared to [**2176-7-2**] chest CT. Decrease in pericardial effusion, bilateral pleural effusions, and enhancing pericardial soft tissue lesion. 2. Numerous less than or equal to 4-mm diameter lung nodules are mostly stable in size since the prior scans except for a 4-mm right upper lobe nodule which has grown from 2 mm. 3. Asymmetrical interstitial thickening involving the left lung greater than the right is concerning for lymphangitic carcinomatosis, but hydrostatic edema and infection may produce a similar appearance. 4. Nonspecific lingular opacities favor an infectious or inflammatory etiology over new foci of metastatic disease. 5. Tiny loculated left basilar pneumothorax with left chest tube in place, which has a partially intrafissural location. Brief Hospital Course: ============================= BRIEF HOSPITAL SUMMARY ============================= 58 yo vietnamese male with history of GERD and new diagnosis of SCLC presented with pericardial effusion and SVC syndrome. Subsequently he developed bilateral pleural effusions, a left pneumothorax, had 3 chest tubes placed and then developed a RLL pneumonia. . # Anemia: Stable, largely unchanged Hct from yesterday. Iron studies normal, hemolysis labs normal. - continue to monitor Hct - transfuse Hct < 24 . # Thrombocytosis: resolved . ============================= ACTIVE ISSUES ============================= . # Pericardial Effusion sp Drain Placement: malignant, recent lung carcinoma diagnosis. The pt was evaluated by cardiology and cardiothoracic surgery. He had a pericardiocentesis which was successful, with drain placement. The drain was removed, and the patient exhibited no signs of tampanade while in the ICU. s/p pericardial window [**7-4**], but [**7-29**] TTE showed reaccumulation of moderate effusion, which is loculated, likely not draining through window, per thoracics, no further intervention. Pt was monitored clinically with daily measurements of pulsus. Pt has appt w/ cardiology on [**2176-9-6**] to f/u. . # SVC syndrome: Chest imaging concerning for near-total attenuation of SVC by mass. Significant edema in UE's. No clear interval change from most recent CT. MRV was done during this hospitalization to attempt to locate site for access (for chemo). Ultimately, there was no place for access, and an abdominal port was placed by surgery. . # Pleural effusions: Bilateral, malignant effusions [**2-7**] recent lung cancer diagnosis. The patient had bilateral chest tubes placed, which were transition from suction to water seal on [**2176-7-6**]. Serial CXR were done for monitoring. Thoracics was following. Cultures were sent, and no organisms were isolated. The tubes continued to drain copious fluid so each pleural space was pleurodesed 2 times, first with doxycycline and then with talc. The three chest tubes were then slowly able to be removed. 9 days later, he had reaccumulation and b/l taps on [**7-22**] and [**7-23**]. He again had reaccumulation bilaterally on [**7-29**], at which time between [**7-29**] and [**7-31**], a R pigtail was placed and a L pleurex was placed. In interval, R pigtail pulled, L pleurex was drained every other day. Most recent CT imaging on [**8-5**] demonstrated decrease in bilateral pleural effusions. Prior to discharge, L pleurex was draining 100-150cc fluid every other day. Pt sent home with VNA, with instructions to drain every other day from L pleurex. Pt to have appt on [**2176-8-13**] w/ Dr. [**Last Name (STitle) **] in IP, with chest tube sutures to be removed. . # Lung Mass: Mixed small cell / non-small cell lung Ca pt initiated chemotherapy ([**Doctor Last Name **]/Etoposide) on [**2176-7-6**] in hopes that this would help not only his cancer, but also treat his malignant effusions. He had a second cycle on [**2176-7-27**]. Recent repeat staging CT demonstrated potential response of lung lesion ([**2176-8-6**]). No acute inpt therapy potential with radiation, per conversation with rad onc. Radiation therapy will be readdressed in the outpt setting. Pt has outpt oncology appt with primary oncologist [**Doctor Last Name **] on [**8-15**]. . # RLL Pneumonia: on the evening of [**2176-7-12**] the patient became hypotensive despite good PO intake and IVF's. W/u revealed a RLL pneumonia for which he was started on Vanc and Cefepime. He was set to be transferred back to the unit but was stabilized on the floor following a bedside echo so he stayed on the floor and was hemodynamically stable since that time. He completed an 8 day course of vancomycin and cefepime for HAP. . # Anemia, Thrombocytosis: most likely related to initiation of chemotherapy ========================= INACTIVE ISSUES ========================= # GERD: The patient does not take medications for this at home, and he was monitored for symptoms. . ========================= TRANSITIONAL ISSUES ========================= 1. sutures from L pleurex placed [**7-31**], to be removed at 8/9 IP appt 2. pt sent home with VNA services to assist with pleurx drainage, qod 3. pt arranged to have hospital bed, wheelchair delivered to home 4. pt needs vietnamese translator for all outpt appts 5. f/u pericardial effusion with cardiology on [**9-6**] 6. f/u w/ ? radiation therapy with primary oncologist on [**8-15**] Medications on Admission: Medications on Admission: None Medications on transfer to the ICU: -Albuterol 0.083% Neb Soln 1 NEB IH Q6H -Ipratropium Bromide Neb 1 NEB IH Q6H -Docusate Sodium 100 mg PO BID -Senna 1 TAB PO BID:PRN Constipation -Dilaudid 0.5-1mg-Bolus's IV Q4H PRN pain -Heparin 5000 UNIT SC BID -Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. 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* 4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. SEMI-ELECTRIC BED PLEASE DISPENSE 6. WHEELCHAIR PLEASE DISPENSE TO PT 7. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0* 8. Bedside commode Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 86**] Discharge Diagnosis: Small Cell Lung Cancer Non Small Cell Lung Cancer Bilateral Pleural effusions Pericardial Effusion Left Pneumothorax Superior Vena Cave Syndrome Tachycardia Hyponatremia Acute Kidney Injury Gastroesophageal Reflux Disease Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital with a cough, chest pain, shortness of breath, weight loss, and swelling in your arms and face. You had several drains put in place to remove accumulating fluid in the linings around your heart and lungs. You still have a tube in place to drain your left lung, and we have arranged for a nurse to visit you at home to help with this. You started receiving chemotherapy for your lung cancer while you were here. You now have a port in your abdomen for the chemotherapy. . You were not previously taking any medications at home. We started the following medications: - Dilaudid as needed for pain (never drive, drink alcohol, or operate heavy machinery with this medication) - Senna and Colace as needed for constipation - Ondansetron as needed for nausea - Metoprolol to control your heart rate . Thank you for allowing us to participate in your care. We wish you a speedy recovery. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2176-8-13**] at 8:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Specialty: Interventional Pulmonary Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2176-8-13**] at 11:00 AM With: [**Name6 (MD) **] [**Name8 (MD) 831**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2176-8-15**] at 10:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, PHD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: FRIDAY [**2176-9-6**] at 10:20 AM 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

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Discharge summary

report

Admission Date: [**2127-8-27**] Discharge Date: [**2127-9-9**] Date of Birth: [**2074-10-8**] Sex: M Service: MEDICINE Allergies: Citalopram Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: right chest wall / RUQ pain Major Surgical or Invasive Procedure: none History of Present Illness: 52M with renal cell carcinoma who presents with pleuritic RUQ pain x 1 day. He reports having the same pain in past (see discharge summary [**2127-6-27**]) with extensive workup and no etiology found. The pain is located under his right anterior lower ribs, radiating up to mid chest and down to RUQ. Associated with nausea/vomiting. Also with cough productive of green sputum x 3 days. Pain much worse with cough and vomiting. Taking oxycontin 80 TID at home plus prn oxycodone 30 mg without relief. Also using Zofran, ativan and Compazine which help with nausea significantly. He has chronic edema in both legs due to prior DVT, on coumadin, he reports this is unchanged. Denies fever. No diarrhea. No other abd pain or CP. Last chemo 9 days ago. No hematuria. In the ED: EKG: ST 106, NA/NI, no STEMI. Given IVF, dilaudid, antiemetics. CT chest/abd with contrast done, no significant new findings. ROS positive as above, otherwise negative in full. Past Medical History: ONCOLOGIC HISTORY: - [**2126-2-12**]: RLE DVT. CT torso showed an 8.9 x 8.4 cm mass in the upper pole of his right kidney with tumor thrombus extending into the right renal vein, IVC, and right iliac/femoral veins. There was suspicion for involvement of the right adrenal gland by his primary tumor. There was also noted to be "bulky" retroperitoneal lymphadenopathy "measuring approximately 4 cm." Core needle biopsy of his left supraclavicular lymph node, demonstrated papillary carcinoma, consistent with metastatic papillary renal cell carcinoma. - [**2-/2126**]: Started on sunitinib 50 mg daily for a 28-day course. Had severe nausea, vomiting, anorexia, diarrhea and stomatitis around the time of completion of the 28-day cycle. - [**2126-4-6**]: Presented to [**Hospital1 18**] ED with severe nausea and worsening abdominal pain. Also noted growth of his left supraclavicular lymph node. - [**2126-4-7**]: Follow up CT demonstrated interval increase in his retroperitoneal lymphadenopathy, increase of the right adrenal mass and presence of his extensive tumor thrombus throughout the right renal vein and inferior IVC up to the confluence of the hepatitic veins. It also showed suspicion for continued deep venous thrombosis of the right common femoral and right superficial femoral veins. - [**2126-4-29**]: Began cycle 1 of bevacizumab and temsirolimus per phase II protocol 08-184 - [**2126-6-21**]: Hospitalized with vomiting and pleuritic chest pain. CT scan ruled out acute PE, showed overall stable disease and decreased size of the supraclavicular lymphadenopathy. Found to have lower extremities DVT was started on LMWH. Bevacizumab was held due to ongoing anticoagulation. - [**2126-8-19**] a CT scan torso performed after cycle #4 showed mixed behavior with overall decreased right renal mass bulk but stable and slight increased periaortic, retrocrural, mesenteric, and supraclavicular lymphadenopathy. Stable extent of tumor/thrombus involvement of right renal vein and IVC. Stable tumor replacement of the right adrenal gland. - [**2126-12-10**] CT TORSO showed stable disease. - [**2126-12-30**] Torisel held due to marked worsening of lower extremities edema - [**2127-1-6**] clinical disease progression. Pt taken off study 08-184 - [**2127-1-7**] start Avastin and Torisel off protocol - [**2126-2-10**] CT torso stable disease . OTHER PMHx: # Renal cell cancer, diagnosed in [**2-/2126**] in the setting of work up of new DVT, vena cava infiltration, and lymphadenopathy # HTN # CAD s/p DES on [**2123**], off Plavix, on low dose aspirin # Hyperlipidemia Social History: The patient is a previously 1 PPD x 25 years. He smokes about three cigarettes per day. He formerly worked in construction. He denies significant EtOH use or other drug use. Family History: Remarkable for a father and sister with lung cancer. Physical Exam: Admission Exam: Gen: uncomfortable appearing man in bed, pale, thin HEENT: MM dry, op clear Neck: supple CV: tachy, [**3-16**] sm, no rub Pulm: diminished at bases, poor effort (due to pain) otherwise clear to auscultation Chest wall: VERY tender to minimal palpation over r anterior chest wall/lower ribs Abd: tender to palpation in RUQ, negative [**Doctor Last Name **]. no rebound/guarding. normal BS. Ext: 2+ b/l LE edema. Neuro: fluent speech, oriented x 3, good recall, moves all 4, normal sensation Psych: appropriate affect Derm: no rash ICU Admission Exam: Vitals: T: 98.4, BP: 126/92 P:138 R: 38 O2: 93% on 5L NC General: Very thin, ill-appeaing male, alert, oriented, in moderate respiratory distress in pain on inspiration HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP mildly elevated 7-8cm Lungs: significant rhonchi bilaterally with audible air leak over RUL; chest tube in place with continuous air leak CV: Regular rate and rhythm, normal S1/S2, II/VI SEM, no audible rub Abdomen: tender to palpation with mild voluntary guarding, non-distended, bowel sounds present, no rebound tenderness GU: no foley Ext: significant 3+ edema to groin bilaterally (equal), warm, well perfused, 2+ pulses, no cyanosis ICU Discharge Exam: Tmax:98.4 Tc:98.1 HR:125 BP:104/70(76) RR: 25 SpO2: 96% General: cachectic ill-appeaing male, alert, oriented, NAD HEENT: Sclera anicteric Neck: supple Lungs: significant rhonchi bilaterally posteriorly and anteriorly and decreased BS over RUL; chest tube in place to suction with, purulent drainage. R-sided rhonchi to mid-chest; left side basilar crackles. CV: Regular rate and rhythm, normal S1/S2, murmur difficult to assess secondary to course breath sounds Abdomen: Soft, non-tender,, non-distended, bowel sounds present, no rebound tenderness. Dependent sacral/frank edema R>L GU: foley in place Ext: significant 3+ edema to groin bilaterally (equal), warm, well-perfused. Pertinent Results: ADMISSION LABS: [**2127-8-27**] 09:30AM GLUCOSE-120* UREA N-21* CREAT-1.5* SODIUM-137 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-19 [**2127-8-27**] 09:30AM ALT(SGPT)-67* AST(SGOT)-89* ALK PHOS-141* TOT BILI-0.4 [**2127-8-27**] 09:30AM LIPASE-13 [**2127-8-27**] 09:30AM WBC-9.0# RBC-6.28* HGB-14.9 HCT-47.0 MCV-75* MCH-23.7* MCHC-31.7 RDW-17.8* [**2127-8-27**] 09:30AM NEUTS-84* BANDS-1 LYMPHS-7* MONOS-7 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2127-8-27**] 09:30AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2127-8-27**] 09:30AM PLT SMR-NORMAL PLT COUNT-250 [**2127-8-27**] 09:30AM PT-19.8* PTT-31.7 INR(PT)-1.8* [**9-5**] PLEURAL FLUID ANALYSIS: WBC [**Numeric Identifier 4756**]* RBC [**Numeric Identifier **]* POLYS 98* MONOS 2, TProt 3.0 Glucose 0 LDH [**Numeric Identifier 86124**] [**9-5**] BAL FLUID ANALYSIS: POLYS 81* LYMPHS 2* MONOS 7* OTHER 10* [**9-3**] GALACTOMANNAN - negative [**9-3**] BGLUCAN - negative [**9-4**] ANCA - negative ********** MICRO . [**2127-9-5**] Sputum GRAM STAIN (Final [**2127-9-5**]): [**12-2**] PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. [**2127-9-5**] 3:43 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [**2127-9-5**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Preliminary): Reported to and read back by [**Doctor First Name **] [**Doctor Last Name 10502**] [**2127-9-6**] 11:40AM. STAPH AUREUS COAG +. MODERATE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): . [**2127-9-5**] 3:44 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [**2127-9-5**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. ~5000/ML. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2127-9-6**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL 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. ACID FAST CULTURE (Preliminary): . [**9-9**] Urine culture no growth to date ********** IMAGING . CTA CHEST / ABD /PELVIS [**8-27**]: 1. No acute aortic pathology or pulmonary embolism. 2. Scattered peripheral lung opacities persist, slightly improved in areas though cavitation in a RUL opacity is new. These opacities are more concerning for infection as this appearance is atypical for RCC mets though metastasis cannot be excluded. 3. Right renal mass, large adrenal metastasis (possibly invading liver), bulky RP lymphadenopathy unchanged from [**2127-4-28**]. IVC Invasion/obstruction unchanged. 4. No stones in the kidneys or proximal ureters bilaterally. The distal ureters are not assessed. . KUB [**9-2**]: IMPRESSION: No pneumoperitoneum. No evidence of bowel obstruction. Moderate fecal loading. Loop of mildly prominent sigmoid within normal limits, although with slightly greater caliber; if pain were to persist, then follow-up radiographs could be considered. . ECHO [**8-29**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. CXR [**9-1**]: INDICATION: Right-sided pleuritic chest pain. FINDINGS: As compared to the previous radiograph, there is a newly appeared moderate right-sided pneumothorax without evidence of tension. In addition, there are at least two consolidations, one of which is located at the bases of the right upper lobe and one of which is located in the right lower lobe. These consolidations have also been documented on a CT examination from [**2127-8-27**]. No pleural effusion. No other focal parenchymal opacities. Unchanged size of the cardiac silhouette. Unchanged position of the left pectoral Port-A-Cath. CXR [**9-2**]: FINDINGS: Compared to the previous radiograph, the patient has received a right-sided chest tube. The right pneumothorax has decreased in size. The pre-existing parenchymal opacities on the right are not substantially changed. No evidence of tension. Unchanged appearance of the left hemithorax. CXR [**9-3**]: Interval development of minimal pneumothorax on the right side since [**2127-9-2**]. Overall increase in the right lower lung consolidation and cavitation within a more discrete consolidation concerning for breakdown in pneumonic consolidation or infected cavitary metastasis. CXR [**9-4**]: Interval development of minimal pneumothorax on the right side since [**2127-9-2**]. Overall increase in the right lower lung consolidation and cavitation within a more discrete consolidation concerning for breakdown in pneumonic consolidation or infected cavitary metastasis. CXR [**9-5**]: Interval removal of a right pleural catheter with placement of a chest tube with its tip at the apex of the lung. Marked improvement in the right pneumothorax with trace apical pneumothorax visualized on the current examination, although lucency at the right lung base raises concern for air within the costophrenic sulcus. There continues to be a diffuse airspace process within the right lung. The left lung is clear, although there is likely a small left effusion. Overall, cardiac and mediastinal contours are stable. Left subclavian Port-A-Cath remains in place with its tip in the distal SVC. The endotracheal tube remains in satisfactory position with the tip at the thoracic inlet. Small amount of subcutaneous emphysema within overlying the right lateral soft tissues likely related to chest tube placement. CXR [**9-6**]: 1. Left subclavian Port-A-Cath is again seen with the tip in the SVC. A right chest tube remains in place. There continues to be a right apical pneumothorax which appears larger than on the previous study from 5:12 a.m. Right mid and lower lung airspace disease with a component of possible cavitation is essentially unchanged. Left lung appears grossly clear. Cardiac and mediastinal contours are stable. CXR [**9-7**]: Right apical chest tube remains in place. The left subclavian Port-A-Cath has its tip near the cavoatrial junction, unchanged. Lungs volumes remain low with patchy opacity at the left base, which likely represents atelectasis as this was not previously appreciated on the most recent comparison. Patchy opacity at the right base is again seen and unchanged in appearance. There is a persistent small right apical pneumothorax, which is stable. Overall, cardiac and mediastinal contours are unchanged. No evidence of pulmonary edema. Brief Hospital Course: 52 M with history of metastatic renal cell carcinoma presented with 1 day of pleuritic RUQ pain. # R chest/RUQ pain: On admission, CT abd/chest showed no acute pathology apart from continued large tumor burden on right side. LFTs were similar to recent baseline. He was noted to have had a similar presentation in [**Month (only) 116**], at which time etiology was not elucidated: no PE, negative cardiac enzymes and EKG, bedside swallow eval negative, bone scan negative, bronchoscopy [**2127-6-26**] was unremarkable, no organisms on gram-stain. Given CT findings, current presentation was thought to be either chemo induced pneumonitis (with steroid benefit), or a possible infectious process in the lungs. Pulmonary Medicine was consulted to evaluate prior to initiation of steroids. It was felt that the CT findings were consistent with his oncologic process, and that given his significant evaluation during the previous admission for the same complaints, that it appears safe to initiate a trial of steroids. He was started on Prednisone 40 mg, with plans for a 2 week taper. He was also started on Azithromycin for presumed bronchitis, and he will complete a 5 day course. His Oxycontin was uptitrated from 80 TID to 100 mg po TID, due to persistent pain rated approx [**8-17**]. Pt noted that much of his pain medication dosing is limited by nausea with increasing dosage. Palliative Care was consulted for assistance with symptom management; they continued to follow him and adjust his pain medication regimen in the ICU (see below) . # CKD: Due to renal cell CA. Stable. . # Metastatic renal cell CA: On bevacizumab and temsirolimus (Torisel). Although temsirolimus may be causing a pneumonitis, it may need to be continued. On the floor this issue was deferred to the primary oncologist. After transfer to the ICU for decompensating respiratory issues, chemotherapy was stopped (see below). . # Anemia: Chronic, stable. Due to CKD/ chronic disease. . # Hx bilateral DVT: Continued warfarin on the floor. According to anticoag sheet in [**Last Name (LF) **], [**First Name3 (LF) **] oncologist, Dr [**Last Name (STitle) **]: "no heparin bridging required for subtherapeutic INR's or procedures." After patient was transferred to the ICU, warfarin was stopped in favor of heparin gtt given ongoing need for thoracic/interventional pulmonary procedures (see below). . # CAD: Continued outpatient aspirin and metoprolol. Statin recently discontinued. ________________________ ICU Course . 52 year old male with metastatic RCC, PTX [**3-12**] cavitary lung lesion s/p chest tube, transferred to the ICU with worsening tachypnea and O2 says, pleuritic chest/abd pain and new right lung infiltrates on CXR. . #PTX Patient developed R PTX prior to transfer to the ICU, requiring chest tube placement by interventional pulmonology. R pneumothorax was monitored & noted to wax and wane, especially worsening when the chest tube was changed from suction to water seal. The continuous air leak/ongoing stable PTX with a chest tube in place was strongly suggestive of a bronchopleural fistula, as discussed below. A small, stable PTX persisted after placement of the larger-sized chest tube by thoracic surgery, also discussed below. . # R PNA/empyema/bronchopleural fistula Given his worsening tachypnea and increasing oxygen requirement s/p chest tube placement for PTX, there was concern for an additional pulmonary process. Continued air leak despite re-expansion of PTX pointed toward development of a bronchopleural fistula, with contribution of splinting and low minute ventilation secondary to pleuritic pain. CXR also showed new right middle and lower lobe infiltrates w/known cavitating R lung lesion (per prior CT), which likely contributed to his increased O2 requirement, as they have not been treated up to this point. WBCs continue to worsen with a bandemia. Steroids were stopped. Vancomycin, Cefepime and Levofloxacin were started for broad-coverage for hospital-acquired PNA. Patient was electively intubated for BAL for micro specimen collection. BAL fluid and pleural fluid were collected during the procedure and sent for culture and studies - they eventually grew coag+ staph. While the patient was intubated, thoracic surgery placed a larger chest tube (at the bedside). The patient was successfully extubated within hours after BAL and chest tube placement. His O2 Sats remained stable, PTX improved, and he looked clinically improved. O2 sats were maintained >93% on supplemental oxygen with mucous suctioning and nebs as needed. However, over the next two days the patient developed an increasing O2 requirement to maximum high-flow oxygen, and serial CXRs showed worsening loculated empyema, with thick purulent drainage from the chest tube. Transient fluid-responsive hypotension and decreased urine output were thought to be manifestations of sepsis secondary to the complicated pulmonary infection. As patient was unable to take much PO, heceived maintenance IVF + boluses as needed for SBP <85. . #Goals of care. Patient had previously indicated that he would not want to be resuscitated, but would be OK with short-term intubation. Primary oncologist confirmed Full Code status with patient. Palliative care was consulted and followed the patient for symptom management, given the lack of further onc treatment options and need for pain management during acute pulmonary developments. The patient remained full code until [**9-7**] when, given concern rapidly worsening pulmonary function despite maximum-flow oxygen, chest tube in place, and broad-spectrum antibiotics (vancomycin/levaquin/cefepime), a family meeting was initiated to communicate concern over poor prognosis and limited therapeutic options. Serial family meetings were held; the patient and family elected to change his code status to DNR/DNR with efforts towards promoting patient comfort. Antibiotics and chest tube drainage continued as before. . #Pain management. The patient was followed by palliative care. He was pain free on a PO regimen of 120 oxycontin TID, 300 mg gabapentin qHS, and dilaudid IV 2-3 mg q2H PRN. When his code status was changed to DNR/DNI it was determined that he may need to transition to IV pain medication. If/when that should occur, he will be started on a continuous 1 mg/hr dilaudid infusion, which is roughly equivalent to his current oxycontin PO dosing. . #Nutrition: Patient noted to have poor PO intake. Appetite likely limited by breathing difficulties and malignancy. Nutrion was consulted; TPN was started because, although patient has no gastrointestinal contraindication to tube feeds, he requires continues oxygen supplementation by high-flow facemask. . # Lower extremity edema [**3-12**] DVTs: Multifactorial with low albumin, known DVTs (on coumadin), and possible burden of known bulky lymphadenopathy in pelvis. Cardiac etiology also possible given the pericardial effusion, but there does not appear to be any tamponade physiology on exam or TTE. Home dose warfarin 5 mg daily on Mo/We/Fr/Sa, 7.5 mg daily on Tu/Th/[**Doctor First Name **], recently restarted this hospitalization; this was held and, in addition, he received 2U FFP to reverse INR 3.9 prior to placement of chest tube and PICC line. Once procedures were completed, he was restarted on a heparin drip and maintained on the heparin drip thereafter. On discharge, patient preferred to be maintained on Coumadin, so he was discharged to hospice with this medication. . # Metastatic renal cell CA: On bevacizumab and temsirolimus (Torisel) prior to admission. Initially deferred further treatment decisions to the primary oncology team, who discussed with the patient that there are no other chemotherapy options. No chemotherapy was administered during the patient's ICU course. . # Acute on chronic kidney disease: Known renal cell CA with prior baseline 1.3-1.7. The acute rise in his creatinine are likely pre-renal secondary to decreased intake from pain, but could also be ATN [**3-12**] hypotension or post-renal. Urine output was low. He was given fluid boluses for low urine output. Labs showed hyponatremia with low urinary sodium, suggesting dehydration. He received maintenance IVF. . # Pericardial effusion: Likely malignant and without tamponade by exam (no appreciable pulsus, mild JVD, and clear heart sounds without a rub) or Echo, but tachycardic and with mildly decreased BPs. Monitored exam for effusion. . # Abdominal pain: Exam worsened early in admission, but we suspected that pleuritic pain was responsible. Exam without rebound, only mild guarding. No signs of peritonitis or free air on CXR. Extensive stool on KUB. Worsening lactate (1.7) likely due to general malperfusion. He was continued on an agressive bowel regimen, especially while on narcotics. . # Microcytic anemia: Chronic, stable MCV 74-75. Likely due to chronic kidney disease with an element of possible malabsorption/iron deficiency. . # CAD: History of CAD with DES placed in [**2123**]. Off plavix. Continued outpatient ASA, metoprolol (statin recently discontinued). . # Communication: Mother [**Telephone/Fax (1) 86125**] and girlfriend [**Name (NI) **] [**Telephone/Fax (1) 86126**]. . # Code: DNR/DNI Medications on Admission: 1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Anxiety or nausea. 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 5. oxycodone 40 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO Q8H (every 8 hours). 6. oxycodone 20 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 7. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours. 8. quetiapine 25 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). --NOT TAKING RECENTLY AS PHARMACY ONLY HAS LIQUID FORM WHICH CAUSES NAUSEA. 10. warfarin 5 mg 4/x week, 7.5 mg 3x/week. 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (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 for Constipation. 15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) Dose PO DAILY (Daily) as needed for constipation. Discharge Medications: 1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety or nausea. Disp:*45 Tablet(s)* Refills:*0* 2. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 3. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. 4. quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) mL PO every eight (8) hours as needed for constipation. 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 10. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:*30 Capsule(s)* Refills:*0* 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 12. quetiapine 25 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for pain. Disp:*30 Capsule(s)* Refills:*0* 14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 16. hydromorphone in 0.9 % NS 30 mg/30 mL (1 mg/mL) Pt Controlled Analgesic [**Last Name (un) **] Sig: One (1) PCA Intravenous AS DIRECTED. Disp:*qs * Refills:*0* 17. CADD Pump Hydromorphone 1 mg/ml CADD Pump; Basal Rate 0.75-1.5 mg/hr; Bolus Dose 2 mg Q6minutes; Lockout: 10 doses/hour 18. Oxyfast Sig: 1-20 mg Q1H as needed for pain or respiratory distress. Disp:*30 mL* Refills:*0* 19. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*30 ml* Refills:*1* 20. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Old [**Hospital **] Hospice Discharge Diagnosis: # Cavitary MRSA Pneumonia # Empyema # Bronchopleural fistula # Pneumothorax # Metastatic renal cell carcinoma # h/o bilateral DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 36653**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with increased pain in your right chest and abdomen. You were found to have a severe necrotizing pneumonia with a connection between the space around your lung and one of your airways. This caused a pneumothorax, which is a buildup of air in the space around the lung. A chest tube was placed to treat the pneumothorax. Additionally, you were found to have a collection of pus surrounding your right lung. We treated you with antibiotics and helped to control your chest pain so you could cough more to clear the infection. The thoracic surgery team thought that there was not much more we could do to treat your lung problems, as your lungs are too weak to tolerate a surgery and intubation. You did not want to be intubated anyway. Given your poor lung condition and metastatic cancer, you, your family, and our medical team all agreed that it would be in your best interest to transition to hospice care with making comfort a top priority. You will go to hospice with pain medication, and will no longer be on antibiotics or have a chest tube in place. Please note the following changes have been made to your medications: - Please START lorazepam 1mg Q8H prn for nausea or anxiety - Please START benzonatate 100mg TID prn for cough - Please START benzonatate 100mg QHS prn for pain - Please START hydromorphone in 0.9 % NS 30 mg/30 mL (1 mg/mL) Pt Controlled Analgesic and CADD pump for pain control - Please START Oxyfast 1-20 mg Q1H as needed for pain or respiratory distress Followup Instructions: Department: BMT/ONCOLOGY UNIT When: MONDAY [**2127-9-15**] at 12:30 PM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage ***Please call the office to inform them if you will no longer be able to make this appointment.*** [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2127-9-11**]

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icd9cm

[ [ [] ] ]

[ "34.09", "99.15", "38.97", "33.24" ]

icd9pcs

[ [ [] ] ]

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62,782

128,331

41662

Discharge summary

report

Admission Date: [**2158-7-25**] Discharge Date: [**2158-8-3**] Date of Birth: [**2110-12-18**] Sex: M Service: SURGERY Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 668**] Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: laparoscopic cholecystectomy History of Present Illness: 47M with long standing history of alcholism presented to [**Hospital 8641**] hospital with 3-4 days history of continuous RUQ pain. Patient states this pain has been a long [**Last Name **] problem for several years and comes after eating or drinking too much. The pain typically is dull and resolves after several hours, sometimes days. He presented to the hospital last evening because the pain was constant, sharper and was associated with cramping. Patient also reports some mild nausea but denies vomiting, change in stool, melena, hematocchezia, fevers, chills, weight loss or fatigue. Past Medical History: PMH: Anxiety, depression, alcholism, chronic back pain PSH: Left inguinal hernia repair 20 years ago Social History: On disability. 1 case of beer weekly, 1.5 PPD smoking, Occ MJ distant cocaine. Tattoos obtained from family member. Family History: FH: Noncontributory Physical Exam: ADMISSION EXAM VS: 97.4 127/97 96 20 GENERAL: Extremely tan male in NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple HEART: Irregularly irregular, normal S1 S2 LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft, no masses noted. TTP in RUQ, [**Doctor Last Name 515**] sign is present EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact. Pertinent Results: IMAGING: ECG: ([**7-24**]) Sinus tachycardia. ECG ([**7-25**]): Atrial fibrillation. ECG ([**7-26**]): Sinus rhythm. Poor R wave progression. Non-specific diffuse low amplitude T waves with T wave inversions in leads V1-V2. Low QRS voltage in the limb leads. Compared to the previous tracing of [**2158-7-25**] atrial fibrillation has been replaced by sinus rhythm. RUQ ULTRASOUND WITH DOPPLERS: 1. Cholelithiasis with gallbladder distention. If there is persistent clinical concern for acute cholecystitis, HIDA scan could be performed. 2. Increased echogenicity of the liver compatible with diffuse fatty infiltration. Please note that more advanced forms of liver disease such as cirrhosis or fibrosis cannot be excluded. 3. Reversal of flow in the portal vein, splenomegaly and multiple splenic varices. 4. Right-sided pleural effusion. HIDA SCAN 1. No evidence of acute cholecystitis. 2. Delayed tracer clearance secondary to hepatic dysfunction. CT ABDOMEN WITH CONTRAST IMPRESSION: 1. Portal vein patency cannot be assessed without a technically adequate portal venous phase image. The patient can be rescanned using bolus tracking technique if clinical concern for portal vein thrombus persists. 2. Portal adenopathy, splenic vein tortuosity, and anasarca consistent with liver cirrhosis. 3. Distended gallbladder with pericholecystic fluid, most likely secondary to third spacing and liver dysfunction rather than cholecystitis. 4. Age indeterminant compression fracture of T11. ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed due to severe hypokinesis of the distal two-thirds of the left ventricle (LVEF= 30-35 %). There is no ventricular septal defect. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. An eccentric, posteriorly directed jet of mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal LV cavity size with severe hypokinesis of the distal [**1-26**] of the ventricle. Dilated and hypokinetic right ventricle. Mild, posteriorly directed, mitral regurgitation, likely due to leaflet tethering. [**2158-8-2**] CXR: As compared to the previous radiograph, the monitoring and support devices, including the Swan-Ganz catheter, are unchanged. Moderate cardiomegaly with bilateral pleural effusions and signs of moderate to severe pulmonary edema. The changes are stable since the previous examination. No evidence of pneumothorax. Stable appearance of the mediastinal and hilar contours. [**2158-8-3**] Echo: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. The right atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %). The right ventricular cavity is mildly dilated with severe global free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque t. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-25**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: The patient was admitted to the hospital to the Medical Service with abdominal pain and a distended and large gallbladder. He underwent a number of imaging studies that demonstrated a distended gallbladder with stones. He also underwent a HIDA scan that did not demonstrate any evidence of cystic duct obstruction. Additionally he underwent additional medical workup which revealed Hep C, cirrhosis with ascites, as well as poor cardiac function with an EF 30-35%. He was watched for several days, but over the course of the weekend of [**2158-7-30**], he developed an increase in abdominal pain despite antibiotics. At that point we elected to take him to the operating room for laparoscopic cholecystectomy. Postoperatively the patient was unable to extubate and was admitted to the ICU. He was oliguric postoperatively and extubated uneventfully. He was conservatively resuscitated with IVF on POD 1 but continued to be oliguric. Echo was performed which showed worsening biventricular heart failure with EF estimated between 15-35% and associted TR. A swan ganz catheter was floated for better hemodynamic monitoring. Over the course of the next days he had had increasing right heart failure, poor oxygenation requiring reintubation, atrial fibrillation requiring chemical and electrical cardioversion as well as volume overload requiring CVVH. He remained hypotensive throughout his sicu course and he had increasing pressor support. There was suspicion for pulmonary embolus but the patient was never stable enough to go to the CT scanner. On [**2158-8-3**] he was on maximal pressor support. A family meeting was held and the decision was made to make the patient comfort measures only. He expired shortly thereafter at 18:10 on [**2158-8-3**]. Medications on Admission: None Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary diagnosis: Chronic colelithiasis Cirrhosis Congestive heart failure CP arrest Secondary diagnosis: alcohol abuse Discharge Condition: none Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "38.91", "51.23", "89.64", "96.71", "96.04", "38.95", "39.95", "38.93", "50.11" ]

icd9pcs

[ [ [] ] ]

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5251+5252+55656

Discharge summary

report+report+addendum

Admission Date: [**2117-2-27**] Discharge Date: [**2117-3-8**] Date of Birth: [**2074-11-24**] Sex: M Service: Surgery, Purple Team CHIEF COMPLAINT: Abdominal pain, nausea, and vomiting. HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old male with a history of alcoholic cirrhosis, perforated duodenal ulcer, status post ventral hernia repair, still drinking despite cirrhosis with ascites and transjugular intrahepatic portosystemic shunt procedure with revision. The patient was seen at [**Hospital3 3583**] with abdominal pain and dark emesis. Last bowel movement was approximately three days ago. No flatus since yesterday. Abdominal pain is constant, epigastric, in right upper quadrant areas. The patient was transferred to the [**Hospital1 190**]. A CT scan revealed a small-bowel obstruction. The patient underwent a exploratory laparotomy, lysis of adhesions, stricturoplasty of distal jejunum, and ventral hernia repair. Estimated blood loss was 300 cc with urine output of 200 cc. The patient received 3 liters of intravenous fluids in the operating room, 2 units of fresh frozen plasma. PAST MEDICAL HISTORY: 1. Alcoholic cirrhosis. 2. Urethral strictures. 3. Upper gastrointestinal bleed. 4. Withdrawal seizures from alcohol. 5. History of pancreatitis five years ago. 6. Status post three transjugular intrahepatic portosystemic shunt procedures. 7. Alcohol abuse leading to cirrhosis and portal hypertension, followed by Dr. [**Last Name (STitle) **]. 8. Duodenal perforation in [**2113**], oversewn by Dr. [**Last Name (STitle) 9035**]. 9. Incisional hernia, status post repair in [**2114-10-1**], no mesh placed secondary to seizure intraoperatively. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Lasix 20 mg p.o. t.i.d., folate, the patient self-discontinued Aldactone. SOCIAL HISTORY: No tobacco use. Alcohol abuse, currently treated, four beers per day. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count of 8.8, hematocrit of 36.5, platelets of 101. Sodium of 141, potassium of 4.3, chloride of 103, bicarbonate of 27, blood urea nitrogen of 12, creatinine of 0.6, glucose of 8.1. Coagulations revealed PT of 16.4, PTT of 33.4, and INR of 1.9. ALT of 22, AST of 61, alkaline phosphatase of 132, total bilirubin of 2.6, albumin of 3.4, amylase of 98, lipase of 36. RADIOLOGY/IMAGING: CT scan at [**Hospital1 46**] revealed ascites, shrunken liver, ventral hernia, and some stranding around it. CT done at [**Hospital1 **] showed (1) numerous distended loops of small bowel with possible transition point within the right upper quadrant; findings consistent with a small-bowel obstruction; (2) cirrhotic liver, status post transjugular intrahepatic portosystemic shunt with moderate ascites; (3) ventral hernia containing fat and a portion of a loop of bowel; (4) cholelithiasis; (5) colonic diverticula without evidence of diverticulitis. PHYSICAL EXAMINATION ON PRESENTATION: Vitals upon presentation with pulse of 82, blood pressure of 124/80. In general, a well-built male in mild distress. Lungs were clear to auscultation bilaterally. Cardiovascular had a normal rate and rhythm, systolic murmur. The patient has a history of murmur. Abdomen was mildly distended, midline scar, generalized tenderness. A few bowel sounds, NG in place. Extremities were warm. ASSESSMENT AND PLAN: So, thus, a 42-year-old with a history of alcoholic cirrhosis and ventral hernia, now with small-bowel obstruction. The patient will be given analgesia as required, n.p.o. with a nasogastric tube in place to low wall suction, urine output, strict ins-and-outs, intravenous hydration, electrolyte repletion. 1. INFECTIOUS DISEASE: The patient was started on ampicillin, ceftriaxone, and Flagyl. 2. HEMATOLOGY: The patient was given 2 units of fresh frozen plasma with vitamin K times one to correct coagulopathy. Thus, the patient was taken to the operating room on [**2117-2-27**], in the evening. For details of the surgical procedure please see dictated Operative Note. HOSPITAL COURSE: Postoperatively, the patient was admitted to the Surgical Intensive Care Unit for observation. At that point in time: 1. NEUROLOGY: His pain was controlled with morphine, otherwise stable. 2. CARDIOVASCULAR: The patient was started on Lopressor. 3. RESPIRATORY: Stable. 4. GASTROINTESTINAL: N.p.o. with a nasogastric tube, and Protonix was started for prophylaxis. 5. GENITOURINARY: The patient had good urine output. The patient's antibiotic was switched to Kefzol and Flagyl. On postoperative day, the patient was deemed stable enough for the floor and was transferred to the floor from the Intensive Care Unit. At that point in time, the patient had a triple lumen right internal jugular, and no A-line, and [**Location (un) 1661**]-[**Location (un) 1662**], and a Foley. 1. NEUROLOGY: The patient was placed on a CIWA scale and started being treated with Ativan q.4h. for delirium tremens prophylaxis during hospital course. The first three to five days postoperatively the patient required Ativan beyond the CIWA scale. At times, the patient was agitated and needed to be restrained and had one-to-one sitters the first four to five days postoperatively. The patient improved neurologically becoming more alert and oriented. The patient was continued on a CIWA scale during hospital course, and Ativan was slowly weaned to 0.5 mg q.d. 2. PAIN: Pain wise, the patient was originally on morphine, but was then, when tolerating p.o., weaned to Dilaudid 2 mg to 4 mg p.o. q.4-6h. which seemed to control the patient's postoperative pain. 3. GASTROINTESTINAL: History of [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**] Dictated By:[**Last Name (NamePattern1) 6763**] MEDQUIST36 D: [**2117-3-8**] 10:42 T: [**2117-3-9**] 08:22 JOB#: [**Job Number 21467**] Admission Date: [**2117-2-27**] Discharge Date: [**2117-3-8**] Date of Birth: [**2074-11-24**] Sex: M Service: Surgery, Purple Team HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old male with alcohol cirrhosis, history of perforated duodenal ulcer, ventral hernia repair, continues drinking despite cirrhosis with ascites and transjugular intrahepatic portosystemic shunt procedure with revision. The patient has noted chronic abdominal pain which worsened over the last four days. The patient was seen at [**Hospital3 6265**] and then transferred to [**Hospital1 **]. The patient has had pain and dark emesis which worsened four days ago. The patient was seen at [**Hospital3 3583**] and then discharged. The patient's pain and dark emesis, the patient had pain continued and began having dark emesis which began on Friday. The patient took ambulance back to [**Hospital3 6265**] and was then transferred to [**Hospital1 **]. The patient's last bowel movement was approximately three days ago with no flatus yesterday. Abdominal pain is constant in the epigastric and right upper quadrant areas. PAST MEDICAL HISTORY: 1. Stab wound to the abdomen at age 16, status post exploratory laparotomy. 2. Two subsequent ventral hernia repairs. 3. Duodenal perforation of ulcer in [**2113**], oversewn by Dr. [**Last Name (STitle) 9035**]. 4. Incisional hernia, status post three repairs in [**2114-10-1**], no mesh placed secondary to seizure intraoperatively. 5. Alcohol abuse leading to cirrhosis and portal hypertension. 6. Status post three transjugular intrahepatic portosystemic shunt procedures; last in [**2112-8-31**] for urethral strictures. 7. Pancreatitis five years ago. 8. Encephalopathy with a variceal bleed in the past. MEDICATIONS ON ADMISSION: Lasix 20 mg p.o. t.i.d., folic acid, and Aldactone (self-discontinued years ago). ALLERGIES: No known drug allergies. SOCIAL HISTORY: Alcohol abuse, currently three to four beers per day. No tobacco or drugs. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories upon presentation with a white blood cell count of 8.8, hematocrit of 36.5, platelets of 101. Sodium of 141, potassium of 4.3, chloride of 103, bicarbonate of 27, blood urea nitrogen of 12, creatinine of 0.6, glucose of 81. Coagulations with PT of 16.4, PTT of 33.4, INR of 1.9. ALT of 22, AST of 61, alkaline phosphatase of 132, total bilirubin of 2.6, albumin of 3.4, amylase of 96, lipase of 36. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination upon presentation with temperature maximum of 100, temperature current of 99.8, pulse of 82, respirations of 14, blood pressure of 160/66, 99% on room air. In general, sleepy but arousable and coherent. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive. Nasogastric in left nostril. Chest revealed decreased breath sounds at the bases. Cardiovascular with a normal rate and rhythm. Abdomen was distended, positive tympanic sounds, ventral defect, reducible, right-sided tenderness to palpation. No guarding. No calf tenderness. RADIOLOGY/IMAGING: A CT of the abdomen and pelvis done at [**Hospital3 3583**] showed small bowel dilatation, gas in the right colon, left colon decompressed. No intravenous contrast given. No obstruction seen. Ventral hernia. CT was repeated at [**Hospital1 **] which showed (1) numerous distended loops of bowel with possible transition point within the right upper quadrant; findings consistent with small-bowel obstruction; (2) cirrhotic liver, status post transjugular intrahepatic portosystemic shunt with moderate ascites; (3) ventral hernia containing fat and a portion of loop of bowel; (4) cholelithiasis; (5) colonic diverticula without any evidence of diverticulitis. HOSPITAL COURSE: At that point in time, the patient is a 42-year-old with a small-bowel obstruction, transition at hernia, with evidence of small-bowel obstruction on repeat CT scan. The risks and benefits were discussed. The patient was taken to the operating room for an exploratory laparotomy, lysis of adhesions, stricturoplasty of distal jejunum, and ventral hernia repair with an estimated blood loss of 300 cc, urine output of 200 cc. The patient received 3 liters of intravenous fluids, 2 units of fresh frozen plasma. For details of procedure, please see Operative Note. The patient was then admitted to the Intensive Care Unit for further observation. During surgery a right internal jugular right arterial line was placed, and intraoperatively [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain was placed. The patient was stabilized and transferred to the floor from the Intensive Care Unit stable on postoperative day one. 1. NEUROLOGY: The patient was continued on a CIWA scale with Ativan as needed. For delirium tremens prophylaxis. The patient at first required q.4h. Ativan with supplemental Ativan above the CIWA scale; but during hospital course, the patient's CIWA scale improved, and the patient's Ativan requirement was weaned until postoperative day eight when the patient's Ativan requirement was weaned to 0.5 mg q.d. The patient became more coherent and less combative during hospital course and was able to answer questions, was alert and oriented times two. At first, the patient was on a Dilaudid patient-controlled analgesia but was then weaned after able to tolerate a regular diet to Dilaudid p.o. which controlled the patient's postoperative pain. 2. GASTROINTESTINAL: History of cirrhosis. Cirrhosis and alcohol abuse, status post transjugular intrahepatic portosystemic shunt procedure with revision. The patient with ascites. The patient was seen by the Liver Service on the floor and in the Intensive Care Unit. Once the patient was stable, the patient was restarted on Lasix 40 mg p.o. q.d. with Aldactone 100 mg q.d. Hepatology serologies were drawn which showed that he was hepatitis C antibody negative, hepatitis B surface antigen negative, hepatitis C surface antibody positive, and hepatitis B core antibody negative. The patient did have a reaccumulation of ascites postoperatively which was incidentally drained after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain was pulled. At least 400 cc, approximately, without rapid reaccumulation. Though the patient had mental status changes, they were most likely secondary to alcohol withdrawal; could also be due to baseline encephalopathy. Gastrointestinal at that point in time did not feel that anything else needed to be done necessarily unless an ultrasound. Doppler of the transjugular intrahepatic portosystemic shunt was done on [**2-28**] which showed that the transjugular intrahepatic portosystemic shunt was patent. [**Location (un) 1661**]-[**Location (un) 1662**] drain was pulled on postoperative day six and led to an ascitic leak which was controlled with one figure-of-eight stitch in place. The ascitic fluid that was seen was straw-colored and clear. The patient should be followed by the liver doctors and continued on a regimen of Lasix and Aldactone. 3. INFECTIOUS DISEASE: Postoperatively, the patient began spiking fevers daily. The patient received six doses of intravenous Flagyl and Kefzol in house and was started on ciprofloxacin on postoperative day three for spontaneous bacterial peritonitis prophylaxis. The patient's white count on postoperative day three was 10.7, which had increased from 8.8, on postoperative day four was 9.2, and on postoperative day five was 8.7. Urine culture upon presentation was negative. Blood culture done on [**2-27**] was negative. Blood culture done subsequently still pending. Transjugular intrahepatic portosystemic shunt culture showed line infection with greater than 15 colonies of coagulase-negative Staphylococcus with sensitivities pending. A chest x-ray was performed on postoperative day six which showed bibasilar atelectasis and small bilateral pleural effusions, but no evidence of pneumonia. The patient had liver function tests drawn at that point in time to see whether there was any evidence of cholecystitis. The patient had an ALT of 21, an AST of 51, and LD of 250, an alkaline phosphatase of 83, and amylase of 5, a total bilirubin of 2.1 (which was stable), lipase of 150 (which was slightly increased), but no evidence of acute cholecystitis. The patient was discontinued on intravenous ciprofloxacin and switched over to p.o. ciprofloxacin when the patient was tolerating p.o. The patient actually stopped spiking temperatures on postoperative day seven (on [**2117-3-7**]) and remained afebrile afterwards, but was continued on ciprofloxacin with no active evidence of spontaneous bacterial peritonitis, pneumonia, or sepsis. 4. HEMATOLOGY: The patient presented with coagulopathy with an INR of 1.9; given 2 units of fresh frozen plasma. The patient maintained adequate urine output postoperatively. On postoperative day three, the patient's hematocrit was 24.4 but was monitored closely and remained stable; and on postoperative day four was 25.9, on postoperative day five was 28.5. The patient's platelet count increased from 104 to 151. Postoperatively, had no evidence of active bleeding and maintained good urine output. The patient required no blood products postoperatively. 5. CARDIOVASCULAR: The patient was stable. 6. PULMONARY: The patient's pulmonary status was stable. The patient remained having decreased breath sounds bilaterally during hospital course and had two x-rays; one originally which showed a patchy density in the left base, consistent with atelectasis versus pneumonia on [**2-28**], with a repeat chest x-ray on postoperative day six which showed decreased lung volumes, consistent with atelectasis and small bilateral pleural effusions. The patient's oxygen requirement was weaned for saturations greater than 95%. On postoperative day eight, the patient still required 3 liters of oxygen with 89% on room air, thought to be secondary to decreased mobility; and, thus, aggressive pulmonary toilet, chest physical therapy was initiated. 7. FLUIDS/ELECTROLYTES/NUTRITION: The patient was originally on hydration fluids and then switched to maintenance intravenous. Electrolytes were replaced as needed. The patient was originally n.p.o. and then started on total parenteral nutrition on postoperative day four; but, while the patient was on total parenteral nutrition, when the patient became more alert and oriented, the patient was started on clears without difficulty and advanced to a regular diet on postoperative day six. When the patient was taking in adequate p.o. and had adequate urine output, the patient's total parenteral nutrition was discontinued. He tolerated a regular diet without any difficulty. 8. PHYSICAL THERAPY: Physical Therapy was consulted for evaluation of home safety seeing as how the patient had been slightly unsteady on his feet originally, but was able to walk the halls and walk up stairs without difficulty or assistance. CONDITION AT DISCHARGE: Thus, discharge condition was stable. DISCHARGE DIAGNOSES: 1. Status post exploratory laparotomy, jejunal stricturoplasty, ventral hernia repair, with small-bowel obstruction. 2. Alcoholic cirrhosis. 3. Alcohol abuse. DISCHARGE STATUS: The patient was discharged to home without services. DISCHARGE FOLLOWUP: To follow up with Dr. [**Last Name (STitle) **] in a couple of weeks. MEDICATIONS ON DISCHARGE: The patient was to continue on Dilaudid for pain, Lasix and Aldactone for ascites, and ciprofloxacin for a course that will be stated in a future Addendum to this dictation when final plans are actually made for Mr. [**Known lastname **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**] Dictated By:[**Last Name (NamePattern1) 6763**] MEDQUIST36 D: [**2117-3-8**] 11:11 T: [**2117-3-9**] 08:55 JOB#: [**Job Number 21467**] Name: [**Known lastname 3572**], [**Known firstname **] P Unit No: [**Numeric Identifier 3573**] Admission Date: [**2117-2-27**] Discharge Date: [**2117-3-9**] Date of Birth: [**2074-11-24**] Sex: M Service: Purple Surgery ADDENDUM: Please see previous discharge summary for details of hospital stay. On postoperative days 8 and 9, Cipro days 6 and 7, patient continued to remain stable status post exploratory laparotomy, jejunal stricturoplasty, ventral hernia repair with history of alcohol abuse and cirrhosis. HOSPITAL COURSE: ID: The patient was afebrile during this period. The patient continued on Cipro po for SBP prophylaxis, 14 days total per liver service. A white cell count was repeated on postoperative day #8. It was 11.8 and on postoperative day #9 it had decreased to 9.7. Patient's hematocrit was stable at 27.9. Patient's platelets were 155,000. GI: Cirrhosis and ascites. The patient was continued on Aldactone 100 mg q day and Lasix 40 mg day and will continue on Lactulose 30 cc tid. The patient will follow-up with the liver service and will call for an appointment, number was given, to follow-up with Dr. [**Last Name (STitle) 3574**], Dr. [**Last Name (STitle) 3575**] within the next 2-3 weeks. Fluids, Electrolytes & Nutrition: The patient remained on a regular diet and continued on Thiamine and Folate q day. Neuro: Patient was taking Dilaudid po prn and Ativan .5 mg q day. The patient is discharged on Dilaudid and Ativan. DISCHARGE DIAGNOSIS: 1. Small bowel obstruction. 2. Ventral hernia. 3. Status post exploratory laparotomy, jejunal stricturoplasty, ventral hernia repair, small bowel obstruction. 4. Alcohol abuse. 5. Cirrhosis. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: The patient is discharged to home without services. On postoperative day #9 social work came to see patient and patient's fiance to discuss alcohol rehabilitation programs. At that point in time patient was sleeping and patient's fiance stated that she would be able to keep him from drinking and that patient would refuse going for rehabilitation services. This is the extent of the conversation and social work left a detailed note in the chart. Patient is to follow-up with liver service, number given, in [**1-3**] weeks. Patient is to follow-up with the general surgery outpatient clinic as well, number was given, in [**2-1**] weeks. DISCHARGE MEDICATIONS: The patient was discharged to home on Dilaudid 2 mg, Protonix 40 mg one po q day, Ativan .5 mg one po q day, only 20 Ativan were given, Lasix 40 mg one po q day, Aldactone 100 mg one po q day, Thiamine 100 mg one po q day, Folic Acid 1 mg one po q day, Cipro 500 mg one po q day times 7 days, Lactulose 30 ml po tid. [**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern4) 2749**], M.D. [**MD Number(1) 2750**] Dictated By:[**Last Name (NamePattern1) 3576**] MEDQUIST36 D: [**2117-3-9**] 14:36 T: [**2117-3-10**] 13:19 JOB#: [**Job Number 3577**] & [**Numeric Identifier 3578**]

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Discharge summary

report

Admission Date: [**2167-8-18**] Discharge Date: [**2167-8-26**] Service: MEDICINE Allergies: Codeine / Digoxin / amiodarone / Bactrim / lisinopril Attending:[**First Name3 (LF) 2901**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]yoF with PMH DM II, HL, CAD s/p LAD STEMI in [**2157**], NSTEMI [**6-/2167**] with BMS to LAD presents with progressive dyspnea and orthopnea and is admitted to the CCU for hypoxia. . According to the patient's daughter, the patient developed progressive dyspnea three days ago. The symptoms progressed and last night she developed orthopena and paroxsymal nocturnal dyspnea. She was agitated and confused overnight and this morning felt presyncopal while trying to get out of bed. . She presented to the [**Hospital1 18**] ED where initial vitals were T:97.6 P:90 BP:104/66 RR:14 sats dropped to 85 on NC (flow not recorded), up to 99% on NRB. She complained of dyspnea, denied chest pain. Labs were remarkable for WBC: 8.1 Hct:33.6, Cr 1.0, Trop-T: 0.09 Lactate:2.6 INR: 4.7. CXR showed bilateral effusions and pulmonary edema. She was given lasix 40mg IV, and started on BIPAP, complained of nausea and was given zofran. She became hypotensive to SBP 77 asleep, came to high 80's while awake, she was started peripheral dopamine and admitted to the CCU. Vitals on transfer BP:98/67 P:111 RR:26 SaO2 100% on BIPAP . On arrival to the CCU, vitals were BP:107/64 P:101 RR: 24 SaO2 95% on 5LNC with shovel mask. She was somnolent and moderately confused, occasionally pulling at lines. She reported that her breathing was comfortable, denied neck/back/chest pain, denied presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: N/A -PERCUTANEOUS CORONARY INTERVENTIONS: s/p STEMI in [**2157**] w/ stent to LAD - s/p NSTEMI [**2167-7-6**] treated w/ BMS to prox and mid LAD -PACING/ICD: N/A 3. OTHER PAST MEDICAL HISTORY: -Osteoporosis -CVA - small vessel stroke in R MCA territory [**7-23**] (no residual effects) -Osteoarthritis (knees) -b/l rotator cuff injuries -Status post hysterectomy 20 years ago -L posterior tibialis injury (L leg brace) -R bimalleus fracture (external cast) -Aspiration PNA in [**4-/2166**], treated with CTX, azithromycin, clindamycin -s/p cataracts surgery Social History: Employment: Had worked as a billing administrator for Volkswagon and other companies around the [**Location (un) 86**] area for 35 years. Tobacco: Never smoker. Alcohol: Has a drink once in a while, less than once a week. Illicits: Denies heroin, cocaine, marijuana. Family History: Son with triple bypass. Parents died of "old age" Physical Exam: ADMISSION EXAM BP:107/64 P:101 RR: 24 SaO2 95% on 5LNC with shovel mask GENERAL: Elderly female slumped forward in bed, somnolent but arrousable, oriented to hospital. HEENT: Pale conjunctiva, mucous membs moist, NECK: Supple with JVP of 10 cm in 45 degree angle. CARDIAC: Tachycardic, S1/S2 regular rate, [**3-22**] holosystolic murmur at the apex. LUNGS: Bilateral inspiratory rales at mid thorax, decreased breath sounds R>L to mid thorax, dullness to percussion over the same area ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Peripheral edema to mid calf BL with right sided chronic venous stasis changes. PULSES: Right: trace DP and PT pulses, Left: trace DP and PT pulses DISCHARGE EXAM: VS: Tm 97.3 BP 90-102/50-61 HR 70-110 RR 18-20 SaO2 98% RA GENERAL: Elderly female in NAD HEENT: Pale conjunctiva, mucous membs moist, NECK: Supple with JVD 2 cm above clavicle CARDIAC: Irregularly irregular, S1/S2 regular rate, [**3-22**] holosystolic murmur at the apex LUNGS: CTAB with slight expiratory wheezes, no increased WOB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Right upper extremity with large hematoma and diffuse ecchymosis [**3-18**] failed PICC attempt. Resolving. PULSES: 1+ pulses bilaterally, uses bilat braces for standing. Pertinent Results: ADMISSION LABS [**2167-8-18**] 09:30AM BLOOD WBC-8.1 RBC-3.30* Hgb-11.0* Hct-33.6* MCV-102* MCH-33.2* MCHC-32.6 RDW-17.6* Plt Ct-185 [**2167-8-18**] 09:30AM BLOOD Neuts-90.8* Lymphs-5.4* Monos-2.9 Eos-0.1 Baso-0.7 [**2167-8-18**] 10:30AM BLOOD PT-45.2* PTT-30.2 INR(PT)-4.7* [**2167-8-18**] 10:30AM BLOOD Glucose-215* UreaN-22* Creat-1.0 Na-142 K-4.8 Cl-107 HCO3-23 AnGap-17 [**2167-8-19**] 02:49AM BLOOD Calcium-9.4 Phos-4.7*# Mg-1.8 [**2167-8-18**] 10:30AM BLOOD TSH-2.8 [**2167-8-18**] 01:48PM BLOOD Type-ART pO2-63 pCO2-41 pH-7.37 Base XS--1 [**2167-8-18**] 09:37AM BLOOD Glucose-227* Lactate-3.5* Na-136 K-7.1* Cl-108 calHCO3-19* CARDIAC ENZYMES [**2167-8-18**] 10:30AM BLOOD CK(CPK)-44 [**2167-8-18**] 06:36PM BLOOD CK(CPK)-46 [**2167-8-19**] 02:49AM BLOOD CK(CPK)-38 [**2167-8-19**] 08:58PM BLOOD CK(CPK)-76 [**2167-8-18**] 09:30AM BLOOD cTropnT-0.09* [**2167-8-18**] 10:30AM BLOOD CK-MB-8 [**2167-8-18**] 06:36PM BLOOD CK-MB-9 cTropnT-0.27* [**2167-8-19**] 02:49AM BLOOD CK-MB-8 cTropnT-0.28* [**2167-8-19**] 08:58PM BLOOD CK-MB-5 cTropnT-0.24* MICROBIOLOGY: - Urine culture [**2167-8-18**]: 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 NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S - Blood culture [**2167-8-18**]: No growth - Blood culture [**2167-8-18**]: No growth - Pleural fluid culture (left side) [**2167-8-22**]: Gram stain 2+ PMNs, no organisms. Culture no growth for bacteria, anaerobes, fungus. AFB smear negative. AFB culture PENDING AT THE TIME OF DISCHARGE. - Pleural fluid culture (right side) [**2167-8-22**]: Gram stain 2+ PMNs, no organisms. Culture no growth for bacteria, anaerobes, fungus. AFB smear negative. AFB culture PENDING AT THE TIME OF DISCHARGE. - Urine culture [**2167-8-25**]: PENDING AT THE TIME OF DISCHARGE IMAGING/STUDIES CXR ([**8-18**]) IMPRESSION: Increased bilateral moderate pleural effusions with compressive lower lobe atelectasis, with probable mild CHF. CXR ([**8-22**]) n the interim, there has been placement of bibasilar pigtail catheters with markedly reduction of bilateral pleural effusions. Small left greater than right pleural effusions remain. There is persistent left lower lobe retrocardiac opacity, most likely due to left lower lobe collapse. There is a discoid atelectasis in the right lower lobe. There is no evident pneumothorax. CXR ([**8-23**]) There is mild-to-moderate cardiomegaly, unchanged compared with [**2167-8-22**]. There is upper zone redistribution and diffuse vascular blurring, consistent with CHF, unchanged allowing for technique. There is increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation, probably slightly improved. The left hemidiaphragm is elevated, with air in the fundus immediately below it. There is patchy opacity at the right base, likely reflecting atelectasis. There is minimal blunting of both costophrenic angles. However, the bilateral effusions seen on [**2167-8-22**] exam have diminished in size. Bilateral chest tubes again noted, slightly different in configuration, particularly on the right. No pneumothorax is detected. CXR [**2167-8-24**] No significant change in upper zone pulmonary vascular redistribution consistent with pulmonary vascular congestion, cardiomegaly, and small bilateral pleural effusions. Discharge Labs: [**2167-8-26**] 06:55AM BLOOD WBC-5.7 RBC-3.11* Hgb-10.1* Hct-31.0* MCV-100* MCH-32.6* MCHC-32.8 RDW-16.6* Plt Ct-186 [**2167-8-26**] 06:55AM BLOOD Glucose-150* UreaN-26* Creat-0.8 Na-140 K-4.3 Cl-98 HCO3-33* AnGap-13 [**2167-8-26**] 06:55AM BLOOD Mg-2.1 [**2167-8-25**] 10:48PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2167-8-25**] 10:48PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2167-8-25**] 10:48PM URINE RBC-10* WBC-154* Bacteri-NONE Yeast-MANY Epi-10 TransE-5 [**2167-8-25**] 10:48PM URINE CastHy-40* [**2167-8-25**] 10:48PM URINE Mucous-RARE Brief Hospital Course: Admission weight 62kg Dry weight 56kg Primary Reason for Admission: [**Age over 90 **] y/o woman with PMH DM II, HL, CAD s/p LAD STEMI in [**2157**], NSTEMI [**6-/2167**] with BMS to LAD presents with progressive dyspnea and orthopnea and is admitted to the CCU for hypoxia secondary to CHF exacerbation. ACTIVE ISSUES: #Acute on chronic CHF and bilateral pleural effusions: Pt was admitted in [**6-/2167**] and ECHO at that time showed LVEF Of 30-35%. CXR on admission showed pleural effusions (singificantly increased in size from prior imaging in [**Month (only) 116**]) and pulmonary edema consistent with CHF exacerbation. Physical exam also consistent with volume overload with severe lower extremity peripheral edema. Repeat echocardiogram showed regional LV wall motion abnormality with EF of ~25%. She was hypoxic on admission to the point of requring NRB oxygen, though never intubated per code status (DNR/DNI). She was intitially treated with a lasix drip with improvement in her oxygen requirement. Nitrates and morphine were held in the setting of hypotension. Despite diuresis, pleural effusions persisted. Interventional pulmonology was consulted and bilateral pigtail catheters were insterted and drained a total of 1.5L of pleural fluid which was culture negative (AFB culture only pending at the time of discharge). Upon discharge patient was euvolemic on exam, symptomatically improved, with oxygen saturations on room in in the mid 90s. Dischrage CXR showed resolution of pulmonary edema with small residual effusions, significantly improved since admission. She will be discharged on torsemide 10 mg PO daily for volume control, and has been educated in low-sodium diet by nutrition consult team. She is not on [**Last Name (un) **] given borderline-low blood pressures, but current plan is for addition of [**Last Name (un) **] once stable on outpatient follow up. She may also benefit from spironolactone or low-dose digoxin if chronically symptomatic. #Hypotension: Pt has baseline SBPs ranging in low 100s. In [**Name (NI) **], pt hypotensive to 77 and started on dopamine drip. Hypotension thought to be secondaruy to worsening LV dysfunction with cardiogenic shock. Given tachycardia and episodes of Afib dopamine was changed to vasopressin. On day 3, pt successfully weaned off pressors and SBPs remained stable throughout the remainder of admission. # Atrial fibrillation: Patient with history of atrial fibrillation and was previously anticoagulated with warfarin. However, given supratherapeutic INRs (see below) and hematoma with attempted PICC placement, she was felt to be a poor candidate for triple therapy. She was placed on subQ heparin during this stay, and aspirin dose was increased to 325 mg. Current plan is for anticoagulation with aspirin and Plavix alone to reduce risk of clot. During this admission, the patient was initially in sinus rhythm on telemetry but subsequently developed multiple episodes of atrial fibrillation with rate to 100s-110s. Her metoprolol was uptitrated as pressures would allow, and she was discharged on 200 mg metoprolol sucinate daily. Amiodarone was suggested to improve rhythm/rate control; however her daughter is concerned that this medication was responsible for a skin reaction during a prior admission and did not want her mother to receive this medication. In the future, amiodarone may be considered if there is poor rate control with current dose of metoprolol succinate as blood pressures may not tolerate further uptitration. # Somnolence: Upon admission pt was somnolent and reportedly confused. ABG shows pCO2 41 with pO2 63 suggesting that somnolence is related to hypoxia rather than hypercarbia. At baseline patient is oriented x3, she enjoys baseball and is able to name team members. Pt was pancultured to rule out sepsis as source. As hypoxia improved, somnolence resolved. She did have an episode of confusion in the evening of [**2167-8-25**] in the setting of low blood pressure to systolic of 90 (other vitals including temperature and O2 sat were stable). Her PM beta blocker was held, and U/A and culture were rechecked. Her symptoms self-resolved and were attributed to low blood pressure with possible component of sundowning. Upon discharge patient back to baseline, alert, oriented and interactive. # UTI: Pt had urine culture positive for pan-sensitive E. coli. She was started on 10 day course of cefpodoxime on [**2167-8-23**]. She had repeat U/A with urine culture checked on [**2167-8-25**], and this showed 154 WBC, +LE, -nitrites, -bacteria, +yeast. No changes were made to her medications. CULTURE FROM [**2167-8-25**] WAS PENDING AT THE TIME OF DISCHARGE. # Anticoagulation/hematoma: INR elevated on admission at 4.7 and her coumadin was held. The following day the INR was 7. Patient was treated with vitamin K for pigtail catheter placement. Pt developed hematoma in R. arm after attempted PICC line placement. Pressure dressings were applied. Heparin was stopped. HCTs remained stable. # CAD: Pt has hx of LAD STEMI in [**2157**] and NSTEMI [**2167-7-6**] with BMS to LAD. EKG on admision shows STD in V3-V6 which are likely related to LV strain in the setting of LVH and tachycardia. Cardiac enzymes peaked at CKMB 8 and troponin 0.28. Pt was changed from ASA 81 to 325 and continued on plavix, atorvastatin and metoprolol. CHRONIC ISSUES: . # Diabetes Mellitus: -She remained on insulin SS for the majority of her hosptial course, but home metformin and glipizide were restarted prior to discharge. . TRANSITIONAL ISSUES: - Pt will require follow up with PCP and Cardiology. She will be sent to rehab for a brief period, with plans to return home where she is overseen by her daughter, who is very involved. - Pleural fluid (left and right side) AFB cultures were pending at the time of discharge (AFB smear negative) - Urine culture from [**2167-8-25**] pending at the time of discharge (U/A from [**2167-8-25**] showed 154 WBC, +LE, -nitrites, -bacteria, +yeast) - For her systolic heart failure, she should be started on [**First Name8 (NamePattern2) **] [**Last Name (un) **] as an outpatient as blood pressures allow. She may also benefit from low-dose digoxin if she experiences symptoms. Her torsemide may require uptitration to maintain euvolemia. - For her atrial fibrillation, her warfarin has been held given the risk of bleeding with concurrent aspirin and clopidogrel. Her metoprolol succinate has been uptitrated to 200 mg PO daily but may require further titration depending on blood pressure and rates while in atrial fibrillation. Amiodarone was briefly initiated but stopped based upon family's concern that this medication caused rash and malaise during a prior admission. It may be appropriate to re-consider use of this medication in the future if rate control proves difficult. Medications on Admission: metoprolol succinate ER 100 mg plavix 75 mg Daily metformin 500 mg Daily Atorvastatin 80 mg Daily glipizide 2.5 mg Daily Aspirin 325 mg Daily warfarin 2 mg MWF, 1mg TTSS Omega 3 Fish Oil -- Unknown Strength Discharge Medications: 1. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO once a day. 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 6. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 7. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime): hold for loose stools. 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. 12. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Omega 3 Fish Oil 684-1,200 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Elmhurst - [**Location (un) **] Discharge Diagnosis: Acute on Chronic Systolic Congestive heart failure Bilateral Pleural effusions Paroxsysmal Atrial fibrillation Urinary tract infection Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure caring for you at [**Hospital1 18**]. You had an acute exacerbation of your congestive heart failure and required bipap ventilation and furosemide intravenously to get rid of the extra fluid. You also had pleural effusions, a collection of fluid near the base of the lung. This was drained and has reaccumulated slightly. You will see the pulmonologist in a few weeks to assess the effusions again. In the meantime, we have changed the furosemide to torsemide to help keep the fluid from reaccumulating. Your atrial fibrillation has been intermittant and is very fast when it occurs. We have increased the metoprolol to prevent a fast heart rate and your warfarin has been discontinued because you are already on 2 other strong blood thinners. Dr. [**Last Name (STitle) **] feels that the risk of serious bleeding from 3 blood thinners is greater than the risk of a stroke at this time. Please weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. Increase metoprolol to slow your heart rate 2. Decrease atorvastatin to lower your cholesterol 3. Discontinue warfarin, you will get some protection from blood clots from the aspirin and plavix 4. Start senna and metamucil to prevent constipation 5. Complete course of cefpodoxime for UTI (5 more days) Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2167-9-1**] at 2:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: TUESDAY [**2167-9-15**] at 10:45am AM For: Walk-in Chest X-ray prior to appt Building: [**Location (un) 591**], [**Location (un) 470**] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2167-9-15**] at 11:15 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2167-8-26**]

[ "041.4", "414.01", "272.4", "E879.8", "427.31", "715.96", "785.51", "V58.61", "V45.82", "733.00", "250.00", "599.0", "412", "998.12", "790.92", "V12.54", "428.23", "511.9", "V49.86", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "34.91" ]

icd9pcs

[ [ [] ] ]

16593, 16682

8339, 8646

281, 287

16885, 16885

4047, 7662

18489, 19429

2693, 2744

15430, 16570

16703, 16864

15199, 15407

17061, 18466

7679, 8316

2759, 3449

1825, 1994

3466, 4028

13894, 15173

222, 243

8661, 13695

315, 1717

16900, 17037

2025, 2392

13711, 13873

1739, 1805

2408, 2677

4,484

140,794

24099

Discharge summary

report

Admission Date: [**2199-7-29**] Discharge Date: [**2199-8-6**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2199-7-29**] - R femoral pseudoaneurysm repair [**2199-7-30**] - AVR(Pericardial) and ascending aorta replacement History of Present Illness: This 82-year-old patient with a history of shortness of breath was investigated and was found to have severe aortic regurgitation with dilated ascending aorta measuring about 4.2 cm with well-preserved sinotubular junction and a normal arch and descending aorta. The left ventricular function was well preserved and the coronary arteries were normal on angiogram. He was electively admitted for aortic valve replacement and ascending aortic aneurysm replacement. Past Medical History: [**Month/Day/Year **] [**Month/Day/Year **] Mitral Regurgitation Asthma Diabetes Colon CA Arthritis Social History: Retired electrical engineer. Never smoked. 1 glass of wine/day. Lives with wife. Family History: Father died of MI at age 70. Physical Exam: BP: 147/88 86 68" 175 GEN: WDWN in NAD HEENT: Unremarkable NECK: Supple, FROM, No JVD LUNGS: Clear HEART: RRR, Mild holosystolic murmur ABD: Benign EXT: 1+ LE edema, Multiple lipoma's on arms, 2+ pulses. NEURO: Nonfocal, A+Ox3 Pertinent Results: [**2199-7-29**] 08:45AM GLUCOSE-167* UREA N-39* CREAT-2.1* SODIUM-141 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15 [**2199-7-29**] 05:15PM PT-12.7 PTT-44.9* [**Month/Day/Year 263**](PT)-1.1 [**2199-7-29**] 09:47PM WBC-7.4 RBC-3.18* HGB-9.9*# HCT-27.4* MCV-86 MCH-31.0 MCHC-36.0* RDW-13.6 [**2199-8-5**] 09:25AM BLOOD Hct-37.6* [**2199-8-3**] 05:40AM BLOOD WBC-10.0 RBC-3.88* Hgb-11.5* Hct-33.7* MCV-87 MCH-29.6 MCHC-34.1 RDW-13.8 Plt Ct-149* [**2199-8-6**] 07:15AM BLOOD PT-23.5* PTT-27.5 [**Month/Day/Year 263**](PT)-2.3* [**2199-8-6**] 07:15AM BLOOD UreaN-68* Creat-2.3* K-4.1 [**2199-7-29**] Femoral Ultrasound Single 3.6 x 1.9 cm pseudoaneurysm lying anterior to the distal right external iliac artery. [**2199-7-31**] Renal Ultrasound 1. No evidence of hydronephrosis, solid renal mass, or renal calculi. 2. Simple cyst in the upper pole of the right kidney. 3. Limited vascular study demonstrates arterial and venous waveforms within both kidneys. Evaluation of resistive indices could not be accurately measured. If clinically indicated, the study could be repeated at a later time point. [**2199-7-30**] ECHO Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. A discrete ST-Junction is seen. The ascending aorta is moderately dilated, 4.1 cm proximally, and 3.7 cm more distally. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion Post-CPB: A prosthetic aortic valve is well-positioned and functioning. No leak, no AI. Minimal chordal [**Male First Name (un) **]. Trace - 1+ MR. [**Name13 (STitle) **] biventricular systolic function. Descending aorta intact. Other parameters as pre-bypass. [**2199-8-5**] CXR Resolving basilar atelectasis and persistent small pleural effusions. Stable postoperative widening of cardiac silhouette, likely due to pericardial effusion. [**Last Name (NamePattern4) 4125**]ospital Course: Mr. [**Known lastname 61260**] was admitted to the [**Hospital1 18**] on [**2199-7-29**] for elective surgical management of his aortic valve and ascending aorta disease. Prior to beginning his surgery, a right femoral bruit was noted. An ultrasound was performed which revealed a single 3.6 x 1.9 cm pseudoaneurysm lying anterior to the distal right external iliac artery. Given these findings, the vascular surgery service was consulted. A repair of his right femoral pseudoaneurysm was performed without complication. On [**2199-7-30**], Mr. [**Known lastname 61260**] was returned to the operating where he underwent an aortic valve replacement with a 25mm pericardial valve and an ascending aorta replacement with a 26mm gelweave graft. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He had a brief episode of atrial fibrillation for which amiodarone was started. By postoperative day one, Mr. [**Known lastname 61260**] was awake, neurologically intact and extubated. He did develop some confusion while taking narcotics which resolved when the narcotics were stopped. He had some mild sternal drainage for which vancomycin and levofloxacin were started. Over the next day, his drainage resolved. As Mr. [**Known lastname 61260**] continued to have paroxysmal atrial fibrillation, coumadin was started for anticoagulation. On postoperative day four, Mr. [**Known lastname 61260**] was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. The [**Last Name (un) **] diabetes service was consulted to assist with his blood sugar management. Glipizide was started with follow-up as an outpatient. Mr. [**Known lastname 61260**] continued to make steady progress and was discharged home on postoperative day seven. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care physician as an outpatient. Dr. [**First Name (STitle) **] will manage his coumadin dosing as an outpatient for a target [**First Name (STitle) 263**] of 2.0-2.5. Medications on Admission: Nifedipine 120mg QD Diovan 320mg QD Lipitor 20mg QD Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400 mg daily x 1 week, then 200 mg ongoing. Disp:*60 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for Diabetes. Disp:*30 Tablet(s)* Refills:*0* 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 2 days: Check [**First Name (STitle) 263**] [**8-8**] with results to Dr. . Disp:*60 Tablet(s)* Refills:*0* 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*0* 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*40 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: R femoral pseudoaneurysm AI Ascending aortic aneurysm MR [**First Name (Titles) 9195**] [**Last Name (Titles) **] asthma CRI (2.1) DM2 colon ca s/p colonoscopy skin ca OA Appy arthritis Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight [**Last Name (un) **] more than 2 pounds in one day or five in one week. No lifting more than 10 pounds or driving until follow up with surgeon. Shower, no baths, no lotions, creams or powders to incisions. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] 4 weeks Dr. [**First Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 263**]/Coumadin per Dr.[**First Name (STitle) **] Completed by:[**2199-8-6**]

[ "441.2", "442.3", "292.81", "V10.83", "250.00", "997.2", "V10.05", "427.31", "401.9", "997.1", "396.3", "272.4" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "38.45", "99.04", "89.60", "39.52", "99.07" ]

icd9pcs

[ [ [] ] ]

7712, 7761

287, 406

7991, 7999

1431, 3726

1138, 1168

6061, 7689

7782, 7970

5984, 6038

8023, 8292

8343, 8528

1183, 1412

3777, 5958

228, 249

434, 899

921, 1023

1039, 1122

269

106,296

7222

Discharge summary

report

Admission Date: [**2170-11-5**] Discharge Date: [**2170-11-27**] Date of Birth: [**2130-9-30**] Sex: M Service: MEDICINE Allergies: Codeine / Bactrim Ds Attending:[**First Name3 (LF) 759**] Chief Complaint: fevers Major Surgical or Invasive Procedure: right IJ placement History of Present Illness: 40 M with HIV (CD 4=664 in [**2169**] and 189 on [**2170-11-5**]) but no history of opportunistic infections who presents with 2 days of fevers to 102 for which he took tylenol. He had a cough productive of clear sputum and back pain secondary to a deep cutaneous abscess. He presented to the ED on [**2170-11-5**] with fever and abscess. The abscess was I&D'd and he was given fluids for tachycardia and oxacillin for abscess. He then abruptly dropped his BP to 60's, a sepsis protocol was initiated and a total of 5 L fluid were given. A central line was placed, vanc, ceftriaxone and dilaudid were given in the ED. Admitted to the [**Hospital Unit Name 153**] for closer monitoring of hypotension and tachycardia. Blood cultures from [**2170-11-5**] grew MRSA x 2. Surgery following. ID consulted for antibiotic therapy and ?indications for propylaxis given low CD4. Past Medical History: 1. HIV: diagnosed in [**2158**], on ZDV/3TC/nevirapine (per OMR note but patient denies ever being on HAART), currently no meds, followed by Dr [**Last Name (STitle) 4844**] 2. Seasonal allergies 3. Right hand tendonitis 4. s/p T and A 5. Right knee cellulitis (MSSA, [**3-21**]) 6. H/o strep pharyngitis, HSV, skin abscesses (per OMR) Social History: Lives alone, currently single, smokes 1 ppd x 12 years, past ecstacy and Ketamine use Family History: Non-contributory Physical Exam: Tm=102.1 Tc=98.6 P=95 (92-104) BP=110/65 (110/65-124/59) RR=21 100% RA Gen - Alert, no acute distress, lying on R side, unable to move secondary to vac dressing HEENT - PERRL, extraocular motions intact, anicteric, moist mucous membranes, poor dentition Neck - 10 cm JVD, no cervical lymphadenopathy, submandibular lymphadenopathy Chest - Right upper lobe crackles, decreased breath sounds at the bases bilaterally R>L CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tenderness; lower back with vac dressing draining 2 cm incised lesion Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**3-1**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Pertinent Results: MRI [**11-19**]: Essentially stable appearance of soft tissue edema/inflammation without evidence of osteomyelitis or drainable abscess collection. Slightly heterogeneous signal within the dependent portions of the iliac bones is non- specific, and most likely represents hematopoietic marrow. CT abdomen [**11-18**]: No intra-abdominal fluid collections. CT chest [**11-14**]: Multiple nodular and focal patchy opacities bilaterally of different sizes, many of which show evidence of cavitation. The largest of these within the right upper lobe although all lobes are affected. These findings are consistent with septic emboli. 2. Elevation of the right hemidiaphragm. Tiny right-sided pleural effusion which is layering posteriorly. 3. Gastric varices. MRI Pelvis [**2170-11-7**]: No evidence of intraosseous infection. CXR [**2170-11-7**] AP: Increased right pleural effusion with right lower lobe atelectasis vs. PNA. Increased pulmonary edema vs. diffuse infection. CXR [**2170-11-6**] AP: Left upper lobe, right upper lobe infiltrates suggestive of PMA. Diffuse intersitital opacities suggestive of pulmonary edema vs. infxn [**2170-11-5**] 07:35AM WBC-12.9* LYMPH-8* ABS LYMPH-1032 CD3-82 ABS CD3-845 CD4-18 ABS CD4-189* CD8-59 ABS CD8-613 CD4/CD8-0.3* [**2170-11-5**] 07:35AM PLT COUNT-240 [**2170-11-5**] 07:35AM WBC-12.9* RBC-5.24 HGB-14.6 HCT-42.8 MCV-82 MCH-27.9 MCHC-34.1 RDW-12.1 [**2170-11-5**] 07:35AM NEUTS-84.4* LYMPHS-8.3* MONOS-6.6 EOS-0.4 BASOS-0.4 [**2170-11-5**] 07:35AM CORTISOL-25.6* [**2170-11-5**] 07:35AM ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-2.9 MAGNESIUM-1.5* URIC ACID-3.8 [**2170-11-5**] 07:35AM LIPASE-12 [**2170-11-5**] 07:35AM ALT(SGPT)-23 AST(SGOT)-21 LD(LDH)-147 ALK PHOS-102 AMYLASE-28 TOT BILI-0.9 [**2170-11-5**] 07:35AM GLUCOSE-111* UREA N-11 CREAT-0.8 SODIUM-132* POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-27 ANION GAP-15 [**2170-11-5**] 08:06AM LACTATE-2.3* [**2170-11-26**] 10:31AM BLOOD WBC-4.1 RBC-4.34* Hgb-11.5* Hct-35.3* MCV-81* MCH-26.5* MCHC-32.7 RDW-14.6 Plt Ct-419 [**2170-11-5**] 07:35AM BLOOD WBC-12.9* Lymph-8* Abs [**Last Name (un) **]-1032 CD3%-82 Abs CD3-845 CD4%-18 Abs CD4-189* CD8%-59 Abs CD8-613 CD4/CD8-0.3* [**2170-11-21**] 05:00AM BLOOD WBC-3.7* Lymph-42 Abs [**Last Name (un) **]-1554 CD3%-91 Abs CD3-1408 CD4%-29 Abs CD4-454 CD8%-57 Abs CD8-888* CD4/CD8-0.5* [**2170-11-22**] 05:50AM BLOOD ALT-46* AST-30 CK(CPK)-20* AlkPhos-131* TotBili-0.2 [**2170-11-19**] 10:06AM BLOOD ALT-57* AST-41* LD(LDH)-174 AlkPhos-127* Amylase-39 TotBili-0.2 [**2170-11-25**] 03:28AM BLOOD Vanco-14.5* Brief Hospital Course: 1. sacral abscess - Abscess was incised and drained in the ED. Surgery consult obtained, and this was felt to be subcutaneous abscess rather than pilonidal cyst. Wound cultures grew out MRSA. Pt placed on vancomycin, ultimately for a 4-week course. Wound vac was placed, with surgery following and doing dressing changes. Wound vac discontinued prior to discharge per surgery team; wet-to-dry dressings were performed, and eventually dry gauze dressings. No evidence of further infection, with abscess appearing to be healing well by discharge. Pt will follow up with Dr. [**Last Name (STitle) **] in surgery in 4 weeks. 2. MRSA sepsis - Pt was admitted to the [**Hospital Unit Name 153**] from the ED on a non-rebreather mask, hypotensive on a levophed drip which was weaned off and the patient remained stable, transferred from [**Hospital Unit Name 153**] to the floor on [**2170-11-8**]. On arrival, pt's CVP continued to be low ([**4-23**]), with further fluid resuscitation resulting in adequate BP. Levophed drip was stopped 48 hours later, and BP remained stable throughout rest of course. Pt had multiple further blood cultures for surveillance purposes, which were negative. Last positive blood culture was on [**11-5**]. Pt on vanco for 4 week course after first negative blood culture. Vancomycin trough levels were persistently low, with continual uptitrating of the dose, up to 1750mg IV q12, and then ultimately was 1000mg IV q8h with a therapeutic trough level. 3. pneumonia - Pt noted to have multiple patchy opacities on CXR and chest CT, some of these lesions were noted to be cavitating. ID was involved early in the course of [**Hospital **] hospital stay. 3 AFB smears were negative, PCP via sputum induction was negative, Legionella urinary antigen was negative, Cryptococcus negative. A PPD was placed, which was negative, as well. CXR showed right pleural effusion with right lower lobe atelectasis vs. pneumonia. This was evaluated with U/S probe and it was determined that the fluid collection was too small to be tapped. Findings on CT scan were consistent with septic emboli, so a TTE and then TEE were performed, both of which were negative for any vegetations. Per ID, it is thought that these are septic emboli, likely of MRSA, from some intravascular source but not valvular vegetations. The appearance of these nodules, in their cavitations is consistent with Staph pneumonia, possibly from hematogenous spread. Pt was placed on 4 week course of vanco, and he continued to improve overall, feeling well by the time of discharge. He maintained good O2 sats and showed no respiratory distress. A followup CT scan was arranged prior to discharge, and pt will follow up in [**Hospital **] clinic to determine if the vancomycin may be discontinued. 4. fevers - fevers persisted even with the vancomycin on board. Pt's cultures were consistently negative and no changes noted on repeat chest imaging. Pt clinically was well-appearing in the last week or so before discharge, but was still having fevers. Other sources of fever were searched for: an abdominal CT showed no fluid collections or occult abscesses; an MRI of the sacral area near the abscess ruled out osteomyelitis. It was thought that perhaps his subtherapeutic vanco dose might be responsible for this. However, no further causes of infection were found, and pt was clinically well. Pt remained afebrile for > 4 days prior to discharge. 5. HIV - CD4 count low 189, but pt had an acute infectious process going on. Repeat CD4 count when pt more stable was 454. Bactrim prophylaxis was stopped. Pt will follow up with Dr. [**Last Name (STitle) 4844**] in [**Month (only) 404**] of next year. No HAART while in house. 6. HSV - pt had some oral HSV and completed a 7-day course of famciclovir with resolution of symptoms. 7. gastric varices - varices were found incidentally on CT scan. LFTs were mildly elevated. Pt asymptomatic. Abd CT scan did not comment on any liver abnormalities. An outpatient EGD appointment was arranged to better assess these varices, as well as a subsequent liver clinic appointment. 8. PPX: H2 blocker, SQ heparin 9. FULL CODE. 10. Dispo: Patient will be discharged to home with VNA for PICC care, as well as help with dressing changes. Medications on Admission: None 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 BID (2 times a day) as needed. 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 6. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Vancomycin HCl 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q12H (every 12 hours) for 11 days: Last day of treatment in [**12-6**]. Patient may need longer duration of therapy to be determined by outpatient infectious disease doctor. [**Last Name (Titles) **]:*22 doses* Refills:*0* 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous QD () as needed: to PICC. 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. saline heparin flushes per VNS protocol 11. PICC line care Discharge Disposition: Home With Service Facility: [**Location (un) **] HOME THERAPIES Discharge Diagnosis: Primary diagnoses: MRSA sacral abscess MRSA bacteremia Septic Pulmonary Emboli HIV Secondary diagnoses: Gastric Varices, seen on CT scan Seasonal allergies Right hand tendonitis s/p T and A Right knee cellulitis (MSSA, [**3-21**]) h/o strep pharyngitis, HSV, skin abscesses (per OMR) Discharge Condition: stable. pain well controlled. wound healing well. Discharge Instructions: Please call your doctor and return to the hospital for fever/chills, increasing warmth, pain, redness, or swelling from the abscess, general malaise, diarrhea, or any other concerns you may have. Please go to all of your appointments. Followup Instructions: You have the following appointments: 1) Provider: [**Name10 (NameIs) **] SCAN Where: CC CLINICAL CENTER RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-12-1**] 10:15 This is on the [**Hospital Ward Name 517**]. Please do not eat any solid food 3 hours beforehand. ***Before this appointment, please call ([**Telephone/Fax (1) 26760**] to update your information. 2) MD Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-12-3**] 10:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-12-3**] 10:30 3) Dr. [**Last Name (STitle) **] - surgery - to take a look at your abscess [**2170-12-24**], 1:00PM; in [**Hospital Ward Name 23**] building (Surgical Subspecialties); phone number ([**Telephone/Fax (1) 26761**] 4) [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**], Dr.[**Name (NI) 4864**] nurse practitioner Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], RNC Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2170-12-25**] 11:00 5) Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-2-7**] 9:50 6)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX) Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2170-12-20**] 10:00 ***You need to arrive at 9 am. Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Where: GI ROOMS Date/Time:[**2170-12-20**] 10:00 This is for evaluation of your liver 7) Liver Clinic appointment: to follow up with liver scan [**2171-2-26**] at 9 am [**Location (un) **] Dr. [**Last Name (STitle) 10924**]

[ "038.11", "995.92", "V08", "V09.0", "482.41", "785.52", "730.08", "415.19", "511.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "86.22", "38.93", "86.04" ]

icd9pcs

[ [ [] ] ]

10636, 10702

5183, 9490

288, 308

11038, 11089

2592, 5160

11375, 13295

1686, 1704

9545, 10613

10723, 10808

9516, 9522

11113, 11351

1719, 2573

10830, 11017

242, 250

336, 1207

1229, 1567

1583, 1670

19,056

172,898

9067+55998

Discharge summary

report+addendum

Admission Date: [**2139-12-6**] Discharge Date: [**2139-12-12**] Date of Birth: [**2079-12-12**] Sex: F Service: [**Location (un) 259**]/MEDICINE HISTORY OF PRESENT ILLNESS: This patient was first admitted to the MICU. This is a 59 year-old female with cholangiocarcinoma diagnosed in [**5-/2137**] status post exploratory laparotomy, status post chemotherapy with Irinotecan and Gemcitabine followed by resection two months later of the left lobe of the liver in [**12/2137**] who is being followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] without recurrence until recently. She was found to have tumor in the dome of her liver and underwent radiofrequency ablation in [**2139-11-12**]. Afterward the lesion was transformed into a 5 by 5 .2 cm low attenuation area with some "air droplets." She did well afterwards except for some nausea and vomiting and was not keeping up with her po intake. This issue becoming prominent about five days ago. Yesterday she came to the Emergency Room, the day prior to admission at an outside hospital in [**Location (un) 3844**] with poor po intake and was found to have a blood pressure in the 90s and was given intravenous fluids. She then had some coffee ground emesis in the Emergency Room and was found to have a hematocrit of 34 and was transferred to the Intensive Care Unit. There she went into rapid atrial fibrillation with a heart rate of 170s and blood pressure of 80/60, which converted after more intravenous fluids were given. Hematocrit was 32.6 six hours after the first hematocrit despite the fluid. The patient was not transfused. Nasogastric lavage was done revealing 400 cc of coffee ground. This was followed by CT of the abdomen, which showed a 10 cm hepatic fluid air collection consistent with abscess. The patient was given 500 each of Levaquin and Flagyl. She was also being treated for hypokalemia and was found to have platelets of 60. The patient was transferred to [**Hospital1 346**] for further management of hypertension and abscess. Here the patient spent three days in the MICU where she received the esophagogastroduodenoscopy for workup of the coffee ground emesis that revealed severe gastritis, esophageal varices and no sign of recent or active bleeding. H-pylori antibodies were negative and the patient's hematocrit remained stable during the admission in the Intensive Care Unit. The patient also received a drainage tube in her hepatic abscess per Interventional Radiology and was started on a course of intravenous Zosyn. Her platelets when transferred to the floor were 45. PAST MEDICAL HISTORY: Hypothyroid on Synthroid. Laparoscopic cholecystectomy, appendectomy and BTO, depression on Paxil, gastric duodenal ulcer in [**1-27**] with massive gastrointestinal bleed and perforation. Subsequent oversewing in gastric duodenal artery ligation, hepatic and subphrenic abscesses at this time. Fungal infection of abdomen after liver resection. SOCIAL HISTORY: The patient lives with her husband [**Name (NI) **], has two children. Drinks a rare glass of wine every six months. Smoked until age 27 one to two packs times twelve years. No other drugs, over counters, herbals. FAMILY HISTORY: Noncontributory. MEDICATIONS: Paxil 30 mg, Nexium 40 mg q.d., Synthroid 50 mcg q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Temperature 98.2. Heart rate 87. Blood pressure 93/52. Respiratory rate 16. O2 sat 99% on room air. Weighing 93 kilograms on admission. General, pleasant, fully alert and oriented in minimal distress. HEENT nasogastric tube in place when arriving to the MICU. When arriving to the floor nasogastric tube had been discontinued. Anicteric. Oropharynx clear, somewhat dry. Neck supple. Cardiovascular regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops appreciated. Lungs clear to auscultation bilaterally. Abdomen positive bowel sounds, soft, mild epigastric and right upper quadrant tenderness, but no rebound or guarding. No hepatosplenomegaly. No stigmata of chronic liver disease. Extremities left upper extremity PICC line. No clubbing, cyanosis or edema bilaterally. Skin no rash. Neurological grossly intact, conversant, articulate. LABORATORIES/STUDIES: Most recent creatinine [**2139-12-1**] was .6, BUN 8, hematocrit stable on [**2139-12-12**] at 31.8, white count 14.0, platelets count risen from 45 to 161. HOSPITAL COURSE: The patient had a stable MICU course for three days and was transferred to the floor on [**2139-12-8**]. Her hematocrit remained stable. Her platelet count began to rise and the patient continued on intravenous Zosyn. On [**2139-12-10**] the patient was taken to CT scan and per Interventional Radiology the patient's drains were placed with larger tubes and at that time there was instrumentation across the diaphragm and a chest tube was placed though the pneumothorax was very small. Serial chest x-rays showed no further pneumothorax. The chest tube was never placed on suction or even hooked up to a Pleura-Vac. The patient remained afebrile on the floor with the cultures pending. Infectious Disease was consulted for recommendations on length of antibiotic course as well as the possibility of changing to po medications for discharge. Infectious disease will make their further recommendations when the cultures have identified a culprit organism. The patient is now tolerating a full po diet and ambulating in the hallways and denies pain except for at drainage sites. The rest of the hospital course will be dictated by the oncoming intern. [**First Name11 (Name Pattern1) 396**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9758**] Dictated By:[**Last Name (NamePattern1) 23892**] MEDQUIST36 D: [**2139-12-12**] 17:57 T: [**2139-12-14**] 07:55 JOB#: [**Job Number 31323**] Name: [**Known lastname 5457**], [**Known firstname **] Unit No: [**Numeric Identifier 5458**] Admission Date: [**2139-12-6**] Discharge Date: [**2139-12-24**] Date of Birth: [**2079-12-12**] Sex: F Service: HOSPITAL COURSE: Serial abdominal CT scans were performed. They showed interval decrease in the size of the hepatic abscess. The patient continued to have decreasing drainage from her chest tube as well as both hepatic abscess drains. She was continued on intravenous antibiotics, and remained afebrile throughout the rest of her hospital course. On [**2139-12-23**], the chest tube and drain #1 were removed. At the time of discharge, the patient continued to have a single drain for her abscess which was discharging a small amount of purulent material each day. Discharge plan was to continue maintenance of the drain with a followup CT examination on [**2140-1-4**]. Patient was discharged in stable condition to home with visiting services. DISCHARGE DIAGNOSES: 1. Hepatic abscess status post drain placement. 2. Cholangiocarcinoma status post radioablation. 3. Hypothyroidism. 4. Depression. 5. Gastroduodenal ulcer. 6. Upper gastrointestinal bleed. DISCHARGE MEDICATIONS: 1. Peroxitine 30 mg po q day. 2. Levothyroxine 50 mcg po q day. 3. Oxycodone 5-10 mg po q4-6h prn. 4. Bacitracin ointment topically to drain site tid. 5. Omeprazole 20 mg po q day. 6. Ceftriaxone 2 grams IV q24h x3 weeks. 7. Metronidazole 500 mg po tid. DISCHARGE PLAN: 1. The patient will continue with intravenous infusion of ceftriaxone and oral treatment with metronidazole for at least three weeks. She will continue with drain for the abscess, and will be re-evaluated by abdominal CT scan on [**2140-1-4**]. At this time, she will follow up with Dr. [**First Name (STitle) **]. 2. The patient will have a follow-up appointment with Dr. [**Last Name (STitle) 5459**] of Infectious Disease on [**2140-1-15**]. A decision will be made on switching to complete oral antibiotic regimen based upon the size of the abscess. 3. Patient should call her primary care provider for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 900**] appointment in [**1-28**] weeks. 4. The patient will call Dr. [**First Name (STitle) **] for a follow-up appointment in [**1-28**] weeks. 5. The patient will having visiting nurse services for PICC care, drain flushing and care, and to have weekly blood draws for complete blood count, chemistry 7 and liver function tests. These will be faxed to Dr. [**Last Name (STitle) 5459**] for monitoring. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-687 Dictated By:[**Last Name (NamePattern1) 3309**] MEDQUIST36 D: [**2139-12-26**] 16:05 T: [**2139-12-29**] 04:46 JOB#: [**Job Number 5460**]

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icd9cm

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47968

Discharge summary

report

Admission Date: [**2196-12-17**] Discharge Date: [**2196-12-19**] Date of Birth: [**2134-9-9**] Sex: F Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 2009**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a 62 year old woman with atrial fibrillation and end stage renal disease presenting with epigastric pain and bradycardia from dialysis suite. Our patient was at home in her usual state of health while she developed epigastric pain while straining during a bowel movement. She then came into dialyis, and while in the suite, she was noted to be bradycardic in the 30s and hypotensive in 90s/40s and refered to the ED. In the ED he presenting vitals were VS 97.4, HR 30s, 107/61 18, 97% RA. Her ECG showed second degree AVB and peaked t waves. Her K was 7.0. Of note she has a history of a similar admission with hyperkalemia and bradycardia in [**9-28**], which was treated with dialysis. On arrival to floor, patient states that abdominal pain has improved. Past Medical History: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **] [**2195**]. She has not been on Coumadin until very recently due to history of upper GI bleeding. On [**Month (only) 404**] of this year, she was admitted to [**Hospital1 18**] with chest pain and shortness of breath in the setting of atrial flutter with rapid ventricular response and hyperkalemia. She was treated for hyperkalemia and subsequently her atrial flutter was converted to sinus rhythm. Myocardial infarction was [**Hospital1 20003**] out based EKG and biomarkers. Thereafter, she underwent right-sided isthmus ablation of clockwise atrial flutter, and was started on quinidine and Coumadin. 2. End-stage renal disease on hemodialysis secondary to IgA nephropathy. She underwent cadaveric kidney transplant in [**2173**] which has eventually failed, and started on hemodialysis in [**2193**]. 3. History of upper GI bleeding on [**2195-2-20**] with evidence of esophagitis, gastric ulcer, and bleeding duodenal vessel. She was treated by clipping, cauterization and PPI. Repeated endoscopy in [**2195-4-21**] revealed mild inflammation and healing ulcer. She has not had any recurrent episodes of GI bleeding since then. 4. Diastolic heart failure supported by an echocardiography from [**2195-12-21**]. Clinically, she is stable and fairly asymptomatic on her current medical regimen. 5. History of malignant hypertension, which was complicated by seizure on [**2193-5-20**]. Not on antiepileptic meds. Denies h/o CVA. 6. Depression. 7. Rheumatic fever in childhood . Social History: She is single, lives by herself in [**Location (un) 686**], and has no children. She quit smoking 25 years ago (10-pack-years). She rarely drinks alcohol, and denies illicit drug use. She used to work part-time in a coffee shop, but currently does not work. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Her father died at the age of 80. Her mother died at the age of 64 from lung CA. She has a sister with breast CA. MI in uncle in his 60s Physical Exam: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI at apex. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Thrill over LUE AV Fistula. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS [**2196-12-17**] 07:30AM PT-16.1* PTT-26.8 INR(PT)-1.4* [**2196-12-17**] 07:30AM WBC-7.8 RBC-3.78* HGB-12.3 HCT-36.6 MCV-97 MCH-32.6* MCHC-33.6 RDW-14.6 [**2196-12-17**] 07:30AM PLT COUNT-206 [**2196-12-17**] 07:30AM NEUTS-73.5* LYMPHS-18.7 MONOS-4.4 EOS-2.4 BASOS-1.0 [**2196-12-17**] 07:30AM GLUCOSE-94 UREA N-92* CREAT-11.8*# SODIUM-135 POTASSIUM-7.6* CHLORIDE-91* TOTAL CO2-27 ANION GAP-25* [**2196-12-17**] 07:30AM CALCIUM-10.7* PHOSPHATE-5.7*# MAGNESIUM-2.8* [**2196-12-17**] 07:30AM CK-MB-3 [**2196-12-17**] 07:30AM CK(CPK)-39 [**2196-12-17**] 07:30AM cTropnT-0.07* [**2196-12-17**] 05:22PM ALT(SGPT)-55* AST(SGOT)-44* LD(LDH)-199 CK(CPK)-31 ALK PHOS-96 AMYLASE-90 TOT BILI-0.4 [**2196-12-17**] 05:22PM LIPASE-42 CXR: No active pulmonary disease. EKG:Sinus bradycardia with pauses and junctional escape beats. Possible blocked premature atrial contractions. Also, evidence for retrograde conduction in lead V1. Tall T waves suggesting hyperkalemia. Probable anteroseptal myocardial infarction. Compared to the previous tracing of [**2196-10-4**] sinus bradycardia, first degree A-V block, junctional beats and tall peaked T waves are new. DISCHARGE LABS 134 | 90 | 67 -------------- 5.6 | 32 | 9.7 ∆ Ca: 10.9 Mg: 2.8 P: 3.0 TSH:3.3 WBC: 8.5 Hgb: 11.8 HCT: 34.8 Plt: 264 PT: 20.6 PTT: 28.7 INR: 1.9 Brief Hospital Course: 62 year old woman with atrial fibrillation and end stage renal disease status post failed transplant and currently on HD who presented with epigastric pain, hyperkalemia, and sinus bradycardia. . # Hyperkalemia: Secondary to ESRD. She has a history of hyperkalemic episodes in the past, that required MICU admission and emergent dialysis. Her baseline K is in the 5-6 range. K was 7.6 at admission and EKG showed peaked T waves and first-second degree AV block with junctional escape rhythm. She received calcium gluconate, bicarb and 10 units insulin in the ED. She was urgently dialyzed and K came down to 4.0. K increased gradually over following 24 hours and requiring 2 hours HD prior to discharge. This was due to diet in the setting of oliguria, and less likely due to ACEi. Patient was taking both captopril and lisinopril at home. She will be discharged on lisinopril at half her prior dose. . # Bradycardia: Sinus bradycardia with 1st degree AV delay with junctional escape beats. The most likely cause was beta-blocker toxicity in setting of worsening CRI. Metoprolol was D/Ced. TSH was WNL. . # Atrial fibrillation: Pt in sinus rhythm. Continued amiodarone and warfarin. INR at D/C was 1.9, which was trending up from 1.4 on home dose of 4 mg warfarin daily. This dose was continued and she will f/u in [**Hospital **] clinic. . # Epigastric pain: Ddx included anginal equivalent/CAD vs viral gastroenteritis vs renal failure vs gastritis. Troponins were flat at prior baseline 0.05-0.07. EKG with no ischemic changes. No diarrhea. Pain improved spontaneously. Continued pantoprazole. . # ESRD on HD: secondary to IgA nephropathy, s/p failed transplant. Underwent HD on [**12-17**] and [**12-19**]. . # HTN: Normotensive. Continued lisinopril at half home dose and D/Ced captopril. Continued norvasc. D/Ced metoprolol for toxicity with ESRD that caused bradycardia. Medications on Admission: AMIODARONE - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **]/c from hosp) - 200 mg Tablet - 1 Tablet(s) by mouth daily AMLODIPINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day Hold on dialysis days CALCIUM ACETATE - 667 mg Capsule - 3 Capsule(s) by mouth three times a day CAPTOPRIL - 12.5 mg Tablet - 1 Tablet(s) by mouth at bedtime CINACALCET [SENSIPAR] - 60 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily) CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth qam LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) pt holds on dialysis days METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth DAILY (Daily) PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day Name Brand Only, No Substitutions - No Substitution SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 3 Tablet(s) by mouth three times a day SODIUM POLYSTYRENE SULFONATE - Powder - 15grams Powder(s) by mouth daily WARFARIN - 1 mg Tablet - Take up to 4 tablets (4mgs) a day or as directed by [**Hospital 191**] [**Hospital 197**] Clinic Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO QMWFSUN (): do not take on dialysis days. 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: primary: hyperkalemia bradycardia secondary to beta-blockers secondary: atrial fibrillation chronic diastolic CHF Discharge Condition: good condition post-hemodialysis with stable vital signs Discharge Instructions: It was a pleasure taking care of you. You were admitted for hyperkalemia (elevated potassium) due to your kidney disease. You were treated with dialysis and your heart was monitored. You also had low heart rate and blood rate due to metoprolol, which does not get cleared as well by your kidneys. You should stop taking metoprolol as well as captopril. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet Please seek medical attention if you experience shortness of breath, chest pain, or any new symptoms. Followup Instructions: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2197-1-27**] 1:00

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icd9cm

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Discharge summary

report

Admission Date: [**2193-6-9**] Discharge Date: [**2193-6-13**] Service: MEDICINE Allergies: Nitroglycerin / Plavix Attending:[**First Name3 (LF) 2186**] Chief Complaint: Respiratory arrest s/p foreign body obstruction Major Surgical or Invasive Procedure: Intubation, extubation NGT placement History of Present Illness: 87 year old woman with PMHx of coronary artery disease (s/p BMS to RCA in [**2184**]), hypothyroidism, GERD/peptic ulcer disease, chronic renal insufficiency, anemia, recurrent UTIs who was in her usual state of health at her nursing home today, baseline A&O X3, who presents with respiratory arrest after choking on lunch. She was eating lunch when she started choking, unclear if witnessed or heard by healthcare personnel who was at her side shortly thereafter. Heimlich maneuver was started on the patient, without success. The Fire Department arrived at the scene first and performed Heimlich maneuver, which expelled a fair amount of food. The patient subsequently lost consciousness when EMS arrived, O2 sat 90% with spontaneous shallow respirations. Using laryngoscope, EMS did not see anything in the oropharynx and started bagging the patient until arrival at [**Hospital1 18**] ED. En route, the patient did not regain consciousness but maintained shallow spontaneous respirations and O2 sats >90%; she never lost cardiac circulation. . On arrival to the [**Hospital1 18**] ED, initial VS were T96.0, HR120, BP123/67, RR18, O2 sat 100% (Ambu Bag). The patient remained unresponsive but agitated, not following commands, so she was intubated for airway protection w/ etomidate and succinate; the ED resident reports not seeing any food around the vocal cords etc. The patient's initial ABG before intubation showed 7.26/36/175/17 with a lactate 5.7. Subsequent ABG was 7.22/43/513/19 with lactate improved slightly to 4.8. The patient was initially sedated with propofol but remained agitated, moving all four extremities and still not following commands although would turn her head to voice. She was switched to fentanyl/versed with some improvement in agitation. CT head and CXR within normal limits (no signs of aspiration). UTox negative. Two large bore IVs and NGT were placed and the patient volume resuscitated with 2L IVF. Labs were otherwise remarkable for creatinine 1.6, mildly positive UA (trace leuks, 2 WBC, few bacteria, <1 epi). The patient's daughter was updated by phone and she subsequently came to the ED, was at the patient's bedside by 4pm. . Upon arrival to the MICU, patient is intubated and on sedating medications but following commands. Respiratory Therapy trialed her on pressure support but RR ~6, too sedated from fentanyl boluses. Daughter and son-in-law at bedside. . ROS: Patient awake, mildly agitated but able to be calmed by family. Denies any pain but endorses discomfort from ETT and strongly wishes to be extubated soon. . . <h3>[**Hospital1 139**] A PGY1 Daily Progress Note, [**2193-6-10**], [**2112**]</h3> . <h3>Accept Note</h3> . <b>Brief HPI:</b> I have received verbal signout from the MICU resident, reviewed pertinent notes and data, and seen and examined the patient; please see MICU admission note for details of the H&P. . Briefly, this is an 87 [**Hospital **] nursing home resident who was admitted to the ICU 1 day ago for respiratory failure after choking on a corned beef [**Location (un) 6002**] and subsequently losing consciousness but who never had cardiopulmonary arrest; her pertinent comorbidities include CAD, first degree AV block, hypothyroid, GERD/PUD, hiatal hernia, recurrent UTIs, CRI. After successful heimlich in the field, she was maintaining sats of 90%, was bagged, brought to ED, intubated for airway protection, and found to be in metabolic acidosis 7.26/36/175/17 with a lactate 5.7. Present CXR and CT-Head were WNL. She is a non-smoker. . ICU Course: * Suctioned out chunks of corned beef * Extubated less than 24h after admission * Repeat UA -> large leuk, wbc 44, many bact, no yeast -> Cipro . Denies dysuria; endorses frequency. . <b>ROS:</b> Notes chronic tension headaches and heartburn, otherwise no CP, palpitations, wheezesm, cough, abdominal pain, leg swelling, rashes. Past Medical History: * Coronary artery disease (s/p BMS to RCA in [**2184**]) * First degree AV block * Hypertension with labile blood pressures * Hyperlipidemia * Myocardial infarction * Hypothyroidism * Orthostatic hypotension * Osteoporosis * Primary hyperparathyroidism * Vertigo * Anxiety/depression with psychotic variant * GERD/Peptic ulcer disease s/p GIB (?upper) in [**8-/2190**] * Hiatal hernia * Chronic renal disease * Recurrent UTIs * Iron deficiency anemia * Tension headaches * Hard of hearing . Social History: Currently [**Hospital1 1501**] resident ([**Hospital3 537**]), formerly [**Hospital3 **] facility resident ([**Location (un) 42423**], [**Location (un) 47**], MA). Retired clerical worker. Lifelong non-smoker. No alcohol or illicits. Daughter involved in her care. Family History: Mother died in her 70s from pneumonia. Father died in his 80s from unclear [**Name2 (NI) 42424**]. Otherwise, no family history of sudden cardiac death, malignancies. Physical Exam: VS: Temp: 95.0 --> 99.0 BP: 184/80 --> 134/78 HR: 71 RR: 16 O2sat 100% GEN: Pleasant, NAD, cooperative, interactive HEENT: PERRL w/ cataracts, EOMI, anicteric, MMM, op without lesions, poor dentition, no lymphadenopathy RESP: CTA b/l with good air movement throughout, no wheezing/rhonchi/rales CV: RRR, S1 and S2 wnl, no murmurs/gallops/rubs ABD: Nontender, nondistended, soft, no masses, surgical incision site well-healed EXT: No cyanosis, ecchymosis or edema SKIN: No rashes/lesions NEURO: AAOx3. Cn II-XII intact. Strength and sensation grossly intact, moving all extremities purposefully . Discharge Exam: Vitals: 99.0 AF 85 108/85 18 95 RA x/x 700/700+BR . Physical Exam: Unchanged Other than** Gen: Pale WDWN elderly woman in NAD HEENT: NCAT, PERRL, EOMi, MMMs, OP clear Neck: Supple, no LAD; no elevated JVP Pulm: Improved expiratory wheezes and airmovement; otherwise no rh/r CV: RRR nml S1/2 no r/g; new S3 Ab: +BS soft NTND no organomegaly Ext: No edema no lesions Neuro: Grossly unchanged and non-focal Pertinent Results: [**2193-6-9**] 10:18PM TYPE-ART TEMP-37.0 PO2-133* PCO2-33* PH-7.42 TOTAL CO2-22 BASE XS--1 INTUBATED-INTUBATED [**2193-6-9**] 07:41PM TYPE-ART TEMP-36.4 PO2-63* PCO2-45 PH-7.29* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED [**2193-6-9**] 07:41PM LACTATE-0.7 [**2193-6-9**] 06:03PM LACTATE-1.3 [**2193-6-9**] 05:45PM GLUCOSE-131* UREA N-39* CREAT-1.2* SODIUM-140 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15 [**2193-6-9**] 05:45PM CALCIUM-10.2 PHOSPHATE-2.8 MAGNESIUM-1.9 [**2193-6-9**] 05:45PM WBC-9.7 RBC-3.57* HGB-11.3* HCT-34.2* MCV-96 MCH-31.8 MCHC-33.1 RDW-13.1 [**2193-6-9**] 05:45PM PLT COUNT-171 [**2193-6-9**] 05:45PM PT-12.7 PTT-20.2* INR(PT)-1.1 [**2193-6-9**] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2193-6-9**] 01:00PM TYPE-ART TIDAL VOL-450 PEEP-5 O2-100 PO2-512* PCO2-43 PH-7.22* TOTAL CO2-19* BASE XS--9 AADO2-179 REQ O2-38 -ASSIST/CON INTUBATED-INTUBATED [**2193-6-9**] 01:00PM LACTATE-4.8* [**2193-6-9**] 12:53PM TYPE-[**Last Name (un) **] PO2-175* PCO2-36 PH-7.26* TOTAL CO2-17* BASE XS--9 COMMENTS-GREEN TOP [**2193-6-9**] 12:53PM GLUCOSE-179* LACTATE-5.7* NA+-139 K+-5.3 CL--105 [**2193-6-9**] 12:40PM LIPASE-47 [**2193-6-9**] 12:40PM cTropnT-<0.01 [**2193-6-9**] 12:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2193-6-9**] 12:40PM WBC-10.3 RBC-3.74* HGB-12.0 HCT-36.9 MCV-99* MCH-32.1* MCHC-32.5 RDW-13.3 [**2193-6-9**] 12:40PM PT-12.5 PTT-21.8* INR(PT)-1.0 . CT head - No acute intracranial pathological process. Large amount of secretions in entire nasopharynx and imaged portion of the oropharynx. Particular matter in incompletely imaged esophagus is also noted. These findings may be compatible with the reported history of recent Heimlich maneuver. s/p Attending review: I do not believe the esophagus is imaged on this study, which proceeds only as far caudally as the oropharynx. If acute brain ischemia is a clinical consideration, MRI is more sensitive. . Presenting CXR: ET tube terminating 4.2 cm above carina. Gastric tube terminating within distal stomach/first portion of duodenum. . CXR [**2193-6-11**]: PA and lateral chest views were obtained with patient in upright position. There is moderate cardiac enlargement. High-positioned diaphragms are consistent with poor inspirational effort or reduced pulmonary compliance in this elderly patient. There are some basal linear densities consistent with plate atelectasis, but no conclusive evidence for acute pulmonary infiltrates is present. The lateral view discloses a markedly increased depth diameter of the chest related to an accentuated kyphotic curvature and osteopenic appearance of the skeletal structures with multiple mildly wedge deformed vertebral bodies, but no true acute vertebral body fracture. Bilaterally, small amounts of pleural effusion have accumulated in the posterior pleural sinuses. When comparison is made with previous chest examinations dated [**2190**], the heart size has moderately increased and the pulmonary vasculature and the pleural effusions suggest a mild degree of chronic CHF. . Discharge labs: . [**2193-6-13**] 07:22AM BLOOD WBC-6.0 RBC-2.93* Hgb-9.3* Hct-28.3* MCV-97 MCH-31.7 MCHC-32.8 RDW-13.6 Plt Ct-194 [**2193-6-13**] 07:22AM BLOOD Neuts-64.8 Lymphs-24.8 Monos-5.4 Eos-4.4* Baso-0.5 [**2193-6-13**] 07:22AM BLOOD Glucose-92 UreaN-33* Creat-1.4* Na-141 K-3.9 Cl-106 HCO3-23 AnGap-16 [**2193-6-13**] 01:15PM BLOOD Glucose-109* UreaN-35* Creat-1.4* Na-140 K-4.3 Cl-104 HCO3-24 AnGap-16 [**2193-6-13**] 01:15PM BLOOD Calcium-10.3 Phos-2.9 Mg-1.8 Brief Hospital Course: 87 [**Hospital **] nursing home resident who was admitted to the ICU for respiratory failure after choking on a corned beef [**Location (un) 6002**] and subsequently losing consciousness but who never had cardiopulmonary arrest; her pertinent comorbidities include CAD, first degree AV block, hypothyroid, GERD/PUD, hiatal hernia, recurrent UTIs, CRI. . ICU COURSE: . # Respiratory arrest: Known choking event at her [**Hospital3 **] facility. Although foreign body aspiration events are not uncommon in the elderly population, patient's course has been complicated by loss of consciousness and inability to follow commands. She was subsequently intubated for airway protection. Can not rule out mental status changes to precipitate the event although daughter states she has had previous partial choking and food stuck in her esophagus in the past. Reportedly significant food output during Heimlich maneuvers and no more food seen during rapid sequence intubation. More food (chunks of roast beef) suctioned out during deep suctioning overnight, extubated the night of admission. No bronch overnight, slight risk of chronic inflammation with residual oily foods if left over in airway, but pt doing well clinically and given age, wouldn't sedate her again for bronch. Speech and swallow evaluation said one time event, can eat ground diet, thin liquids. . FLOOR COURSE: . ACTIVE ISSUES: . # Pre-Renal [**Last Name (un) **]: Cr elevated to 1.4 the day of discharge from 1.1; received 1L of NS prior to discharge and repeat Cr was stable at 1.4. Discharge planning included provisions to re-check Cr the day after discharge and to give fluids if still elevated. . # Aspiration Pneumonitis: Transferred to the floor with O2 requirement of 3L above baseline of no O2. CXR and history pointed to aspiration pneumonitis; PNA was considered but thought unlikely in the absence of clinical sequallae. O2 was weaned to RA. Follow-up CXR showed small pleural effusions, no infiltrate. . # Complicated UTI: UA from foley was positive; culture was positive for E.Coli > 100k. Treated for a complicated UTI with Cipro and discharged on this antibiotic to complete a total course of 7 days. . INACTIVE ISSUES: . # Anemia: Previously diagnosed with iron deficiency although also on Vitamin B12. Currently normocytic. Baseline Hct 32-34 and patient currently is close to this. - Continued home ferrous sulfate - Continued home Vitamin B12 . # CRI: @ Baseline 1.0 . # Coronary artery disease: s/p BMS to RCA in [**2184**], GIB in [**2190**]. - Continued home lipitor, atenolol - Continued home losartan, nifedipine . # Hypothyroidism: - Continued home levothyroxine . # Anxiety/depression: With psychotic variant, reportedly. Stable. - Continued home seroquel, venlafaxine, clonazepam . # GERD/Peptic Ulcer Disease: s/p GIB in [**8-/2190**] although unclear source at the time. The patient also has known hiatal hernia. - Continued home pantoprazole - Continued home ranitidine . # Osteoporosis: - Continued home vitamin D, calcium and multivitamin . # Seasonal allergies: - Therapeutic exchange from loratadine to fenafexadine in-house; discharged on loratadine. . TRANSITIONAL ISSUES: # Code: Patient admitted to ICU unconsious; daughter requested the patient be made DNR but OK to intubate after already intubated. When patient transferred to the floor, she expressed wanting to be FULL CODE (was AO x 3 and able to manipulate the facts) and so was made such after conferring with the daughter. Discharged FULL CODE with her PCP ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]) aware; further discussions will need to be had in the future to clarify this matter. # [**Last Name (un) **]: Cr will be checked after discharge and will be overseen by [**Hospital1 1501**]. # Elevated eosinophils: Last CBCd showed elevated eosinophils; this should be rechecked on follow-up with primary care physician. Medications on Admission: * Acetaminophen 1 gram three times daily * Acidophilus 10mg three times daily * Atenolol 50mg daily * Clonazepam 0.5mg (take [**1-8**] vs. half tablet) twice daily * Docusate 100mg qHS * Ferrous sulfate 325mg daily * Fiber laxative one tablet twice daily * Levothyroxine 75mcg daily * Lidoderm 5% patch to left buttock/lower back daily (12 hours on, 12 hours off) * Lipitor 10mg daily * Loratadine 10mg daily * Losartan 50mg daily * Multivitamin daily * Nifedipine ER 90mg daily * Pantoprazole 40mg daily * Ranitidine 150mg daily * Seroquel 25mg qHS * Venlafaxine ER 37.5mg daily * Vitamin D 1000 units daily * Vitamin B-12 100mcg daily * Ketoconazole 2% to breasts twice daily PRN * Mylanta 15mL three times daily PRN heartburn . Allergies: Plavix, nitroglycerin Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 2. Acidophilus Capsule Sig: One (1) Capsule PO three times a day. 3. atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 6. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: [**1-6**] to 1 Tablet, Rapid Dissolve PO twice a day. 9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Mylanta 200-200-20 mg/5 mL Suspension Sig: Fifteen (15) ml PO three times a day as needed for heartburn. 14. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO at bedtime. 16. Fiber Laxative 500 mg Tablet Sig: One (1) Tablet PO twice a day. 17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): left buttock/lower back daily (12 hours on, 12 hours off) . 18. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 19. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 21. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. ketoconazole 2 % Cream Sig: One (1) Application Topical twice a day as needed for itching: Breasts. 23. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 24. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: d1 [**6-10**], end [**6-16**]. 25. Outpatient Lab Work Discharge Disposition: Extended Care Facility: [**Hospital3 6560**] Care & Rehab Center - [**Location (un) 86**] Discharge Diagnosis: PRIMARY: -Aspiration of food -Intubation for airway protection -Complicated UTI SECONDARY: -None Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It has been a privilege to take care of you at [**Hospital1 18**]. . You were hospitalized in the intensive care unit because you inhaled part of your [**Location (un) 6002**] and were temporarliy unconscious. You were intubated with a breathing tube to prevent you from further inhaling oral secretions while you were unconscious. The breathing tube was then removed when you regained consciousness and you were transferred to the regular medical floor where your condition continued to improve. . You were found to have a urinary tract infection and were treated for this with antibiotics; continue the antibiotics after discharge until the prescription is complete. . You were a little dehydrated before discharge; you were given IV fluids to correct this. . No changes were made to your medications, other than as detailed below: START -Ciprofloxacin for a urinary tract infection -Duonebs for wheeze or shortness of breath . You are to eat a ground solid diet and thin liquids to prevent further inhalation of food. Followup Instructions: None. Your physician at the nursing home will oversee your care after discharge from the hospital.

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Discharge summary

report

Admission Date: [**2163-5-6**] Discharge Date: [**2163-5-13**] Date of Birth: [**2113-5-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Pneumonia, Hypoxia Major Surgical or Invasive Procedure: BRONCHOSCOPY History of Present Illness: 49F with hx of GERD, hypothyroidism, IBS and depression transferred from OSH per patient request for multifocal pneumonia and hypoxia. Briefly, patient initially presented to [**Hospital 1514**] Hospital on [**4-30**] complaining of N/V/D and RUQ abdominal pain following 2 antibiotics courses prescribed and ENT evaluation for sinusitis. She had leukocytosis of 13 without bandemia, normal chemistries, and had a CT abd/pelvis showing mild proximal small bowel wall thickening c/w regional enteritis and a RUQ U/S which was negative for cholecystitis. She was admitted to the medical floor for managment of gastroenteritis. She thereafter developed hypoxia and cough as well as severe basilar headaches without photophobia, phonophobia, neck stiffness, or neurological symptoms. She had a CTA chest which was negative for PE but bibasilar infiltrates and CXR was c/w with extensive bilateral pneumonia as well as a non-con CT scan of her head which was negative. Also, urine legionella Ag negative and pneumococcal antigen was also negative. She was initially started on azithromycin and rocephin which was changed to zosyn and cipro due to worsening hypoxia on nasal cannula. She had a pulmonary consultation and was started on solumedrol 40mg Q6hrs and given a single dose of IV lasix 20mg with good UOP. Family sought transfer to [**Hospital1 18**] for further management given concern for slow recovery. On arrival to the MICU, patient's VS: 98.6, 100, 120/90, 29, 94%6LNC. Patient feels unwell and defers to her sister to relate her recent history. Her sister confirms the above history. The patient states her major complaint is discomfort with breathing and anterior lower chest pain with deep inspiration. She denies prior history of aspiration but does describe vomiting with a choking/coughing sensation. Past Medical History: Past Medical History: IBS GERD HTN Hyperthyroidism ADD Depression s/p hysterectomy without oophorectomy s/p appendectomy s/p sling procedure in [**2151**] . Social History: Social History: Lives alone in an apartment. Administrative assistant. Lifelong non-smoker. Only drinks EtOH socially. She lived in [**Country 84632**] in the past. Negative for HIV 5 years ago. No IVDU. Family History: Family History: Mother - emphysema. Father asthma and died of CHF. Also, CAD, DM, OA. Physical Exam: ADMISSION: 98.6, 100, 120/90, 29, 94%6LNC. General: Alert, oriented, but slowed response to questions, OSA-pattern of breathing HEENT: Sclera anicteric, MMM, mild thrush on tongue, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Rales halfway up lung fields, higher on right, course crackles at bases bilaterally Abdomen: soft, obese non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: Foley Ext: Warm, well perfused, 2+ pulses, 1+ at ankles clubbing Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, no meningismus DISCHARGE: VS 99.2 168-169/90-96 72-76 18-20 95-96% ON RA GENERAL - middle aged woman in NAD, comfortable HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear, no swelling noted on exam. Oral cavity appears clear and unremarkable. NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - Crackles in both bases, similar to before HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-28**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait not assessed Pertinent Results: Admission Labs: [**2163-5-6**] 03:18AM BLOOD WBC-14.4* RBC-3.51* Hgb-10.5* Hct-31.8* MCV-91 MCH-29.9 MCHC-33.0 RDW-13.0 Plt Ct-335 [**2163-5-6**] 03:18AM BLOOD PT-15.0* PTT-29.9 INR(PT)-1.4* [**2163-5-6**] 03:18AM BLOOD Plt Ct-335 [**2163-5-6**] 03:18AM BLOOD ESR-118* [**2163-5-6**] 03:18AM BLOOD Glucose-152* UreaN-11 Creat-0.6 Na-142 K-3.5 Cl-102 HCO3-30 AnGap-14 [**2163-5-6**] 03:18AM BLOOD ALT-38 AST-32 LD(LDH)-196 AlkPhos-118* TotBili-2.5* [**2163-5-6**] 03:18AM BLOOD Lipase-29 [**2163-5-6**] 03:18AM BLOOD proBNP-1247* [**2163-5-6**] 03:18AM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.4 Mg-2.0 [**2163-5-6**] 05:27AM URINE [**2163-5-6**] 05:27AM URINE CastHy-1* [**2163-5-6**] 05:27AM URINE RBC-32* WBC-<1 Bacteri-FEW Yeast-NONE Epi-0 [**2163-5-6**] 05:27AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2163-5-6**] 05:27AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 MICU labs: [**2163-5-7**] 06:11AM BLOOD WBC-9.7 RBC-3.51* Hgb-10.4* Hct-31.9* MCV-91 MCH-29.6 MCHC-32.6 RDW-13.1 Plt Ct-377 [**2163-5-7**] 09:30AM BLOOD WBC-11.0 RBC-3.60* Hgb-10.7* Hct-32.7* MCV-91 MCH-29.8 MCHC-32.8 RDW-13.1 Plt Ct-389 [**2163-5-8**] 04:00AM BLOOD WBC-12.9* RBC-3.85* Hgb-11.5* Hct-35.1* MCV-91 MCH-29.8 MCHC-32.7 RDW-13.0 Plt Ct-418 [**2163-5-9**] 03:53AM BLOOD WBC-12.4* RBC-3.96* Hgb-11.8* Hct-35.9* MCV-91 MCH-29.7 MCHC-32.7 RDW-13.3 Plt Ct-380 [**2163-5-10**] 03:38AM BLOOD WBC-13.1* RBC-3.77* Hgb-10.9* Hct-33.3* MCV-88 MCH-29.0 MCHC-32.9 RDW-12.8 Plt Ct-413 [**2163-5-7**] 06:11AM BLOOD Neuts-75.2* Lymphs-15.4* Monos-6.7 Eos-2.3 Baso-0.4 [**2163-5-7**] 09:30AM BLOOD Neuts-80.3* Lymphs-13.6* Monos-3.2 Eos-2.6 Baso-0.4 [**2163-5-10**] 03:38AM BLOOD Neuts-74.4* Lymphs-12.9* Monos-5.9 Eos-5.0* Baso-1.8 [**2163-5-7**] 06:11AM BLOOD Plt Ct-377 [**2163-5-7**] 09:30AM BLOOD Plt Ct-389 [**2163-5-8**] 04:00AM BLOOD Plt Ct-418 [**2163-5-9**] 03:53AM BLOOD Plt Ct-380 [**2163-5-10**] 03:38AM BLOOD Plt Ct-413 [**2163-5-8**] 04:45PM BLOOD ESR-125* [**2163-5-9**] 03:53AM BLOOD ESR-112* [**2163-5-10**] 03:38AM BLOOD ESR-118* [**2163-5-7**] 06:11AM BLOOD Glucose-117* UreaN-13 Creat-0.6 Na-142 K-4.0 Cl-102 HCO3-29 AnGap-15 [**2163-5-8**] 04:45PM BLOOD Glucose-135* UreaN-9 Creat-0.7 Na-139 K-4.1 Cl-98 HCO3-29 AnGap-16 [**2163-5-9**] 03:53AM BLOOD Glucose-131* UreaN-12 Creat-1.0 Na-139 K-4.4 Cl-100 HCO3-30 AnGap-13 [**2163-5-10**] 03:38AM BLOOD Glucose-119* UreaN-15 Creat-1.4* Na-140 K-4.7 Cl-100 HCO3-30 AnGap-15 [**2163-5-7**] 06:11AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9 [**2163-5-8**] 04:00AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.2 [**2163-5-8**] 04:45PM BLOOD Calcium-8.7 Phos-4.7* Mg-2.0 [**2163-5-9**] 03:53AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.2 [**2163-5-6**] 01:26PM BLOOD RheuFac-15* [**2163-5-8**] 04:00AM BLOOD CRP-107.4* [**2163-5-8**] 04:01AM BLOOD Vanco-26.7* [**2163-5-8**] 06:07AM BLOOD Vanco-18.7 [**2163-5-9**] 06:10AM BLOOD Vanco-30.2* [**2163-5-9**] 02:44PM BLOOD Vanco-17.9 [**2163-5-10**] 09:15AM BLOOD Vanco-21.8* [**2163-5-6**] URINE URINE CULTURE-PENDING INPATIENT [**2163-5-6**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2163-5-10**] 06:48AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2163-5-10**] 06:48AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2163-5-10**] 06:48AM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE Epi-1 [**2163-5-10**] 06:48AM URINE Mucous-RARE [**2163-5-10**] 06:48AM URINE Eos-POSITIVE [**2163-5-10**] 06:48AM URINE Hours-RANDOM UreaN-309 Creat-55 Na-43 K-15 Cl-12 DISCHARGE LABS: [**2163-5-13**] 06:00AM BLOOD WBC-11.0 RBC-3.57* Hgb-10.7* Hct-32.8* MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 Plt Ct-374 [**2163-5-13**] 06:00AM BLOOD Glucose-93 UreaN-11 Creat-1.4* Na-141 K-4.7 Cl-103 HCO3-25 AnGap-18 [**2163-5-13**] 06:00AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.1 [**2163-5-13**] 06:00AM BLOOD Vanco-17.0 Bronchoalveolar Lavage results: [**2163-5-6**] 05:00PM OTHER BODY FLUID Polys-38* Lymphs-0 Monos-0 Mesothe-6* Macro-56* MICRO [**2163-5-8**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2163-5-7**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2163-5-6**] 5:00 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2163-5-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2163-5-8**]): NO GROWTH, <1000 CFU/ml. ACID FAST SMEAR (Final [**2163-5-9**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT [**2163-5-6**] 5:27 am URINE Source: Catheter. **FINAL REPORT [**2163-5-7**]** URINE CULTURE (Final [**2163-5-7**]): NO GROWTH. [**2163-5-6**] 3:18 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2163-5-8**]** MRSA SCREEN (Final [**2163-5-8**]): No MRSA isolated. Cytology Report BRONCHIAL WASHINGS Procedure Date of [**2163-5-6**] Bronchial lavage: ATYPICAL.Rare cluster of atypical epithelial cells in a background of macrophages and bronchial cells. Imaging Portable TTE (Complete) Done [**2163-5-6**] at 2:37:14 PM FINAL The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. 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. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Tricuspid regurgitation is present but cannot be quantified. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CHEST (PORTABLE AP) Study Date of [**2163-5-6**] 2:00 AM IMPRESSION: Given the rapid appearance of the bilateral confluent lung opacities between [**5-1**] and [**2163-5-5**] and worsening over last 24 hours reflects pulmonary edema. However, concurrently associated infection remains a possibility . CT CHEST W/O CONTRAST Study Date of [**2163-5-6**] 11:12 AM IMPRESSION: Extensive bilateral, predominantly right lung parenchymal changes, consisting of ground-glass opacities, parenchymal opacities and consolidations. The changes are accompanied by signs of predominantly interstitial fluid overload, as reflected by bilateral pleural effusions and thickening of the interlobular septa. Finally there is generalized mediastinal and extrathoracic lymphadenopathy. Overall, the morphological findings are nonspecific, although the absence of cavitary lesions would be indicative of an extensive infectious process rather than for vasculitis. Neither of the two diagnoses, however, can be excluded on the basis of the imaging findings alone. No airway wall lesions. No indications for osteolytic lesions, mild degenerative spinal changes. If bronchoscopy is intended, the right upper lobe would be a good target region. CHEST (PORTABLE AP) Study Date of [**2163-5-7**] 7:20 AM FINDINGS: Comparison is made to prior study from [**2163-5-6**]. There is no interval change. There are again seen bilateral pleural effusions and extensive bilateral airspace opacities consistent with pulmonary edema or multifocal pneumonia. CHEST (PORTABLE AP) Study Date of [**2163-5-8**] 3:34 AM FINDINGS: In comparison with the study of [**5-7**], there is slightly improved aeration in the right upper zone. Indeed, the diffuse opacification bilaterally is generally slightly less prominent than on the previous study. The overall appearance again is consistent with some combination of severe pulmonary edema and multifocal pneumonia. CHEST PORT. LINE PLACEMENT Study Date of [**2163-5-8**] 10:01 AM FINDINGS: In comparison with the earlier study of this date, there has been placement of a right subclavian PICC line that projects to about the level of the cavoatrial junction. This information was discussed with the IV nurse, [**Doctor First Name **] by the resident on call. CHEST (PORTABLE AP) Study Date of [**2163-5-9**] 3:16 AM Cardiac size is normal. Extensive multifocal bilateral consolidations consistent with multifocal pneumonia have minimally improved. Small bilateral pleural effusions are probably unchanged allowing the difference in positioning of the patient. There is no evident pneumothorax. Right PICC is in standard position. There are no new lung abnormalities. The component of pulmonary edema has almost resolved. CHEST (PORTABLE AP) Study Date of [**2163-5-10**] 2:01 AM FINDINGS: As compared to the previous radiograph, there is improvement of the pre-existing predominantly right upper lobe pneumonia. The opacity preexistent in the left upper lobe is also slightly improved. Unchanged small pleural effusions, left more than right, unchanged moderate cardiomegaly with retrocardiac atelectasis. Brief Hospital Course: Assessment and Plan: 49F with hx of GERD, depression, recent gastroenteritis sx and sinusitis transferred from OSH for multifocal pneumonia and hypoxia. Was treated with IV antbiotics and was dc-ed on a 14 day course of iv vancomycin and po levofloxacin # Multifocal PNA with Hypoxia: Patient with imaging concerning for multifocal community-acquired pneumonia on CXR and CTA at OSH, visible on portable CXR here with leukocytosis to 13, no bands, and satting in the mid-90's on 6LNC. Prior to transfer from OSH, her abx were switched from azithromycin/rocephin to zosyn/cipro, she was started on solumedrol, and given a single dose of IV lasix. No culture data to tailor abx choice. Given the appearance of her CXR, she has significant bilateral multifocal pneumonia and significant fluid overload which is likely contributing to her hypoxia and seems to have responded well to IV lasix. Interestingly, CT abd/pelvis at OSH is with clear lung bases and CTA chest is with mild basilar opacities with subsequent CXR showing significant worsening with bilateral infiltrates. This could represent aspiration PNA/pneumonitis perhaps progressing to ARDS in the setting of recent N/V and aspiration or atypical organisms should be considered given her lack of improvement. Patient was treated with Vancomycin and Zosyn and levofloxacin. Patient also noted to have elevated ESR >100 and CRP and was complaining sinus pain. Patient's inflammatory markers improved during hospital course. There was some concern for vasculitic process though Cr is not elevated. Renal evaluated the urine for red cell casts but they did not find results concerning for vasculitis. Patient had a Chest CT on [**2163-5-6**] which was unable to distinguish between early vasculitis and multifocal pneumonia. Patient ANCA was negative. Patient then had a bronchoscopy with BAL which showed only lymphocytes with cytology with no malignant cells. Given the severity of her symptoms and previous travel history and HIV test was sent which was negative. Patient also appeared fluid overloaded and was gently diuresed. A TTE was also performed which showed preserved LVEF no significant valve regurgitation. Patient was maintained on Vancomycin, Zosyn, Levofloxacin while in the MICU with improvement of her respiratory status. After call out to medicine floor and stabilization on room air, she was norrowed to IV vanc and PO levofloxacin. She was dc-ed with a 14-day course total given the severity of her infection. She was set up with a pulmonology outpt visit for followup. #[**Last Name (un) **]. Patient Cr elevated mildly during her MICU stay from baseline of 0.7 to 1.4. Patient had urine lytes which showed of FeNA=0.08, thus this was felt to be prerenal, she did have +Urine Eosinophils and Serum eosinophils around 5%. She was fluid rehydrated and her Cr stbailized and did not rise any furhter. Likley etiology of kidney injury was pre-renal due to poor po intake, with an element of vancomycin and contrast induced injury. We held her lisinopril-HTZ which will need to be restarted by PCP. # Nausea: pt continued to have nausea after initially presenting with n/v and gastroenteritis from OSH. [**Month (only) 116**] be likely [**2-24**] antibiotics. We continued zofran q8h;prn and prochlorperazine 10 mg PO Q6H. Nutrition was consulted who recommneded a type of ensure. She was able to tolerate POs at time of dc. # Headaches: Patient with significant headaches although currently comfortable. No menigitic or neurological symptoms. Pain was controlled with Acetaminophen-Caff-Butalbital q6h;prn # Facial Swelling: pt initially had facial swelling as an outpt which improved but remains concerned. CT scan done by ENT in OSH was -ve. Exam completely unremarkable. However, pt urged to hold off CT as Cr still high. We arranged outpt ENT f/up and CT if needed. # Hypothyroidism: We continued home levothyroxine. # HTN: Her lisinopril/HTZ was held due to [**Last Name (un) **] kidney function and will need to be restarted by PCP after normalization of kidney function # Depression/ADHD: Her home sertraline and wellbutrin were continued. # GERD: Her home prilosec was continued. # Microscopic Hematuria: Repeat UA recommended on follow up, and possibly urology follow up needed. TRANSITIONAL ISSUES: >Pt dc-ed with IV vancomycin which is being followed by infusion services. Needs chem panel, cbc and vanc trough which needs to be followed up by PCP. >ENT follow up for 'facial swelling' >PCP follow up on [**5-20**] - needs to restart lisinopril if Cr normalised > CT scan abdomen pelvis with 3-4cm Right ovarian cyst, rec ultrasound follow-up in [**7-1**] weeks. Follow up with pulmonologist and repeat CXR in [**4-29**] weeks. Medications on Admission: Medications on Transfer: - cipro 400mg IV BID - Zosyn 4.5g IV q6H - Ketorolac 30mg IV q6H - Pantoprazole 40mg PO daily - Saccharomyces 250mg PO BID - Levothyroxine 112mcg PO daily - Bupropion 100mg PO daily - Calcium carbonate chews PO TID - Guaifenesin 600mg PO q12H - Sertraline 200mg PO daily - Colace 100mg PO BID - Enoxaparin 40mcg SC daily . Home Medications: - Wellbutrin 150mg PO daily - Lisinopril/HCTZ 20/25mgs PO daily - Adderall ER 20mg PO daily during week - Zoloft 200mg PO daily - Synthroid 112mcg PO daily - Prilosec Discharge Medications: 1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 2. Adderall XR 20 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day: daily during week. 3. Zoloft 100 mg Tablet Sig: Two (2) Tablet PO once a day. 4. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 7 days. Disp:*15 injections* Refills:*0* 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*7 Tablet(s)* Refills:*0* 8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea . Disp:*30 Tablet(s)* Refills:*0* 9. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-24**] Tablets PO Q6H (every 6 hours) as needed for HA. Disp:*30 Tablet(s)* Refills:*0* 10. Outpatient Lab Work Please draw complete metabolic panel, complete blood count and vancomycin trough on [**2163-5-16**] and forward results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], NP, Location: [**Hospital3 **] CENTER Address: ONE MEDICAL CENTER DR, [**Country **],[**Numeric Identifier 110078**] Phone: [**Telephone/Fax (1) 110079**]. 11. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10) ml Intravenous once a day as needed for flush for 7 days: Flush with 10 mL Normal Saline daily and PRN per lumen. Disp:*15 flushes* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Infusion Solutions Discharge Diagnosis: PRIMARY DIAGNOSES: 1. PNEUMONIA SECONDARY DIAGNOSES: 1. VIRAL GASTROENTERITIS 2. FACIAL SWELLING Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [**First Name8 (NamePattern2) **] [**Known lastname 58066**], It was a pleasure taking care of you at the [**Hospital1 18**]. You presented with a pneumonia from an outside hospital and were initially admitted to the intensive care unit. You responded well to the treatment, which consisted of intravenous antibiotics, and you were discharged home to complete a 14 day course. MEDICATIONS STARTED: 1. VANCOMYCIN: PLEASE TAKE THIS MEDICATION INTRAVENOUSLY TWICE A DAY UNTIL [**2163-5-20**] FOR A 14 DAY COURSE. 2. LEVOFLOXACIN: PLEASE TAKE THIS MEDICATION TWICE A DAY UNTIL [**2163-5-20**] for A 14 DAY COURSE. 3. COMPAZINE: please take as needed upto thrice a day for nausea 4. FIRONIAL: please take 1-2 tablets upto 4 times a day for headache. MEDICATIONS STOPPED: 1. LISINOPRIL/HYDROCHLOROTHIAZIDE: We are holding this medication as your kidney function is still not back to normal. Please discuss with your PCP to restart this medication at your clinic visit. Followup Instructions: Name: [**Last Name (LF) 1239**],[**First Name3 (LF) **] S Location: [**Hospital3 **] CENTER Address: ONE MEDICAL CENTER DR, [**Country **],[**Numeric Identifier 110078**] Phone: [**Telephone/Fax (1) 110079**] Appointment: Friday [**2163-5-20**] 11:00am Department: PULMONARY FUNCTION LAB When: MONDAY [**2163-5-30**] at 3:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2163-5-30**] at 3:30 PM With: DR. [**Last Name (STitle) 51373**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: OTOLARYNGOLOGY (ENT) When: TUESDAY [**2163-6-7**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**] Building: LM [**Hospital Unit Name **] [**Location (un) 895**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE *Please bring the disk with the CT Scan on it.

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Discharge summary

report+report

Admission Date: [**2152-3-16**] Discharge Date: [**2152-1-31**] Date of Birth: [**2082-2-7**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old female with a past medical history significant for nonalcoholic steatohepatitis with end-stage liver disease complicated by multiple admissions for hepatic encephalopathy, esophageal varices, insulin-dependent diabetes mellitus, hypothyroidism, asthma, and fibromyalgia who was transferred from [**Hospital 4199**] Hospital for further management of acute renal failure and hypotension. The patient presented to [**Hospital 4199**] Hospital on [**3-13**] after twisting her ankle with increasing shortness of breath and frequency episodes of nausea and vomiting with decreased oral intake. She twisted her ankle on [**3-12**], and the shortness of breath began on [**3-13**]. She was being treated for a left lower extremity cellulitis with levofloxacin for 10 days with improvement of her cellulitis. Of note, the dose of levofloxacin had been increased from 250 mg to 500 mg p.o. twice per day. The patient had also noticed a decrease in her urine output starting on [**3-12**]. At [**Hospital 4199**] Hospital, the patient was noted to be in acute renal failure with her creatinine increased to 5.7 (from a baseline of 1.2 to 1.5), a potassium of 6.3, and a blood urea nitrogen of 121. The initial impression at [**Hospital 4199**] Hospital was that the acute renal failure was secondary to acute interstitial nephritis secondary to levofloxacin. She received two dialysis treatments at [**Hospital 4199**] Hospital. The patient was noted to be hypertensive status post dialysis at [**Hospital 4199**] Hospital, requiring pressors. She was started on dopamine at [**Hospital 4199**] Hospital prior to transfer to [**Hospital1 346**] for further management. Upon transfer to [**Hospital1 69**] Medical Intensive Care Unit, the patient was noted to be tachycardic and in atrial fibrillation. Therefore, the dopamine was changed to Levophed; which was quickly weaned off. The patient was also dialyzed twice in the Medical Intensive Care Unit with minimal fluid removal secondary to hypotension. Urine eosinophils were negative, and the fractional excretion of sodium was noted to be less than 0.4%, with a urine sedimentation showing muddy brown casts; consistent with a prerenal/acute tubular necrosis picture secondary to volume depletion. The patient was started on clindamycin and Flagyl for her cellulitis. However, after blood cultures obtained in the Medical Intensive Care Unit revealed 2/4 bottles positive for coagulase-negative Staphylococcus, antibiotic coverage was changed to vancomycin and Flagyl. The patient also ruled in for a non-ST-elevation myocardial infarction with electrocardiogram showing global ST depressions and a peak troponin to 14.7. An echocardiogram was done which showed no wall motion abnormalities. The patient was transferred to the General Medicine floor for further care. PAST MEDICAL HISTORY: 1. Nonalcoholic steatohepatitis with end-stage liver disease; complicated by varices, hepatic encephalopathy, and ascites. 2. Hypothyroidism. 3. Insulin-dependent diabetes mellitus; complicated by neuropathy. 4. Asthma. 5. Migraine headaches. 6. Cholelithiasis. 7. Fibromyalgia. 8. Macrocytic anemia. 9. Recurrent cellulitis. 10. Obesity. 11. Glaucoma. 12. Cataracts. 13. Cervical spondylosis. 14. Hyperlipidemia. MEDICATIONS ON TRANSFER: 1. Vancomycin 1 g intravenously times one. 2. Aztreonam 1 g intravenously times one. 3. Aspirin 81 mg p.o. once per day. 4. NPH insulin 29 units subcutaneously q.a.m. and 12 units subcutaneously q.p.m. 5. Humalog insulin sliding-scale. 6. Levothyroxine 75 mcg p.o. once per day. 7. Metronidazole 500 mg intravenously twice per day. 8. Lactulose 30 cc p.o. q.8h. as needed (titrated to three bowel movements per day). 9. Vitamin E. 10. Sevelamer ocular eyedrops. 11. Prednisolone acetate eyedrops. 12. Flurbiprofen eyedrops. 13. Brimonidine eyedrops. 14. Tramadol 15 mg p.o. q.12h. as needed. 15. Albuterol 1 to 2 puffs inhaled q.4-6h. as needed. 16. Protonix 40 mg p.o. once per day. ALLERGIES: PENICILLIN, VIOXX, and ASPIRIN. SOCIAL HISTORY: The patient lives with her husband at home. She denies any tobacco, alcohol, or intravenous drug use. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 98.4, blood pressure was 98 to 116/25 to 53, heart rate was 79 to 88, respiratory rate was 19, and oxygen saturation was 95% on room air. In general, the patient was an obese female in no acute distress. Head and neck examination revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. Mild scleral icterus. Mucous membranes were moist. No oropharyngeal lesions. The neck with a right internal jugular line clean, dry, and intact. The neck was supple. Cardiovascular examination revealed normal first heart sounds and second heart sounds. A regular rate and rhythm. There was a 2/6 systolic ejection murmur heard over the left upper sternal border. The lungs revealed rales in the lower one half of the lung fields bilaterally. No wheezes or rhonchi. The abdomen was obese, soft, and nontender. There were normal active bowel sounds. The spleen tip was palpable. Extremity examination revealed 2+ pitting edema in the arms and legs. There was a 5-cm X 2-cm ulcer on the left pretibial region. Neurologic examination revealed alert, mentated well, and moved all four extremities spontaneously. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data revealed sodium was 136, potassium was 3.3, chloride was 104, bicarbonate was 22, blood urea nitrogen was 34, creatinine was 2.2 (decreased from 3.6 on [**3-20**]), and blood glucose was 195. White blood cell count was 6.9, hematocrit was 27.3, and platelets were 50. INR was 1.6 and partial thromboplastin time was 33.5. ALT was 111, AST was 124, alkaline phosphatase was 354, total bilirubin was 4.2, amylase was 48, and lipase was 40. A.m. cortisol was 12.5; increased to 23.4 with cosyntropin stimulation test. Calcium was 8.7, phosphate was 3.2, and magnesium was 1.7. Creatine kinase levels were 141, 112, and 125 with corresponding troponin levels of 14.7, 12.9, 12.2, and 10.1. Urinalysis with 69 red blood cells, 305 white blood cells, 30 mg/dL of protein, trace ketones, and small bilirubin. No bacteria. No yeast. No eosinophils. Antinuclear antibody negative. Rheumatoid factor negative. SPEP with immunoglobulin G of 1592, immunoglobulin A of 468, immunoglobulin M of 174, C3 of 51, and C4 of 14. PERTINENT RADIOLOGY/IMAGING: A chest x-ray on [**3-20**] with bilateral interstitial edema with bilateral pleural effusions. An echocardiogram done on [**3-17**] revealed a left ventricular ejection fraction of greater than 70% with no regional wall motion abnormalities. Trivial mitral regurgitation. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: Our impression was that this patient is a 70-year-old female with a past medical history significant for nonalcoholic steatohepatitis, with end-stage liver disease, and insulin-dependent diabetes mellitus whose clinical picture was thought to be consistent with hypotension and prerenal azotemia leading to acute tubular necrosis in the setting of intravascular volume depletion secondary to decreased oral intake and nausea and vomiting with concomitant diuretic use and possibly sepsis secondary to cellulitis. 1. RENAL ISSUES: The patient likely initially had prerenal azotemia secondary to volume depletion, leading to acute tubular necrosis. In the Medical Intensive Care Unit, the patient was virtually anuric and was requiring dialysis. However, upon transfer to the floor, the patient no longer required dialysis and had spontaneous recovery of her renal function, with her creatinine decreasing to 1.4 and an increase in her urine output. As the patient was still significantly volume overloaded with anasarca, Lasix was re-initiated at 40 mg intravenously twice per day with good diuresis and continued improvement in her renal function. Aldactone was restarted at 25 mg p.o. twice per day and titrated upward to 50 mg p.o. twice per day. 2. CARDIOVASCULAR SYSTEM: The patient ruled in for a non-ST-elevation myocardial infarction with a peak troponin to 14.7 while in the Medical Intensive Care Unit. Cardiac enzymes were cycled and continued to trend downward. A cardiac echocardiogram was done which showed an ejection fraction of 70% with no wall motion abnormalities. The patient had some degree of pulmonary edema secondary to extravascular volume overload due to a combination of acute tubular necrosis and cirrhosis. The patient was given Lasix 40 mg intravenously twice per day with excellent diuresis. The patient always maintained good oxygenation with oxygen saturations in the mid 90s on room air. 3. INFECTIOUS DISEASE ISSUES: The patient had a left lower extremity cellulitis, and 2/4 bottles grew coagulase-negative Staphylococcus. The source for the bacteremia was thought to be related to her central line. The patient was to be continued on a 14-day course of vancomycin and Flagyl to cover her cellulitis and a possible line infection. The patient also had a urinalysis checked on the floor secondary to hematuria which revealed many bacteria. She was started on Levaquin as well; pending urine culture identification and sensitivity results. The patient remained afebrile throughout her stay on the floor. 4. GASTROINTESTINAL ISSUES: The patient has end-stage liver disease and cirrhosis secondary to nonalcoholic steatohepatitis. While in the Medical Intensive Care Unit, there was a transient elevation in her transaminases which was attributed either to hepatic congestion versus hepatic ischemia from hypotension. However, the patient's transaminases returned toward her baseline toward the end of her hospital stay. 5. HEMATOLOGIC ISSUES: The patient had one blood transfusion while in the Medical Intensive Care Unit for a hematocrit of 27. No bleeding source was identified. The patient likely has anemia secondary to liver disease. The patient is also thrombocytopenic; likely from sequestration with her liver disease and splenomegaly. 6. ENDOCRINE ISSUES: The patient was continued on NPH and a regular insulin sliding-scale; as [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. Insulin doses were constantly adjusted as the patient had increasing insulin requirements throughout her hospital stay as her oral intake increased. 7. MOBILITY ISSUES: The patient was fairly reluctant to mobilize herself and to cooperate with Physical Therapy, as she continuously complained of feeling tired and felt uncomfortable with the edema in her hands and legs. However, Physical Therapy recommended that the patient would benefit from a rehabilitation stay prior to discharge home. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: The patient was to be discharged to rehabilitation. MEDICATIONS ON DISCHARGE: 1. Levofloxacin 250 mg p.o. q.24h. 2. Spironolactone 50 mg p.o. twice per day. 3. Potassium chloride 40 mEq p.o. twice per day. 4. Vancomycin 1 g intravenously q.12h. (to complete a 14-day course). 5. Lactulose 30 cc p.o. q.8h. as needed (titrated to three loose bowel movements per day). 6. Miconazole powder. 7. Heparin 5000 units subcutaneously q.12h. 8. Furosemide 40 mg intravenously twice per day. 9. Flagyl 500 mg p.o. three times per day. 10. Albuterol nebulizers as needed. 11. Acular. 12. Prednisolone. 13. Flurbiprofen eyedrops. 14. Aspirin 81 mg p.o. once per day. 15. Tocopheryl 400 units p.o. once per day. 16. Tramadol 15 mg p.o. q.12h. as needed. 17. Tylenol p.o. as needed. 18. Phenaseptic throat spray as needed. 19. Colace 100 mg p.o. twice per day. 20. Brimonidine eyedrops. 21. Albuterol meter-dosed inhaler 1 to 2 puffs inhaled q.4-6h. as needed. 22. Protonix 40 mg p.o. once per day. 23. Levothyroxine 75 mcg p.o. once per day. 24. NPH 40 units subcutaneously q.a.m. and 20 units subcutaneously q.p.m. 25. Regular insulin sliding-scale. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**] Dictated By:[**Name8 (MD) 2692**] MEDQUIST36 D: [**2152-3-28**] 19:25 T: [**2152-3-28**] 19:37 JOB#: [**Job Number 102150**] Admission Date: [**2152-3-16**] Discharge Date: [**2152-3-30**] Date of Birth: [**2082-2-7**] Sex: F Service: [**Hospital1 **] MED HISTORY OF PRESENT ILLNESS: This 70 year old woman is transferred from the Medical Intensive Care Unit to the Floor after originally being transferred to the Medical Intensive Care Unit from [**Hospital 4199**] Hospital with acute renal failure and hypotension. She has a history of cirrhosis secondary to NASH and has recently been treated for left lower extremity cellulitis. She was admitted to [**Last Name (un) 4199**] on [**3-16**], originally presenting for a twisted ankle, but found to have a creatinine of 5.7. After dialysis she had a systolic blood pressure in the 90s and was started on a Dopamine drip. She was transferred to [**Hospital1 69**] later that day. Here, she has required multiple dialysis sessions for volume overload as well as vasopressors (initially Dopamine changed to Norepinephrine for tachycardia) to maintain her blood pressure. She has grown coagulase negative Staphylococcus from two blood culture bottles. Her urine was negative for Eosinophils and had muddy casts. Her initial FENA was less than 0.4%. She has also had elevated troponin with peak 14.7, and an echocardiogram revealing no wall motion abnormalities. Overall, her clinical picture has been considered to be most consistent with hypotension secondary to intravascular volume depletion resulting in decreased renal perfusion, prerenal azotemia, and acute tubular necrosis. PAST MEDICAL HISTORY: 1. Cirrhosis secondary to nonalcoholic steatohepatitis complicated by ascites, esophageal varices, hepatic encephalopathy, decreased synthetic function (hypoalbuminemia and coagulopathy), anemia with increased MCV and thrombocytopenia. 2. Type 2 diabetes mellitus requiring insulin. 3. Chronic lower extremity edema and recurrent cellulitis. 4. Hypothyroidism. 5. Dyslipidemia. 6. Asthma. 7. Obesity. 8. Migraine headaches. 9. Cholelithiasis. 10. Glaucoma. 11. Cataracts. 12. Sensory neuropathy. 13. Cervical spondylotic radiculopathy. MEDICATIONS ON TRANSFER: 1. Vancomycin. 2. Aztreonam. 3. Aspirin. 4. NPH insulin 29 units in the morning and 12 units in the evening. 5. Humalog insulin sliding scale. 6. Levothyroxine 75 micrograms q. day. 7. Metronidazole. 8. Lactulose. 9. Vitamin E. 10. Renagel. 11. Tramadol p.r.n. 12. Albuterol p.r.n. 13. Protonix. 14. Eye drops including Acular, prednisolone, Flurbiprofen, and Brimonidine. ALLERGIES: Penicillin causes rash; clarithromycin causes rash and Keflex causes an unknown reaction. SOCIAL HISTORY: The patient lives at home with her husband. She denies alcohol use, smoking, and illicit drug use. She has a son who lives in [**Name (NI) 78383**], [**Name (NI) 531**]. FAMILY HISTORY: A maternal uncle and aunt had type 2 diabetes mellitus and coronary artery disease. Her father is deceased from a pulmonary embolism. PHYSICAL EXAMINATION: At time of transfer, temperature maximum 98.4 F.; heart rate 79 to 88; blood pressure 98 to 116 over 25 to 53; respirations 19; oxygen saturation 95% on room air. Intake 1230, output 705. In general, obese, jaundiced woman, sitting in a bedside chair, in no distress. HEENT: Sclerae anicteric. Pupils round, 3 millimeters going to 2 millimeters with light. Oral mucosa moist without lesions. Neck with right IJ line, nontender, non-erythematous. No left carotid bruit; supple. Lungs with crackles one half of the way up in bilateral lung fields. Heart: Regular rate, rhythm, normal S1, S2, Grade II/VI systolic ejection murmur over the upper sternal border. Abdomen: Obese, soft, nontender, palpable spleen, normoactive bowel sounds. Extremities: Two plus pitting edema in arms and legs; 5 by 2 centimeter ulcer in the left pretibial region. Neurological: Alert, mentating well, moving four extremities spontaneously. LABORATORY: White blood cell count 6.9, hematocrit 27.3, platelets 50, INR 1.6, PTT 33.5. Sodium 136, potassium 3.3, chloride 104, total carbon dioxide 22, BUN 34, creatinine 2.2, glucose 195, calcium 8.7, magnesium 1.7, phosphate 3.2. ALT 124, AST 111, alkaline phosphatase 354, total bilirubin 4.2, LDH 362, amylase 48, lipase 40. Blood cultures [**3-17**], coagulase negative Staphylococcus times two bottles, oxacillin resistant; [**3-19**], no growth to date from four bottles. Chest radiograph [**3-20**] with bilateral interstitial edema, bilateral pleural effusions. Echocardiogram [**3-17**], left ventricular ejection fraction greater than 75%, no regional wall motion abnormalities, trivial mitral regurgitation. HOSPITAL COURSE BY PROBLEM: 1. ACUTE RENAL FAILURE: The patient, as stated above, had acute renal failure likely secondary to acute tubular necrosis. By the time she was transferred to the Floor, she was producing a good amount of urine. Her creatinine continued to trend downward and returned to her baseline level of 1.2 prior to discharge. 2. EXTRAVASCULAR VOLUME OVERLOAD WITH PERIPHERAL AND INTERSTITIAL PULMONARY EDEMA: These problems likely had multiple contributing factors, including the patient's renal failure and her hypoalbuminemia secondary to liver failure. Initially, after arrival to the floor, the patient auto-diuresed without the aid of supplemental diuretics. Prior to discharge, the patient was placed back on a Lasix regimen and produced good urine in response. Her discharge dose of Lasix was 80 mg p.o. twice a day. 3. NON-ST ELEVATION MYOCARDIAL INFARCTION: As aforementioned the patient had evidence of myocardial infarction based on cardiac enzymes when she was in the Intensive Care Unit. This infarction was attributed to increased myocardial oxygen demand as opposed to a discrete coronary artery lesion. The patient was continued on aspirin. She did not complain of any chest pain throughout her admission. 4. LEFT LOWER EXTREMITY CELLULITIS, MSSE BACTEREMIA: The patient was continued on antibiotics for these problems. She received a total of a 14 day course of Metronidazole and Vancomycin. By the time of discharge, her cellulitis appeared to be improving. She was afebrile throughout her time on the floor. DISCHARGE DIAGNOSES: 1. Status post acute renal failure secondary to acute tubular necrosis. 2. Status post non-ST elevation myocardial infarction. 3. Non-cardiogenic pulmonary edema. 4. Chronic liver failure secondary to nonalcoholic steatohepatitis and complicated by hypoalbuminemia, esophageal varices, anasarca, history of hepatic encephalopathy. 5. Obesity. 6. Chronic macrocytic anemia, likely secondary to liver failure. 7. Chronic thrombocytopenia secondary to splenic sequestration. 8. Recurrent cellulitis. 9. Coronary artery disease. 10. Dyslipidemia. 11. Type 2 diabetes mellitus requiring insulin. 12. Hypothyroidism. 13. Asthma. 14. History of migraine headaches. 15. Fibromyalgia. 16. Glaucoma. 17. Cataracts. 18. Cervical spondylosis. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To [**Hospital6 310**]. DISCHARGE MEDICATIONS: 1. Synthroid 75 micrograms q. day. 2. Protonix 40 mg q. day. 3. Albuterol. 4. Brimonidine drops. 5. Colace. 6. Tramadol 50 mg q. 12 hours p.r.n. 7. Vitamin E. 8. Aspirin 81 mg q. day. 9. Flurbiprofen eye drops. 10. Prednisolone eye drops. 11. Ketorolac eye drops. 12. Metronidazole 500 mg three times a day for three days. 13. Vancomycin one gram q. 12 hours for three days. 14. Heparin 5000 units subcutaneously q. 12 hours. 15. Lactulose 30 ml q. eight hours p.r.n. 16. NPH insulin 42 units q. a.m. and 22 units q. p.m. 17. Levofloxacin one tablet q. 24 hours for a seven day course for a urinary tract infection. 18. Spironolactone 100 mg twice a day. 19. Potassium 40 mEq twice a day. 20. Furosemide 80 mg p.o. twice a day. 21. Regular insulin sliding scale. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**] Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD MEDQUIST36 D: [**2152-5-11**] 15:33 T: [**2152-5-19**] 21:23 JOB#: [**Job Number 102151**]

[ "572.2", "428.0", "789.5", "682.6", "584.5", "707.10", "410.71", "571.5", "287.4" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

15394, 15530

18801, 19542

19644, 20729

11207, 12719

7071, 11057

15554, 17218

11072, 11180

17246, 18780

12749, 14106

14699, 15186

14128, 14674

15204, 15376

19568, 19621

25,596

107,350

23437

Discharge summary

report

Admission Date: [**2108-12-29**] Discharge Date: [**2109-1-10**] Date of Birth: [**2036-11-27**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 72-year-old male with a known history of coronary artery disease, status post percutaneous transluminal coronary angioplasty ten years ago. He presented to an outside hospital emergency department on [**2108-12-29**] with complaints of dyspnea. He was found to be bradycardiac with a heart rate in the 30's and had ST depressions and congestive heart failure. He was transferred to [**Hospital1 69**] for evaluation and treatment. He was admitted to the hospital on [**2108-12-29**] via the Medical Service and then referred to the Cardiology service for treatment of his congestive heart failure and evaluation of his coronary artery disease. He was diuresed over the first two days of admission. PAST MEDICAL HISTORY: 1. Coronary artery disease status post percutaneous transluminal coronary angioplasty ten years ago. 2. Hypertension. 3. Congestive heart failure. Please note, the patient denied a history of hypertension. PAST SURGICAL HISTORY: Tonsillectomy. ALLERGIES: No known drug allergies. MEDICATIONS: At the time being seen by Cardiac Surgery consult: 1. Cardizem 30 mg daily. 2. Aspirin 325 mg p.o. daily. The patient lives with his wife, he works part time as an instructor at the Buck [**Doctor Last Name **] Community College. He quit smoking four years ago with an approximately 30 to 40 pack year history. He admits to one glass of wine or beer at dinner occasionally. FAMILY HISTORY: Noncontributory. He stated that he was "exceedingly healthy." PHYSICAL EXAMINATION: On examination he is 5 feet, 10 inches tall, 175 pounds. Blood pressure 150/70, heart rate 70, respiratory rate 18, sating 96 percent on room air. He was laying flat in bed in no apparent distress when he was seen on consult. He was alert and oriented times three and appropriate and grossly neurologically intact. His lungs were clear to auscultation bilaterally anteriorly. His heart was regular rate and rhythm with frequent premature ventricular contractions and premature atrial contractions. He had a Grade 1/6 systolic ejection murmur heard best at apex. His abdomen was soft, nontender, nondistended with bowel sounds. His extremities were warm and well perfused. He had 2 plus radial pulses on the right, 1 plus on the left. 2 plus dorsalis pedis pulses on the right, 1 plus on the left, 1 plus posterior tibial pulses on the right, 2 plus on the left. LABORATORY FINDINGS: Preoperative labs were as follows, white count 6.9, hematocrit 41.8, platelet count 167,000. Sodium 143, creatinine 3.8, chloride 107, bicarbonate 26, BUN 16, creatinine 0.9 with a blood sugar of 164. Preoperative chest x-ray showed minimal upper zone redistribution and small bilateral pleural effusions indicating possible left heart failure. No other significant cardiopulmonary abnormality was identified. Please refer to the final report dated [**2108-12-30**]. Additional labs: Protime 12.5, PTT 53.1, INR 1.2, ALT 15, AST 15, alkaline phosphatase 59, total bilirubin 0.7, albumin 3.6. Preoperative echocardiogram showed an ejection fraction of 15 percent and left ventricular hypokinesis. The patient was treated for his congestive heart failure in preparation for cardiac catheterization to evaluate his coronary artery disease. Cardiac catheterization was performed on [**2108-12-31**] with the following results. The patient was right dominant coronary system. He had a tapering 20 percent distal left main lesion, 80 percent left anterior descending coronary artery lesion, 80 percent circumflex lesion proximally and a 50 percent posterior descending coronary artery lesion. The patient was referred to Dr. [**Last Name (STitle) **] for coronary artery bypass surgery. Urinalysis was negative. Please refer to the final report. The patient was seen by Dr. [**Last Name (STitle) **]. Risks and benefits of surgery were discussed. The patient's cardiac enzymes were negative. He was started on Carvedilol preop 3.125 mg p.o. twice a day. He was also continued on aspirin, Lipitor and intravenous Heparin therapy. Given his poor ejection fraction Dr. [**Last Name (STitle) **] requested a myocardial viability study which showed that there was perfused myocardium. The patient had a left bundle branch block on electrocardiogram preoperatively as well as many premature ventricular contractions. The patient was accepted for coronary surgery and on [**2109-1-3**] underwent coronary artery bypass graft times two by Dr. [**Last Name (STitle) **] with a left internal mammary artery to the left anterior descending coronary artery and vein graft to the circumflex. He was transferred to Cardiothoracic intensive care unit in stable condition. Of note, Swann-Ganz catheter was unable to be placed in the operating room despite multiple attempts under echocardiography by Anesthesia Team. The patient was transported to the cardiac catheter laboratory prior to the start of his surgery for Fluoroscopic placement of a right IJ Swann. Fluoroscopy and injection at Catheter laboratory revealed a communication of the right IJ with a persistent left SVC without flow through any right SVC. Swann-Ganz catheter in the Catheterization Laboratory was placed using left femoral vein approach. Please refer to the Catheterization laboratory report dated [**2109-1-3**]. On postop day one the patient had no events overnight, remained ventilated on Propofol drip at 0.8 mcg per kg per minute. He was also on an epinephrine drip at 1.0 and Lidocaine drip at 2.0. Postop labs are as follows: White count 10, hematocrit 31, K 4.1, BUN 11, creatinine 0.9 with a blood sugar of 90. On postoperative evening on [**2109-1-3**] the Swann-Ganz catheter was inadvertently pulled out. The Swann-Ganz catheter was refloated by Cardiology under fluoroscopy in the Cardiothoracic Intensive care unit. The patient continued to be followed as he was preoperatively by Dr. [**Last Name (STitle) **] from Cardiology Heart Failure Service. On postop day two the patient was extubated and was weaned off his epinephrine drip. Lasix diuresis was begun. He was hemodynamically stable at blood pressure 117/56, slightly tachycardiac in the 90's but sating at 96 percent on four liters nasal cannula. Melranone drip continued at 0.4 mcg per kg per minute and insulin drip at 4 units per hour. His creatinine remained stable at 1.0, the patient was doing well. Was alert and oriented appropriately and he remained in the CSRU for monitoring. On postop day three, Melranone drip was weaned off, Neo- Synephrine was off, the patient remained on an insulin drip at 3 units per hour. His Carvedilol was restarted at 3.125 mg p.o. twice a day to try and bring his heart rate back down. On examination his heart rate was at 78 with Carvedilol in sinus rhythm and a stable blood pressure 110/51. His hematocrit also remained stable at 30.6. Swann- Ganz catheter was removed later in the day as was the cortis introducer and his radial A-line. On postop day four the patient's pacing wires were removed. He was switched over to p.o. Percocet for pain. He was hemodynamically stable, alert and oriented. His examination was unremarkable. Incisions were clean, dry and intact. His pacing wires were removed. He continued on his aspirin therapy and Ace inhibitor therapy was restarted with Lisinopril at 2.5 mg p.o. once daily. The patient was transferred out to the floor where he was evaluated by physical therapy and continued to be seen by the Congestive Heart Failure fellow every day who recommended continuing him on Carvedilol. The patient did have some slightly erythematous areas over his coccyx with some broken skin spots. His coccyx was covered with DuoDerm for protection, also a small area of skin sloughing and to help keep the area cleaned. He also had some small skin tears at his right groin catheter site, this was also treated with DuoDerm, his incisions continued to heal. The patient was out of bed and ambulating. He had occasional premature atrial contractions on telemetry but continued to progress. He also had one episode of wide complex tachycardia, approximately 20 beats in the heart rate range of 112 to 180. On the evening of the 13th electrocardiogram was done which showed his original bundle branch block and heart rate back in 70 to 80 range with frequent premature ventricular contractions and couplets. At the time his potassium was 5.1,, his magnesium 2.2. He maintained his blood pressure throughout the episode. His 12 lead electrocardiogram showed no ischemia. The patient was evaluated by the Cardiac Surgery Fellow at the time this occurred. He was evaluated by the EP Fellow the next morning who recommended he should be worked up in approximately one month for re-evaluating his very low ejection fraction at 15 percent and be evaluated as an outpatient with a cardiac MRI and repeat viability study by Dr. [**Last Name (STitle) 60086**]. His Carvedilol was increased to 6.125 mg twice a day. On postop day six, his exam was again unremarkable other than some rales at the left base. He continued with his Carvedilol and Lisinopril therapy and remained on sliding scale insulin for slightly elevated blood sugars. His hematocrit remained stable at 29.7, white count of 9.0 and creatinine of 1.1. He continued to have frequent premature ventricular contractions and some couplets but no other episodes of V-tach in that 24 hour period. He continued to improve his ambulation status and ambulated four times during that day prior to discharge. Request was filed for cardiac MR to be performed at the request of Dr. [**Last Name (STitle) 60086**]. On postop day seven the patient completed a Level Five, was doing very well with plans to discharge him during the day. He was in sinus rhythm at a rate of 70 with a blood pressure of 141/72 and respiratory rate of 18. LABORATORY FINDINGS: Before discharge white count 8.4, hematocrit 28.6, platelet count 307, sodium 141, K 4.4, chloride 103, bicarbonate 31. BUN 22, creatinine 1.0, blood sugar 115. Magnesium 2.0. His examination was unremarkable. His heart was regular rate and rhythm on examination. Lungs clear bilaterally. The incisions were clean, dry and intact. His Lisinopril was increased to 5 mg p.o. once a day, Lasix was decreased to once a day therapy. He was discharged to home with VNA services on [**2109-1-10**] after his final evaluation by Physical Therapy. DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass graft times two. 2. Cardiomyopathy. 3. Coronary artery disease status post percutaneous transluminal coronary angioplasty ten years ago. 4. Hypertension. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. once a day times two weeks. 2. Potassium chloride 10 mEq p.o. once a day times two weeks. 3. Colace 100 mg p.o. twice a day times one month. 4. Percocet 5/325 mg one to two tablets p.o. q 4 hours as needed for pain. 5. Aspirin Entericoated 81 mg one tablet p.o. once a day. 6. Lisinopril 5 mg once a day. 7. Carvedilol 6.25 mg p.o. twice a day. The patient was instructed to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 39288**] in approximately one to two weeks post discharge and do follow-up with Dr. [**Last Name (STitle) 60086**] of the Electrophysiology Service in one month after he completed his Magnetic resonance imaging study. The patient was told the Radiology Department would schedule his magnetic resonance imaging for approximately one month after surgery and he should see Dr. [**Last Name (STitle) 60086**] after that. The patient was also instructed to follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**], his heart failure cardiologist in approximately three to four weeks post discharge and to see Dr. [**Last Name (STitle) **] in the office in three to four weeks after his operation for his postop surgical check. He was discharged to home in good condition on [**2109-1-10**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2109-2-13**] 09:58:19 T: [**2109-2-13**] 12:55:14 Job#: [**Job Number 60087**]

[ "496", "V45.82", "428.0", "411.1", "424.0", "425.4", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "89.64", "88.52", "88.56", "37.23", "36.11", "36.15" ]

icd9pcs

[ [ [] ] ]

1598, 1662

10830, 12359

10610, 10807

1137, 1581

1685, 10589

167, 880

902, 1113

5,996

165,806

53041+53042

Discharge summary

report+report

Admission Date: [**2167-9-18**] Discharge Date: [**2167-9-24**] Date of Birth: [**2106-12-16**] Sex: F Service: MED ICU HISTORY OF PRESENT ILLNESS: This is a 60 year old white female with a history of bronchospasm, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (ejection fraction of 60 to 70% on [**2167-8-30**]) who presents with shortness of breath with productive cough and lower extremity edema. The patient was recently admitted from [**9-1**] until [**2167-9-3**], with complaints of shortness of breath and bilateral lower extremity edema, and facial edema. Chest x-ray showed mild congestive heart failure at that time. She was treated with Lasix which is new for her congestive heart failure, even though the ejection fraction was 60 to 70% by transthoracic echocardiogram. She was also given a Prednisone taper for suspected chronic obstructive pulmonary disease flare which ended on [**2167-9-17**]. Since discharge on [**2167-9-3**], the patient did fine for the first week, however, four days prior to admission, the patient called her primary care provided, Dr. [**Last Name (STitle) **], with increased bilateral lower extremity edema because she had stopped her Lasix secondary to excessive urination. The patient was told to restart the Lasix. One day prior to admission, the patient came in to the primary care provider's office with an increased lower extremity edema and mild productive cough. She also complained of shortness of breath without fevers or chills. She was started on two liters of home O2 one day prior to admission and then returned to her primary care provider on day of admission looking pale, off her oxygen. Her saturation was 60% on room air and 88% on two liters of oxygen by nasal cannula. She was sent to the [**Hospital1 69**] Emergency Department where her blood pressure was 108/60 and heart rate of 90. Her respiratory rate at that time was 32 and she was saturating at 90% on ten liters and non-rebreather. An arterial blood gas revealed a pH of 7.29, CO2 of 84 and pO2 of 30. Since she was somnolent, she was started on Bi-PAP 5/5/35% FIO2 with oxygen saturation at 98%. Chemistries in the Emergency Department revealed a sodium of 117. CPK was 175 with MB of 25. The troponin was less than 0.3. The patient was started on dictation ended abruptly [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern1) 4270**] MEDQUIST36 D: [**2167-9-24**] 12:52 T: [**2167-9-24**] 13:24 JOB#: [**Job Number 109315**] Admission Date: [**2167-9-18**] Discharge Date: [**2167-9-24**] Date of Birth: [**2106-12-16**] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 60 year old white female with a history of bronchospasm, chronic obstructive pulmonary disease, hypertension, and congestive heart failure with a left ventricular ejection fraction of 60% to 70% in [**2167-8-30**], who presents with shortness of breath with productive cough and increased lower extremity edema. The patient was recently admitted from [**9-1**] with complaints of shortness of breath, bilateral lower extremity edema and facial edema. Chest x-ray showed mild congestive heart failure at that time and she was treated with Lasix, which is new for her. She was started on Lasix despite the fact that her transthoracic echocardiogram revealed a left ventricular ejection fraction of 60% to 70% and 1 to 2+ aortic regurgitation. She was also given a Prednisone taper for suspected chronic obstructive pulmonary disease flare during that hospitalization, and this taper ended on [**2167-9-17**]. Since discharge on [**2167-9-3**], the patient did well for the first week, however, four days prior to admission, she called her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], with complaints of increased bilateral lower extremities edema because she had stopped her Lasix secondary to excessive urination. Dr. [**Last Name (STitle) **] told the patient to restart her Lasix. One day prior to admission, the patient [**Doctor First Name **] to Dr. [**Last Name (STitle) 109316**] office with increased bilateral lower edema, a mild productive cough and shortness of breath. She was started on two liters of home oxygen on the day prior to admission. The patient then returned to her primary care physician on the day of admission looking pale off of her oxygen. Her oxygen saturation was 60% in room air and 88% on two liters of oxygen. The patient was sent to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **], where her blood pressure was 159/79, heart rate 83, respiratory rate 18 and oxygen saturation 94% on four liters. Arterial blood gases were done and revealed a pH of 7.29, pCO2 84 and pO2 30. Since the patient was somnolent, she was started on BIPAP 5/5/35% FiO2. Her oxygen saturation was 98% with the BIPAP. Chemistries showed a sodium of 117 and CPK of 175 with an MB of 25 and troponin of less than 0.3. The patient was initially started on intravenous Solu-Medrol 80 mg three times a day and nebulizers. She was electively intubated for hypercarbic respiratory failure. ALLERGIES: Tiazac and E-Vista. MEDICATIONS ON ADMISSION: Celexa 20 mg p.o.q.d., Remeron 30 mg p.o.q.d., Proventil meter dose inhaler, Zantac 150 mg p.o.b.i.d., aspirin, Lasix 40 mg p.o.q.d. and Prednisone 16 mg taper which ended one day prior to admission. PAST MEDICAL HISTORY: 1. Bronchospasm. 2. Chronic obstructive pulmonary disease with pulmonary function test on [**2167-4-6**] showing FVC 1.51/2.66 giving 57% of predicted, FEV1 0.74/1.94 given 38% of predicted, FEV1FVC 49/73 giving 60% predicted with no response to bronchodilators. 3. Hypertension. 4. Congestive heart failure, [**2167-9-3**] transesophageal echocardiogram revealing a left ventricular ejection fraction of 60% to 70%, right and left atrial dilation, right ventricular hypertrophy, global hypokinesis, 1 to 2+ aortic regurgitation and 2+ tricuspid regurgitation, no pericardial effusion at the time. 5. Anxiety. 6. Depression. 7. Hiatal hernia. 8. Glaucoma/cataracts. 9. Gastroesophageal reflux disease. SOCIAL HISTORY: The patient lives at home alone. She denies any alcohol or illicit drug use, however, she still smokes one pack per day with a 50 pack year history. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a temperature of 97.1, blood pressure 116/63, pulse 72, respiratory rate 20 and oxygen saturation 98% on BIPAP 5/5/35%. General: Very drowsy and barely arousable female, not tachypneic or using respiratory muscles. Head, eyes, ears, nose and throat: Pupils equal, round, and reactive to light, oropharynx moist, BIPAP mask on, prominent external jugular vein with mild jugular venous pressure. Cardiovascular: Regular rate and rhythm, normal S1 and S2, hard to appreciate secondary to BIPAP. Lungs: Poor air movement bilaterally with occasional bilateral wheezes, coarse crackles in bases bilaterally one-third up. Abdomen: Soft, nontender, obese, positive bowel sounds. Extremities: Bilateral lower extremity edema, right greater than left. LABORATORY DATA: Admission white blood cell count was 9.8, hemoglobin 14.8, hematocrit 44.3, platelet count 299,000, differential with 84% neutrophils, 2% bands, 10% lymphocytes and 4% monocytes, sodium 117, potassium 4.2, chloride 74, bicarbonate 37, BUN 19, creatinine 0.6, glucose 106, anion gap 18, ALT 32, AST 34, alkaline phosphatase 103, total bilirubin 0.4, albumin 3.9, CK 174, CK/MB 25, index 14.4, troponin less than 0.3 and TSH 0.61. Electrocardiogram: Normal sinus rhythm at 57 beats per minute, normal axis and intervals, biphasic T waves in V2, otherwise no other acute ST-T changes. Chest x-ray: Possible mild congestive heart failure with no signs of pneumonia or effusion, breast tissue attenuation with mild bilateral atelectasis, positive chronic obstructive pulmonary disease. Arterial blood gases: pH 7.29, pCO2 84, pO2 30; pH 7.34, pCO2 68, pO2 73. HOSPITAL COURSE: 1. Respiratory: (a) Hypercarbic respiratory failure. The patient was initially continued on pressure of [**2100-5-2**]%. An arterial line was put in and she was continued on intravenous Solu-Medrol 80 mg every eight hours. She was also given albuterol/Atrovent nebulizers every one to two hours. Since she was on the Solu-Medrol, the patient was put on a regular insulin sliding scale and intravenous Protonix 40 mg daily. Sputum cultures were sent for Gram stain also. The patient was sedated with Ativan and fentanyl since she was intubated. The patient was then switched over to SIMV with pressure support of 550 times 10 for respiratory rate, 5 of pressure support and 5 of PEEP with an FiO2 of 40%. The patient was then weaned off to just pressure support and eventually extubated. She did quite well and her intravenous Solu-Medrol was weaned down to 40 mg daily and then switched over to oral Prednisone 60 mg daily. During the hospitalization, the patient was continued on her respiratory therapy, nebulizers and worked with the nurses in getting out of bed. (b) Tracheobronchitis: The patient did show signs of tracheobronchitis with initial sputum production. Sputum Gram stain did show gram positive cocci so the patient was put on intravenous Levaquin 500 mg daily. Upon discharge, she completed six out of a ten day course for her tracheobronchitis. The patient is to finish the last of her course at rehabilitation. 2. Cardiovascular: The patient was cycled on her cardiac enzymes. The patient was initially put on heparin but that was discontinued after her cycled CKs turned out to be normal. The patient was then just put on aspirin 325 mg daily. Since the patient was self-diuresing herself quite well, she was not given any Lasix and ended up being minus four liters over the course of the hospitalization. She did not become symptomatic for her congestive heart failure. The patient had episodes of bradycardia early in the hospitalization, so her Haldol was discontinued because her electrocardiogram showed some prolonged QT that may be secondary to the Haldol. The patient also developed tachycardia during the hospitalization. She had one or two episodes where she would have 12 to 16 beats of supraventricular tachycardia. Her electrolytes at the time revealed a potassium a bit low at 3, but then that was replenished. Her cardiac enzymes were cycled a second time and were found to be negative once again. During times of her bradycardia and tachycardia, the patient also showed some new electrocardiographic changes. During the bradycardia, the patient had developed some new biphasic T waves in V2 and V3, During the tachycardia, she developed biphasic T waves in II and III. Again, her cardiac enzymes were normal, so nothing was done. It is believed that her hypoxia may be contributing to the slight ischemic changes on electrocardiogram. 3. Endocrine: The patient had hyponatremia which may be secondary to dehydration or her congestive heart failure. She was initially given one liter of normal saline slowly so that she is not depleting more than 0.5 mEq per hour. Her sodium was then corrected back to baseline. 4. Gastrointestinal: The patient did develop some positive gastric occult tests while on the high dose of Solu-Medrol. Her Protonix was increased from 40 mg daily to twice a day, however, her hematocrit remained stable at around 39 to 40. It was recommended that an esophagogastroduodenoscopy may be done on an outpatient basis; we did not do one at this time because of her stable hematocrit. 5. Neurologic: (a) Change in mental status: The patient's change in mental status may be due to many factors. It may be due to steroid psychosis, hyponatremia, stroke, hypoxia, nicotine withdrawal and/or alcohol withdrawal. To address these issues, we corrected her hyponatremia and hypoxia. Her steroids were tapered. She was given a 21 mg patch of nicotine each day and given Ativan as needed for any alcohol withdrawal signs. Also, she was sent for a CT scan of the head, which showed no new bleeds or mass. (b) Alcohol use: The patient was checked for B12 and folate levels, which were normal. She was also given B12, folate and thiamine. Her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] check into her drinking history. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE DIAGNOSES: 1. Hypercarbic respiratory failure secondary to chronic obstructive pulmonary disease. 2. Tracheobronchitis. 3. Congestive heart failure. 4. Hyponatremia. 5. Change in mental status. DISCHARGE MEDICATIONS: Celexa 20 mg p.o.q.d. Remeron 30 mg p.o.q.d. Prevacid 30 mg p.o.q.d. Aspirin 325 mg p.o.q.d. Proventil meter dose inhaler two puffs q.i.d. Levaquin 500 mg p.o.q.d. times four days. Lasix 40 mg p.o.q.d. Prednisone 40 mg p.o.q.d. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern4) 93107**] MEDQUIST36 D: [**2167-9-24**] 13:13 T: [**2167-9-24**] 13:28 JOB#: [**Job Number **]

[ "491.21", "428.0", "276.1", "276.4", "401.9", "518.81", "293.0", "410.11", "305.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.91", "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

12660, 12708

12729, 12918

12941, 13439

5415, 5616

8251, 11868

6548, 8233

2816, 5388

11884, 12638

5639, 6357

6374, 6525

63,621

124,508

35528

Discharge summary

report

Admission Date: [**2134-6-18**] Discharge Date: [**2134-7-2**] Date of Birth: [**2068-8-13**] Sex: M Service: SURGERY Allergies: Gammar Attending:[**First Name3 (LF) 1481**] Chief Complaint: esophageal carcinoma Major Surgical or Invasive Procedure: [**2134-6-18**] laparoscopic esophagogastrectomy [**2134-6-23**] thoracentesis History of Present Illness: 65-year-old man with a history of Barrett's esophagus, who has been followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He had an endoscopy for surveillance and had a very small raised area, which was biopsied and found to be adenocarcinoma in a segment of Barrett's esophagus. Since then, he has undergone a number of studies such as a PET-CT, which shows an abnormal focus of uptake in the distal esophagus. There was a focus of uptake in the distal rectum, which was probably physiological. Dr. [**Last Name (STitle) **] has done a colonoscopy, which shows no lesion. Endoscopic ultrasound was done here, which showed a very small mass, which was 4x6 mm. This was thought to be a T1 lesion. Past Medical History: Past medical history: -Early onset Alzheimer's disease -History of prostate cancer status post prostatectomy. ALLERGIC to IgG with an unknown reaction. Past surgical history: -knee surgery -appendectomy -[**Last Name (un) **] surgery for the eye -radical prostatectomy and repair of a right knee meniscal tear. Social History: The patient lives with his wife. [**Name (NI) **] drinks occasionally. He is a heavy smoker and has smoked one and a half pack of cigarettes per day for 36 years. He has tried to quit several times but has gone back to smoking and despite multiple requests by his caregivers recently, he is still smoking though less than one pack per day. He is retired. Family History: History of breast cancer in his mother. Physical Exam: Gen: WDWN male, pleasant, 6"2, 200lbs HEENT: WNL Neck: Supple, without mass, nodes, thyromegaly Chest CTAB with normal percussion Heart: normal sounds, no m/r/g Abd: soft, no t/d/r/g Ext: no c/c/e; diminished pulses in feet; L heel ulcer On discharge, essentially the same except L neck JP drain with small amounts of sputum draining. CTAB and feeding jejunostomy tube in place. Pertinent Results: [**2134-6-18**] 04:44PM BLOOD WBC-12.1* RBC-3.99* Hgb-12.6* Hct-36.8* MCV-92 MCH-31.7 MCHC-34.3 RDW-13.2 Plt Ct-158 [**2134-6-19**] 03:34AM BLOOD WBC-13.1* RBC-4.13* Hgb-13.1* Hct-38.1* MCV-92 MCH-31.7 MCHC-34.4 RDW-13.4 Plt Ct-165 [**2134-6-30**] 07:25AM BLOOD WBC-15.0* RBC-3.84* Hgb-11.8* Hct-34.9* MCV-91 MCH-30.8 MCHC-33.9 RDW-13.7 Plt Ct-468* [**2134-7-1**] 06:45AM BLOOD WBC-12.7* RBC-4.08* Hgb-12.7* Hct-37.3* MCV-92 MCH-31.1 MCHC-34.0 RDW-13.5 Plt Ct-512* [**2134-6-18**] 04:44PM BLOOD PT-14.4* PTT-31.4 INR(PT)-1.3* [**2134-6-18**] 04:44PM BLOOD Glucose-161* UreaN-10 Creat-0.7 Na-135 K-4.6 Cl-107 HCO3-21* AnGap-12 [**2134-6-19**] 03:34AM BLOOD Glucose-140* UreaN-11 Creat-0.8 Na-135 K-4.4 Cl-105 HCO3-21* AnGap-13 [**2134-6-30**] 07:25AM BLOOD Glucose-129* UreaN-16 Creat-0.6 Na-130* K-4.7 Cl-97 HCO3-22 AnGap-16 [**2134-7-1**] 06:45AM BLOOD Glucose-143* UreaN-16 Creat-0.6 Na-130* K-5.0 Cl-98 HCO3-21* AnGap-16 [**2134-6-19**] 09:58PM BLOOD CK(CPK)-495* [**2134-6-18**] 10:03AM BLOOD Type-ART pO2-154* pCO2-43 pH-7.39 calTCO2-27 Base XS-1 Intubat-INTUBATED [**2134-6-18**] 12:03PM BLOOD Type-ART pO2-268* pCO2-49* pH-7.33* calTCO2-27 Base XS-0 Intubat-INTUBATED [**2134-6-18**] 12:03PM BLOOD Glucose-118* Lactate-2.9* Na-137 K-4.0 Cl-106 [**2134-6-18**] 01:19PM BLOOD Glucose-152* Lactate-2.6* Na-137 K-3.9 Cl-104 Pathology: Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 80898**],[**Known firstname 1112**] [**2068-8-13**] 65 Male [**Numeric Identifier 80899**] [**Numeric Identifier 80900**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 80901**]/mtd SPECIMEN SUBMITTED: Esophagectomy, periazygos tissue. Procedure date Tissue received Report Date Diagnosed by [**2134-6-18**] [**2134-6-18**] [**2134-6-24**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/ttl Previous biopsies: [**Numeric Identifier 80902**] Slides referred for consultation. DIAGNOSIS: I. Esophagus and proximal stomach, esophagectomy (A-X, Z-AK): Adenocarcinoma, moderately differentiated, arising in a background of Barrett's esophagus with dysplasia; see synoptic report. II. Periazygous tissue (Y): a. Three lymph nodes with no carcinoma identified (0/3). b. Mature fibroadipose tissue. Esophagus: Resection Synopsis MACROSCOPIC Specimen Type: Esophagectomy. Tumor site: Gastroesophageal junction. Tumor Size Greatest dimension: 1.4 cm. Additional dimensions: 0.5 cm. MICROSCOPIC Histologic Type: Adenocarcinoma. Histologic Grade: G2: Moderately differentiated. EXTENT OF INVASION Primary Tumor: pT1b: Tumor invades submucosa (seen best on slide G, recut level 3). Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 15. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins Proximal margin: Uninvolved by invasive carcinoma. Distal margin: Uninvolved by invasive carcinoma. Circumferential (adventitial) margin: Uninvolved by invasive carcinoma. Distance of invasive carcinoma from closest margin: Approximately 7 mm. Specified margin: Circumferential. Lymphatic (Small Vessel) Invasion: Absent. Venous (Large vessel) invasion: Absent. Additional Pathologic Findings: Intestinal metaplasia, dysplasia, mild esophagitis; active. Chest CT: 1. Postoperative changes following esophagectomy and pull-up procedure, with no evidence of mediastinal extraluminal collections. However, assessment for a leak is limited due to request for no oral contrast. If there remains clinical suspicion for this complication, a fluoroscopic study may be helpful if warranted clinically. 2. Moderate dependent pleural effusions, left greater than right with adjacent atelectasis. 3. Perihilar ground-glass opacities, which may reflect mild hydrostatic edema. Final Report EXAM: PA and lateral chest [**2134-6-30**]. INDICATION: Status post laparoscopic esophagectomy. Please re-evaluate small apical pneumothorax. FINDINGS: Comparison made to multiple priors, most recently [**2134-6-29**]. Small right apical pneumothorax has decreased. Upper mediastinal drain, and overlying surgical staples are unchanged. Cardiomediastinal contours, and neoesophagus are not significantly changed. Left lung remains clear. There is new ill-defined opacity at the right lung base, which may represent areas of subsegmental atelectasis, though aspiration cannot be excluded. Minimal pleural effusion is unchanged. IMPRESSION: 1. Decreased small right apical pneumothorax. 2. New right basilar airspace opacity could represent areas of subsegmental atelectasis, but aspiration cannot be excluded. Brief Hospital Course: The patient went to the operating room for his minimally invasive esophagectomy and jejunostomy-tube placement by Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **]. Intraoperatively there was trouble placing a foley catheter and urology was called for cystoscopy, foley placement, and urethral stricture dilation at bladder neck. He subsequently underwent the above mentioned the procedure and was admitted to the SICU for observation. On [**6-19**] he self-discontinued his nasogastric tube and was noted to be in atrial fibrillation which required a diltiazem drip. On [**6-20**] Dr. [**Last Name (STitle) **] replaced his nasogastric tube without significant event. He was placed on a lasix drip for fluid overload, and an echo was performed without significant result. He was started on trophic tube feeds at that point. On [**6-21**] he converted back to sinus rhythm and his PCA was d/c'ed. His lasix drip continued and he was noted to have som mild amount of erythema around the chest tube site. On [**6-22**] his lasix drip was weaned off, and a CT chest was performed to assess for leak. None was immediately seen though a significant left pleural effusion was noted and ultimately tapped by Dr. [**Last Name (STitle) **] on [**6-23**]. On [**6-24**] he was d/c'ed off his diltiazem drip and was switched to PO. His Chest tube was placed to waterseal. On [**6-25**] he was moved to full strength tube feeds. On [**6-27**] he was noted with RUE swelling and tenderness, UENI was negative. On [**6-27**] he was transferred from the ICU. On [**6-29**] his chest tube and foley were both discontinued with minimal apical pneumothorax (stable). The remainder of his hospital stay was uneventful and he worked with PT in a sufficient manner to be able to be discharged home with services and family supervision. He was NPO the entire time with tube feeds and he will remain that way at least until follow up. He was essentially pain free and excited to leave the hospital. Discharge Medications: 1. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML Mucous membrane [**Hospital1 **] (2 times a day): swish and spit. Disp:*300 ML(s)* Refills:*2* 4. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): please crush and give through J tube. Disp:*120 Tablet(s)* Refills:*2* 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): please crush and give through J-Tube. Disp:*60 Tablet(s)* Refills:*2* 6. Outpatient Physical Therapy Home Physical Therapy per inpatient recommendations Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Status post laparoscopic esophagogastrectomy for esophageal adenocarcinoma Atrial Fibrillation Controlled anastomotic leak Discharge Condition: Stable Discharge Instructions: All medications must be given to J tube only. Nothing by mouth. Diet is tube feeds only. Followup Instructions: Call Dr.[**Name (NI) 1482**] office to follow up in [**11-17**] days. Completed by:[**2134-7-2**]

[ "331.0", "305.1", "427.32", "511.9", "427.31", "512.1", "151.0", "E878.8", "274.9", "294.10", "V10.46", "530.85", "E849.7", "598.2", "707.14" ]

icd9cm

[ [ [] ] ]

[ "96.6", "42.41", "57.32", "43.5", "58.6", "93.56", "54.91", "34.91", "46.39", "57.94" ]

icd9pcs

[ [ [] ] ]

9861, 9910

7166, 9151

286, 367

10076, 10085

2311, 7143

10222, 10322

1855, 1896

9174, 9838

9931, 10055

10109, 10199

1326, 1463

1911, 2292

226, 248

395, 1127

1171, 1303

1479, 1839

26,134

111,956

43882

Discharge summary

report

Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-12**] Date of Birth: [**2060-9-10**] Sex: M Service: NEUROMEDICINE HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old man with bulbar predominant myasthenia [**Last Name (un) 2902**]. His myasthenia was diagnosed in the spring of [**2136**]. His prior treatment has included Mestinon, prednisone, CellCept, IV Ig and Plasmapheresis. He had previously been admitted to the Neurology Service and was discharged to rehabilitation about one month prior to this admission. Over the two weeks prior to admission, his voice became less and less forceful and had an increasing nasal quality to it. He also had progressive dysphagia. He received an IV treatment at rehabilitation but did not have any significant improvement. With his worsening hypophonia and dysphagia, he was sent to the [**Hospital6 1760**] Emergency Department for further evaluation. PAST MEDICAL HISTORY: 1. Myasthenia [**Last Name (un) 2902**]. 2. Diabetes mellitus. 3. Right L5 radiculopathy, status post L5-S1 diskectomy. 4. Old right exotropia. 5. Glaucoma. 6. High cholesterol. 7. Hypertension. 8. BPH, status post TURP. ADMISSION MEDICATIONS: 1. Calcium carbonate 500 mg p.o. t.i.d. 2. Glyburide 5 mg p.o. q.d. 3. Metformin 1 gram p.o. b.i.d. 4. Protonix 40 mg p.o. q.d. 5. Lisinopril 10 mg p.o. q.d. 6. Paxil 10 mg p.o. q.d. 7. Zocor 40 mg p.o. q.d. 8. Flomax 0.4 mg p.o. q.h.s. 9. Nystatin swish and swallow. 10. Lumigan 0.03% drops. 11. Ativan 0.5 mg p.r.n. 12. Insulin sliding scale. 13. CellCept 1,500 mg p.o. b.i.d. 14. Prednisone 100 mg p.o. q.d. 15. Mestinon 75 mg p.o. q.i.d. 16. Mestinon Time Span 180 mg p.o. q.h.s. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.7, heart rate 112, blood pressure 122/43, respiratory rate 20, 02 saturation 97% on room air. General: He was uncomfortable appearing with perfuse secretions. Lungs: His lung sounds were coarse throughout. His negative inspiratory force was -12 and his FVC was 550. Cardiovascular: Tachycardiac without murmurs. Abdomen: Benign. Neurologic: He was awake and alert. His voice was very nasal and of very low volume. He was able to count to 45 in one breath. There was no diplopia or ptosis. He had mild neck flexor weakness. There was mild bilateral deltoid weakness. The rest of the examination was deferred at that time due to his worsening pulmonary status. HOSPITAL COURSE WHILE IN THE ICU: He was admitted to the Intensive Care Unit for close monitoring. His ICU course by system is as follows. 1. NEUROLOGIC: The etiology of his worsening myasthenia symptoms was unclear. However, it was found that he did have a pneumonia which may have triggered his worsening symptoms. His Mestinon was changed to Neostigmine 1.5 mg q. three hours. His prednisone was changed to Solu-Medrol 80 mg IV q.d. His status remained relatively stable over the first few days in the ICU. He was noted to have increased secretions and his Neostigmine dose was decreased and Scopolamine was briefly added but this did not seem to help with his secretions. His respiratory status declined slowly and then more acutely on [**2137-9-2**] requiring intubation. Because of his worsening status, he received plasmapheresis. This was started on [**2137-9-1**] and he received five rounds of plasmapheresis every other day. In addition, cyclosporin was added to his regimen on [**2137-9-2**] at a dose of 50 mg b.i.d. His goal level is 100 with a plan to increase very slowly at 0.5 mg per kilogram per day every month up to an approximate goal dose of 150 mg b.i.d. With the plasmapheresis and cyclosporin, his neurologic examination quickly improved in the ICU. He was able to be extubated on [**2137-9-6**]. His Neostigmine was converted back to PG Mestinon. He was continued on his other myasthenia [**Last Name (un) 2902**] medications. 2. CARDIOVASCULAR: The patient had intermittent tachycardia at times in the ICU of unclear etiology. In the setting of his respiratory distress and emergent intubation, his systolic blood pressure decreased into the 80s and he was briefly on Neo-Synephrine drip to maintain his blood pressures. He also had episodes of bradycardia in relation to the Neostigmine and this resolved when he was converted back to his Mestinon. 3. PULMONARY: On admission, his negative inspiratory force was -12, FVC 550, and he was able to count to 42 in one breath. Chest x-ray on admission showed retrocardiac opacity. Chest CT showed bilateral lower lobe consolidation, left greater than right consistent with aspiration pneumonia. He was initially started on ceftriaxone without significant improvement and, therefore, was changed to levofloxacin and then Flagyl and received a total of ten days of antibiotics. On [**2137-9-1**], he had increasing respiratory distress with markedly elevated carbon dioxide and was, therefore, placed on CPAP. On [**2137-9-2**], he had an acute desaturation into the 70s with a possible aspiration event and required emergent intubation. He was placed on IMV with trials of CPAP and was ultimately extubated on [**2137-9-6**]. 4. INFECTIOUS DISEASE: The patient was febrile at times in the ICU with a presumed source of his aspiration pneumonia. He received antibiotics for a total of ten days, initially ceftriaxone and then levofloxacin and Flagyl. 5. GASTROINTESTINAL: The patient underwent PEG tube placement on [**2137-8-30**] due to his inability to provide adequate nutrition orally. EGD at this time showed a single 4 mm ulcer in the stomach. He was placed on a proton pump inhibitor and H. pylori titers were checked which were negative. In the ICU, he later developed anemia. He, therefore, underwent repeat EGD on [**2137-9-4**] which showed healing of the previously seen ulcer. However, there were multiple erosions and ulcers in the second part of the duodenum. This was thought possibly to be related to his prednisone and CellCept. However, given his tenuous neurologic status these medications were not changed. He was continued on the proton pump inhibitor. The GI Service recommend a follow-up EGD in approximately six to eight weeks to check on the status of these erosions and ulcers. 6. HEME: On [**2137-9-4**], his hematocrit dropped to 26.2. He was transfused 2 units of blood. His workup included stool Guaiac which were negative, EGD, as above, and abdominal CT scan which was negative for retroperitoneal bleed. His PTT was also markedly elevated to as high as 126. This seemed to be related to subcutaneous heparin as it resolved after this was discontinued. The patient was, therefore, continued on Pneumoboots for DVT prophylaxis. 7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was kept on an insulin sliding scale. He briefly required an insulin drip. NPH was added to his regimen. Electrolytes were followed closely and repleted as needed. The Nutrition Service followed the patient and recommended tube feedings which the patient was tolerating. 8. DERMATOLOGY: The patient had a penile ulcer which was treated with sulfadiazine. 9. ACCESS: For access, the patient had a left subclavian Quinton catheter placed on [**2137-9-1**]. With the patient's improved neurologic and respiratory status after the plasmapheresis and cyclosporin, the patient was transferred to the Neurology floor on [**2137-9-8**]. At that time, he felt much improved. His only complaint at that time was hypophonia. He felt that his swallowing and breathing were at about baseline. PHYSICAL EXAMINATION UPON TRANSFER: General: The patient is a chronically ill appearing man in no acute distress. Lungs: He had coarse breath sounds bilaterally. Cardiac: Regular rate and rhythm without murmurs, rubs, or gallops. Abdomen: Benign. The G tube site was clean, dry, and intact. Neurologic: He was awake and alert. On cranial nerve examination, he had a right exotropia. His pupils were equal, round, and reactive to light. His extraocular movements were intact without nystagmus. There was mild bilateral facial weakness. He was able to fully close his eyes but these could be opened by the examiner. His tongue was midline. His tongue strength was decreased. On motor examination, there was mild 5- weakness of the triceps bilaterally. Sensation was intact to light touch. His reflexes were 2+ and symmetric. His toes were downgoing. His finger-nose-finger was normal. HOSPITAL COURSE WHILE ON THE NEUROLOGY FLOOR: 1. NEUROLOGY: The patient was continued on Mestinon, prednisone, CellCept, and cyclosporin. He received his fifth and final round of plasmapheresis on [**2137-9-9**]. His neurologic examination continued to slowly improve. His facial strength improved and he was able to press his lips and whistle. The volume of his voice continued to improve. On [**2137-9-10**], his cyclosporin dose was increased to 100 mg b.i.d. per the Neuromuscular Service. The plan of the Neuromuscular Service at this time is to continue on his current medications and then to perform IV Ig every two weeks with the next round being on [**2137-9-23**]. He has a scheduled follow-up in the [**Hospital 7817**] Clinic on [**2137-9-23**] at 4:00 p.m. 2. CARDIOVASCULAR: There are no significant issues at this time. 3. PULMONARY: The patient continued to have increased secretions but was able to clear these with coughing and suctioning. His chest x-ray on [**2137-9-11**] revealed a small left pleural effusion and stable left lower lobe consolidation. As the patient was afebrile with a stable respiratory status, antibiotics were not restarted. 4. INFECTIOUS DISEASE: The patient had a low-grade fever to 99.3 and a mildly elevated white count. Urinalysis was negative. Urine culture was consistent with contamination. Chest x-ray was stable, as above. Stool C. difficile was negative times two and a third sample was pending. He subsequently had temperatures in the normal range. 5. GASTROINTESTINAL: The patient was continued on a proton pump inhibitor and his tube feeds. He had no significant issues. He had a swallow study on [**2137-9-11**] which cleared him for a pureed solid and thin liquids, extra sauces. 6. HEME: The patient's hematocrit was stable. 7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient's sugars continued to remain high in the 200s and his NPH was gradually increased. PHYSICAL EXAMINATION ON DISCHARGE: Similar to as described above with moderate improvement in his facial strength. MOST RECENT LABORATORY DATA: White blood cell count 10.2, hematocrit 31, platelets 283,000. Sodium 139, potassium 3.7, chloride 102, bicarbonate 32, BUN 22, creatinine 0.7, glucose 224, calcium 8.2, magnesium 2.1, phosphorus 2.1. Cyclosporin 57. The patient has a CBC and chemistries pending from [**2137-9-12**]. The most recent chest x-ray is as above. CONDITION ON DISCHARGE: Stable. NEUROLOGIC FOLLOW-UP with Dr. [**First Name (STitle) **] [**Name (STitle) 557**] DISCHARGE STATUS: To [**Hospital **] [**Hospital **] Hospital. DISCHARGE DIAGNOSIS: 1. Myasthenia [**Last Name (un) 2902**] crisis. 2. Aspiration pneumonia. 3. Diabetes mellitus. DISCHARGE MEDICATIONS: 1. Tylenol 325 to 650 mg PG p.r. q. four hours p.r.n. pain. 2. Lidocaine jelly 2% one application p.r.n. 3. Silver sulfadiazine 1% cream applied to penile ulcer b.i.d. 4. Lorazepam 0.5 to 1 mg IV q. four hours p.r.n. anxiety. 5. Lansoprazole 30 mg PG q.d. 6. CellCept 1,500 mg PG b.i.d. 7. Prednisone 100 mg PG b.i.d. 8. Mestinon 75 mg PG q. six hours and q.h.s. 9. Paxil 20 mg p.o. q.d. 10. Cyclosporin 100 mg PG q. 12. 11. Neutra-Phos one packet p.o. t.i.d. 12. Zinc sulfate 220 mg PG q.d. started on [**2137-9-11**] with a planned duration of 14 days. 13. Vitamin C 500 mg p.o. b.i.d. 14. NPH insulin 14 units q. 12 hours. 15. Insulin sliding scale (please see nursing sheet). 16. Tube feeds Probalance full-strength 70 cc per hour, free water flushes 30 cc q. four hours. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17304**] Dictated By:[**Name8 (MD) 33494**] MEDQUIST36 D: [**2137-9-12**] 10:38 T: [**2137-9-12**] 10:38 JOB#: [**Job Number 94214**]

[ "365.9", "272.0", "263.9", "358.0", "401.9", "507.0", "707.0", "531.90", "285.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "45.13", "43.11", "38.93", "38.91", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

11305, 12354

11183, 11282

1220, 1789

10539, 10981

1804, 10524

967, 1197

11006, 11162

7,381

115,088

48504

Discharge summary

report

Admission Date: [**2173-8-9**] Discharge Date: [**2173-8-26**] Date of Birth: [**2107-5-2**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 102099**] is a 66-year-old woman with past medical history significant for symptoms consistent with neuromuscular disorder. Her symptoms began approximately six months prior to admission and were significant for lower extremity weakness which progressed to the point where she was unable to ambulate. Three weeks prior to admission, she developed upper extremity weakness and dysphagia. She is admitted to outside hospital where workup included equivocal EMG studies, positive P/Q voltage-gated calcium channel antibody, and negative acetylcholine receptor antibody. She was subsequently transferred to [**Hospital1 69**] for further evaluation and management. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non-Q-wave myocardial infarction in [**2173-3-23**]. 2. Congestive heart failure with ejection fraction of 25%. 3. History of atrial fibrillation status post cardioversion in [**2173-3-23**]. 4. Hyponatremia, question secondary to SIADH. 5. Depression. 6. History of deep venous thrombosis. 7. Obesity. 8. Hepatitis C. 9. History of osteomyelitis of the skull status post craniotomy which is complicated by a grand mal seizure. 10. Chronic low back pain. 11. History of compression fractures. 12. Type 2 diabetes mellitus, diet controlled. 13. Hypothyroid. MEDICATIONS ON ADMISSION: 1. Lasix 80 mg q day. 2. Potassium chloride 30 mEq po q day. 3. Lopressor 50 mg [**Hospital1 **]. 4. Aspirin 81 mg po q day. 5. Flovent two puffs [**Hospital1 **]. 6. Lipitor 40 mg q day. 7. Phenobarbital 30 mg tid. 8. Prilosec 20 mg q day. 9. Imodium. 10. Multivitamin. 11. Ambien 5 mg q hs. 12. Darvocet prn. 13. Coumadin 3 mg q day. 14. Colace. 15. Zinc sulfate. 16. Sodium chloride. 17. Vitamin C. 18. Rhinocort. 19. Neurontin 100 tid. 20. Levoxyl 50 q day. 21. Zoloft 75 q day. 22. [**Doctor First Name **] 60 q day. 23. Water restriction to 1 liter q day. ALLERGIES: Morphine which causes a rash. She is allergic to codeine which causes a rash. SOCIAL HISTORY: She is married and denies alcohol or tobacco use. She formally worked as a nurse. She currently lives in a rehabilitation facility. EXAMINATION: Temperature 98.8, heart rate 70, blood pressure 120/70, respiratory rate 22, and oxygen saturation is 96% on 3 liters. She is a morbidly obese woman lying motionless in bed. She is in no apparent distress. Pupils are equal, round, and reactive to light and accommodation. Sclerae are anicteric. Moist mucous membranes. Neck was supple with no lymphadenopathy. There were several palpable nodules in the thyroid. Lungs had bibasilar rales going 1.5 up the posterior lung field. Heart was regular with normal first and second heart sounds. No murmurs, rubs, or gallops. Abdomen is obese, soft, nontender, nondistended. There are active bowel sounds and no abdominal bruits. The extremities showed 2+ pitting edema at the knees. There were 2+ palpable peripheral pulses. Neurological examination was notable for a disoriented woman with slurred speech. She was also to close her eyes, but she is not able to hold them closed against resistance. Her motor strength was [**1-25**] in the upper extremities bilaterally. Motor strength is 0/5 in the lower extremities bilaterally. There was no clonus or vesiculations. Her tone was flaccid in the lower extremities. Her upper extremities were mildly rigid. Deep tendon reflexes were absent in all four extremities. DATA: White count 15.6, hematocrit 35.4, platelets 271. INR 2.2, PTT 32.2. Sodium 142, potassium 4.0, chloride 103, bicarb 24, BUN 38, creatinine 1.5, glucose 138. Sed rate 172. ALT 20, AST 40, alkaline phosphatase 211, total bilirubin 0.6, albumin 2.4, total protein 6.3. HOSPITAL COURSE: Ms. [**Known lastname 102099**] was admitted to the hospital for further management of her neuromuscular disease. Due to impending respiratory failure, she was transferred to the Medical Intensive Care Unit soon after she arrived in the hospital. 1. Pulmonary: Ms. [**Known lastname 102099**] was subsequently intubated secondary due to her respiratory muscle weakness. At the time of intubation, she had a decreased vital capacity and decreased NIF. Her pulmonary issues were complicated by progressive fluid overload leading to cardiogenic pulmonary edema. She did not demonstrate any significant improvement in her respiratory mechanics for the remainder of her hospital stay. She did have a diagnostic therapeutic thoracentesis, which resulted with a removal of 1 liter of fluid, however, this did not improve her respiratory mechanics. 2. Cardiac: She has a history of coronary artery disease, congestive heart failure, and atrial fibrillation. She was in atrial fibrillation while she was in the MICU. This was complicated by worsening congestive heart failure and decreased urine output. She became more fluid overloaded during the course of her hospital stay. She required fluid to maintain her blood pressure. She was unable to diurese with Lasix drip and dopamine drip. She was cardioverted back into normal sinus rhythm with improvement of her blood pressure. However, this did not effect her urine output at all. 3. Renal: She developed acute renal failure during her hospital stay. It was thought that part of her acute renal failure were due to contrast induced ATN. However, she did not develop any improvement in her renal function, perhaps due to inadequate tissue perfusion. She was dialyzed several times during her MICU course to remove fluid in an attempt to improve her hemodynamic status. 4. Neurology: Her differential diagnosis of her neuromuscular disease included myasthenia [**Last Name (un) 2902**] and [**Location (un) **]-[**Location (un) **] myasthenic syndrome. Her serologic tests were thought to be more consistent with [**Location (un) **]-[**Location (un) **]. She underwent seven rounds of plasmapheresis with minimal improvement in her clinical status. 4. I&D: She developed a methicillin-resistant Staphylococcus aureus pneumonia, and a methicillin-resistant Staphylococcus aureus sacral decubitus ulcer. Her sacral decubitus ulcer also grew Pseudomonas. She received Vancomycin for treatment of her infections. Her sacral decubitus ulcer was debrided by Surgery. Due to her hematologic issues, however, she had problems clotting after the debridement, and she continued to ooze from her decubitus ulcer for the remainder of her hospital stay. 5. Hematology: Her course is complicated by both anemia and thrombocytopenia. It is thought that the thrombocytopenia might be due to Heparin, so the Heparin was discontinued, and she was started on lepirudin. She remained coagulopathic for the rest of her hospital stay. Despite aggressive measures in the Intensive Care Unit, Ms. [**Known lastname 102099**] continued to get worse. After further discussion with her family, decision was made to shift the focus of our care for comfort measures for Ms. [**Known lastname 102099**]. She expired on [**2173-8-26**]. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: 1. [**Location (un) **]-[**Location (un) **] myasthenic syndrome versus myasthenia [**Last Name (un) 2902**]. 2. Hypercarbic respiratory failure requiring mechanical intubation. 3. Methicillin-resistant Staphylococcus aureus pneumonia. 4. Atrial fibrillation status post DC cardioversion. 5. Congestive heart failure. 6. Acute renal failure requiring hemodialysis. 7. Sacral decubitus ulcer complicated by infection of methicillin-resistant Staphylococcus aureus and Pseudomonas. 8. Anemia. 9. Thrombocytopenia, question Heparin-induced thrombocytopenia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**] Dictated By:[**Last Name (NamePattern1) 7787**] MEDQUIST36 D: [**2174-12-29**] 16:59 T: [**2175-1-2**] 06:15 JOB#: [**Job Number 102100**]

[ "427.31", "358.1", "199.1", "585", "707.0", "276.1", "428.0", "518.81", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "99.71", "96.6", "96.72", "96.04", "34.91", "86.22" ]

icd9pcs

[ [ [] ] ]

7223, 8054

1487, 2142

3885, 7202

154, 842

864, 1461

2159, 3867

14,467

172,106

28547

Discharge summary

report

Admission Date: [**2118-8-8**] Discharge Date: [**2118-9-2**] Date of Birth: [**2069-10-26**] Sex: F Service: SURGERY Allergies: Zantac 75 Attending:[**First Name3 (LF) 371**] Chief Complaint: Fevers, further medical management of recurrent diverticulitis Major Surgical or Invasive Procedure: [**8-9**] Placement of central venous catheter [**8-18**] Endotracheal intubation [**8-18**] Placement of central venous catheter History of Present Illness: Ms. [**Known lastname 69147**] is a 48 year old female who was transferred to [**Hospital1 18**] on [**8-8**] via ambulance from an OSH. She has a history or recurrent diverticulitis and underwent a total colectomy with an ileorectal anastomosis on [**7-21**]. Post-operatively she developed an anastomotic leak and underwent a takedown of the ileorectal anastomosis, [**Doctor Last Name **] pouch, and recreation of the ileostomy on [**7-23**]. Post-operatively she remained intubated; on [**8-6**] she had brown purulent material expressed from her abdominal wound with cultures growing gram positive cocci and pseudomonas; blood cultures were negative; sputum cultures demonstrated methicillin resistant staphylococus aureus. She had a temperature spike of 106 and required pressure support, she was transferred to [**Hospital1 18**] for further management and admitted to the surgical intensive care unit. Past Medical History: Past Medical History: Diverticulitis Anxiety Past Surgical History: [**7-21**] Exploratory laparotomy with total colectomy [**7-23**] Takedown of ileorectal anastomosis, [**Doctor Last Name **] pouch, ileostomy '[**15**] Sigmoid Colectomy Social History: Married Family History: Non-contributory Physical Exam: On admission: 99.2 105 107/78 33 100% SIMV (600 x 12) Gen: Intubated, sedated, has nasogastric tube Heart: Regular rate and rhythm Lungs: Difficult to assess Abd: Ostomy with dark brown output, open midline wound with retention sutures Ext: Pulses present Pertinent Results: Admission Labs: [**2118-8-8**] 09:45PM BLOOD WBC-12.5* RBC-2.86* Hgb-8.9* Hct-25.3* MCV-89 MCH-31.0 MCHC-35.0 RDW-15.2 Plt Ct-429 [**2118-8-8**] 09:45PM BLOOD Neuts-87.2* Lymphs-8.3* Monos-3.2 Eos-1.1 Baso-0.2 [**2118-8-8**] 09:45PM BLOOD PT-13.8* PTT-26.6 INR(PT)-1.2* [**2118-8-8**] 09:45PM BLOOD Ret Aut-1.5 [**2118-8-8**] 09:45PM BLOOD Glucose-102 UreaN-31* Creat-0.5 Na-145 K-3.2* Cl-111* HCO3-24 AnGap-13 [**2118-8-8**] 09:45PM BLOOD ALT-42* AST-43* LD(LDH)-224 AlkPhos-278* Amylase-69 TotBili-0.8 [**2118-8-8**] 09:45PM BLOOD Lipase-56 [**2118-8-8**] 09:45PM BLOOD Albumin-2.6* Calcium-8.0* Phos-2.8 Mg-2.2 [**2118-8-8**] 10:13PM BLOOD freeCa-1.20 [**2118-8-9**] 9:49 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2118-8-9**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. [**2118-8-17**] 5:50 pm URINE URINE CULTURE (Final [**2118-8-19**]): NO GROWTH. Discharge Labs: RESPIRATORY CULTURE (Final [**2118-8-12**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. YEAST. SPARSE GROWTH. [**2118-8-18**] 4:09 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2118-8-24**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2118-8-24**]): NO GROWTH. [**2118-8-18**] 1:52 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2118-8-18**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2118-8-21**]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. Please contact the Microbiology Laboratory ([**6-/2418**]) immediately if sensitivity to clindamycin is required on this patient's isolate. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Discharge Labs: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2118-8-24**] 04:01AM 8.7 3.34* 10.1* 28.8* 86 30.4 35.2* 14.7 294 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2118-8-24**] 04:01AM 109* 20 0.6 138 4.3 100 30 12 CT PELVIS W/O CONTRAST [**2118-8-17**] 9:43 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: EVAL ANASTOMOTIC LEAK S/P COLECTOMY Field of view: 40 [**Hospital 93**] MEDICAL CONDITION: 48F s/p anastomotic leak following colectomy REASON FOR THIS EXAMINATION: gastrografin contrast to eval for leak, ?abscess- please no IV contrast- patient has renal problems CONTRAINDICATIONS for IV CONTRAST: renal INDICATIONS: 48-year-old woman with history of anastomotic leak status post colectomy. Evaluate for leak. TECHNIQUE: Axial non-contrast CT imaging of the abdomen and pelvis was obtained. At the request of the referring physicians, intravenous contrast was not administered because of renal insufficiency, and gastrografin was administered as oral contrast. CT OF THE ABDOMEN WITHOUT IV CONTRAST: A nasogastric tube terminates in the stomach. There is discoid atelectasis in the lingula and left lower lobe. Otherwise, the lung bases are clear without effusions. The liver appears normal. The patient is status post cholecystectomy. The spleen, adrenal glands, pancreas, and kidneys are unremarkable. The stomach and proximal small bowel are within normal limits. This patient is status post colostomy and Hartmann's pouch. The bowel is not dilated, and there is no evidence of obstruction. Contrast passes into the ileostomy. The is a site of narrowing in the distal small bowel, which may be due to underdistention, although stricture or post- operative edema at an anastamotic site cannot be excluded. There is a large amount of fat stranding in the right retroperitoneum near the ileostomy site. In addition, there is a hazy appearance of peripheral intra- abdominal fat, which extends down into the left pelvis, within the the left paracolic gutter. In the mid lateral left abdomen, there are some densites which may represent extraluminal inspissated contrast related to the history or prior bowel leak. There is no free air, ascites, or lymphadenopathy. There is no evidence of free leakage of contrast. CT OF THE PELVIS WITH IV CONTRAST: The uterus is present. Anastomotic suture lines are seen associated with the Hartmann's pouch. There is no lymphadenopathy or free fluid. BONE WINDOWS: There are no suspicious lytic or blastic lesions. There is a sclerotic focus in the left proximal femur, a probable bone island. IMPRESSION: 1. Status post ileostomy without evidence of obstruction or free leakage of contrast. 2. Extensive inflammatory change in the right retroperitoneal fat and left paracolic gutter. This appearance is non-specific but may all reflect recent post-operative change. Date: [**2118-8-25**] OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION EVALUATION: An oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with Radiology. Thin liquid, Nectar-thick liquid, pureed consistency barium, one quarter ground cookie coated with barium and one half cookie were administered. Results follow: ORAL PHASE: Bolus formation was mildly reduced with mildly prolonged mastication of the cookie. Bolus control was also mildly reduced with her head in the upright position with premature spillover to the valleculae. AP tongue movement was mildly reduced with mild tongue weakness, although noted to be significantly improved from the last evaluation. Oral transit time was wfl for liquids and purees and mildly prolonged with the cookie. There was a trace coating of oral residue that was cleared with repeat swallows. PHARYNGEAL PHASE: Swallow initiation was timely with adequate palatal elevation. Laryngeal elevation and laryngeal valve closure were both mildly reduced. Epiglottic deflection was only present with larger, heavier boluses with her head upright, but deflection was seen ith all consistencies when using the chin tuck. She had a moderate amount of residue in the vallecular after purees and solids with her head upright that was significantly reduced to a trace to mild amount with the chin tuck. Repeat swallows cleared the remaining residue. No significant residue was seen in the pyriform sinuses. ASPIRATION/PENETRATION: The pt had trace to mild penetration during the swallow with the thin liquids [**1-6**] reduced laryngeal valve closure and spillover. While the chin tuck reduced the penetration and no aspiration was seen on today's evaluation, there is concerned for fatigue over the course of a meal which could result in increased premature spillover and/or increased pharyngeal residue which could result in aspiration. TREATMENT TECHNIQUES: The chin tuck reduced the amount of penetration and residue in the valleculae and increased oral control and laryngeal valve closure / epiglottic deflection. Using and effortful swallow with the chin tuck further reduced the amount of residue in the valleculae as did taking repeat swallows using the chin tuck and alternating between consistencies. SUMMARY: The pt presented with a mild oral and pharyngeal dysphagia with significant improvement from the previous evaluation. She has reduced oral control and mild oral weakness resulting in premature spillover that can be eliminated with the use of a chin tuck. Pharyngeal residue seen in the valleculae is reduced by using a chin tuck and effortful swallow for liquids and solids, taking a repeat swallow with a chin tuck and alternating between bites and sips. While she did not aspirate today, there is concern for aspiration of thin liquids over the course of a meal secondary to fatigue which could result in decreased oral control and / or increased pharyngeal residue. For now, the recommendation is for a PO diet of nectar thick liquids and ground consistency solids using the above strategies. RECOMMENDATIONS: 1. Suggest a PO diet of nectar thick liquids and ground consistency solids. 2. When swallowing: a) Tuck your chin to your chest for liquids and solids b) Swallow "hard" c) Take a second, dry swallow for each bite and sip with her chin tucked. d) Alternate between every bite and sip 3) Please crush all pills and give with purees, following the above strategies 4. Speech therapy at rehab for her dysphagia to continue swallowing therapy and to safely advance her diet as tolerated These recommendations were shared with the patient, the nurse and the medical team. ___________________________________ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.S., CCC-SLP Pager #[**Numeric Identifier 2622**] PGY-3 Psychiatry Consultation Followup S: Met with patient and husband for supportive contact. The patient was taken down for a video swallowing eval today, which she passed, and she is now able to eat netcar think liquids and ground solids. When I arrived, two empty trays of food were next to the patient. She reports that she is so relieved to finally be able to eat, and that overall she is feeling much better. She also has been up and moving around with the help of PT. She reporrts that her back has been quite sore, is a little disappointed by how tired she continues to be, though she understands that things will be difficult as she has been lying in bed for almost 6 weeks now. She does report ongoing struggles with anxiety, though feels as if the medications are appropriate for now. She also says that she is having some difficulty sleeping, but she is trying to get increased activity during the day in order so that she will be more tired at night. Impression: 48 year old woman with a history of sigmoid diverticulitis, sigmoid colectomy, admitted to an OSH for abdeominal pain, now s/p total colectomy, recreation of ileostomy after ileorectal anastomosis leaking. Her course has also been compicated by a MRSA aspiration pneumonia. She had been quite frustrated earlier in the week due to being NPO, but passed a video swallow test today, and is feeling better now that she has some control over her eating. 1. Recommend continuing Ativan 0.5 mg po q4-6h prn. 2. Would continue Lexapro 20 mg po qday. 3. If continued difficulty sleeping, could increase Trazodone to 100 mg qhs. 6. At night and on weekends, plase page x[**Pager number 68120**]. ABDOMEN (SUPINE & ERECT) [**2118-8-29**] 8:44 AM Reason: Rule out small bowel obstruction [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with diverticulitis, s/p total colectomy and ileostomy c/b intubation x 2 and ICU admissions, diet advanced, now with nausea & vomiting REASON FOR THIS EXAMINATION: Rule out small bowel obstruction INDICATION: 48-year-old woman with history of diverticulitis, status post total colectomy and ileostomy. Now with nausea and vomiting. COMPARISON: Abdominal and pelvic CT, [**2118-8-17**]. TWO VIEWS OF THE ABDOMEN. No evidence of free air under the hemidiaphragms. Nonspecific bowel gas pattern is seen with several air-fluid levels on the upright view, as well as small amount of gas noted within the small bowel. No distended loops of small bowel are seen. Surgical clips noted in the right upper quadrant and small amount of retained contrast noted in the region of the rectum. IMPRESSION: Nonspecific bowel gas pattern with several air-fluid levels and small amount of gas noted within the small bowel. No distended loops of small bowel identified. [**2118-9-1**] 7:02 am SWAB Site: ABDOMEN Source: Abdominal wound. GRAM STAIN (Final [**2118-9-1**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Pending): ANAEROBIC CULTURE (Pending): [**2118-8-25**] 8:53 am URINE **FINAL REPORT [**2118-8-26**]** URINE CULTURE (Final [**2118-8-26**]): NO GROWTH. Brief Hospital Course: Upon admission to the surgical service and intensive care unit she remained intubated and sedated. Vancomycin, Zosyn, and Fluconazole were initiated for coverage of the pseudomonas and gram positive cocci in her wound and MRSA in sputum. She was afebrile and did not require pressure support. On HD 2 a Dobbhoff was placed and tube feeds were initiated. On HD 5 she was extubated without difficulty. A wound vacuum assisted device was placed secondary to purulent drainage with removal of her retention sutures. She completed treatment of the Fluconazole on HD 6 and the Vancomycin and Zosyn were completed on HD 7. She was transferred from the surgical intensive care unit to an in-patient nursing unit on HD 8. On HD 9 she underwent a oropharyngeal swallow study and was found to be at a high risk for aspiration, she was maintained nothing by mouth and tube feeds continued. On HD 10 she was febrile and developed respiratory distress. She was intubated, mechanically ventilated and transferred back to the surgical intensive care unit. A CT of the chest was negative for a pulmonary emboli and CT of the abdomen was negative for obstruction or leak, her abdominal wound was stable and she continued with the vacuum assisted closure device. She had a work-up for her septic episode and was started on Vancomycin and Zosyn along with intravenous hydration. Her blood and urine cultures drawn at the time of her febrile episode were negative for bacteria. She was successfully extubated on HD 12 and transferred back to an in-patient nursing unit on HD 14. The Zosyn was discontinued after three days of therapy and the Vancomycin was continued after final cultures of her sputum demonstrated methicillin resistant staphylococcus aureus. On HD 15 the surgical team felt she would benefit from a psychiatry consult since she was expressing frustrations over prolonged hospitalization. It was recommended to continue the Ativan as needed for anxiety and her Lexapro for a past history of depression and providing Trazodone at bedtime for sleep aid. Her biggest concern was the ability to eat and swallow. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was placed on HD 16 for further evaluation of her elevated blood glucose, she had been on an insulin sliding scale since admission to the hospital. Per recommendation she was placed on Lantus. On HD 18 she underwent a repeat swallow study with improvement, her diet was advanced to pureed solids with nectar thick liquids. Her Lantus was discontinued as [**First Name8 (NamePattern2) **] [**Last Name (un) 9718**] recommendation and she was maintained on a Regular Insulin sliding scale. [**Last Name (un) **] felt that her insulin requirements would change based on her oral intake and that she would benefit from follow-up with her primary care provider in one to two weeks to evaluate her glucose levels and amounts of Insulin taken from the sliding scale. On HD 19 her diet was advanced to a soft, dysphagia diet which she tolerated well. She remained afebrile, her ileostomy was functioning well and had increased ambulation with the help of physical therapy. Her abdominal continued to improve with dressing changes every three days. The vacuum assisted device dressing was changed every three days, on HD 19 the abdominal wound was noted to be 3cm by 7cm with good healing of pink/red tissue, granulating well, no debridement was necessary. On HD 21 the wound VAC was discontinued and normal saline wet to dry dressing changes were started, twice a day. Her pain was well controlled with Percocet. On HD 22 she had nausea with an episode of emesis, an abdominal x-ray was negative for a small bowel obstruction, her nausea improved with the advancement of her diet to include ensure pudding supplements which she tolerated well. She completed 14 days of Vancomycin on HD 24 and her central venous line was removed. On HD 25 her wound had cream colored drainage with a foul smell, a culture was done which demonstrated gram negative rods, probable pseudomonas. The dressing changes were changed from normal saline to Ascetic Acid 0.25% wet to dry twice a day. There was no need to treat with antibiotics since the infection was localized to the wound, she was afebrile, and the wound was without erythema or induration. A Nystatin oral regimen was initiated on HD 25 for mild thrush in her mouth. She had two falls while ambulating to the bathroom on HD 25 and 26. The first fall she was ambulating without assistance, the second she was being assisted to the shower. She had no injuries from either fall, she reported feeling weak and light-headed after reaching the bathroom. She was provided a gait belt during ambulation and will need assistance at all times with ambulation. She was instructed to change her positions slowly and oral intake was encouraged throughout the day. She was also given a mulitpodous boot to her left leg after complaints of cramping in her foot during the night, her symptoms have improved with the boot. Upon discharge her blood glucose levels were stable from 110-130, her finger sticks with a Regular Insulin sliding scale were decreased to twice a day, she will follow-up with her PCP upon discharge from rehab. for further management of her insulin requirements. She was discharged to [**Hospital3 **] facility in good condition on [**9-2**] for continued physical, occupation, speech, and swallow therapy. Medications on Admission: Anacordol Lopressor 5mg q4 hr Fentanyl 100mcg Nocuron Morphine Protonix Zosyn Mycostatin Subcutaneous Heparin Vancomycin Fluconazole Discharge Medications: 1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed: Apply to affected areas. 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed: Apply to affected areas. 3. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Must be crushed and placed in pureed food. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain: Must be crushed and placed in pureed food. 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed: Must be crushed and placed in pureed food. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Continue until patient ambulatory. 8. Other Sig: Insulin sliding scale twice a day: [**Known lastname **],[**Known firstname 3679**] I [**Numeric Identifier 69148**] Insulin SC (per Insulin Flowsheet) Sliding Scale Fingerstick BIDInsulin SC Sliding Scale Regular Insulin Dose 0-60 mg/dL [**12-6**] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 6 Units 161-180mg/dL 9 Units 181-200 mg/dL 12 Units 201-220 mg/dL 15 Units 221-240 mg/dL 18 Units 241-260 mg/dL 21 Units 261-280 mg/dL 24 Units 281-300 mg/dL 27 Units > 300 mg/dL Notify M.D. . 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for HR < 60 Hold for SBP < 100 Please crush and place in applesauce. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): please give mixed in applesauce. 11. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please crush pill and place in apple sauce. 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO every 4-6 hours. 13. Acetic Acid 0.25 % Solution Sig: One (1) Appl Irrigation [**Hospital1 **] (2 times a day): For wound dressing changes [**Hospital1 **]. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Diverticulitis Aspiration pneumonia Psuedomonal wound infection Discharge Condition: Good Discharge Instructions: Notify MD/NP/PA/RN at rehabilitation facility if you experience: *Increased or persistent pain *Fever > 101.5 *Nausea or vomiting *Difficulty swallowing *Inability to pass gas or stool from ileostomy *Difficulty swallowing or shortness of breath *If wound develops increased erythema, drainage, or induration *Any other symptoms concerning to you Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in [**12-6**] weeks, call [**Telephone/Fax (1) 2300**] for an appointment. Follow-up with your Primary Care Provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 42310**] in 2 weeks, call [**Numeric Identifier 69149**] for an appointment. Completed by:[**2118-9-2**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "93.59", "33.24", "38.93", "96.72", "96.71" ]

icd9pcs

[ [ [] ] ]

22249, 22319

14602, 20036

330, 462

22427, 22434

2024, 2024

22830, 23155

1709, 1727

20219, 22226

13182, 13336

22340, 22406

20062, 20196

22458, 22807

4637, 5058

1495, 1668

1742, 1742

4599, 4620

228, 292

13365, 14579

490, 1402

2041, 2984

1757, 2005

1447, 1471

1684, 1693

28,594

188,752

32049

Discharge summary

report

Admission Date: [**2187-10-6**] Discharge Date: [**2187-10-8**] Date of Birth: [**2161-10-14**] Sex: M Service: MEDICINE Allergies: Cefazolin Attending:[**First Name3 (LF) 2160**] Chief Complaint: ETOH intoxication s/p assault Major Surgical or Invasive Procedure: You were intubated in the emergency department to protect your airway. History of Present Illness: History of Present Illness: Pt is a 25M with no known significant PMH brought to ED on [**2187-10-5**] after an assault. The patient had been at a bachelor party and reportedly was drinking alcohol and had used cocaine. During the nights event, the patient was involved in a fight and sustained head trauma after being punched and kicked to the ground with loss of consciousness of one minute. In ED, the pt was afebrile, vital signs notable for tachycardia to 130's, but other vitals stable. Initial EKG demonstrated T wave flattening in anterolateral leads, but no other acute changes were noted. In ED, he was evaluated with head and C-spine CT which were unrevealing. His toxicology screen was notable for EtOH level of 310 and positive for cocaine. In ED, he was notably combative with altered mental status, and he received haldol 5 mg IV x 3, ativan 2 mg IV x 5. The patient was intubated in the ED for airway protection in the setting of sedation. He was then admitted to MICU for further monitering. In MICU, pt was monitered overnight, extubated earlier today without complication. His agitation and altered mental status has subsided. Labs were monitered including cardiac enzymes, which have demonstrated elevated CK, but flat troponins, which have been attributed to the pt's LOC prior to his presentation to the ED. His tachycardia seen on initial presentation has resolved. Currently pt feels ok - no complaints, no pain, no difficulty breathing. Past Medical History: none Social History: Significant for alcohol and cocaine abuse Family History: unknown Physical Exam: Physical Examination: Vital signs: T 98.7, HR 93, BP 131/65, RR 18, O2 100% 2L NC General: Asleep, arousable but somewhat sleepy/lethargic, NAD HEENT: PERRL, EOMI, abrasion on right temple, upper lip swollen with slight abrasion Heart: RRR, no MRG Lungs: CTA b/l Abdomen: Soft, NT/ND, normoactive BS Extremities: no LE edema b/l Skin: No rashes, no eccymoses Neurologic: A+Ox3, strength 5/5 UE and LE b/l Pertinent Results: [**2187-10-6**] 12:40AM WBC-7.6 RBC-4.70 HGB-15.2 HCT-43.9 MCV-94 MCH-32.4* MCHC-34.7 RDW-12.9 [**2187-10-6**] 12:40AM NEUTS-47.1* LYMPHS-44.2* MONOS-5.7 EOS-2.6 BASOS-0.4 [**2187-10-6**] 12:40AM PLT COUNT-331 [**2187-10-6**] 12:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [**2187-10-6**] 12:40AM ASA-NEG ETHANOL-310* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2187-10-6**] 12:40AM GLUCOSE-101 UREA N-12 CREAT-1.1 SODIUM-145 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-27 ANION GAP-17 [**2187-10-6**] 05:09AM CK-MB-15* MB INDX-1.8 cTropnT-<0.01 [**2187-10-6**] 05:09AM CK(CPK)-835* [**2187-10-6**] 10:11AM PT-13.7* PTT-34.1 INR(PT)-1.2* [**2187-10-6**] 10:11AM CALCIUM-7.2* PHOSPHATE-2.3* MAGNESIUM-1.9 [**2187-10-6**] 10:11AM CK-MB-17* MB INDX-1.4 cTropnT-<0.01 [**2187-10-6**] 10:11AM ALT(SGPT)-30 AST(SGOT)-40 LD(LDH)-211 CK(CPK)-1206* ALK PHOS-53 AMYLASE-37 TOT BILI-0.3 [**2187-10-6**] 10:11AM GLUCOSE-80 UREA N-9 CREAT-0.7 SODIUM-144 POTASSIUM-4.0 CHLORIDE-113* TOTAL CO2-22 ANION GAP-13 [**2187-10-6**] 04:14PM CK-MB-17* MB INDX-1.2 cTropnT-<0.01 [**2187-10-6**] 04:14PM CK(CPK)-1369* . [**2187-10-6**] CT Head: IMPRESSION: No intracranial hemorrhage or edema. . [**2187-10-6**] CT ABD/PELVIS CT ABDOMEN WITH CONTRAST: The lung bases demonstrate bibasilar atelectasis. There is no evidence of pericardial or pleural effusion. A tiny hepatic cyst is present near the fissure for ligamentum teres. The spleen, pancreas, adrenal glands, and kidneys appear unremarkable, and there is no evidence of traumatic injury of these organs. The kidneys enhance symmetrically and excrete contrast normally, and there is no hydronephrosis or hydroureter. Intra-abdominal loops of large and small bowel are unremarkable, and there is no free air or free fluid or pathologically enlarged mesenteric or retroperitoneal lymph nodes. The appendix is visualized and is of normal caliber. The abdominal aorta is of normal caliber throughout. CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, prostate, seminal vesicles, and bladder are unremarkable. A Foley is present within the bladder. There is no free fluid within the pelvis or pathologically enlarged lymph nodes. Bone windows reveal no worrisome lytic or sclerotic lesions. No traumatic osseous injuries are identified. IMPRESSION: No evidence of traumatic injury within the abdomen or pelvis . [**2187-10-6**] CXR IMPRESSION: Endotracheal tube in satisfactory position. No consolidation or edema. Brief Hospital Course: Assessment/Plan: Pt is a 25 yo man with no PMH who presents with alcohol and cocaine intoxication, s/p assault, initially intubated for airway protection and admitted to MICU. . # Agitation: Presumed [**3-2**] alcohol and cocaine intoxication. Pt required intubation for airway protection, now extubated without complication. Head CT w/out pathology. Pt currently comfortable without distress/discomfort; low CIWA scores. Remainder of hospital course uncomplicated, did not require additional ativan, denied headache with full neurologic function prior to D/C. Follow up was arranged with primary care physician. . # Elevated CK: Pt w/ CK elevated to 835 on presentation to ED, trended up to 1369 thus far as peak, now headed down. MB-Index slightly elevated at 15-17 during hospital course, but trop have consistently been < 0.01. Etiology is likely [**3-2**] musculoskeletal injury from being down versus cocaine abuse. Unlikely ACS. Unlikely rhabdo and CK not elevated to extent for concern. . # Substance abuse: Pt presented intoxicated with EtOH and cocaine. Drug/alcohol slowly worn off. Pt advised about health implications of ETOH and cocaine abuse. Follow up arranged with PCP. [**Name10 (NameIs) **] was evaluated by social work, however he refused further treatment for substance abuse and stated that he uses very rarely and does not feel that he has a problem. . # Status post assault: All radiological examination including head CT, c-spine, abd/pelvis CT without any evidence of internal trauma. . # Anemia: Pt with Hct 43 on admission, currently 35. Likely [**3-2**] IVF. HCT remained stable, was 36.7 on discharge . # FEN: Regular diet . # PPX: SC heparin, bowel regimen PRN . # Code: Full Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Rhabomyolysis Substance Abuse, cocaine and alcohol (possible alcohol withdrawal) Trauma Anemia Discharge Condition: Good Discharge Instructions: You were admitted to the hospital to evaluate you for head injury. You were intubated in the emergency department to protect your airway. You had a cat scan of your head which did not show any bleeding or other abnormality. You also had a cat scan of your torso which did not show any internal injuries and there was no fracture of your spine that was seen. . No medications were added during this admission. . Please refrain from abusing alcohol and other substances as this puts you at increased risk for medical complications such as cocaine induced heart damage and traumatic injury. . Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks after discharge. You should call your doctor or return to the emergency department if you develop any concerning symptoms including severe headache, nausea or vomiting, change in your level of consciousness or confusion, or visual changes. Followup Instructions: You have an appointment at [**Hospital3 **] in [**Location (un) **] with Dr. [**First Name (STitle) 2398**] who is the resident physician working with Dr. [**Last Name (STitle) 75052**]. This appointment is on [**2187-10-17**] at 4:00 in General Internal Medicine on 4East. You need to call your insurance company and inform them of your new PCP. [**Name10 (NameIs) **] phone number to reschedule if you can not keep this appointment is [**Telephone/Fax (1) 75053**].

[ "285.9", "924.8", "305.60", "303.90", "291.81", "E960.0", "728.88", "E849.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6774, 6780

4976, 6690

301, 374

6918, 6925

2419, 3607

7894, 8369

1969, 1978

6745, 6751

6801, 6897

6716, 6722

6949, 7871

1993, 1993

2015, 2400

232, 263

430, 1866

3616, 4953

1888, 1894

1910, 1953

22,114

136,444

43099

Discharge summary

report

Admission Date: [**2120-5-16**] Discharge Date: [**2120-5-18**] Date of Birth: [**2061-12-11**] Sex: M Service: MEDICINE Allergies: Bactrim / Prednisone / Codeine / Iodine Attending:[**First Name3 (LF) 1257**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 58 yo male with HIV (CD4 463, VL undetectable on [**2120-3-1**]), HCV c/b stage II cirrhosis, COPD GOLD stage II, chronic pain and spinal stenosis on [**Date Range **]/narcotics who presents with dyspnea. Patient reports acute shortness of breath at rest and with exertion for the past 2 days. He reports associated pleuritic chest pain on the right side. SOB is not positional. He reports recent fever to 102, fatigue, cough, muscle aches for the past 2 days. He denies sick contacts. [**Name (NI) **] denies recent travel or increased immobility. Patient tried inhalers at home which did not improve his symptoms. Patient reports orthopnea for the past several months, but denies chest pain, PND or lower extremity edema. Prior to this he was his usual state of health. He takes his HIV medications regularly. . On presentation to ED VS 97.3, 124/73, 52, 22, 99% RA. O2 sat ranging 96-100 on RA to 2 L. Pt afebrile. Patient given pentamidine, morphine 8 mg, ativan 2 mg, magnesium sulfate, duconeb, dexamethasone 10 mg IV, NS 500cc, Atovaquone, Zofran, Phenergan. Admitted to the ICU for close monitoring. . Of note, patient recently had admission [**Date range (1) 46889**] due to abscess following cat scratch and discharged on augmentin and doxycycline for 10 days total (history 10 days total). Past Medical History: *HIV/AIDS x 20 years with (CD4 463, VL undetectable on [**2120-3-1**]) - dx [**2094**]; IVDU or heterosexual contact (known HIV+) - CD4 nadir 12 ([**2097**]) - OI/OM: Pneumocystis pneumonia, [**2102**] Thrush, intermittent *Hepatitis B: positive core antibody, cleared infection *Hepatitis C: stage three fibrosis in [**2-/2119**] *History of MSSA and Strep Milleri abscesses *COPD COPD Gold Stage 2. [**8-4**] PFTs: FEV1/FVC 57, FEV1 = 57% predicted *H/o nephrolithiasis leading to several admissions for abdominal pain *S/p MVA with residual neck/back pain, numbness in fingers *Spinal Stenosis with chronic back pain and peripheral neuropathy *Depression *S/p celiac trunk patch angioplasty and division of median arcuate ligament syndrome in [**2114**] *Bilateral Hydroceles and Uroceles *Gastritis (EGD in [**3-/2118**]) *History of EtOH abuse, IVDU 20 y.a. including heroin and cocaine abuse *BPH *Macrocytic anemia *Cataract Social History: Smokes ~1ppd for >20 yrs, quit 4 months ago. Denies current EtOH. Former illicit drug use (IVDU cocaine last in [**2105**]). Currently lives alone in [**Hospital1 392**]. Widowed after wife passed away in [**2118**] s/p liver transplant. History of incarceration from [**2106**]-[**2112**] (per pt, due to gambling but per OMR, due to armed invasion/assault). Former corrections officer currently on disability secondary to back pain. 2 children who live with their mother (his ex-wife). Family History: Father: brain aneurysm; Mother: lung cancer; Brother: [**Name (NI) 2320**]; Brother: died of drug overdose Physical Exam: Tmax: 36.1 ??????C (96.9 ??????F) Tcurrent: 36.1 ??????C (96.9 ??????F) HR: 51 (51 - 66) bpm BP: 140/86(96) {137/79(91) - 161/102(115)} mmHg RR: 16 (14 - 18) insp/min SpO2: 98% Heart rhythm: SB (Sinus Bradycardia) GEN: pleasant, comfortable, NAD, thin HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no jvd RESP: Diffuse wheezes throughout CV: RR, S1 and S2 wnl, no rubs ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, no fluid wave EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. Pertinent Results: [**2120-5-16**] 01:50PM BLOOD Neuts-45.4* Lymphs-42.7* Monos-8.4 Eos-3.0 Baso-0.5 [**2120-5-16**] 01:50PM BLOOD WBC-6.4 Lymph-43* Abs [**Last Name (un) **]-2752 CD3%-95 Abs CD3-2607* CD4%-33 Abs CD4-899 CD8%-65 Abs CD8-1794* CD4/CD8-0.5* [**2120-5-16**] 01:50PM BLOOD Glucose-91 UreaN-17 Creat-0.8 Na-135 K-5.4* Cl-102 HCO3-25 AnGap-13 [**2120-5-16**] 01:50PM BLOOD LD(LDH)-610* [**2120-5-17**] 02:40AM BLOOD Calcium-9.1 Phos-2.0* Mg-2.2 [**2120-5-16**] 02:27PM BLOOD Type-ART pO2-62* pCO2-40 pH-7.42 calTCO2-27 Base XS-0 Respiratory Viral Antigen Screen (Final [**2120-5-17**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. . Chest Xray [**2120-5-16**] - UPRIGHT AP VIEW OF THE CHEST: The cardiac, mediastinal and hilar contours are normal. Pulmonary vascularity is not engorged. Except for minimal linear atelectasis in the left lung base, the lungs appear clear without focal consolidation. No pleural effusion or pneumothorax is present. Known old right posterior rib fractures are better evaluated on the CT from [**2120-2-19**]. IMPRESSION: Subsegmental atelectasis in the left lung base. No acute cardiopulmonary abnormality otherwise demonstrated. . RIB FILMS FINDINGS: Slightly low lung volumes. Focal heterogeneous opacity within the right lower lobe, likely representing atelectasis, cannot exclude infection. Linear opacity in the left lung base, likely subsegmental atelectasis. No definite pleural fluid. The heart and mediastinum are normal. No definite rib lesions. No displaced rib fractures identified. Mild AC joint degenerative changes with osseous proliferation. IMPRESSION: 1. No definite displaced rib fracture. 2. Bilateral lower lobe atelectasis, cannot exclude infection on the right. Brief Hospital Course: HOSPITAL COURSE: This is a 58 yo male with HIV (CD4 463, VL undetectable on [**2120-3-1**]), HCV, c/b stage II cirrhosis, COPD GOLD stage II, chronic pain and spinal stenosis on [**Date Range **]/narcotics who presented with dyspnea and was treated for a COPD exacerbation and community acquired pneumonia. . ACTIVE ISSUES ICU Course - admitted to ICU for observation as concern for increased work of breathing. Due to history of HIV, ED gave pentamidine for concern of PCP; however CD4 count 899 when checked on overnight labs. Flu swab sent, placed on tamiflu pending negative test. Continued treatment for CAP with Ceftriaxone and Azithromycin, started in ED. Due to wheezes on exam, started standing nebulizer treatments and IV steroids. Overnight, patient's oxygen was weaned to room air, tolerated it well. He complained of right sided pleuritic rib pain, unclear etiology as no evidence of PNA. Rib films showed no definite displaced rib fracture. Patient was continued on outpatient pain regimen and HAART for HIV. He was transferred to the floor the following morning, saturating 97% on room air with significant improvement in his lung exam. . MEDICAL Course: On the general medical floors he was continued on prednisone burst of 60mg daily for a total of five days which were continued on discharge. Ceftriaxone and azithromycin were discontinued in favor of levofloxacin for a total of a five day course for treatment of community acquired pneumonia. . INACTIVE ISSUES # HIV: Last CD4 463, VL undetectable [**2120-3-1**]. CD4 count rechecked in the ICU and was 899. He was continued on efavirenz, lamivudine-zidovudine, tenofovir, and vit B6. . # SPINAL STENOSIS/CHRONIC BACK PAIN: Patient on narcotics contract. He was continued on outpatient oxycodone, oxycontin and oxycodone, as well as gabapentin. He complained of rib pain sustained during a recent fall, with tenderness on palpation of left lateral ribs. Intravenous dilaudid started on the evening of admission was discontinued when the patient was suspected of pain seeking behavior. . # DEPRESSION: He was continued on citalopram. . # NAUSEA: Chronic due to HIV medications. He was continued on outpatient promethazine and zofran. . TRANSITIONAL ISSUES # Medical Management: Levofloxacin and prednisone x 2 days # Pending Labs: Blood Cx x 2 from Ed # Code: Full Medications on Admission: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheeze. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheeze. 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. lamivudine-zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. [**Hospital1 **] 10 mg Tablet Sig: One [**Age over 90 1230**]y Five (155) mg PO DAILY (Daily). 9. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 10. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 13. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO three to four times a day as needed for pain. 16. OxyContin 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO four times a day as needed for pain. Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 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. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 6. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 7. lamivudine-zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. [**Age over 90 **] 10 mg Tablet Sig: One [**Age over 90 1230**]y Five (155) mg PO DAILY (Daily). 9. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 10. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 12. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 13. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. 16. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q6H (every 6 hours) as needed for pain. 17. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 18. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Acute Exacerbation of Chronic Obstructive Pulmonary Disease Community Aquired Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of shortness of breath and wheezing. You were briefly admitted to the intensive care unit (ICU). You were treated for an exacerbation of your underlying COPD and for a possible pneumonia with steroids, bronchodilators and antibiotics. You also complained of pain at the site where you fell on your back. Xrays of your ribs revealed no evidence of a fracture. You were continued on your home pain regimen. The following changes were made to your medication list: 1. START Prednisone 60mg daily for 2 more days 2. START Levofloxacin 750mg daily for 2 more days Followup Instructions: Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] to schedule a follow-up appointment regarding this hospital stay. Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Location: THE TRANSPLANT CENTER Address: [**Doctor First Name **], [**Apartment Address(1) 34213**], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 457**] Department: LIVER CENTER When: THURSDAY [**2120-8-8**] at 10:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "E931.7", "V65.2", "V15.82", "493.22", "571.5", "338.29", "356.9", "724.00", "365.9", "305.50", "070.70", "042", "600.00", "281.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11475, 11481

5761, 5761

309, 316

11621, 11621

3844, 5738

12393, 13139

3135, 3244

9723, 11452

11502, 11600

8131, 9700

5778, 8105

11772, 12370

3259, 3825

262, 271

344, 1647

11636, 11748

1669, 2613

2629, 3119

13,868

116,913

10426

Discharge summary

report

Admission Date: [**2129-4-8**] Discharge Date: [**2129-4-15**] Date of Birth: [**2059-3-27**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Patient is a 70-year-old female with a history of coronary artery disease suffered an acute myocardial infarction in [**2128-4-14**], and she was taken to catheterization laboratory and found three vessel disease with successfully stented left anterior descending artery, found to have left ventricular diastolic dysfunction with a preserved ejection fraction of 57% with anterior apical dyskinesis and anterolateral hypokinesis. In [**2128-11-14**], the patient returned to [**Hospital3 **] for chest pain. Catheterization revealed totally occluded left anterior descending artery with brachytherapy. Echocardiogram in [**2128-11-14**] showed an ejection fraction of 50%, mild symmetric left ventricular hypertrophy with hypokinetic anterior wall and kinetic anteroseptal wall, hypokinetic anterior apex, akinetic septal apex, and lateral apex and akinetic apex, 1+ mitral regurgitation. The patient was admitted to an outside hospital for a GI bleed, where aspirin and Plavix were discontinued upon the outside hospital. The patient is found to have "several ulcers". EGD performed with cauterization of lesions. The patient is discharged home 48 hours. On the morning of admission, she awoke, had a bowel movement, and shortly after that, she developed severe substernal chest pain [**6-23**] radiating to the back, positive diaphoresis, no nausea or vomiting. The patient took nitroglycerin x3 with no relief and called EMS. Electrocardiogram was 3-[**Street Address(2) 1755**] elevations in leads V2 through V4. Morphine, Heparin drip, and nitroglycerin drip were started. REVIEW OF SYSTEMS: The patient with one pillow orthopnea. No change in weight. She has dyspnea on exertion with walking one block, no stairs. FAMILY HISTORY: Mother has diabetes. Father has coronary artery disease. Died at age 56 of a myocardial infarction. SOCIAL HISTORY: A half pack per day smoker. No alcohol, seven children, divorced, former telephone operator. PAST MEDICAL HISTORY: 1. Coronary artery disease in [**2129-11-14**], received brachytherapy through a restented left anterior descending artery, instent restenosis in [**2128-4-14**], stented left anterior descending artery. 2. Lower back pain. 3. Congestive obstructive pulmonary disease/asthma, O2 dependent at night. 4. Gastrointestinal bleed status post esophagogastroduodenoscopy with cauterization. 5. Hyperlipidemia. 6. Peripheral vascular disease status post aorto-bifemoral bypass. 7. Congestive heart failure. 8. Hypothyroidism. 9. Hypertension. ALLERGIES: She has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg po q day. 2. Prednisone 10 mg po q day. 3. Atenolol 25 mg po q day. 4. Lisinopril 5 mg po q day. 5. [**Year (4 digits) **] prn. 6. Flovent two puffs q hs. 7. Serevent two puffs [**Hospital1 **]. 8. Diltiazem. 9. Lipitor 10 mg q day. 10. Compazine. 11. Plavix 75 mg q day. 12. Lasix 25 mg q day. 13. Vicodin. 14. Buthalital. 15. Isosorbide 30 mg q day. 16. Trazodone 100 mg q hs. 17. Prevacid 40 mg [**Hospital1 **]. LABORATORY VALUES ON ADMISSION: White blood cell count 16.5, hematocrit 29.7, platelets 250. Sodium 140, potassium 3.8, chloride 107, CO2 23, BUN 11, creatinine 0.6, glucose 97, calcium 8, phosphate 4, magnesium 1.6. On coronary artery catheterization, she had a 60% right coronary artery proximal lesion, 60% right coronary artery distal lesion, right posterolateral 100% stenosis, left anterior descending artery 100% occlusion proximal to previous stent, LCX without significant lesion. A postcatheterization electrocardiogram showed atrial flutter/fibrillation, left axis deviation, [**Street Address(2) 4793**] elevations in V2 through V4, T-wave inversions in V2 through VI, poor R-wave progression. VITALS ON ADMISSION: Temperature 99.0, heart rate is 82, blood pressure 98/48, respiratory rate 16, and oxygen 94% on 4 liters nasal cannula. In general, this is a frail appearing woman in no apparent distress, alert and oriented times three. HEENT: No lymphadenopathy, no jugular venous distention. Pupils are equal, round, and reactive to light. Cardiovascular: Faint heart sounds. Pulmonary: Bivalve sounds secondary to emphysematous changes. Abdomen is soft, nontender, nondistended no hepatosplenomegaly. Extremities: No edema, no pulses, dopplerable, no cyanosis or clubbing. HOSPITAL COURSE BY SYSTEMS: 1. Coronary artery disease/ischemia: The patient was found to have a large acute myocardial infarction. She received successful cardiac catheterization with stenting of the left anterior descending artery. In the post myocardial infarction period, she did have a period of tachycardia to 160s, which was found to be VT. For this she was bolused with lidocaine and put on a lidocaine drip. EP was consulted to assess the need for further EP studies and also defibrillator placement. The patient was talked to extensively and declined EP study, and pacemaker, and AICD placement at this time. To lower the risk of recurrent VT, she was placed on amiodarone 400 mg po q day, and additionally, she was sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor for which strips will be examined over the next two weeks by EP. She has an outpatient with this EP in approximately four weeks from discharge for followup and further discussion of risk of morbidity and mortality from cardiac arrhythmias. Nevertheless, after the first 24 hours, she did not have any recurrence of ventricular arrhythmias. She was kept on the lidocaine for the first 48 hours. The lidocaine drip was weaned off for 72+ hours prior to discharge, she was off lidocaine and had no further arrhythmic events. Pump: The patient had repeat echocardiogram in-house, which showed an ejection fraction of 25-35% reduced from the 50% before. This should be followed up. It is unclear how much of this is from damage versus myocardial stunning. It is possible the patient will recover from significant amount of ejection fraction in the future. Other systems: GI: She has a history of gastrointestinal bleed. We followed her hematocrit. There was no drop in hematocrit. No recurrent gastrointestinal bleed. She was kept on proton-pump inhibitor, and stool softeners. Heme: The patient did receive 1 unit of packed red blood cells for a decreased hematocrit, which was most likely secondary to the prior gastrointestinal bleed. She had no need for blood and her hematocrit was stable. Renal: The patient's renal function was stable. No acute issues. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Plavix 75 mg po q day. 3. Prednisone 10 mg po q day. 4. Atenolol 25 mg po q day. 5. Lisinopril 5 mg po q day. 6. Fluticasone two puffs [**Hospital1 **]. 7. Salmeterol 1-2 puffs [**Hospital1 **]. 8. Lipitor 10 mg po q day. 9. Lasix 20 mg po q day. 10. Lansoprazole 30 mg po q day. 11. Levothyroxine 75 mcg po q day. 12. Spironolactone 12.5 mg po q day. 13. Amiodarone 400 mg po q day. 14. Levofloxacin 250 mg po q day for three days. 15. Prochlorperazine 25 mg prn. 16. Vicodin prn. 17. Bubatol prn. 18. Ativan prn. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Acute anterior myocardial infarction. 3. Congestive heart failure. 4. Ventricular arrhythmia. 5. Congestive obstructive pulmonary disease. 6. Hypertension. 7. Hyperlipidemia. [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Last Name (NamePattern1) 1737**] MEDQUIST36 D: [**2129-4-14**] 15:24 T: [**2129-4-20**] 08:53 JOB#: [**Job Number 34496**]

[ "427.1", "410.11", "428.32", "414.01", "599.0", "443.9", "496", "996.72", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.55", "37.22", "88.52", "36.06", "36.01" ]

icd9pcs

[ [ [] ] ]

1906, 2009

7288, 7774

6720, 7267

2751, 3204

4518, 6697

1764, 1889

155, 1744

3919, 4490

2143, 2725

2026, 2121

25,578

198,958

50057

Discharge summary

report

Admission Date: [**2185-5-8**] Discharge Date: [**2185-5-8**] Service: MEDICINE Allergies: Percocet / Simvastatin Attending:[**First Name3 (LF) 2485**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Mr. [**Known lastname 38685**] is an 88 yo Man w/ HTN, sick sinus s/p PPM, multiple GIB, Afib, prostate ca, MGUS, 2+ AI, CRF (Cr [**2-13**]), high ammonia (w/o liver disease), who was discharged from [**Hospital1 18**] on [**5-2**] with VRE bacteremia and fungemia (likely due to infected midline) on linezolid and fluconazole for 14 day course, who presents obtunded from his NH with hypoxia to 60%. He was placed on NRB, given lasix 60mg iv and 1 inch of nitropaste with resultant O2 sat 70-80% on transfer by EMS. Per EMS to ER resident, his NH reported him full code. On arrival to the ER he was making respiratory effort but had very minimal air movement. He was intubated on AC 500*20, peep 5, fio2 1.0, L EJ was placed for access and the patient has a PICC in place. He was given levofloxacin and aspirin. He was placed on a bair hugger for hypothermia. His vitals were otherwise unremarkable. KUB showed a large amount of bowel gas. CXR was fairly unremarkable. He was on a minimal amount of versed for sedation and was minimally responsive. He was guaiac positive. . The patient's family was informed of his transfer and came to the ER to find him intubated, stating that he was DNR/DNI. After discussion with the resident they decided to keep him intubated for the night and to revisit this in the MA, but to maintain his DNR status. He was subsequently found to be hypotensive with SBPs in the 70s. Per telephone discussion between the ER resident and the patient's daughter, the family declines central line and declines pressors. He was admitted to the MICU for furhter care and management. . Note that on prior admission the pt also had ARF with urinary retention of 400cc, which resolved with placement of foley catheter. Baseline MS is to be sleepy most of day and respond to questions appropriately, moments of clarity where recognizes family. . ROS: unable to perform given intubated/sedated Past Medical History: 1. Prostate cancer dx'd [**2179**]- maintained on lupron (no surgery/xrt). 2. Hypertension 3. Aortic insufficiency (2+). 3. Paroxysmal atrial fibrillation (not on anticoagulation due to many GIBs) 4. Sick sinus syndrome s/p PPM for symptomatic bradycardia, [**5-18**] 5. Iron deficiency anemia/ anemia of chronic disease 6. Chronic Renal Failure 7. Pulmonary Hypertension (TTE [**10-17**] PASP 38mmhg) 8. Secondary hyperparathyroidism (low 25-hydroxyvitamin D, s/p tx) 9. MGUS, IgG monoclonal gammopathy 10. s/p GSW with retained pleural fragment 11. s/p pacemaker placement. 12. Severe bilateral DJD of the knees 13. Gout 14. Refractory UGIB from jejunal AVMs, diagnosed in [**7-/2180**], and duodenal ulcers, diagnosed in [**4-/2183**] 15. Encephalopathy and hyperammonemia without evidence of hepatic dysfunction. Social History: living at rehab. HCP is wife. Family History: noncontributory Physical Exam: Vitals: cannot read temp, 60, 96/44, 100% on AC 500*20, peep 5, fio2 1.0. General: appears uncomfortable, opens eyes to stimulation HEENT: pupils sluggish but reactive Neck: R EJ in place Chest/CV: RRR, s1s2, decreased heart sounds Lungs: CTAB Abd: soft, nt, nd, +bs Rectal: per ER guaiac positive Ext: 2+ pitting edema BLE Pertinent Results: - WBC-8.1 RBC-2.89* HGB-9.3* HCT-28.0* MCV-97 MCH-32.1* MCHC-33.1 RDW-19.0* PLT COUNT-133* - NEUTS-87* BANDS-2 LYMPHS-8* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 - GLUCOSE-198* UREA N-52* CREAT-3.6*# SODIUM-132* POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-16* CALCIUM-8.5 PHOSPHATE-6.5*# MAGNESIUM-2.1 - LACTATE-2.3* - CK-MB-NotDone proBNP-[**Numeric Identifier 104520**]* CK(CPK)-26* cTropnT-0.05* Brief Hospital Course: Patient was admitted with hypoxic respiratory failure secondary to CHF and renal failure. He was intubated for this. However, it was then clarified with the family that he was DNR/DNI. Patient was anuric while on floor. It was decided to withdraw mechanical ventilation due to goals of care. Patient expired on [**2185-5-8**]. Mr [**Known lastname 104521**] family was in attendance at the time of withdrawl of care and patient expired without event. Medications on Admission: 1. Lactulose 30 mL PO Q 6 hours 2. Calcitriol 0.25 mcg PO QD 3. Atorvastatin 10 mg PO QD 4. Pantoprazole 40 mg PO QD 5. Donepezil 5 mg PO QHS 6. Fluticasone (intranasal) 7. Metoprolol Tartrate 50 mg PO TID 8. Amlodipine 5 mg PO QD 9. Tylenol PRN 10. Ipratropium Bromide Q6 PRN 11. Fluconazole 200 mg PO Q24H (until [**5-10**]) 12. Albuterol Q6 PRN 13. Linezolid 600 mg PO Q12H (until [**5-10**]) 14. nephrocaps 1 po qday Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA Completed by:[**2185-5-8**]

[ "424.1", "V45.01", "274.9", "585.9", "427.31", "427.81", "588.81", "185", "518.81", "593.9", "428.0", "403.90" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

4880, 4889

3924, 4381

236, 261

4940, 4949

3497, 3901

5000, 5032

3109, 3126

4853, 4857

4910, 4919

4407, 4830

4973, 4977

3141, 3478

189, 198

289, 2203

2225, 3046

3062, 3093

21,273

167,890

52099

Discharge summary

report

Admission Date: [**2113-7-19**] Discharge Date: [**2113-7-28**] Date of Birth: [**2056-10-31**] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 2145**] Chief Complaint: status epilepticus Major Surgical or Invasive Procedure: intubation placement of right subclavian central venous catheter EEG monitoring History of Present Illness: 56 year-old right-handed gentleman with a history of frontotemporal dementia, seizure disorder, who presented to the [**Hospital 4068**] Hospital with status epilepticus that was poorly responsive to medications, requiring intubation + sedation, transferred to [**Hospital1 18**] for further eval and mgmt. . The pt was recently admitted twice for seizures, once to [**Hospital **] Hospital from [**3-19**] to [**2113-3-21**], and once at [**Hospital1 18**] in late [**3-13**]. From his first seizure admit, he had a CT that showed moderate ventriculomegaly and bifrontal atrophy, but no evidence of hemorrhage or infarct. He also had an EEG that was unremarkable. Then on his most recent admit to [**Hospital1 18**], he presented after a series of seizures in the setting of PNA and fever, found to have a left retrocardiac opacity and lactate of 4.5. He had a lumbar puncture that was unrevealing, a repeat head CT which was negative for a bleed but remarkable for marked frontotemporal atrophy. He also underwent an MRI to evaluate for a focal lesion responsible for a seizure. Aside from motion artifact there was no clear focal lesion. Wellbutrin, trazodone and Nameda were discontinued because of their associated risks with seizures. He was loaded with 1gram IV Dilantin at OSH. Dilantin was continued and dose was adjusted for goal dilantin level of [**11-19**]. An EEG was done which showed encephalopathy but no seizure activity. He did not have further seizures while in house. He was sleepy and slow to respond initially and this was thought likely due to the ativan he had gotten in the ER and prior to MRI. Prior to discharge he was alert and thought to be at his baseline per family. . This episode, the patient was found seizing at his NH, [**Location (un) 107817**]. The EMTs transported him to [**Hospital 4068**] Hospital, and in route noted his O2 sat to be 86% on a NRB, and his temp to be 102.1F. Several attempts at intubation and IV access were unsuccessful en route. At [**Last Name (un) 4068**], the pt was still in status epilepticus, and remained so until after about 70 minutes of seizing he was intubated and managed with valium, ativan and versed boluses. The ED had not been able to intubate, but Anesthesia was successful. On CXR, he was found to have a RUL PNA. He received Tylenol, Etomidate, Succinycholine and 4.5L NS at the OSH ED. . He was transferred to [**Hospital1 18**], where Neuro evaluated him in the ED, and felt that his infection may have lowered his seizure threshold as previously. A head CT was performed, results stable. His blood pressure ran low in the ED (SBP 80's), and his lactate was elevated (3.6). His pressure has improved with fluid boluses. Also of note, his troponin is trending up (0.18 up from 0.02), and despite high CK has had normal CK-MB fraction and an unchanged ECG. He received BCx, CTX, Vanc, Ativan, ASA, Acyclovir, and 2L NS in the ED, as well as an LP. Past Medical History: -frontotemporal dementia, followed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. Per the pt's wife, at baseline he is generally able to make his needs known. His speech consists of mostly answering questions with "yes/no/OK." He is fully dependent on his caretakers in all of his ADLs. -coronary artery disease, with history of myocardial infarction, angioplasty and stent placement -anxiety -depression -hyperlipidemia -status-post prostate resection -obstructive sleep apnea, on CPAP -admitted to [**Hospital **] Hospital in [**2-10**] with pyelonephritis -clostridium difficile enterocolitis Social History: The pt had been living with his wife until he was discharged from [**Name (NI) **] in [**Month (only) 404**], at which time he was placed in a rehab facility. He has a distant history of cigarette use. No history of alcohol or illicit drug abuse. He previously worked in real estate. As above, he is now fully dependent on his caretakers for all of his ADLs. He is DNR, though no longer DNI (reversed today). Family History: Remarkable for mother with frontotemporal dementia. No history of seizure in other family members. Physical Exam: Vitals: T102.1, HR 97, BP 113/67, AC 600 x 14, 5 PEEP, 100% FiO2, O2 sat 97% General: lying in bed with eyes closed, turning his head back and forth, chewing on his ETT HEENT: no visible head trauma, no scleral icterus, MM dry, oropharynx appears clear with no tongue biting though exam limited by ETT Neck: no JVD or carotid bruits, no nuchal rigidity Pulmonary: from anteriorly exam, low breath sounds throughout, unable to appreciate any adventitial noise in R upper lung field, no rales, wheeze, rhonchi Cardiac: tachycardic, no m/g/r Abdomen: obese, ND, no scars, decreased bowel sounds, soft with no masses or HSM Groin: dried blood bilaterally, with L fem line in place, dressing poorly adherent and site not appearing clean Extremities: extensor posturing in LE bilaterally; shaking up RUE; 2+ DP and PT pulses bilaterally Skin: no rashes or lesions noted Neurologic: -mental status: Lying in bed with eyes closed. Does not open eyes to voice or noxious stimuli. -cranial nerves: PERRL, horizontal nystagmus -motor: normal bulk, increased tone throughout especially LUE; some RUE shaking, -sensory: no response to noxious stimuli on either side -DTRs: deferred as pt restrained -Plantar response was extensor on left, equivical on right Pertinent Results: [**2113-7-28**] 06:30AM BLOOD WBC-6.0 RBC-4.24* Hgb-12.9* Hct-36.5* MCV-86 MCH-30.4 MCHC-35.4* RDW-13.6 Plt Ct-209 [**2113-7-27**] 09:40AM BLOOD WBC-7.0 RBC-4.50* Hgb-13.3* Hct-38.6* MCV-86 MCH-29.5 MCHC-34.4 RDW-13.4 Plt Ct-214 [**2113-7-26**] 05:36AM BLOOD WBC-6.9 RBC-4.12* Hgb-12.6* Hct-35.9* MCV-87 MCH-30.6 MCHC-35.1* RDW-13.2 Plt Ct-201 [**2113-7-19**] 06:30AM BLOOD Neuts-77.2* Lymphs-17.0* Monos-4.4 Eos-0.9 Baso-0.4 [**2113-7-28**] 06:30AM BLOOD PT-12.9 PTT-28.7 INR(PT)-1.1 [**2113-7-18**] 09:50PM BLOOD Ret Aut-1.6 [**2113-7-28**] 06:30AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-141 K-3.9 Cl-103 HCO3-29 AnGap-13 [**2113-7-25**] 05:49AM BLOOD CK(CPK)-474* [**2113-7-24**] 08:08PM BLOOD CK(CPK)-423* [**2113-7-24**] 06:05AM BLOOD CK(CPK)-606* [**2113-7-19**] 12:30PM BLOOD CK(CPK)-[**Numeric Identifier 101751**]* [**2113-7-25**] 05:49AM BLOOD CK-MB-4 cTropnT-0.02* [**2113-7-24**] 08:08PM BLOOD CK-MB-2 cTropnT-0.03* [**2113-7-20**] 03:00AM BLOOD CK-MB-9 cTropnT-0.26* [**2113-7-19**] 09:00PM BLOOD CK-MB-12* MB Indx-0.1 cTropnT-0.30* [**2113-7-19**] 12:30PM BLOOD CK-MB-20* MB Indx-0.2 cTropnT-0.34* [**2113-7-19**] 06:30AM BLOOD CK-MB-30* MB Indx-0.3 cTropnT-0.53* [**2113-7-19**] 04:00AM BLOOD cTropnT-0.49* [**2113-7-19**] 04:00AM BLOOD CK-MB-30* MB Indx-0.4 [**2113-7-28**] 06:30AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 [**2113-7-18**] 09:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Radiology: Head CT [**7-19**]: IMPRESSION: 1. Ventricular enlargement and cerebral atrophy, unchanged since [**2113-3-27**]. 2. No evidence of intracranial hemorrhage or mass effect. CXR [**7-18**]: IMPRESSION: 1. Endotracheal tube and nasogastric tube in appropriate position. 2. Right upper lung opacity could relate to aspiration or pneumonia. EEG [**7-19**]: IMPRESSION: Abnormal portable EEG due to the slow low voltage background with occasional generalized slowing. This indicates a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features. MRI/MRA [**7-22**]: FINDINGS: Comparison was made with the previous study of [**2113-3-28**]. Again moderate-to-severe ventriculomegaly seen involving the lateral and third ventricles including prominence of the temporal horns. The ventricular size has remained unchanged. There is diffuse hyperintensity seen in the white matter predominantly involving the both frontal lobes, but also seen in the parietal lobes in the periventricular white matter. In the frontal lobes, the hyperintensities extending to the subcortical region. There is diffuse brain prominence of sulci indicating cortical atrophy, which is more predominant in the frontal region. Overall, the appearance of the brain has not changed from the previous study. Following gadolinium, no abnormal enhancement is identified. No acute infarct is seen on the diffusion images. IMPRESSION: No significant change from previous MRI of [**2113-3-28**]. Ventriculomegaly and cortical atrophy are again seen. Diffuse hyperintensities in the white matter are also noted. No enhancing lesions seen. MRA OF THE HEAD: The 3D time-of-flight MRA of the head is limited by motion, specifically in the level below the level of the supraclinoid carotids. The posterior fossa vascular structures are not evaluated secondary to motion. Both supraclinoid internal carotid, middle cerebral and anterior cerebral arteries demonstrate normal flow signal. IMPRESSION: Limited study with normal appearances of both supraclinoid internal carotid, middle cerebral, and anterior cerebral arteries. In the posterior foci only, the posterior cerebral arteries are visualized and have normal appearances and demonstrate normal flow signal. Video swallow [**7-27**]: VIDEO OROPHARYNGEAL SWALLOW. Multiple swallowing attempts were recorded under fluoroscopy, with varying different consistencies. Note is made of residual in the oral cavity at multiple swallowing attempts, which subsequently spill over to the pharynx. At the swallowing of volumes with mixed consistencies, note is made of penetration, followed by spontaneous cough and clearing. There is no aspiration. Please also refer to the official report by speech and language pathologist for interpretation and recommendations. Brief Hospital Course: Seizures: The patient presented after episode of generalized status epilecticus lasting 70minutes. Initially his Keppra dose was increased, and he was monitored on continuous EEG. EEG showed no additional seizure activity. He had a head CT that showed no acute changes, persistant ventriculomegaly and corticol atrophy. He also had an LP performed which showed no evidence of meningitis. Seizure was thought to occur in setting of pneumonia and fever, and standing Tylenol was given to prevent recurrent fever. He remained seizure free until day three of his hospitalization when he had another seizure. Trileptal was added to his antiepileptic regimen at that time. He had no further seizure activity. He was followed by the Neurology service throughout his hospitalization and will follow up with them as an outpt (Dr. [**Last Name (STitle) **]. RUL pneumonia: Patient was initially intubated for airway protection in the setting of status. He was treated for RUL nosocomial pneumonia with ceftriaxone, azithromycin, and vancomycin. Ceftriaxone was changed to Cefepime on day four when sputum culture returned with GNR's, concerning for pseduomonas. The azithromycin was discontinued. He was extubated on day three of his hospitalization without incident. He completed a 7-day course of antibiotics for his pneumonia, remained afebrile, and did well off antibiotics. NSTEMI: The patient sustained an NSTEMI during the episode of status epilepticus. He has a history of prior MI and is s/p stent placement. NSTEMI was managed medically with aspirin, atorvastatin, metoprolol and captopril. There were no ECG changes. Rhabdomyolysis: patient presented in rhabdo after seizures with peak CK 10,069. He was treated with iv fluid hydration without compromise to his renal function. This was felt to be due to the seizures. OSA: continutes on CPAP after extubation Swallowing: He had a bedside swallow eval as well as a video swallow which showed no signs of aspiration. Please see the Page 1 for specific diet instructions. C diff: He had a low-grade temp, and a stool sample grew C diff, which he has had in the past. He should be treated with flagyl for a total 14 day course, last day [**2113-8-9**]. In the past, he has required oral vanco to clear his CDiff, but currently he should be treated with flagyl per infectious disease recs. If he fails to improve, he may switch to vanco. Medications on Admission: -ASA 81mg po daily -atenolol 25mg po daily -enalapril 5mg po daily -zetia 10mg po daily -trazodone 50mg po qhs -MVI 1 tablet po daily -folic acid 400 mcg daily -Keppra 500mg [**Hospital1 **] -Lipitor 10mg qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection TID (3 times a day). 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: Thirty (30) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Oxcarbazepine 300 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Continue until [**8-9**]. . Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Status epilepticus C. Diff diarrhea NSTEMI Discharge Condition: Good. Pt not interactive but smiles when wife walks into room. Able to open eyes and grimace to painful stimuli. Discharge Instructions: Return to hospital if fevers, SOB, diarrhea, or persistent seizures. We have started you on new medications: Trileptal Keppra Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**] Date/Time:[**2113-9-7**] 11:30 You should follow-up with your primary care physician [**Last Name (NamePattern4) **] [**2-6**] wks. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

[ "482.1", "518.81", "287.5", "564.09", "008.45", "331.19", "345.3", "410.71", "342.90", "276.52", "294.10", "412", "281.9", "728.88", "V45.82", "458.8", "414.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "93.90", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

13997, 14074

10276, 12692

289, 370

14161, 14276

5806, 9084

14451, 14804

4423, 4523

12950, 13974

14095, 14140

12718, 12927

14300, 14428

5528, 5787

4538, 5416

231, 251

398, 3338

9101, 10253

5431, 5511

3360, 3979

3995, 4407

19,152

109,035

23661

Discharge summary

report

Admission Date: [**2162-4-26**] Discharge Date: [**2162-5-2**] Date of Birth: [**2112-2-5**] Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 16920**] Chief Complaint: right breast cancer Major Surgical or Invasive Procedure: bilateral breast reconstructions with [**Last Name (un) 5884**] flaps on [**2162-4-26**] History of Present Illness: 50-year-old woman who in [**2148**] felt a lump within the superior aspect of her right breast when her 1- year-old baby at the time kicked her in the chest. She showed it to a neighbor who immediately set her up with a surgeon where she was living in Tel [**Last Name (LF) 25539**], [**First Name3 (LF) **]. She was brought in for a mammogram and underwent a lumpectomy. This returned as cancer and she was brought back for an axillary dissection. She remembers the size of the tumor being 2.2 cm. According to a letter sent, this is a grade 3. Her lymph nodes were negative. Her estrogen receptor was weakly positive, with progesterone receptor being strongly positive. She was then given CMF for 6 cycles as well as radiation therapy. She had a fine needle aspiration several years later of the scar tissue in that breast which showed only fat necrosis. She otherwise has been doing well. On her routine mammogram, she was noted to have a new density within the deep, slightly lateral, right breast. An ultrasound was performed and this revealed no definitive mass. She then underwent a stereotactic core needle biopsy of this at the [**Hospital1 882**] on [**2162-3-12**] which revealed an infiltrating ductal carcinoma. It appeared poorly differentiated. Per the report, it is estrogen receptor negative, progesterone receptor negative and HER2/neu negative. She is here now to discuss further local treatment options. Past Medical History: right breast cancer hypertension Social History: non-contributory Family History: Her family history is significant for her father who had both breast cancer and prostate cancer. In addition, her younger sister died of breast cancer 4 years ago. She has another sister who was noticed to have microscopic breast cancer on prophylactic mastectomy. She has a paternal aunt who had 2 breast cancers in her 40s and 60s. Her father's half sister has a younger daughter who also has breast cancer. Ms. [**Known lastname 60505**] first child was at the age of 36. Physical Exam: On physical exam, she is well appearing in no acute distress. Her blood pressure is 139/82, pulse is 74, and weight is 277 lbs. On auscultation of her lungs, they are clear and equal bilaterally and she has a regular rate and rhythm on coronary exam without murmurs, rubs or gallops. On breast exam she is status post right lumpectomy with radiation. She has no suspicious skin changes in four positions. To palpation, she has no masses within either breast. She has no axillary, supraclavicular or infraclavicular lymphadenopathy. She is status post right axillary dissection. The skin of her chest, neck and face is normal, with the exception of a small scar just above her left clavicle where she has just had a skin biopsy, found to be a basal cell carcinoma. On musculo skeletal exam she has a normal gait and station. Her spine, pelvis and extremities are stable. Pertinent Results: [**2162-4-26**] 09:03AM BLOOD freeCa-1.16 [**2162-4-26**] 12:08PM BLOOD freeCa-1.13 [**2162-4-26**] 02:58PM BLOOD freeCa-1.12 [**2162-4-26**] 05:52PM BLOOD freeCa-1.10* [**2162-4-26**] 09:03AM BLOOD Hgb-12.2 calcHCT-37 [**2162-4-26**] 12:08PM BLOOD Hgb-11.2* calcHCT-34 [**2162-4-26**] 02:58PM BLOOD Hgb-11.7* calcHCT-35 [**2162-4-26**] 05:52PM BLOOD Hgb-11.5* calcHCT-35 [**2162-4-26**] 09:03AM BLOOD Glucose-114* Lactate-2.4* Na-142 K-4.6 Cl-106 [**2162-4-26**] 12:08PM BLOOD Glucose-143* Lactate-4.0* Na-138 K-4.6 Cl-107 [**2162-4-26**] 02:58PM BLOOD Glucose-144* Lactate-3.8* Na-138 K-4.2 Cl-106 [**2162-4-26**] 05:52PM BLOOD Glucose-159* Lactate-4.0* Na-137 K-4.3 Cl-107 [**2162-4-26**] 09:03AM BLOOD Type-ART Tidal V-620 FiO2-60 pO2-187* pCO2-41 pH-7.36 calHCO3-24 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [**2162-4-26**] 12:08PM BLOOD Type-ART Rates-/12 Tidal V-650 FiO2-47 pO2-180* pCO2-38 pH-7.40 calHCO3-24 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2162-4-26**] 02:58PM BLOOD Type-ART Rates-/12 Tidal V-600 FiO2-46 pO2-156* pCO2-38 pH-7.41 calHCO3-25 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2162-4-26**] 05:52PM BLOOD Type-ART Rates-/12 Tidal V-650 pO2-138* pCO2-38 pH-7.41 calHCO3-25 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2162-4-26**] 11:59PM BLOOD Calcium-7.6* Phos-7.3* Mg-1.3* [**2162-4-26**] 11:59PM BLOOD Glucose-180* UreaN-14 Creat-0.4 Na-146* K-4.0 Cl-107 HCO3-20* AnGap-23* [**2162-4-26**] 11:59PM BLOOD PT-13.3 PTT-23.6 INR(PT)-1.1 [**2162-4-26**] 11:59PM BLOOD Plt Ct-422 [**2162-4-26**] 11:59PM BLOOD WBC-15.8* RBC-3.95* Hgb-11.1* Hct-33.4* MCV-85 MCH-28.2 MCHC-33.3 RDW-13.2 Plt Ct-422 [**2162-4-27**] 12:06AM BLOOD freeCa-1.11* [**2162-4-27**] 12:06AM BLOOD O2 Sat-98 [**2162-4-27**] 12:06AM BLOOD Lactate-3.7* [**2162-4-27**] 12:06AM BLOOD Type-ART Temp-36.5 O2 Flow-6 pO2-172* pCO2-43 pH-7.33* calHCO3-24 Base XS--3 Intubat-NOT INTUBA [**2162-4-28**] 02:22AM BLOOD Calcium-8.1* Phos-1.9*# Mg-2.0 [**2162-4-28**] 01:40PM BLOOD Phos-2.1* Mg-2.0 [**2162-4-28**] 02:22AM BLOOD Glucose-104 UreaN-9 Creat-0.4 Na-139 K-3.7 Cl-109* HCO3-28 AnGap-6* [**2162-4-28**] 01:40PM BLOOD K-3.7 [**2162-4-28**] 02:22AM BLOOD PT-13.1 PTT-28.5 INR(PT)-1.1 [**2162-4-28**] 02:22AM BLOOD Plt Ct-319 [**2162-4-28**] 02:22AM BLOOD WBC-11.3* RBC-3.04* Hgb-8.5* Hct-25.5* MCV-84 MCH-27.9 MCHC-33.2 RDW-13.4 Plt Ct-319 [**2162-4-28**] 06:00AM BLOOD Hct-24.6* [**2162-4-28**] 01:40PM BLOOD Hct-26.3* Brief Hospital Course: Ms. [**Known lastname 4901**] was admitted on [**2162-4-26**] and taken to the operating room where she underwent a bilateral mastectomy with bilateral [**Last Name (un) 5884**] reconstruction. She tolerated the procedure well. She was transferred to the ICU where frequent flap checks consistently revealed good dopplerable pulses. She was transferred to the floor on POD 2. We also took out her foley on POD 2 and she voided appropriately. She tolerated a regular diet and ambulated well on the floor. Physical exam of her flaps continued to reveal well-perfused breast flaps bilaterally. She was discharged home with services in good condition on POD 6. Medications on Admission: Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 7 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p bilateral breast reconstructions with [**Last Name (un) 5884**] flaps on [**2162-4-26**] Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. Followup Instructions: Call to schedule a follow-up appointment in [**1-10**] weeks with Dr. [**First Name (STitle) 3228**]. His phone number is ([**Telephone/Fax (1) 23640**]. Call to schedule an appointment with Dr. [**Last Name (STitle) **]. Her phone number is [**Telephone/Fax (1) 6733**].

[ "174.8", "458.0", "V16.3" ]

icd9cm

[ [ [] ] ]

[ "85.44", "85.7" ]

icd9pcs

[ [ [] ] ]

7371, 7429

5814, 6479

333, 424

7566, 7572

3367, 5791

8353, 8631

1983, 2460

6656, 7348

7450, 7545

6505, 6633

7596, 8330

2475, 3348

274, 295

452, 1877

1899, 1933

1949, 1967

73,553

196,981

35459

Discharge summary

report

Admission Date: [**2132-2-2**] Discharge Date: [**2132-2-23**] Date of Birth: [**2050-1-31**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Erythromycin Base / Penicillins Attending:[**First Name3 (LF) 2009**] Chief Complaint: Right-sided weakness and aphasia Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 82 year-old right-handed woman with a history of atrial fibrillation on warfarin, hypertension, diabetes, dyslipidemia, congestive heart failure, and chronic kidney disease who presents to the [**Hospital3 **] emergency room after reportedly being found by her family at approximately 9:45 am today, with difficulty speaking and right-sided weakness. The patient had suffered from a "cold" recently, and was last seen normal last evening by her husband at 11 pm. At 7:30 am, she was seen by family, sleeping in bed. When her daughter came to visit at approximately 9:45 am today, the patient was found downstairs, but was having difficulty "getting words out." Her right face was drooped. She tried to rise to her walker, but had difficulty grasping it with her right hand. Emergency medical services were notified and arrived on the scene at approximately 10:10 am. Her vital signs on the scene included a blood pressure 204/94, pulse 76, respirations 14, oxygen saturation 98%. A fingerstick glucose was 246. Her rhythm strip suggested atrial fibrillation. She was seated in a chair, leaning toward the right. A right facial droop was noted. She was reportedly "A x O x3" but it was observed that it was "very difficult for the patient to speak." The patient was brought to [**Hospital3 **] for further evaluation and management. A Neurology consult was emergently called; the patient was sent for non-contrast CT of the head. Given unclear time of onset and inability to speak with family, the decision was made to proceed with a CTA of the head and neck as well as CT perfusion in order to determine if she might be a candidate for an intervention. The study was ordered by the emergency room and I confirmed this order with the stroke fellow, Dr. [**Last Name (STitle) 78537**]. We decided to proceed in the absence of a BUN and creatinine. We later learned of her prior history of worsening renal failure in the setting of iodine contrast media. Past Medical History: -Atrial fibrillation on warfarin -Hypertension -Diabetes mellitus, non-insulin dependent -Congestive heart failure -Chronic kidney disease secondary to hypertension and diabetes, baseline creatinine 1.4-1.6. Has had acute renal failure previously when exposed to contrast dye with iodine. -Left breast cancer diagnosed 11 years ago, s/p mastectomy and lymph node removal. Received Tamoxifen. -Osteoarthritis -Right rotator cuff injury -s/p right hip replacement -s/p bilateral knee replacements Social History: Lives at home with her husband. Uses a walker. No history of smoking, alcohol, or illicit drug use. Family History: Mother reportedly had transient ischemic attacks. Physical Exam: On admission: Vitals: Temperature was not obtained BP 162/70 P 75 RR 28 SaO2 95 on nasal cannula General: elderly woman, intermittently somnolent, breathing with effort at times HEENT: NC/AT, sclerae anicteric, dry MM Neck: no nuchal rigidity, no bruits appreciated Lungs: rhoncherous breath sounds bilaterally CV: irregularly irregular rate and rhythm, no MMRG appreciated Abdomen: soft, obese, non-tender, non-distended, bowel sounds present Ext: warm, no edema, pedal pulses appreciated Skin: no rashes, has scars at knees suggestive of possible prior knee surgery Neurologic Examination: Mental Status: Somnolent but arousable, she is able to offer her first name in dysarthric, halting speech, but little other speech is produced, cooperative with exam as able, though she appears to have difficulty following many of the exam commands, she is able to show me her left thumb at request. Cranial Nerves: Optic disc margins sharp; blinks to threat bilaterally without field cut detected. Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Extraocular movements intact, no nystagmus. Edentulous but appears to have a right UMN pattern facial droop. Hearing to conversational volume (follows some verbal commands). Palate elevates midline. Tongue protrudes midline, no fasciculations. Does not follow commands to assess spinal accessory nerve. Sensorimotor: Reduced tone in the right arm compared to the left, increased tone in the lower extremities. Formal motor examination is difficult at this time given her somnolence and possible difficulties with comprehension. She is able to maintain her right arm ant-gravity at the deltoid and extended for at least five seconds. Her right arm is plegic. She is able to raise the left iliopsoas against gravity with the heel off the bed for several seconds. She is able to raise the right iliopsoas just against gravity, but is unable to raise the heel off the bed. She grimaces to noxious in the left arm only. She withdraws the left foot minimally. There is no withdrawal on the right side. Reflexes: She is relatively [**Name2 (NI) 19912**] throughout the right arm, and is normoreflexic elsewhere, except at the ankles, where reflexes could not be elicited. Toes were upgoing bilaterally. Coordination and gait could not be assessed given somnolence and weakness. Pertinent Results: [**2132-2-2**] 10:30AM GLUCOSE-201* UREA N-48* CREAT-1.6* SODIUM-137 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17 [**2132-2-2**] 10:30AM ALT(SGPT)-59* AST(SGOT)-53* LD(LDH)-290* CK(CPK)-79 ALK PHOS-191* [**2132-2-2**] 10:30AM cTropnT-0.02* [**2132-2-2**] 10:30AM CK-MB-4 [**2132-2-2**] 10:30AM ALBUMIN-4.1 CALCIUM-10.4* PHOSPHATE-3.4 MAGNESIUM-2.3 [**2132-2-2**] 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-8.5 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2132-2-2**] 10:30AM WBC-19.8* RBC-4.27 HGB-12.4 HCT-36.3 MCV-85 MCH-29.1 MCHC-34.2 RDW-14.4 [**2132-2-2**] 10:30AM NEUTS-80.2* LYMPHS-14.2* MONOS-4.1 EOS-1.1 BASOS-0.5 [**2132-2-2**] 10:30AM PLT COUNT-395 [**2132-2-2**] 10:30AM PT-14.3* PTT-30.1 INR(PT)-1.2* [**2132-2-2**] 05:43PM CK-MB-NotDone cTropnT-0.01 [**2132-2-2**] 05:43PM CK(CPK)-54 [**2132-2-2**] 04:25PM %HbA1c-6.3* [**2132-2-2**] 12:40PM proBNP-[**Numeric Identifier 80817**]* [**2132-2-2**] 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2132-2-2**] 12:40PM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-NONE EPI-0 [**2132-2-2**] 10:54AM LACTATE-1.3 [**2132-2-2**] 05:43PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG IMAGING: CT Head [**2132-2-2**]: 1. No evidence of acute intracranial hemorrhage or large vascular territory infarction seen. However, if there is concern for acute infarction, MRI would be recommended for more sensitive evaluation. 2. Mucosal thickening with layering air-fluid level in the right maxillary sinus could represent acute-on-chronic sinusitis. 3. Small hyperdensity in left frontal region within a sulcus is likely due to vascular calcification. CTA Head [**2132-2-2**]: 1. CT head demonstrates subtle [**Doctor Last Name 352**]-white matter differentiation loss in the left temporal region suspicious for an acute infarct. Small vessel disease and brain atrophy seen. 2. CT perfusion demonstrates evidence of an acute infarct in the left temporal region. 3. CT angiography of the neck demonstrates bilateral moderate stenosis in the carotid bifurcation with calcification. 4. CT angiography of the head demonstrates abrupt cutoff of the temporal branch of the left middle cerebral artery suspicious for branch occlusion. Otherwise, normal CTA of the head. MR [**Name13 (STitle) 430**] [**2132-2-2**]: Acute left temporal infarct. No evidence of significant vasogenic edema or blood products. Small vessel disease and brain atrophy. TTE [**2132-2-4**]: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is probably mildly depressed (LVEF= 40-45 %) with septal, inferior and apical hypokinesis. There is no ventricular septal defect. Right ventricular chamber size is normal. with depressed free wall contractility. 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Head CT [**2132-2-5**]: 1. Findings consistent with continued evolution of infarct in the left temporal region. 2. In addition, there is new loss of [**Doctor Last Name 352**]-white matter differentiation and hypodensity along the left occipital lobe indicating cytotoxic edema related to interval acute infarction in the left PCA territory; no "hyperdense PCA" is seen. 3. No new intracranial hemorrhage or shift of normally midline structures seen. Head CT [**2132-2-7**]: Continued evolution of left MCA and left PCA infarcts. No intracranial hemorrhage. Brief Hospital Course: 82 yo female with hx of a.fib on coumadin, DM, htn, sCHF, CKD admitted on [**2-2**] with right hemiplegia and aphasia and found to have an acute left MCA stroke; also later developed a left PCA stroke, now transitioned to comfort care. # Acute MCA and PCA ischemic strokes: The patient was brought to the ED with right hemiparesis and difficulty with speech. She had run out of her coumadin prior to her event and her INR was subtherapeutic at 1.2 on admission. In the ED where neurology emergently evaluated her given her right facial droop and aphasia. A head CT showed no bleed and a CTA was preformed which showed a cutoff in blood flow in the MCA distribution. She was not felt to be a candidate for intervention. As her INR was subtherapeutic and the origin of her stroke was thought to be cardioembolic she was admitted to the neruo ICU and started on a heparin gtt. On HD [**2-27**] she was noted to be more somnolent and had a repeat head CT which showed a new left PCA stroke (even with a therapeutic PTT on the heparin gtt). She underwent a TTE which showed no thrombus. From the strokes she has right hemiparesis (arm worse then the leg) and aphasia. Her R hemiparesis, R arm worse than R leg, remained relatively stable throughout her hospital course. Over her hospital course her awakfulness waxed and waned, but the trend was for her to be sleeping most of the time. She was usually arousable to voice, but would often immediately close her eyes again. On [**2-19**] a family meeting was held with neurology, speeech and swallow, the medicine team, social work, her husband, two brothers, and 5 of her 8 children. During the meeting her poor prognosis for recovery was discussed as well as the goals of care. Her family felt that she would not want to choose quanity over quality of life and chose to pursue palliative care; the palliative care team met with them later in the day. Her code status was advanced to DNR/DNI and two days later her goals of care where fully changed to focus on comfort. Prior to her transfer the DNR/DNI order was again confirmed with the husband over the phone, but a signed form should be obtained when able. For her comfort she can be given morphine prn for pain, ativan prn for anxiety, scopolamine patch prn to decrease secretions, compazine prn for nausea, tylenol supp for pain, haldol prn for agitation, bisacodyl supp for constipation. # Respiratory distress/Pneumonia: She had significant respiratory distress throughout the first half of her ICU course, requiring BIPAP on ICU day 2 to maintain her O2 sats, which was titrated down to face tent, and finally weaned off O2 requirement on ICU day 5. She was started on Levoquin on admission for PNA ([**2-2**]); Flagyl and vancomycin were added on [**2-4**] for extended coverage with improvement/resolution of her PNA and flagyl was stopped on [**2-6**]. On [**2-12**] while on the floor she had acute worsening of her respiratory status with tachypnea and new 02 requirement. She had a CXR concerning for an increased infiltrate in the left lower lobe and was given lasix. She maintained sats >95 on non-rebreather. The ICU was consulted and she was transfered to their care for further management of acute respiratory distress which was felt to be due to a combination of acute on chronic CHF and HAP. She was started on aztreonam for better gram negative coverage. Sputum culture grew out MRSA. Aztreonam was stopped on [**2-15**] given lack of evidence of gram negative infection. Levofloxacin was stopped on [**2-15**] as she had received a 10-day course. Vancomycin was stopped on [**2-16**] as she appeared to have recovered from her respiratory distress which was now thought to have been an aspiration pneumonitis. # Acute on chronic CHF: The patient had a TTE during this hospitalization showing an EF of 40-45% and CXR showing increasing pleural effusions. She also appeared volume overloaded on exam with edema in her upper and lower extremities. She was slowly diuresed with lasix and continued on her heart failure regimen of lisinopril 10 mg daily, metoprolol 100 mg tid, and amlodipine 10 mg daily. These medications were stopped when her goals of care were changed to focus on comfort. # Hypertension: The patient has a history of hypertension requiring multiple agents for control. Her SBP were targeted by neuro in specific ranges at different times of her hospitalization given her acute ischemic strokes. Most recently they recommend that her SBP should range 120-140. She was continued on lisinopril, metoprolol, lasix, hydralazine, clonidine, and amlodipine for SBP control. These medicaitons were stopped when her goals of care were changed to focus on comfort. # Atrial fibrillation: The patient has a history of a.fib on coumadin as an outpatient, but unfortunately had stopped taking her coumadin prior to presentation with her stroke. Since admission she had been anticoagulated with a heparin gtt and was on metoprolol for rate control. The metoprolol and heparin gtt were stopped when goals of care were shifted to comfort care. # Acute on Chronic kidney disease: She had ARF early in her hospital course due to dye given with the CTA of her head/neck which resolved with hydration. # Diabetes: The patient was on glyburide as an outpatient. Her FS were checked qid and she was covered with SSI. When goals of care were readjusted to comfort the fingersticks and SSI were held. # FEN: The patient had a post-pyloric feeding tube placed on [**2-14**] and had been receiving tube feeds throughout her hospital course. NPO given inability to manage her own secretions and recent stroke per speech and swallow. She feeding tube clogged and was removed on [**2-18**] and since then she has not received tube feeds or po medications. Her code status was changed on [**2-19**] and goals of care were readjusted to focus on comfort. # CODE: The patient was initally full code, but as it became apparent that her prognosis in terms of recovery from the stroke was poor, her code status was changed to DNR/DNI and her goals of care were refocused on comfort as above. Medications on Admission: -Warfarin 4.5 mg MF, 5 mg other days. Ran out of medication and did not take it last evening. Followed by the [**Hospital1 2025**] coagulation clinic. -Lipitor 10 mg qhs -Glyburide 2.5 mg daily -Hydralazine 25 mg TID -Lopressor 150 mg TID -Lasix 80 mg q 9 am, 40 mg at noon, 40 mg 5 pm daily -Clonidine 0.2 mg [**Hospital1 **] -Zestril -Norvasc -KCl -Vitamin E -Vitamin C -Calcium/Vitamin D -Tylenol QID -Ambien 2.5 mg q hs -Omeprazole 40 mg daily She has an 1800 cc per day fluid restriction. Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours). 3. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO q1h prn as needed for pain for difficulty breathing. 4. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety: [**Month (only) 116**] crush and give sublingually as patient unable to swallow. 5. Colytrol 19.4-103.7-6.5 mcg Suspension Sig: Two (2) drops PO every four (4) hours as needed for secretions. 6. ABHR suppositories Sig: One (1) suppository every six (6) hours as needed for nausea. 7. Haloperidol Lactate 2 mg/mL Concentrate Sig: One (1) mg PO every six (6) hours as needed for agitation: Please give under the tongue every 6 hours as needed for agitation. 8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 9. Prochlorperazine 25 mg Suppository Sig: One (1) suppository Rectal every six (6) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**] Discharge Diagnosis: Primary - Ischemic stroke of the MCA and PCA Community aquired pneumonia Aspiration pnuemonitis Acute on chronic systolic heart failure Acute on chronic renal failure Secondary - Atrial fibrillation Hypertension Diabetes II Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to a stroke which left you with decreased ability to move your right arm and right leg, and difficulty with your speech. During your hospitalization a second stroke developed despite anticoagulation (blood thinners). You will be transferred to an inpatient hospice care center for further care which will focus on optomizing your comfort. For medication changes please see the discharge medication list. Followup Instructions: You should follow up with your primary doctor, Dr. [**Last Name (STitle) **] as you see fit. Completed by:[**2132-2-23**]

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icd9cm

[ [ [] ] ]

[ "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

17242, 17342

9465, 15605

352, 369

17611, 17620

5469, 9442

18113, 18237

3023, 3074

16151, 17219

17363, 17590

15631, 16128

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3089, 3089

280, 314

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3103, 3667

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2903, 3007

29,140

182,842

25309

Discharge summary

report

Admission Date: [**2166-8-11**] Discharge Date: [**2166-8-13**] Date of Birth: [**2094-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Fall with L hip fracture Major Surgical or Invasive Procedure: Left hemiarthroplasty History of Present Illness: Pt is a 72 yo Haitian Creole-speaking man with PMHx sig. for HTN, DM II, CRF, PVD who presents after a fall and was found to have a L femoral neck fracture on X-ray. This history was taken through an interpreter; pt also has dementia at baseline. Pt reported that he fell in his home because he couldn't see well (he is legally blind) and items had been moved around in his house. He had landed on his L hip, denied head trauma. Pt also denies associated headache, dizziness, lightheadedness, CP, palpitations, SOB. At baseline, he walks with a cane. . In [**Name (NI) **], pt had X-rays of his L shoulder, hip, and pelvis, which showed a fracture of the L femoral neck. Ortho saw him and have tentatively scheduled for hip fixation on [**8-14**]. He is to be admitted on the medical floor for preop evaluation and optimization. . On review of symptoms, pt reported having multiple episodes of emesis, first episode occuring about 1 week ago and again [**2166-8-10**] and AM of admission. Pt had another episode while eating on the floor this PM. Pt denies any abdominal pain, diarrhea. Past Medical History: DM II with retinopathy, nephropathy HTN CRF PVD Legally blind due to B macular edema, L glaucoma, and R retinal detachment Dementia Social History: Pt lives with his wife. [**Name (NI) **] denies tob, etoh, and illict drug use. Family History: N/C Physical Exam: Vitals: T100.5, P118, BP 174/100, R20, O2sat 95 RA General: NAD, Haitian-creole speaking, pleasant HEENT: conjunctiva clear, sclerae nonicteric, MM slightly dry Neck: no carotid bruits, JVD difficult to assess to due thickness of neck CV: sinus tachycardia, no loud murmurs noted Pulm: decreased BS, otherwise clear Abd: +BS, soft, NT/ND, no HSM Ext: warm, 2+ DP pulses, no edema Neuro: alert, orientedx1, moves UEs and R LE without problems. Pertinent Results: [**2166-8-11**] 10:35AM WBC-16.8* RBC-5.48 HGB-12.6* HCT-38.2* MCV-70* MCH-23.1* MCHC-33.0 RDW-15.3 [**2166-8-11**] 10:35AM NEUTS-91.7* LYMPHS-5.0* MONOS-2.4 EOS-0.8 BASOS-0.1 [**2166-8-11**] 10:35AM RET AUT-1.3 [**2166-8-11**] 10:35AM GLUCOSE-266* UREA N-19 CREAT-1.5* SODIUM-141 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-26 ANION GAP-17 [**2166-8-11**] 10:35AM ALT(SGPT)-18 AST(SGOT)-23 LD(LDH)-322* CK(CPK)-152 ALK PHOS-101 AMYLASE-142* TOT BILI-0.9 [**2166-8-11**] 10:35AM LIPASE-15 [**2166-8-11**] 10:41AM LACTATE-3.6* [**2166-8-11**] 10:35AM cTropnT-<0.01 [**2166-8-11**] 10:35AM CK-MB-3 [**2166-8-11**] 10:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2166-8-11**] 10:45AM URINE RBC-[**7-20**]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 . CHEST (PORTABLE AP) [**2166-8-11**] 11:16 AM 1. No evidence of acute intrathoracic injury. If clinical suspicion for injury is high, CT would be suggested. 2. Minimal focal left basilar opacity, likely atelectasis. Attention to this area on a followup PA/lateral chest radiograph would be helpful when the patient's condition permits. Alternatively, if CT is performed, this area could be better evaluated at that time. . HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) [**2166-8-11**] 11:28 AM Fracture involving the left femoral neck with minimal varus angulation. Brief Hospital Course: Pt is a 72 yo Haitian Creole-speaking man with PMHx sig. for HTN, DM II, CRI, PVD who presented after a fall and was found to have a L femoral neck fracture on X-ray. He was admitted to the medical floor for medical optimization for surgery. EKG and CXR were performed and did not show any sig. pathology. Previous records from his PCP were also obtained. There was no stres test on file. Pt was continued on his outpatient HTN regimen (nifedipine, HCTZ) and a beta blocker was also added with good BP control. Pt was also placed on an RISS instead of his oral hypoglycemics with good BS control. Pt's pain was well controlled with morphine. He was taken to the OR by orthopedics on [**2166-8-12**] for L hip hemiarthroplasty. During the operation, pt had an episode of hypotension that was stabilized. However, after closing, pt developed bradycardia followed by supraventricular tachycardia. Resuscitation efforts were initiated by protcol including medications and defibrillation. Efforts were continued for approximately 30 minutes without success. The patient went from supraventricular tachycardia to asystole and after 30 minutes of resuscitation efforts, he was pronounced deceased at 12:20 a.m. on the [**9-13**]. The family was notified as well as the medical examiner. Medications on Admission: Nifedipine HCTZ Metformin Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: L hip fracture Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "81.51" ]

icd9pcs

[ [ [] ] ]

5057, 5066

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111,295

30576

Discharge summary

report

Admission Date: [**2186-5-18**] Discharge Date: [**2186-6-9**] Date of Birth: [**2117-6-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Fevers, malaise Major Surgical or Invasive Procedure: right hepatectomy and small bowel resection of GIST [**2186-5-18**] History of Present Illness: The patient is a 68 year- old male who recently presented with fever and malaise. A CT scan of the chest and abdomen demonstrated 2 small left upper lobe pulmonary nodules of uncertain etiology but concerning for malignancy. His abdominal CT demonstrated a left lower quadrant mass that on biopsy was demonstrated to be a GIST tumor that was C-kit positive. In addition, this CT demonstrated a large mass in the right lobe of the liver that was initially thought to represent an abscess but an attempted CT guided drainage demonstrated only a small amount of blood. Biopsies demonstrated only granulation tissue. The patient had a recent follow-up CT scan that demonstrated rapid and significant enlargement of the right lobe mass. It was uncertain whether this represented a liver abscess or a tumor with necrosis and secondary infection. Because of the rapid enlargement of the mass and inability to drain this percutaneously along with continued fevers and malaise, the patient is brought to the operating room after informed consent was obtained for right hepatic lobectomy, cholecystectomy and resection of the left lower quadrant GIST tumor. Past Medical History: Hypertension Hypercholesterolemia Benign esophageal growth h/o prostate CA s/p resection in [**2179**] Social History: Denies tobacco, drinks 2 glasses of wine after dinner, retired, married Family History: NC Pertinent Results: ADMISSION LABS ---> [**2186-5-18**] 09:50PM BLOOD WBC-18.6* RBC-3.36* Hgb-9.3* Hct-28.1* MCV-83 MCH-27.5 MCHC-33.0 RDW-15.6* Plt Ct-745* [**2186-5-18**] 09:50PM BLOOD PT-15.3* PTT-33.5 INR(PT)-1.4* [**2186-5-18**] 09:50PM BLOOD Glucose-100 UreaN-19 Creat-1.3* Na-132* K-4.9 Cl-94* HCO3-26 AnGap-17 [**2186-5-18**] 09:50PM BLOOD ALT-51* AST-26 AlkPhos-321* Amylase-61 TotBili-0.6 [**2186-5-18**] 09:50PM BLOOD Lipase-32 [**2186-5-18**] 09:50PM BLOOD Albumin-3.2* Calcium-9.1 Phos-4.2 Mg-2.3 [**2186-5-19**] 04:43AM BLOOD calTIBC-198* Ferritn-264 TRF-152* [**2186-5-31**] 05:00AM BLOOD Triglyc-50 [**2186-5-28**] 05:30AM BLOOD Triglyc-41 [**2186-5-26**] 06:45PM BLOOD Ammonia-31 [**2186-5-26**] 06:57PM BLOOD TSH-0.63 [**2186-5-26**] 06:57PM BLOOD Free T4-1.4 [**2186-5-26**] 06:57PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2186-5-26**] 06:57PM BLOOD CEA-1.8 PSA-<0.1 AFP-2.1 [**2186-5-21**] 03:30PM BLOOD AFP-1.1 [**2186-5-26**] 06:57PM BLOOD HIV Ab-NEGATIVE CERULOPLASMIN 16 L 18-36 MG/DL Alpha-1-Antitrypsin, S 167 100-190 mg/dL HERPES I (IGG) ANTIBODY 4.16 A NEGATIVE HERPES II (IGG) ANTIBODY NEGATIVE NEGATIVE CA [**98**]-9 49 H 0-37 SEE NOTE COCCIDIOIDES ANTIBODY, ID NEGATIVE NEGATIVE . DISCHARGE LABS ---> [**2186-6-9**] 05:45AM BLOOD WBC-6.9 RBC-2.90* Hgb-8.8* Hct-26.5* MCV-91 MCH-30.4 MCHC-33.3 RDW-20.8* Plt Ct-192 [**2186-6-9**] 05:45AM BLOOD Plt Ct-192 [**2186-6-9**] 05:45AM BLOOD PT-14.9* PTT-33.2 INR(PT)-1.3* [**2186-6-9**] 05:45AM BLOOD Glucose-76 UreaN-26* Creat-1.3* Na-128* K-4.7 Cl-99 HCO3-23 AnGap-11 [**2186-6-9**] 05:45AM BLOOD ALT-86* AST-74* AlkPhos-210* TotBili-11.9* [**2186-6-8**] 05:00AM BLOOD Lipase-106* [**2186-6-9**] 05:45AM BLOOD Albumin-2.3* Calcium-8.2* Phos-2.6* Mg-2.3 [**2186-5-29**] 03:44AM BLOOD calTIBC-95* Ferritn-243 TRF-73* . IMAGING/STUDIES ---> . [**5-19**] CT Abd/Pelvis: IMPRESSION: 1. Unchanged left upper lobe ground-glass ill-defined nodules may represent metastatic disease versus primary pulmonary neoplasm. 2. Left lower quadrant mass as described consistent with biopsy proven GI stromal tumor. 3. Large multiloculated low-density collection with enhancing rim seen on prior examination, slightly increased in size and in segment VI consistent with progression of hemorrhage/malignancy. 4. Diverticulosis without evidence of diverticulitis. 5. Stable lymph nodes in the gastrohepatic ligaments and in the retroperitoneum. 6. New trace perihepatic fluid. . [**5-19**] CT Head: IMPRESSION: 1. No intracranial hemorrhage or mass effect. 2. Maxillary sinusitis. . [**5-19**] Liver biopsy: Liver core biopsy: Granulation tissue with a focally prominent acute inflammatory component. Organizing fibrinous exudate. The adjacent hepatic parenchyma shows acutely inflamed portal triads; no malignancy identified. . [**5-23**] Duplex: CONCLUSION: Status post right hepatic lobectomy with patent portal, hepatic arterial and hepatic venous flow. Echogenic material surrounding the remaining liver may represent areas of surgical packing, omental plugs and/or Surgicel. . [**5-25**] KUB: IMPRESSION: 1. Multiple dilated loops of small bowel and large bowel. This appearance is suggestive of ileus. 2. Bilateral atelectatic changes are noted at lung bases, more prominent on the right. 3. Small pneumoperitoneum, not unexpected after recent surgery. . [**5-26**] US: IMPRESSION: Limited exam. The portal vein is patent with antegrade flow. The appearance of the liver parenchyma and adjacent small hematoma is not significantly changed from 3 days earlier. . [**6-2**] KUB: IMPRESSION: Non-obstructive bowel gas pattern. . [**6-4**] Duplex: IMPRESSION: Patent portal veins, hepatic veins, and main hepatic artery. Left and right branches of the hepatic artery are not visualized on today's study, possibly secondary to technical factors. . Brief Hospital Course: This patient was admitted to the transplant surgical service on [**5-18**] with the chief complaint of fevers and malaise. A CT head and CT abd/pelvis were obtained (see reports above), and he was started on his home medications. On admission, his temperature was 102.1. A CXR showed no acute cardio-pulmonary process. On [**5-19**], the pt was seen by Thoracic Surgery and had a liver biopsy performed. He was also seen by GI and ID and nutrition labs were sent. On [**5-21**], the pt was found to have a positive C.Diff (sent for watery stools). On [**5-22**], the patient was seen by the urology service, and in light of his urological history, he had a Foley placed via cystoscopy during his surgery. Patient was taken to the OR on [**5-22**] for his procedure (see operative note for details). He was taken to the ICU after his procedure and extubated the same day. He had a PA line in place, with a CVP from [**2-11**] and making approx 10-15cc/hr of urine. Overnight of POD0, he received 2 Litres in fluid bolus in total for low urine output and SBP in the 80's. Overnight of POD0, the patient was sleepy and not following commands. On POD1, the patient remained very sleepy and was not responding to stimuli. He was then given IV narcan by the ICU team, and was then noted to become more awake. On [**5-23**] (POD1), he received 2 units of FFP (for an elevated INR) with no correction of INR. He was then given Vit K SC x 3 days and 1 unit of PRBC. On [**5-24**], the patient was transfered from the SICU to the floor. On POD3 ([**5-25**]), patient's respiratory saturations were noted to be approx 93%, most likely due to atelectasis. He was encouraged to use IS. His diet was advanced from sips to clears. On [**5-26**], he was noted to have signs of hepatic decompensation with decreased mental status, asterixis, decreased urine output, ascites and increased bilirubin. He was transfered back to the SICU for closer monitoring. On [**5-26**], the patient had an ultrasound of the liver to exclude portal vein thrombosis; this was unchanged from the prior study. On [**5-28**], a PICC was placed for hydration, antibiotics and TPN. TPN was started the same day. He was transfered from the SICU back to the floor on this day. The patient had a voiding trial on [**5-30**], as reccomended by the urology service. He was tolerating PO's by [**5-31**], and received nutritional supplements. A bedside swallowing evaluation was done on [**6-1**] during which he presented with mild oral dysphagia and it was determined he could continue with a regular consistency diet with thin liquids. TPN was stopped on [**6-3**]. The patient's LFT's were found to be elevating from [**6-3**] onwards. Hence, an ERCP was performed on [**6-7**]. This showed a normal appearing biliary tree with no evidence of obstruction or a leak. LFT's continued to rise, and then remained stable on [**6-8**]. On [**6-8**], a suture was removed from the patient's abdomen, but then re-sutured as ascitic fluid leaked from the incision. On discharge, the patient's total bili had come down; he remained jaundiced but was taking in good amount of PO's (approx [**2179**] calories); he had 2 bowel movements and was ambulating. His wound was clean, dry and intact, and only required a dry gauze dressing over the area (no packing necessary). He will require home physical therapy, and he should continue ciprofloxacin for SBO prophylaxis. Medications on Admission: Aspirin 81', Fluticasone 50", HCTZ 25', Iron 325', Atorvastatin 10 ' Discharge Medications: 1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*1 * Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. 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* 4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: colonic GIST with metastasis to liver LUL nodules c.diff hepatic encephalopathy, resolved Discharge Condition: good Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, increased jaundice (yellowing of skin), increased abdominal pain, fluid retention, weight gain of 3 pounds in a day, increased size of abdomen or any questions. Drink plenty of fluids. . You should aim to take in more than [**2179**] calories per day. You should drink at least 3 cans of nutritional supplements each day (these can be obtained from the pharmacy). . Keep your wound clean at all times. There is a small aspect of your wound that is open, but this is not infected. You should put a dry piece of gauze over this area and change it daily. If you notice purulent drainage from this area, call your doctor immediately. . Continue the antibiotic (ciprofloxacin) until furthur notice by Dr [**Last Name (STitle) **]. You should not resume your hydrochlorthiazide medication, but should begin those that we are now prescribing to you. In terms of your other medications: - Aspirin 81' - do not resume (discuss this with Dr [**Last Name (STitle) **] when you see him in the clinic next week) - Fluticasone 50" - you may resume this - HCTZ 25' - do not resume, you have been given Lopressor as an alternative - Iron 325' - you may resume - Atorvastatin 10 - you may resume. . You may take pain medications as you need them. . Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2186-6-14**] 9:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2186-6-9**]

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icd9cm

[ [ [] ] ]

[ "51.85", "50.3", "50.11", "99.15", "99.07", "51.22", "45.62", "38.93" ]

icd9pcs

[ [ [] ] ]

10288, 10326

5812, 9228

328, 397

10459, 10465

1829, 4427

11854, 12182

1806, 1810

9347, 10265

10347, 10438

9254, 9324

10489, 11831

273, 290

425, 1574

4436, 5789

1596, 1700

1716, 1790

9,132

122,403

29944

Discharge summary

report

Admission Date: [**2199-1-6**] Discharge Date: [**2199-2-9**] Date of Birth: [**2121-4-19**] Sex: M Service: MEDICINE Allergies: Dilantin / Heparin Agents Attending:[**First Name3 (LF) 9240**] Chief Complaint: Transfer from OSH with intravetricular bleed. Major Surgical or Invasive Procedure: PICC line placement. History of Present Illness: 77 year-old male with history of seizure and atrial fibrillation on coumadin who presents with intraventricular bleed. He was found yesterday sitting on the floor of his apartment and was incontinent of urine and confused. He went to [**Hospital3 **] in Methuan where he was found to have fever 101.2 and leukocytosis of 14. INR was 1.1 and hematocrit 58.6. Head CT was obtained and showed an intraventricular bleed. Patient was transferred to [**Hospital1 18**] for further work-up and management. The patient was loaded with dilantin prior to transfer. . In the [**Hospital1 18**] ER, repeat CT head was obtained without change from the OSH study. The patient was followed by neurosurgery and it was decided not to proceed with surgical intervention at this time. Incidental finding was made of a T2 compression fracture and the patient was placed in a C-collar. The patient was given one dose of levofloxacin in the ED. . MICU course: He was continued on Dilantin intially with stable neurologic exam. Ortho Spine was consulted for the T2 fracture, and they recommended continuing C-collar and bedrest as he was felt unable to tolerate flex-ex films. He was also found to have a large pulsatile abdominal mass and ultrasound showed a 6 cm AAA. [**Hospital1 **] Surgery was consulted and recommended CTA and deferred intervention for now as would require heparin for repair. He was started on NTG gtt for BP, then changed to labetalol gtt, ultimately transitioned to po. He developed agitation and dyskinesia. Neurology was consulted with change of dilantin changed to keppra for dyskinesia. The patient was maintained on CIWA scale for possible alcohol withdrawal. EEG showed encephalopathy but no seizure activity. MRI/A with no aneurysm or infarct. He failed two swallow evaluations and tube feeds were initiated. He completed a three-day course of ciprofloxacin for presumed urinary tract infection. He continued to spike fevers and was started on Vancomycin/Zosyn for empiric treatment of aspiration pneumonia. The patient was afebrile prior to transfer to the floor. PICC line placed [**1-10**]. Mental status now improving, off 1:1 sitter. . On transfer to the floor, the patient complained of discomfort at NG tube site. Denies headache, neck pain, chest pain, shortness of breath, abdominal pain. Unable to provide further history. Past Medical History: 1. Seizure disorder 2. Atrial fibrillation on coumadin 3. Hypertension 4. Status post cholecystectomy [**1-12**] Social History: Retired from [**Company 2676**], lives alone, Non smoker, no alcohol, has son and daughter-in-law. Family History: Non-contributory. Physical Exam: On admission to the MICU: VS: Temp 97.9 HR 117 BP 148/93 O2 sat 96% RA RR 21 Gen: thin, elderly male, confused HEENT: dry MM, anicteric sclera Neck: supple Pulm: CTA b/l ant Cardio: RRR, nl S1 S2, 2/6 systolic murmur loudes LUSB Abd:soft, NT, pulsatile abd mass felt, though abd is thin Ext: no peripheral edema, 2+ DP pulses Neuro: A&0 x1, no oriented to place or time Pupils pinpoint but reactive to light CN 2-12 intact Muscle strength 5/5 in bilateral upper and lower extremities sensation to light touch intact . On transfer to the floor: Vitals- 99.3, HR 84, BP 144/87, RR 25, O2sat 99%RA, Wt 52kg General- elderly man lying in bed, awake, oriented to self only, answering questions, follows simple commands, intermittently picks at sheets HEENT- NCAT, sclerae anicteric, tacky MM Neck- soft collar in place Pulm- CTAB with good effort, ?poor cough CV- irregularly irregular, no murmur Abd- large pulsatile mass, soft, nontender Extrem- trace ankle edema, DP pulses 2+ b/l Neuro- alert, oriented to self only, CN III-XII intact to challenge, UE/LE strength 5/5 throughout, pt reports intact sensation throughout, no pronator drift Pertinent Results: Labwork on admission: [**2199-1-6**] 02:50AM WBC-16.5* RBC-5.91 HGB-18.9* HCT-53.7* MCV-91 MCH-32.0 MCHC-35.2* RDW-14.2 [**2199-1-6**] 02:50AM PLT COUNT-234 [**2199-1-6**] 02:50AM NEUTS-81.5* LYMPHS-12.1* MONOS-6.3 EOS-0.1 BASOS-0.1 [**2199-1-6**] 02:50AM PT-13.3* PTT-25.0 INR(PT)-1.2* [**2199-1-6**] 02:50AM GLUCOSE-179* UREA N-55* CREAT-1.7* SODIUM-140 POTASSIUM-6.3* CHLORIDE-100 TOTAL CO2-27 ANION GAP-19 [**2199-1-6**] 02:50AM CK(CPK)-201* [**2199-1-6**] 02:50AM CK-MB-4 cTropnT-<0.01 . CT HEAD W/O CONTRAST [**2199-1-6**] IMPRESSION: 1. Intraventricular hemorrhage within the right lateral ventricle and layering both ventricles posteriorly. 2. Hypodensity with sulcal effacement within the right parietal lobe, which may represent a subacute infarct. There is equivocal hyperdensity within the right MCA. 3. Mild dilatation of the ventricles, particularly the third ventricle. 4. Chronic lacunar infarcts in the left basal ganglia. 5. Mucosal thickening of the sphenoid sinuses. NOTE ADDED AT ATTENDING REVIEW: The right parietal infarction appears chronic. There is a possible tiny, nondisplaced, fracture of the left parietal bone, seen on images 43 and 44 of series 3. There is no associated soft tissue swelling or hemorrhage, and this may alternatively represent a venous channel. There does not appear to be a nasal fracture on these images, but the nose is not completely included in the study. The periventricular hypodensity appears to be due to chronic small vessel ischemia, there is not evidence of hydrocephalus at this time. The right internal carotid artery and MCA appear enlarged. These may be due to hypertension. However, given the intraventricular hemorrhage, it may be advisable at some point to obtain an MR, a CTA, or both to evaluate the possibility of an arteriovenous malformation. . CT C-SPINE W/O CONTRAST [**2199-1-6**] IMPRESSION: 1. T2 compression fracture. 2. Interventricular hemorrhage as described on head CT scan. NOTE ADDED AT ATTENDING REVIEW: The T2 fracture involves the posterior aspect of the vertebral body with buckling of the cortex and retropulsion of bone into the canal. . RETROPERITONEAL US [**2199-1-6**] IMPRESSION: Large fusiform abdominal aneurysm, measuring up to 6cm in the mid abdomen. Findings d/w the covering medical resident. . CHEST (SINGLE VIEW) [**2199-1-6**] IMPRESSION: 1. Emphysema. 2. No focal consolidations. . ECG Study Date of [**2199-1-6**] 2:43:56 AM Technically difficult study Atrial fibrillation Early R wave progression Extensive ST-T changes Consider left or biventricular hypertrophy . CTA HEAD W&W/O C & RECONS [**2199-1-7**] IMPRESSION: 1) Stable right choroid plexus, intraventricular hemorrhage. 2) No focal aneurysm, however, there is diffuse broadening of the anterior communicating artery and likely atherosclerotic irregularity of the M1 segment of the right MCA. 3) Stable right posterior parietal encephalomalacia, likely from chronic infarct. 4) Previously questioned left parietal fracture is not seen on today's study and thought to most likely have represented a small venous channel. . CHEST (PORTABLE AP) [**2199-1-9**] IMPRESSION: 1. Too proximal position of the NG tube should be advanced for at least 10 cm. 2. Pulmonary hypertension and lung hyperinflation suggests chronic lung disease. 3. Worsening of pulmonary edema. An underlying infectious process or aspiration in the right upper lobe cannot be excluded. Please correlate clinically. . CTA CHEST/ABDOMEN/PELVIS [**2199-1-9**] IMPRESSION: 1. Infrarenal abdominal aortic aneurysm measuring 6.6 cm in transverse x 6.1 cm in AP x 7.8 cm in craniocaudal dimensions with a dissection of fresh blood between two layers of old thrombus. 2. Bilateral pleural effusions, emphysematous change and calcified bronchiectasis in the upper lobes. 3. Pneumobilia in patient status post cholecystectomy. 4. Enlarged prostate and bladder diverticula. . MRI/A BRAIN W/O CONTRAST [**2199-1-10**] IMPRESSION: Findings consistent with interventricular hemorrhage. No definite evidence of acute infarction. No definite stigmata to suggest the presence of a [**Year/Month/Day 1106**] malformation. Examination is limited due to patient motion. IMPRESSION: Limited MRA of the Circle of [**Location (un) 431**] with no evidence of major [**Location (un) 1106**] flow abnormality. . CT HEAD W/O CONTRAST [**2199-1-16**] IMPRESSION: 1. Since [**2199-1-6**], decrease in size of intraventricular hemorrhage with stable appearance of enlarged ventricles. 2. New air-fluid level within the left sphenoid sinus, with a nasogastric tube in place. 3. Old infarcts of the right frontal and parietal lobes with extensive small vessel infarcts. . BONE SCAN [**2199-1-18**] IMPRESSION: No evidence of increased tracer activity in the upper thoracic spine suggesting that the known T2 compression fracture is chronic. . PERC PLCMT GASTROMY TUBE [**2199-1-23**] IMPRESSION: Successful placement of 14 French 63 cm [**Doctor Last Name 9835**] GJ tube with pigtail formed in the duodenum and tip present in the jejunum. The tube is now ready for use. . ECHO Study Date of [**2199-1-25**] Conclusions: 1. The left atrium is normal in size. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6.There is borderline pulmonary artery systolic hypertension. 7.There is no pericardial effusion. . CTA ABD W&W/O C & RECONS [**2199-1-29**] IMPRESSION: 1. Unchanged appearance of infrarenal abdominal aortic aneurysm measuring 6.6 TV x 6.1 AP x 7.8 CC cm. No evidence of progression of abdominal aortic aneurysm. No evidence of infection of the aneurysm. No fluid collections identified in the abdomen or pelvis. 2. Pneumobilia. 3. Enlarged prostate. 4. Previously noted small bilateral pleural effusions are predominantly resolved. Small amount of atelectasis is seen at the right lung base. . UNILAT UP EXT VEINS US LEFT [**2199-1-29**] IMPRESSION: Thrombus identified within the left internal jugular vein extending to the junction with the subclavian vein. Occlusive thrombus also identified within the left basilic vein. Brief Hospital Course: 77 year-old male with past medical history of seizure disorder, atrial fibrillation on coumadin presenting with intraventricular bleed and incidental findings of T2 compression fracture and 6 cm AAA. The patient developed MRSA bacteremia with PICC catheter tip positive for MRSA and heparin-inducted thrombocytopenia. . 1. Intraventricular bleed: Status post fall. The patient was not coagulopathic on admission. No clear [**Month/Day/Year 1106**] abnormalities on MRA. The patient was initially on Dilantin for seizure prophylaxis, but was changed to Keppra for dyskinesia. The patient's imaging and neurologic exam was stable during hospitalization. Repeat CT head one week after admission showed decrease in size of intraventricular hemorrhage with stable appearance of enlarged ventricles. The patient was continued on serial neurologic checks. The patient will follow-up with neurosurgery in four weeks with repeat CT head at that time to monitor. . 2. Encephalopathy/agitation: Patient appears to have severe inattention following a fall and right intraventricular hemorrhage greater than left with some early hydrocephalus (and pneumocephalus, bone fracture) on imaging; inattention could be due to injury to right side, versus old right-deficits from prior injury or stroke exacerbated in context of toxic-metabolic derangement. The patient also had akasthesia/dyskinesias on admission that resolved by changing dilantin to keppra. EEG showed nonspecific encephalopathy. MRI/A without evidence of infarction or [**Month/Day/Year 1106**] malformation. RPR negative, TSH normal. B12 low, folate low normal. The patient was continued on thiamine/folate/MVI/B12 daily. The patient's mental status is not at baseline on discharge; baseline mental status is AAOx3 and independent per family. This may continue to improve as the patient recovers from his acute insult. The patient will follow-up with neurosurgery in four weeks. . 3. Seizure disorder: The patient was on dilantin as an outpatient and loaded with dilantin at OSH. The patient was followed by Neurology during admission. There was no seizure activity noted on EEG. The patient's dilantin was changed to keppra for dyskinesia. The patient was started on keppra 500 twice daily and titrated per Neurology recommendations to [**Telephone/Fax (1) 36883**] on [**2199-1-16**] and 1000 twice daily on [**2199-1-23**]. . 4. Renal insufficiency: Creatinine elevated on admission to 1.7 and BUN 55, thought pre-renal with response to fluids. Improved to 0.9-1.3. Unclear baseline creatinine. The decreased creatinine later in admission likely represented decreased muscle mass and was not a true increase in glomerular filtration rate. . 5. Infectious disease: The patient is status post three-day course of ciprofloxacin on admission for presumed urinary tract infection [**1-8**] and eight-day course of Vancomycin/Zosyn [**1-16**] for RUL infiltrate while in MICU. The patient spiked a fever to 101.8 overnight [**1-22**] with leukocytosis on laboratories. The patient subsequently had multiple positive blood culture bottles for MRSA from [**Date range (1) 71521**]. The patient was started on vancomycin and trough were therapeutic. PICC tip removed [**1-24**] and positive for MRSA. The persistently positive blood cultures were believed secondary to an endovascular source; hematoma at site of PICC or seeding of the AAA. Left upper extremity ultrasound was ordered and showed a hematoma the site of previous PICC. CT abdomen performed to evaluate AAA negative for change or signs of infection. The patient was followed by Infectious Disease. The patient should complete an eight-week course of antibiotics from the first day of negative blood cultures, [**1-28**], to treat the bacteremia complicated by hematoma and possible endocarditis or bone spread. The patient will have weekly bloodwork drawn and results sent to the Infectious Disease clinic. The patient will follow-up in the Infectious Disease clinic. The patient may need suppressive therapy after this time. There were no new murmurs or peripheral stigmata of endocarditis during admission. TTE was negative for signs of endocarditis and the patient did not tolerated TEE. No soft tissue source. Unlikely secondary to osteomyelitis with recent negative bone scan. Differential includes dental as patient has poor dentition and attempts at NGT placement prior and sinus disease although unlikely with speciation. CXR negative. Urinalysis negative. No localizing signs or symptoms. . 6. Heparin-induced thrombocytopenia: The patient was positive for HIT antibodies with optical density > 1.0. Platelet count on admission 229 with drop in platelets [**1-24**] from 179 to 109. The patient was first exposed to heparin [**1-11**] and heparin discontinued [**1-25**]. The patient was started on argatroban and transitioned to coumadin. The patient should continue coumadin indefinitely. The patient was followed by hematology. . 7. Abdominal aortic aneursym: Incidental finding was made of a 6 cm AAA. The patient was followed by [**Month/Year (2) 1106**] surgery during admission. Repair was deferred secondary to the patient's acute illness. The patient will follow-up with [**Month/Year (2) 1106**] sugery in four weeks regarding elective AAA repair. . 8. Hypertension: The patient was started on metoprolol and enalopril with good effect. . 9. T2 compression fracture: The patient was followed by ortho spine during admission. The patient was initially on C-spine protection but this was discontinued per orthopedic recommendations when bone scan showed the fracture was chronic. The patient does not need follow-up with orthopedics unless new findings arise. . 10. Atrial fibrillation: Rate controlled on metoprolol. Coumadin was initally held for intraventriculat hemorrhage. Per neurosurgery and [**Month/Year (2) 1106**] surgery, the patient was able to restart anticoagulation seven days after initial diagnosis of IVH, [**2199-1-6**]. Anticoagulation was initially held for placement of PEG tube. . 11. COPD: No current issues. The patient was given nebulizers as needed. . 12. Skin lesion: The patient was noted to have a 1 cm round lesion under the right eye with central necrosis. The appearance is concerning for basal versus squamous skin cancer. The patient was scheduled for follow-up with dermatology as an outpatient. . 13. Nutrition: The patient failed Speech and Swallow evaluations on multiple occasions during admission. The decision was made with the family to place a PEG tube for nutrition. Patient had speech and swallow videos while in-house. Plan was to continue NPO but trial with nectar fluids with nursing daily. Please evaluate at rehab. . Code status: DNR/DNI . Disposition: The patient was discharged to rehabilitation. Medications on Admission: Dilantin Coumadin Atenolol Discharge Medications: 1. Outpatient Lab Work Weekly CBC with differential, BUN and creatinine, liver function tests, and vancomycin trough. Please fax to [**Telephone/Fax (1) 1419**]. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Acetaminophen 650 mg Suppository Sig: [**1-8**] Suppositorys Rectal Q4-6H (every 4 to 6 hours) as needed for fever or pain. 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Enalapril Maleate 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day) as needed. 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): First dose PM of [**2-9**] with recheck of PT/INR daily, goal INR [**2-9**]. 10. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous q24hours: TO STOP [**2199-3-26**]. THIS WILL COMPLETE 8-WEEK COURSE FROM TIME OF NEGATIVE BLOOD CULTURE ON [**2199-1-28**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary: 1. Intraventricular hemorrhage 2. Abdominal aortic aneursym 6 cm 3. Chronic T2 compression fracture 4. Urinary tract infection 5. Acute on chronic renal failure 6. Skin lesion, question basal cell versus squamous cell carcinoma versus other lesion 7. MRSA bacteremia/septicemia 8. thrombocytopenia/HIT antibody positive . Secondary: 1. Atrial fibrillation 2. Seizure disorder 3. Hypertension 4. Status post cholecystectomy [**1-12**] Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: You were hospitalized with head bleed after a fall. The bleed is stable on imaging. You will follow-up with neurosurgery and have a repeat head CT. . While hospitalized, you were noted to have an aortic aneursym. You will follow-up with [**Month/Year (2) 1106**] surgery regarding elective repair of this aneursym. . While hospitalized, you were noted to have an old spine fracture. You do not need to follow-up with orthopedics unless you have pain or develop new findings. . While hospitalized, you developed a bloodstream infection. You will take vancomycin, an antibiotic, for 8 weeks for treatment. You will have labwork drawn every week and faxed to the Infectious Disease clinic. You will follow-up in the Infectious Disease clnic. . While hospitalized, you developed a reaction to heparin. You should take coumadin as you were taking previously to prevent clots. . Please contact a physician if you experience fevers, chills, headache, focal neurologic symptoms, back pain, or any other concerning symptoms. . Please take your medications as prescribed. - Take your medications as prescribed. Vancomycin to be administered until [**2199-3-26**], to complete 8-week course. . Please verify your follow-up appointments as below. . Patient needs PT/INR checks daily to assess for change in coumadin dosing. Argatroban and coumadin were bridged until [**2-8**]. Followup Instructions: 1. Follow-up CT head: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-2-19**] 11:45 . 2. Follow-up appointment neurosurgery: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. NEUROSURGERY WEST Date/Time:[**2199-2-19**] 1:00 . 3. Follow-up with [**Month/Day/Year 1106**] surgery regarding repair of AAA: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2199-2-21**] 10:30. Please call ([**Telephone/Fax (1) 9393**] if you have any questions or concerns. . 4. Follow-up with Infectious Disease regarding your bloodstream infection: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] ID WEST (SB) Date/Time: [**2199-3-26**] 11:00a. Please call ([**Telephone/Fax (1) 4170**] if you have any questions or concerns. . 5. Follow-up with dermatology regarding the lesion under your right eye: [**Last Name (LF) **], [**First Name3 (LF) **]. Date/Time:[**2199-4-2**] 02:15 pm. Please call ([**Telephone/Fax (1) 8132**] if you have any questions or concerns. . 6. Follow-up Urology - [**2202-3-1**]:00AM. [**Hospital Ward Name 23**] Building, [**Location (un) 470**], surgical specialities. . 7. Patient needs to be evaulated by speech and swallow at rehab to assess for ability to swallow. Had video swallow here, team was about to implement NPO but trials of nectar feeds with nursing tid:prn. Please reassess.

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icd9cm

[ [ [] ] ]

[ "38.93", "46.32", "96.6" ]

icd9pcs

[ [ [] ] ]

18784, 18831

10817, 17599

330, 352

19318, 19350

4184, 4192

20766, 20780

2993, 3012

17676, 18761

18852, 19297

17625, 17653

19374, 20743

3027, 4165

245, 292

380, 2724

20789, 22273

4206, 10794

2746, 2861

2877, 2977

76,319

141,797

40588

Discharge summary

report

Admission Date: [**2108-8-15**] Discharge Date: [**2108-8-23**] Date of Birth: [**2024-9-23**] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 618**] Chief Complaint: right sided weakness and dysarthria Major Surgical or Invasive Procedure: none History of Present Illness: 83 yo F with hx HTN, HLD, CABGx4 in [**2099**] complicated by stroke with minimal residual deficits, chronic renal insufficiency, and AAA with leak s/p repair three years ago, transferred from [**Hospital **] Hospital as a code stroke. She was in her usual state of health and seen normal at 08:30. At 08:45 she was found down on the bathroom floor, not moving her right side, moaning, not speaking or following commands. She arrived at [**Hospital **] Hospital where her SBP was > 200 and was given a total of 20 mg labetalol. Her NIHSS was 23 and a CT head was reported to be unrevealing. Labs notable for INR 0.99 and Cr 1.8. She was intubated for airway protection, started on propofol, and transferred here for further evaluation and management. Per daughter, she had stopped her antihypertensives for the past 2-3 weeks after a dental procedure when she was told her blood pressure was running low (and was recommended to stop one [**Doctor Last Name 360**]). ROS unobtainable. Past Medical History: -HTN -HLD -CABG in [**2099**] c/b stroke with minimal residual deficits (had left arm tremor and ? left facial droop after procedure) -AAA s/p repair three years ago -chronic renal insufficiency -hernia repair -osteoporosis Social History: -lives with husband. [**Name (NI) **] four children who live in area. Family History: -unable to be obtained Physical Exam: At admission: VS; T 96.8 P 70 BP 199/79 RR 16 100% RA Gen; intubated, off sedation, eyes closed CV; RRR, no murmurs Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Neuro; (off propofol for a few minutes) MS; eyes closed, grimaces to noxious but does not make effort to speak (although she is intubated) and does not follow any simple commands. CN; PERRL 3mm-->2.5mm, eyes conjugately deviated to the left, unable to cross midline. Does not reliably blink to threat in any visual quadrants. Facial asymmetry obscured by ETT. Motor; normal bulk and tone. Some spontaneous movement of LUE, antigravity at forearm and withdraws LUE and LLE briskly to noxious stimuli. Grimaces to noxious in RUE but no movement and no grimace or movement to noxious in RLE. Reflexes; Plantar response is extensor on the right, flexor on the left. Pertinent Results: [**2108-8-15**] 01:50PM PT-11.7 PTT-23.3 INR(PT)-1.0 [**2108-8-15**] 01:50PM WBC-7.5 RBC-3.74* HGB-11.3* HCT-33.9* MCV-91 MCH-30.3 MCHC-33.5 RDW-18.6* [**2108-8-15**] 01:50PM cTropnT-<0.01 [**2108-8-15**] 01:50PM CK-MB-2 [**2108-8-15**] 01:50PM CK(CPK)-65 [**2108-8-15**] 01:50PM GLUCOSE-108* UREA N-27* CREAT-1.7* SODIUM-140 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 [**2108-8-15**] 01:55PM URINE RBC-0 WBC-3 BACTERIA-FEW YEAST-NONE EPI-1 [**2108-8-15**] 01:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR CTA IMPRESSION: 1. Occlusion of the posterior division of the left middle cerebral artery with an evolving acute infarction in the left parietal lobe MCA territory. There is evidence of a small area of ischemic penumbra on perfusion imaging. No evidence of hemorrhagic transformation. 2. Multifocal intracranial atherosclerosis, most notable in the left internal carotid artery with less than 50% narrowing. ECHO Conclusions: The left atrium is dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast (single injection). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: The patient was admitted to the Neuro ICU after suffering a left MCA stroke. Her neurological exam failed to show much improvement off of the sedation. The patient did not regain alertness despite prolonged time off sedation. Given the patient's age, underlying health condition, and failure to regain any meaningful neurological activity, the patient's family decided that the patient would want her care to be focused on comfort measure. The patient was extubated on [**8-21**] and transferred to the neurology floor on [**8-22**]. She was placed on palliative care measures. She passed the morning of [**8-23**] surrounded by family. Autopsy was declined. Medications on Admission: -aspirin 81 mg daily -synthroid 50 mcg daily -evista 60 mg -lasix 20 mg daily -atenolol 25 mg daily -lisinopril 20 mg daily -zetia 10 mg daily -zocor 40 mg daily -iron Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Left MCA Stroke Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2108-8-23**]

[ "403.90", "E879.8", "997.31", "V45.81", "E849.7", "V66.7", "784.3", "342.00", "434.91", "V49.86", "414.00", "585.4", "733.00" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.97", "96.72" ]

icd9pcs

[ [ [] ] ]

5352, 5361

4441, 5105

328, 334

5420, 5429

2604, 4418

5481, 5607

1707, 1732

5324, 5329

5382, 5399

5131, 5301

5453, 5458

1747, 2585

253, 290

362, 1355

1377, 1603

1619, 1691

15,509

181,919

11944+56307+56308

Discharge summary

report+addendum+addendum

Admission Date: [**2143-12-4**] Discharge Date: Date of Birth: [**2069-2-13**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 5715**] is a 74 year old woman, initially transferred to the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Intensive Care Unit from [**Hospital6 37142**] with a two week hospital course significant for multi-organ failure of unknown etiology. The patient was in her usual state of health until [**2143-11-21**], when she started having acute shortness of breath and chest tightness. She called 911 and, upon their arrival, she was found on the floor with her head down, lethargic but responsive. In the outside hospital Emergency Room, the patient was found to be hypothermic, saturating at 80% with pulmonary crackles. She was treated with intravenous Lasix initially for possible congestive heart failure. Her blood pressure dropped. She was bolused with intravenous fluids and started on intravenous Levophed and Dopamine for pressors. She was intubated soon after for hypoxemic respiratory distress, and was admitted to the [**Hospital 4199**] Hospital Intensive Care Unit. While there, the patient's Intensive Care Unit course was notable for: 1. Hypotension requiring intravenous fluid and pressors for several days, normal echocardiogram and question of an ischemic event versus a troponin leak. 2. Pulmonary: Intubation on the day of admission for hypoxemic respiratory failure, chest x-ray showing diffuse alveolar infiltrates with a question of congestive heart failure versus acute respiratory distress syndrome; intubation and extubation with improvement and resolution of alveolar infiltrates followed by reintubation several days later due to metabolic acidosis associated with acute renal failure. 3. Renal: Acute renal failure with a rising creatinine on admission, peaking at 6.3, oliguria, urine sediment showing muddy brown casts, necessitating hemodialysis for volume overload and metabolic acidosis; hemodialysis complicated by question of a line infection. 4. Hematologic complications, including question induced thrombocytopenia and disseminated intravascular coagulation with a positive DIC screen. She received at least five units of packed red blood cells, platelets, cryoglobulin and fresh frozen plasma; shocked liver with an AST of 9,210, ALT 4,390 in the setting of hypotension. 5. Infectious disease: One out of four blood cultures significant for coagulase negative Staphylococcus sensitive to vancomycin and one out of four blood cultures with [**Female First Name (un) 564**]. The patient was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] at the family's request for further management and treatment of her multiple medical problems. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Hypothyroidism. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: (at home) Zocor, Norvasc, Levoxyl and Vioxx; (upon transfer) Imipenem 250 mg i.v.b.i.d., azithromycin 250 mg i.v.q.d., fluconazole 200 mg i.v.q.d., Pepcid, Synthroid 50 mcg q.d., Solu-Cortef 60 mg i.v.b.i.d., and total parenteral nutrition. SOCIAL HISTORY: The patient is a retired secretary. She does not use alcohol or tobacco. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On physical examination upon admission, the patient was intubated, relaxed, in no acute distress. Vital signs: Temperature 99.6, heart rate 80, blood pressure 130/70, respiratory rate 16, oxygen saturation 99% on pressure support of [**10-25**], FiO2 40%. Cardiovascular: Regular rate and rhythm without murmur, rub or gallop. Lungs: Decreased ventilation to both bases, vesicular bibasilar wet crackles. Abdomen: Soft, nontender, mildly distended, tympanitic, no costovertebral angle tenderness. Extremities: 1+ bilateral pitting edema with 2+ pulses throughout, large hematoma over suprapubic area. Neck: Supple, no lymphadenopathy, no bruits, 8 cm jugular venous distention. Head, eyes, ears, nose and throat: Oral mucosa dry, large sores over tip of tongue and hard palate. Neurologic: Grossly nonfocal, followed commands and answered "yes" or "no" questions. The patient had a left internal jugular line, a right groin Vas-Cath, an endotracheal tube was in place and she had a Foley catheter. LABORATORY DATA: Admission white blood cell count was 8.9, hematocrit 24.7, platelet count 93,000, sodium 144, potassium 4, chloride 111, bicarbonate 21, BUN 93, creatinine 4.5, glucose 407, prothrombin time 13.9, partial thromboplastin time 29.1, INR 1.4, ALT 16, AST 21, alkaline phosphatase 128, total bilirubin 1.2, albumin 2.1, calcium 7.9, phosphorous 5.1 and magnesium 1.8. HOSPITAL COURSE: The patient had a complex medical course, both in her previous Medical Intensive Care Unit stay as well as her Intensive Care Unit stay at this hospital and on the floor. Her hospital course will be summarized by organ system. 1. Pulmonary: The patient was initially intubated for management of metabolic acidosis, with a question of other pulmonary insult, with a question of acute respiratory distress syndrome versus congestive heart failure versus pneumonia. She was extubated on [**2143-12-5**], reintubated on [**2143-12-7**], extubated on [**2143-12-9**] and called out to the floor, where she did poorly, and reintubated shortly afterwards for respiratory distress. At that point, the patient was readmitted to the Intensive Care Unit for an additional three days and called out once again to the floor where she, from that point on, did well from a pulmonary standpoint. 2. Infectious disease: The patient had a history, upon arriving, of both candidal as well as coagulase negative staphylococcal sepsis. Blood cultures were repeated upon her arrival and they confirmed both Staphylococcus and [**Female First Name (un) 564**] albicans infection. The patient was initially started on liposomal amphotericin as initial reports from the outside hospital reported a different strain of [**Female First Name (un) 564**]. However, repeat speciation of the outside [**Female First Name (un) 564**] at the outside hospital confirmed [**Female First Name (un) 564**] albicans and she was changed to fluconazole and completed a complete course. She was started on vancomycin for the coagulase negative Staphylococcus. She completed a complete course of intravenous vancomycin. After the institution of antibiotics for the candidal and staphylococcal infections, the patient had no further fevers. During her Intensive Care Unit stay, she suffered from diarrhea and a Clostridium difficile toxin assay was positive, for which she was started on oral Flagyl. She will complete a full course of oral Flagyl. The lesions previously mentioned, found upon the tongue and hard palate worsened throughout the course of the [**Hospital 228**] Medical Intensive Care Unit stay and subsequent culture revealed them to be herpes simplex type I. These lesions gradually encompassed the entire perioral area, causing bleeding and difficulty with speech. She was started on intravenous acyclovir, with resolution of these sores over the subsequent week. Throughout the course of her hospitalization, the patient was followed by the infectious disease service. 3. Renal: The patient has not required hemodialysis while at this hospital. Her vascular access catheters were removed and she entered the diuresis phase of acute tubular necrosis. At the time of this dictation, her creatinine has normalized to 1.8 and her renal function is nicely recovering. 4. Gastrointestinal: During her Intensive Care Unit course, the patient had an episode of a gastrointestinal bleed, with guaiac positive stool and a dropping hematocrit. An esophagogastroduodenoscopy showed a small hiatal hernia, watermelon stomach, otherwise normal study. The total parenteral nutrition initiated at the outside hospital was stopped and the patient was started on tube feeds initially in the Intensive Care Unit through a nasogastric tube. This was continued throughout her course secondary to a high aspiration risk from vocal cord trauma from multiple intubations. As the patient's swallowing recovers, it is expected that she will pass a swallowing evaluation and be able to be restarted on a normal oral diet. 5. Hematologic: The patient had disseminated intravascular coagulation at the outside hospital, where she received multiple transfusions. She received an additional four units of packed red blood cells at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. There was a question of heparin induced thrombocytopenia. An HIT antibody test was sent and results are still pending. Should this return negative, she should not receive heparin in the future. In the meantime, she should receive no heparin products. 6. Fluids, electrolytes and nutrition: The patient's course had been complicated by fluid overload requiring hemodialysis at the outside hospital, but autodiuresed well upon arrival here. She had suffered at one point from hyponatremia, thought likely secondary to total parenteral nutrition. This was treated by increasing her free water boluses. 7. Endocrine: Although the patient was initially thought to have diabetes mellitus per her family, this was not the case. Although she had elevated serum glucose levels, this was felt likely to be secondary to steroids she received initially at the outside hospital, coupled with her sepsis and infection. She did receive a regular insulin sliding scale, however, at the time of this dictation, she is no longer requiring insulin. 8. Neurologic: Upon her arrival to the floor, it was noted that the patient was profoundly weak, likely secondary to critical care polyneuropathy. She will require extensive physical therapy at a rehabilitation facility. She has failed several swallowing studies at the time of this dictation and will need continuing swallowing evaluations prior to reinstituting oral intake. Until then, she is to be continued on tube feeds via a gastrostomy tube. The patient's speech initially was very poor, able to speak only single words and at very low volume. This was felt to be both secondary to possible trauma to her vocal cords as well as pain in her mouth secondary to the oral herpes. As her oral sores resolved on the acyclovir, she was able to vocalize better. At the time of this discharge summary, she is speaking in full sentences with significantly less pain. She has yet to pass a swallowing study, however. At the time of this dictation, Mrs. [**Known lastname 5715**] is much improved since her time of arrival at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] and since her call out from the Intensive Care Unit approximately one week ago. Her oral sores have resolved. Her renal issues are resolving. Her pulmonary status is good. Rehabilitation for her weakness will be an ongoing issue and she will likely require an extensive rehabilitation stay. Still pending are an echocardiogram to rule out any vegetations on her valves given her recurrent bacteremia while in the Intensive Care Unit. Also pending is a colonoscopy and upper gastrointestinal study secondary to continuing low hematocrit and guaiac positive stools. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**] Dictated By:[**Name8 (MD) 4733**] MEDQUIST36 D: [**2143-12-19**] 21:43 T: [**2143-12-25**] 12:51 JOB#: [**Job Number **] Name: [**Known lastname **], [**Known firstname 6758**] Unit No: [**Numeric Identifier 6783**] Admission Date: [**2143-12-4**] Discharge Date: Date of Birth: [**2069-2-13**] Sex: F Service: Medicine ADDENDUM: HOSPITAL COURSE: As of [**12-19**] the patient was transfused two units of packed red cells overnight from [**12-19**] to [**12-20**] with an appropriate bump in creatinine. She also undertook a GoLYTELY prep for colonoscopy. Colonoscopy on [**12-20**] showed a colitis. Biopsies were done. The colitis was consistent with a CMV or ischemic colitis being most likely cause of her colitis. This colitis manifested itself as ulcers, granularity, friability and erythema and is to be the cause of her OB positive stools over the past few days. The patient remained afebrile. On exam the patient had a very constricted affect and was minimally interactive. Celexa was started for depression and this is being continued. The patient remained npo and she was being given tube feeds through her NG tube for nutrition. On [**2143-12-21**] the patient continued to improve with increased mobility and exercise tolerance. Her tube feeds were continued. Her electrolytes were somewhat abnormal after the GoLYTELY prep and free water boluses were increased. Over the next few days her electrolytes corrected themselves very nicely with the increased free water. On [**12-22**] the patient continued to improve. There were no significant events overnight. Her oral lesions continued to improve. On [**12-23**] a transesophageal echocardiogram was performed to exclude vegetations and rule out endocarditis after her sepsis from coag positive staph. This was done and no vegetations were seen. LV function was normal. There were minimal findings including 1+ MR, TR and aortic insufficiency on the echocardiogram. In addition, the patient had a swallowing evaluation. The patient continued to aspirate thin and thick liquids, however, it was noted that this was significantly improved compared with last week. This will continue to be evaluated in ongoing basis as the patient has no underlying reason for aspiration and should, as her oral lesions from herpes resolve and she regain strain, should be able to return to a regular diet. However, until that point she will be maintained on tube feeds and free water boluses via an NG tube. On [**12-23**] after the negative TTE and swallowing evaluation, it was deemed that the patient was stable and ready for placement in a short term rehab facility. She will most likely be discharged on [**2143-12-25**] although pending availability of a bed at the rehab facility in stable condition. DISCHARGE DIAGNOSIS: 1. Sepsis with coag negative staph. 2. Acute renal failure. 3. Clostridium difficile colitis. 4. Fungemia. 5. HSV1 oral lesions. 6. Acute tubular necrosis causing acute renal failure. 7. Ob positive stool with likely ischemic vs CMV colitis while on pressors in the Intensive Care Unit. [**Unit Number **]. Disseminated intravascular coagulation while in the Intensive Care Unit. [**Unit Number **]. Watermelon stomach. 10. Hypertension. 11. Hypothyroidism. 12. Heparin induced thrombocytopenia. DISCHARGE MEDICATIONS: Tylenol 650 mg po q 4-6 hours prn, Acyclovir 400 mg po tid, Celexa 20 mg po q d, Fluconazole 200 mg po q d, Magic mouthwash 10 cc po qid as needed, Prevacid liquid 30 mg po bid, Synthroid 50 mcg po q d, Flagyl 500 mg po tid, Nystatin swish and swallow 5 ml po qid, Orabase ointment applied to affected areas [**Hospital1 **]. In addition to her tube feeds which are Ultracal with ProMod targeted at a goal of 50 cc per hour and free water boluses 250 cc qid. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-329 Dictated By:[**Last Name (NamePattern1) 3253**] MEDQUIST36 D: [**2143-12-24**] 15:49 T: [**2143-12-24**] 15:51 JOB#: [**Job Number 6784**] Name: [**Known lastname **], [**Known firstname 6758**] Unit No: [**Numeric Identifier 6783**] Admission Date: [**2143-12-4**] Discharge Date: [**2143-12-27**] Date of Birth: [**2069-2-13**] Sex: F Service: Medicine Addendum: The patient was discharged to [**Hospital **] Rehabilitation on [**2143-12-27**] to continue her recovery. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-329 Dictated By:[**Last Name (NamePattern1) 3253**] MEDQUIST36 D: [**2144-9-8**] 13:47 T: [**2144-9-14**] 13:51 JOB#: [**Job Number 6785**] 1 1 1 R

[ "518.81", "286.6", "537.82", "054.2", "112.5", "790.6", "558.9", "008.45", "584.5" ]

icd9cm

[ [ [] ] ]

[ "45.13", "96.72", "38.93", "96.04", "96.71", "96.6", "45.25", "99.15" ]

icd9pcs

[ [ [] ] ]

3449, 3467

15123, 16431

14593, 15099

3098, 3340

12140, 14572

3490, 4884

149, 2928

2951, 3071

3357, 3432

6,908

185,974

19068+19069

Discharge summary

report+report

Admission Date: [**2142-9-13**] Discharge Date: [**2142-9-28**] Date of Birth: [**2082-7-14**] Sex: M Service: [**Location (un) 259**] MEDICINE HOSPITAL COURSE: Patient is a 60-year-old man with a history of end-stage renal disease on hemodialysis, alcoholic cirrhosis, who was brought to the [**Location (un) 620**] Emergency Room on [**2142-9-7**] after his hemodialysis session when he was found to be confused with a low-grade fever. His workup included negative head CT and demonstration of no ascites on ultrasound. He was found to have a left sided pleural effusion on chest x-ray. This was tapped and found to be with a white blood cell count of 2,000, red blood cell count of 320,000, neutrophils 93, lymphocytes 2, monocytes 5, glucose 1, LDH [**2074**]. This was unable to be fully drained. One day prior to his discharge, the patient was febrile to 101.1. Was started on levofloxacin and metronidazole. He was transferred to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 2742**] with video assisted thoracostomy. On presentation, the patient denied chest pain, shortness of breath, nausea, vomiting, diarrhea, headache, fevers, chills, or cough. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis. 2. Alcoholic cirrhosis. 3. Positive hepatitis A, B, and C. 4. Gout. 5. Hypertension. 6. History or MRSA line infection. 7. Delirium tremens. ALLERGIES: Dilantin to which the patient gets a rash. MEDICATIONS ON ADMISSION: 1. Ativan 0.5 mg prior to dialysis. 2. Folate. 3. Thiamine. 4. Protonix. 5. Nephrocaps. 6. Depakote p.o. b.i.d. 7. Lopressor 50 mg p.o. b.i.d. 8. Renagel 800 mg p.o. t.i.d. 9. Vicodin 1 mg p.o. q.4h. prn. 10. Levofloxacin 200 mg IV q48h. 11. Metronidazole 500 mg IV q.8h. PHYSICAL EXAMINATION: Vital signs: Temperature 99.5, blood pressure 120/78, pulse 71, respirations 20, and sating 95% on room air. In general, lying in bed comfortable. HEENT is normocephalic, atraumatic. Right pupil smaller than left. Slight ptosis of the left eye. Neck: No JVD. Chest: Decreased breath sounds, dullness on the left, clear on the right. Cardiovascular: Regular rate, normal S1, S2, with no murmurs, rubs, or gallops. Abdomen is soft, mildly diffusely tender, no fluid wave or rebound, positive bowel sounds. Extremities: No clubbing, cyanosis, or edema. No palmar erythema. Neurologic: No asterixis. LABORATORY: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**] Dictated By:[**Name8 (MD) 7583**] MEDQUIST36 D: [**2142-9-28**] 13:45 T: [**2142-9-28**] 13:54 JOB#: [**Job Number 52058**] Unit No: [**Numeric Identifier 52059**] Admission Date: [**2142-9-13**] Discharge Date: [**2142-9-25**] Date of Birth: [**2082-7-14**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 60-year-old male with a history of end stage renal disease on hemodialysis, alcoholic cirrhosis who was brought to the [**Location (un) 620**] emergency room on [**2142-6-7**] after hemodialysis for increased confusion and low grade fevers. The patient has had extensive work up including ultrasound with no ascites, negative head CT and chest x-ray which demonstrated left-sided pleural effusion. This was tapped and found to be hemorrhagic and viscus and the Foley drained. Fluid did show [**2139**] white blood cells, 320,000 red blood cells with a differential of neutrophils 93 percent, lymphocytes 2 percent and monocytes 5 percent. Glucose was 100. LDH was 1,935. One day prior to discharge, the patient spiked to 101.1 and was started on Levofloxacin and metronidazole. The patient was transferred to the [**Hospital1 1444**] for possible video assisted thorascopic surgery. At the time of discharge, all culture data was negative including blood and pleural cultures. Currently, the patient denies chest pain, shortness of breath, nausea and vomiting, headache, fevers, chills, nausea or cough. PAST MEDICAL HISTORY: 1. End stage renal disease and hemodialysis. 2. Alcoholic cirrhosis with hepatitis A, B and C. 3. Exudative effusion. 4. Gout. 5. Hypertension. 6. History of MRSA line infection. 7. Alcohol withdrawal seizures. 8. Questionable history of congestive heart failure. PHYSICAL EXAMINATION: Vital signs: Temperature is 99.5, blood pressure is 128/78, pulse 71, respiratory rate is 20, saturation is 95 percent on room air. In general, lying in bed, appears comfortable. HEENT: Normocephalic and atraumatic. Right pupil is smaller than left. Slight ptosis of the left eye. These are chronic per patient. Neck has no jugular venous distention. Chest has decreased breath sounds and dullness on the left. Clear to auscultation on the right. COR has a regular rate with no murmurs, rubs or gallops. Abdomen is soft and mildly diffusely tender. No fluid wave. No rebound. Positive bowel sounds. Extremities has no cyanosis, clubbing or edema. No pulmonary erythema. Neurological has no asterixis. LABORATORY DATA: White blood cell count is 7.5 with 69 percent polys, 2 percent bands. BUN 28, creatinine 4.5. HOSPITAL COURSE: 1. Pleural effusion: The patient was taken for VATS on [**2143-9-18**]. Postoperatively, he developed atrial fibrillation and hypotension despite fluid resuscitation. The patient was placed on pressors and transferred to the ICU. The patient was continued on empiric antibiotics including ceftriaxone and clindamycin for empyema DICTATION ENDED [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2014**], MD [**MD Number(2) 20382**] Dictated By:[**Last Name (NamePattern1) 4671**] MEDQUIST36 D: [**2143-6-3**] 20:40:14 T: [**2143-6-4**] 12:11:33 Job#: [**Job Number 52060**]

[ "427.31", "070.32", "070.54", "403.91", "780.39", "997.1", "789.5", "511.8", "571.2" ]

icd9cm

[ [ [] ] ]

[ "39.95", "33.23", "96.6", "34.51", "34.21" ]

icd9pcs

[ [ [] ] ]

1499, 1772

5180, 5819

4332, 5163

2901, 4021

4043, 4309

13,033

184,545

42982

Discharge summary

report

Admission Date: [**2186-4-3**] Discharge Date: [**2186-4-7**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: N/V, hypertensive urgency, hypoglycemia Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 37 y/o male with Type I DM, complicated by gastroparesis and ESRD on HD, difficult to control HTN thought [**3-17**] to autonomic dysfunction, who presented to the ED with hypertensive urgency. Pt had an episode of hyperglycemia last night (400s), took a 5 units of regular insulin (normally takes 3u) then began to develop gastroparesis in middle of night with nausea/vomiting and was unable to take POs. He subsequently came to the ER. . On arrival to the ER, his BP was 242/131 with HR 51. He continued to have nausea and vomiting. Initially received ativan 2 mg IV, dilaudid 2 mg, labetolol 20 IV with improvement in BPs to the 160s and improvement of his nausea and vomiting. BP and N/V fluctuated throughout the day. He was given what appears to be a total of 8 mg dilaudid and 8 mg of ativan for his N/V. He received metoprolol 75 mg PO x2, clonidine 0.2 mg x2 and what appears to be a total of 100 mg of IV labetolol over a 16 hour period. He also was initially hypoglycemic with a BS of 44 and received dextrose with improvement of his sugars. He did not receive any additional insulin until ~8pm when he received 4 units of regular insulin. Prior to coming to the MICU he was started on a labetolol gtt for uncontrolled BPs. . Of note the patient presents to the hospital 2-3x per month with complaints of N/V and hypertension (last admit [**Date range (1) 86467**]). His blood pressures have been very labile. More recently his blood sugars have been more labile, with several recent episodes of severe hypoglycemia. Past Medical History: 1. DM type I 2. ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, gastroparesis, and orthostatic hypotension. 4. History of esophageal erosion, MW tear 5. CAD with 1-vessel disease (50% stenosis D1 in [**7-/2181**]), normal stress [**11/2182**] 6. hx of Foot Ulcer 7. h/o clot in AV graft x2 ([**Month (only) 958**] and [**2185-8-13**]) 8. h/o of infected portacath that was removed on [**2-19**] Social History: Denies alcohol or tobacco use. Endorses occassional marijuana use. Lives with his [**Hospital1 **] mother and their three children. Family History: His father recently died of ESRD and diabetes. His mother is in her 50s and has hypertension. He has two sisters, one with diabetes, and six brothers, one with diabetes. Physical Exam: VS: T 95.8 HR BP RR O2 sat Gen: sleepy but conversant HEENT: anicteric, dry MM Neck: R EJ Cardio: RRR, nl S1 S2, 2.6 loudest LUSB Pulm: CTA b/l ant Abd: soft, mildly diffusely tender, hypoactive BS, no rebound/guarding Ext: no edema, 1+ DP pulses b/l Neuro: A&Ox3 (though thought he was at [**Hospital1 392**] as oppsed to [**Hospital1 **]) CN 2-12 intact, though EOMI not checked and right pupil slightly smaller than left Moves all 4 extremities, muscle strength intact Decreased sensation in feet b/l downgoing babinskis bilaterally Pertinent Results: [**2186-4-5**] 04:12AM BLOOD WBC-7.0 RBC-3.99* Hgb-10.9* Hct-32.8* MCV-82 MCH-27.3 MCHC-33.2 RDW-18.5* Plt Ct-216 [**2186-4-4**] 03:55AM BLOOD Neuts-78.2* Lymphs-15.2* Monos-5.4 Eos-0.8 Baso-0.2 [**2186-4-3**] 08:25PM BLOOD freeCa-0.93* [**2186-4-5**] 04:12AM BLOOD Glucose-162* UreaN-20 Creat-6.4*# Na-140 K-4.4 Cl-99 HCO3-32 AnGap-13 [**2186-4-4**] 03:55AM BLOOD PT-17.2* PTT-30.9 INR(PT)-1.6* [**2186-4-5**] 04:12AM BLOOD PT-19.3* PTT-32.4 INR(PT)-1.8* Brief Hospital Course: 37 y/o male with Type I DM, complicated by gastroparesis and ESRD on HD, difficult to control HTN thought [**3-17**] to autonomic dysfunction, who presented to the ED with hypertensive urgency, gastroparesis and hypoglycemia. . #Hypertension: He had hypertensive urgency on admission without evidence of end organ damage. Pt with history of labile blood pressures due to autonomic dysfunction. Home medication regimen includes clonidine PO and TD, metoprolol and nifedepine but with episodes of gastroparesis it is difficult for him to take his medications. Blood pressures were labile in the ER over 16 hours and initially responded to labtelol but then systolic pressures went back up to the 240s-260s. He was sent to the MICU on a labetolol gtt. This was quickly tapered off. Pt was treated for his gastroparesis and was able to tolerate POs. He was started on his home regimen of clonidine (patch and PO pills), metoprolol and nifedepine. Pressures were well controlled with transient increases in pressure when pt in pain or feeling nauseous. . #Diabetes/labile blood sugars: Pt with long h/o of DM. Came in after episode of hyperglycemia in the 400s. Took extra insulin and was hypoglycemic to the 40s in the ER. Was treated with dextrose. Seen by [**Last Name (un) **] here and regimen changed to lantus 10 units qhs from his home regimen of NPH. Fingersticks and sugars were followed and he was covered with a regular insulin sliding scale. . # Gastroparesis: On admission, pt had his usual gastoparesis symptoms. He was treated with his regular regimen of reglan, ativan, and dilaudid and improved. He was rapidly able to tolerate POs. . # Mental status changes: Resolved. On admission to MICU, appeared sleepy but arousable and answered questions appropriately. Likely [**3-17**] to receiving dilaudid and ativan in large amounts in the ER. Neuro exam was nonfocal. -cont to follow exam . # ESRD - He is on HD and followed by renal. Has dialysis on T/Th/Sa. He continued with dialysis here and transplant evaluation was started during this admission. With regard to his electrolytes, his initially recorded potassiums were in the 8s, but the specimens were hemolyzed and these values were likely aberrant as he had an initial K of 4.5. His potassium had normalized by discharge. . # AVF: Patient uses this for access for HD. Has clotted several times in the past and he was on [**Month/Day (2) **] to keep it from clotting. [**Month/Day (2) 197**] held during this admission as he was scheduled to have a portacath placed to help with access issues. . # Anemia - Hct slowly trended down during admission/ Will guaiac stools. recheck Hct this afternoon. Will discuss possible EPO w/ renal . # Access - Pt has very difficult access. Currently with R EJ in place. Portacath recently removed [**3-17**] to infection. Patient scheduled for portacath placement on [**4-7**]. [**Month/Year (2) 197**] was held in anticipation of procedure. . #FEN - regular diabetic, renal diet . #PPx - PPI, SQ heparin . #Communication: patient . #Code status: Full Code Medications on Admission: Medications per last d/c summary [**2186-3-25**]: 1. Metoclopramide 10 mg q6 hours 2. Metoprolol Tartrate 75 mg PO TID 3. Calcium Acetate 667 mg TID with meals 4. Ativan 1 mg Tablet q6 hours for agitation 5. Hydromorphone 4 mg Tablet q3-4 hrs PRN 6. Clonidine 0.3 mg/24 hr Patch weekly qFRI 7. Clonidine 0.2 mg Tablet TID 8. Warfarin 1.5 mg qhs 9. Nifedipine 30 mg SR qd 10. Pantoprazole 40 mg qd 11. Aspirin 81 mg qd 12. Humalog sliding scale 13. Insulin NPH 2 units [**Hospital1 **] Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea, anxiety. 5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFriday. 7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Warfarin 1 mg Tablet Sig: 1 and [**2-14**] Tablet PO at bedtime. 9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Two (2) Units Subcutaneous twice a day. 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: According to sliding scale Subcutaneous qACHS. 14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Diabetic Gastroparesis Hypertensive urgency . Secondary diagnoses: Chronic renal failure Type 2 diabetes with complications Discharge Condition: Vital signs stable, tolerating oral diet, hypertension controlled. Discharge Instructions: You were admitted for nausea, vomitting, and high blood pressure. This was due to your gastroparesis. You were treated with medications for all of these and responded well. You also had a Portacath inserted to help with receiving IV medications and drawing bloodwork. Followup Instructions: Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]. His phone number is ([**Telephone/Fax (1) 773**]. Completed by:[**2186-4-16**]

[ "250.61", "250.81", "403.01", "414.01", "337.1", "285.21", "536.3", "585.6" ]

icd9cm

[ [ [] ] ]

[ "86.07", "39.95" ]

icd9pcs

[ [ [] ] ]

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3862, 6937

354, 360

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36927

Discharge summary

report

Admission Date: [**2151-7-11**] Discharge Date: [**2151-8-3**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: thoracic aortic aneurysm Major Surgical or Invasive Procedure: [**2151-7-12**] L carotid to subclavian bypass [**2151-7-13**] thoracic aortic stent graft [**2151-7-28**] Tracheostomy and PEG History of Present Illness: 87F with a known thoracic aneurysm presents for preadmission hydration for a left carotid to subclavian bypass graft. She reports she has been well since her last admission. She reports no [**Month/Day/Year 5162**], chilld, chest/back/abdominal pain. No dyspnea. Past Medical History: - breast cancer 6-7 years ago s/p left lumpectomy and 5 years of Tamoxifen - L CEA [**2-22**] - HTN - hyperlipidemia - TAA - seasonal allergies Social History: smoked [**1-15**] ppd x 20 years, quit 40 years ago, drinks 1 glass, was previously working in real estate. Lives with daugther who assists with ADLs and medications. Family History: pt reports mother with HTN and stroke in 80s. Denies family history of MI. Physical Exam: VS: T 98.7 HR 78 SR, BP 136/52 RR 19-20 on CPAP/Vent O2 sat 100% Gen: Awake, alert, following commands and MAE. Neck: w/ seroma(visibly swollen, stable. Cards: RRR, VSS Lungs: CTA b/l Abd: soft, NT, ND Ext: well perfused, no edema Pertinent Results: [**2151-7-28**] 12:42PM BLOOD Hct-26.1* [**2151-7-28**] 02:42AM BLOOD WBC-7.4 RBC-2.83* Hgb-8.6* Hct-26.8* MCV-95 MCH-30.5 MCHC-32.2 RDW-14.5 Plt Ct-367 [**2151-7-28**] 02:42AM BLOOD Plt Ct-367 [**2151-7-28**] 02:42AM BLOOD Glucose-100 UreaN-36* Creat-1.1 Na-139 K-3.7 Cl-101 HCO3-28 AnGap-14 [**2151-7-27**] 05:29AM BLOOD Glucose-107* UreaN-36* Creat-1.1 Na-141 K-3.9 Cl-101 HCO3-31 AnGap-13 [**2151-7-22**] 02:09AM BLOOD Lipase-53 [**2151-7-14**] 02:38AM BLOOD Lipase-17 [**2151-7-17**] 12:38PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2151-7-17**] 04:20AM BLOOD CK-MB-2 cTropnT-0.02* [**2151-7-28**] 02:42AM BLOOD Calcium-10.9* Mg-2.3 [**2151-7-27**] 05:29AM BLOOD Calcium-11.4* Phos-2.5* Mg-1.9 Radiology: CXR (PORTABLE AP) Study Date of [**2151-7-28**] 1:19 PM FINDINGS: As compared to the previous radiograph, the endotracheal tube has been removed. The patient has undergone tracheostomy, the tracheostomy tube is in correct position. The left-sided chest tube has been removed. There is minimal pneumopericard, but no evidence of pneumothorax. Status post removal of the nasogastric tube. No other relevant changes. CT CHEST W/O CONTRAST Study Date of [**2151-7-22**] 10:47 AM IMPRESSION: 1. Minimal enlargement largely serous left supraclavicular fluid collection since [**2151-7-15**], new small high-density component suggests prior bleeding. CTA would be required to exclude vascular connections, but the absence of appreciable change argues against active bleeding. 2. No change in the appearance or location of the left subclavian artery stent and aortic endoprosthesis. No enlargement of aortic aneurysm. 3. Probable pulmonary artery hypertension, calcific aortic stenosis, and possible mitral annulus dysfunction from calcification. 4. Mild bronchiolitis, improved right upper lobe, increased right lower lobe suggests aspiration. Complete left lower lobe collapse is stable, subtotal lingular atelectasis worsened, right basal segmental atelectasis stable. CT CHEST W/O CONTRAST Study Date of [**2151-7-15**] 10:59 PM IMPRESSION: 1. Left supraclavicular fluid collection might be related to post-operative seroma. 2. Small bilateral pleural effusions, new, left more than right. Worsening of bibasilar atelectasis, now involving the entire left lower lobe. 3. Stent graft in place, patency assessment is limited without contrast, overall appears to be unremarkable. 4. The NG tube tip impinging the stomach wall and should be pulled back approximately 5 cm. 5. Centrilobular nodules seen in the right lung as described, grossly unchanged since [**2151-6-22**], may represent airway infection/inflammation. No evidence of interstitial lung disease seen. 6. Several pulmonary nodules that might be of different origin and might be followed in six months if clinically warranted. Attention to the left lower lobe collapse should be given with subsequent imaging to document its resolution. CHEST (PRE-OP PA & LAT) Study Date of [**2151-7-11**] 9:04 PM IMPRESSION: PA and lateral chest read in conjunction with a chest CT scan, particularly frontal and lateral scout views on [**2151-6-22**]. Allowing for differences in radiographic technique there is no evidence of change since [**6-22**] in the heavily calcified thoracic aorta with aneurysmal dilatation of the ascending and arch portions, left lower lobe collapse, normal heart size. Heavy aortic valvular calcifications not appreciated on the conventional radiographs, but clearly seen on the CT scan. Lungs are otherwise clear. No pleural effusion. Cardiology: Portable TTE (Complete) Done [**2151-7-17**] at 11:05:18 AM FINAL Conclusions The left atrium is elongated. The estimated right atrial pressure is 10-15mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Moderate concentric left ventricular hypertrophy. Hyperdynamic left ventricular function. Moderate mitral stenosis. Mild aortic stenosis. Moderate pulmonary hyeprtension. ECG Study Date of [**2151-7-13**] 12:36:02 PM Baseline artifact. Sinus tachycardia. Otherwise, probably normal. Compared to the previous tracing of [**2151-7-11**] the findings appear similar, although comparison of atrial rhythm and atrial morphology is difficult because of underlying artifact. ECG Study Date of [**2151-7-11**] 9:58:58 PM Normal sinus rhythm. Axis is 0 degrees. Late transition. Compared to the previous tracing of [**2151-6-22**] no diagnostic interval change. Brief Hospital Course: [**2151-7-11**] Admitted to Vascular Surgery for hydration and pre-op left carotid to subclavian bypass graft in preparation of endograft repair of thoracic AAA. Routine nursing, ECG and CXR were done. Made NPO fater MN, IV hydrated. [**2151-7-12**] HD1: Cardiothoracic surgery consulted for Thoracoabdominal aneurysm-recs -endo candidate and that pre procedure left corotid subclavian bypass should be done due to lack of sufficient landing zone in her aortic arch. Taken to OR and underwent Left common carotid to subclavian artery bypass, PTFE graft from the common carotid artery to the subclavian artery. Tolerated procedure well, recovered in the PACU then transferred back to the VICU for further observation. Patient was Was pre-oped and consented for Stent graft repair of thoracic aortic aneurysm in am. [**2151-7-13**] Taken to the angio suite and underwent Stent graft repair of thoracic aortic aneurysm. Post-op patient was placed on BIPAP for respiratory acidosis. Transferred to CVICU. [**2151-7-14**] Remained in CUICU, required low dose Neo for BP support. Remained on BIPAP. Had periods of agitation requiring medication. RISS per CVICU, electrolytes repleted. 7/2-14/09: Pt. developed respiratory distress and was re-intubated, agitated and confused requiring sedation w/ Propofol. Her CT chest done- showed a new basal L pleural effusion. This was followed by serial CXRs, and a L CT was placed on [**2151-7-21**] that has drained 65 mls SS in the last 24 hrs. The CT is placed anteriorly and is not draining the fluid present in the dependant postero basal part of the pleural cavity. On [**2151-7-22**] CT showed LLL consolidation with mild to moderate element of pleural effusion. Also noted to have left neck seroma. BAL/BRONCHOSCOPY was positive for gm -rods/+cocci, Vanc and Zosyn were started. Had some problems w/ tachycardia resumed beta blockers. DVT prohylaxis w/ heparin SC. Transfused w/ 2 units of packed cells for low HCT. Patient became febrile on [**2151-7-22**] Urine cx- showed UTI- added Cipro to ABX. Cental line d/c'd- tip cultured. Pan cultured, ID consulted- presumed VAP and poss line sepsis-recs continue Vanc/Zosyn. Pulmonary consut for vent weaning. [**7-28**]: Pt to OR for Percutaneous tracheostomy (#7 Portex cuffed), Placement of PEG tube, Therapeutic bronchoscopy. Patient unable to be separated from vent. [**2062-7-28**]: Patient stable with tracheostomy, receiving tube feeds via PEG, and continuing antibiotics until [**8-5**] for VAP, possible line infection. Awaiting vent rehab placement. [**2151-8-3**]: No acute events. Rehab bed offer at the [**Hospital1 **] in [**Location (un) 701**], Patient was discharged in good condition, to continue IV antibiotics till [**2151-8-5**]. Neuro: Patient alert and oriented following commands. Patient had problems w/ agitation w/ intubation, off and on IV sedation for agitation management. Currently on Oxycodone-acetaminophen elixer for pain and Haldol prn for agitation. Resp: Patient developed VAP, treated w/ Vanco and Zosyn to continue till [**2151-8-5**]. Prolonged intubation and failed ventilator weaning, trached on [**7-28**], failed trache collar attemps. Mechanical Ventilation: MMV (Volume targeted - Mechanical Breaths Optional)mv target: 4.0 l/m Tidal volume (mechanical): 400 cc Respiratory rate: 10 Pressure support level: 10 cm/h2o PEEP: 5 cm/h2o FIO2: 40 %. Requested for [**Hospital 5442**] rehab placement on [**2151-7-29**]- bed offer Cards: Patient had been on sinus rythm during her hospital stay, there were issues w/ tachycardai managed w/ home dose beta blockers. GI: PEG on [**2151-7-28**], used after 24 hours. Tube feeds (Pulmonary Nutren): Goal rate: 40 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Flush w/ 30 ml water q12h, Reglan as needed for nausea. Moving bowels, last BM [**2151-8-2**]. GU: Foley remained from day of surgery [**2151-7-12**], adequate urine output, had UTI by Urine cultures, treated w/ Cipro. Endo: Patient had been on Glargine at HS and RISS for glycemic control. Skin: intact, no decubiti or skin breakdown, L neck seroma is stable. ID: ID following: [**7-21**] Blood Cultures: positive for [**2-15**] Coag neg staph, [**7-21**] sputum cultures STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML. Diagnosed w/ VAP as well as possible line infection- treated w/ Vanco and Zosyn. [**7-26**] C-diff cultures negative. Medications on Admission: Metoprolol Tartrate 50 [**Hospital1 **] Lisinopril 10 mg qd Aspirin 81 mg qd Atorvastatin 10 mg qd Allopurinol 200 mg qd Discharge Medications: 1. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: Two (2) Recon Soln Intravenous Q6H (every 6 hours) for 2 days: 2.25grams IV. Discontinue on [**8-5**]. Disp:*16 Recon Soln(s)* Refills:*0* 2. HydrALAzine 10 mg IV Q4H:PRN SBP >150 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 100mg PO BID (2 times a day). Disp:*60 100mg* Refills:*2* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezes. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop Ophthalmic QHS (once a day (at bedtime)). 10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 11. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain, fever. 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation . 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 2.5-5 MLs PO Q6H (every 6 hours) as needed for pain. 20. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 21. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 22. Regular Insulin SC Sliding Scale Q6H Glucose Insulin Dose 0-60 mg/dL 4 oz. Juice 61-100 mg/dL 0 Units 101-130 mg/dL 3 Units 131-160 mg/dL 6 Units 161-200 mg/dL 9 Units 201-240 mg/dL 12 Units > 240 mg/dL Notify M.D. 23. Glargine 20 Units subcutaneously every bedtime 24. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q 24 h for 2 days: D/C [**2151-8-5**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Thoracic aneurysm Pneumonia-VAP Sepsis-r/t central line, line was d/c'd, treated w/ Vanco/Zosyn Post-op Respiratory failure- requiring re-intubation, failed vent wean and eventual tracheostomy Anemia-acute requiring blood transfusion UTI- from urine cultures, treated w/ Cipro- resolved History of: HTN hyperlipidemia hypercholesterolemia gout acute renal failure thoraco-abdominal aortic aneurysm PSH: s/p hysterectomy [**2102**], s/p, left lumpectomy [**6-20**] yrs ago s/p tamoxifen treatment, s/p Left MRM ~02, s/p RT TKR [**2142**], s/p lt CEA Discharge Condition: Stable Discharge Instructions: Vascular Surgery Discharge Instructions - You were admtted for Thoracic aneurysm, you underwent [**2151-7-12**] L carotid to subclavian bypass and [**2151-7-13**] thoracic aortic stent graft after which you developed difficulty of weaning from the ventillator that required you to have Tracheostomy and PEG on [**2151-7-28**]. - You were discharged to rehab, for ventillator weaning and physical therapy, - Continue all your medications as precribed, - You may shower, no baths, - Diet for now is Pulmonary Nutren w/ a goal of 40 cc per hour via PEG, you will remain NPO until your trache is discontinued, and possibly swallowing studies, - You will FU w/ Dr. [**Last Name (STitle) 1391**], please call his office for an appointment, - You will also, FU w/ Dr. [**Last Name (STitle) **] after you are discharged from rehab, please call his office for an appointment [**Telephone/Fax (1) 18152**]. - Followup Instructions: Call Dr.[**Name (NI) 1392**] office for follow up in 2 weeks. Phone: [**Telephone/Fax (1) 1393**] Call Dr.[**Name (NI) 7446**] office after you are discharged from rehab, call his office for an appointment [**Telephone/Fax (1) 9393**]. Completed by:[**2151-8-3**]

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icd9cm

[ [ [] ] ]

[ "39.22", "88.42", "33.23", "96.72", "43.11", "96.6", "31.1", "96.04", "39.73", "33.24" ]

icd9pcs

[ [ [] ] ]

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44186+58670

Discharge summary

report+addendum

Admission Date: [**2127-12-26**] Discharge Date: [**2127-12-29**] Service: MEDICINE Allergies: Meperidine Attending:[**First Name3 (LF) 4232**] Chief Complaint: hyponatremia, fatigue Major Surgical or Invasive Procedure: Right internal jugular central line History of Present Illness: 89 yoF w/ a h/o CAD s/p CABG, HTN, PVD, CRI, AF s/p cardioversion who is transferred from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] for hyponatremia. Patient's typical sodium in 130s to 140s. She was recently started on hctz [**12-18**] and on [**12-23**] her Na was found to be 125. Her hctz was stopped at that time and she was placed on free H2O restriction. She then had a further decrease in her Na to 122 today and patient was complaining of fatigue and mild nausea. At [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] they were unable to gain IV access and she was referred to [**Hospital1 18**] ED. Of note, she fell 2 days ago and was seen in [**Hospital1 18**] where she had a head CT performed which was unremarkable. Also of note, she has recently been complaining of intermittent double vision. During her most recent admission she was seen by optho and there was no evidence of diplopia; no evidence of CN3,4,6 palsy. . Recent admission [**Date range (1) 39549**]/07 for SOB, palpitations, and LE edema and was found to be in new AF in 120s. A TTE [**12-3**] and TEE [**12-4**] showed evidence of severe MR with a tear on the mitral chordae, EF >55%, 2+TR and moderate PAH. She was cardioverted on [**12-4**], started on heparin, transitioned to coumadin, and also started on amiodarone. She was thought to be volume overloaded as well, possibly secondary to worsened MR and she was diuresed. . In [**Hospital1 18**] ED, T 98.4, BP 128/66, HR 68, RR 20, O2 96%RA. Patient was mentating appropriately without other concerning symptoms. Labs showed a sodium of 125, and a Cl of 90 but was otherwise unremarkable. She received 1L NS in ED and was sent to the floor. Past Medical History: -CAD, s/p CABG x 3 [**2114**] and IMI w/ RBBB and inferolateral wall motion defect [**2116**], s/p PCI TAXUS of the LCX [**10-10**] -EF 66% per cath [**10-10**] -HTN -Hypercholesterolemia -Chronic stable angina -PVD with claudication -CRI (baseline 1.4-1.6) -Bilateral cataracts with s/p implants -Arthritis -Vasovagal syncope [**11/2117**] -Peripheral neuropathy with gait instability -Depression . Cardiac Risk Factors: Diabetes: (-) Dyslipidemia: (+) Hypertension: (+) . Cardiac History: CABG, in [**2114-3-19**] anatomy as follows: LIMA to LAD, SVG to OM1-OM3, SVG to PDA. Social History: She is widowed and lives alone. She has two very supportive children. She used to be an x-ray tech at [**Hospital1 18**], +TOB with 1PPD-quit 20 years ago. Family History: Family History: (+) FHx CAD: Mother had "angina" problems. Physical Exam: T: 97.9 BP: 142/72 HR: 70 RR: 18 O2 96% RA Gen: Pleasant, well appearing, elderly female, NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, JVP ~10 cm H2O. No thyromegaly. CV: RRR. Fine bibasilar crackles ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. 2+ DP pulses BL SKIN: Large ecchymoses over L elbow. NEURO: A&Ox3. Appropriate. + anisocoria w/ L 4mm and R 3.5 mm both minimally reactive. Otherwise CN 2-12 intact. Preserved sensation throughout. 5/5 strength throughout. Pertinent Results: [**2127-12-26**] ADMISSION LABS: CBC: WBC-4.5 RBC-4.16* Hgb-12.8 Hct-35.2* MCV-85 MCH-30.9 MCHC-36.4* RDW-17.8* Plt Ct-170 Neuts-71.5* Bands-0 Lymphs-19.0 Monos-7.9 Eos-1.0 Baso-0.5 . COAGS: PT-33.3* PTT-41.6* INR(PT)-3.5* . CHEM: Glucose-120* UreaN-25* Creat-1.8* Na-125* K-4.2 Cl-90* HCO3-26 AnGap-13 Calcium-9.2 Phos-2.6* Mg-2.1 . LFTs: ALT-18 AST-46* LD(LDH)-495* AlkPhos-87 Amylase-127* TotBili-1.0 Lipase-72* Albumin-3.9 . TSH-9.3* . [**12-26**] URINE (for hyponatremia w/u) URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG Creat-138 Na-43 K-94 Cl-75 TotProt-18 Prot/Cr-0.1 Osmolal-581 . STUDIES: CT HEAD W/O CONTRAST [**2127-12-25**] IMPRESSION: No evidence for hemorrhage. . CHEST (PORTABLE AP) [**2127-12-27**] As compared to the previous study, mild CHF has resolved. Biapical scarring with calcified granulomata appear unchanged. Small left pleural effusion has nearly resolved. . CHEST (PA & LAT) [**2127-12-29**] IMPRESSION: No evidence of new acute changes. . [**12-29**] DISCHARGE LABS CBC: WBC-4.0 RBC-3.72* Hgb-11.4* Hct-31.9* MCV-86 MCH-30.7 MCHC-35.8* RDW-17.6* Plt Ct-150 CHEM: Glucose-87 UreaN-16 Creat-1.5* Na-132* K-3.9 Cl-99 HCO3-26 AnGap-11 Calcium-9.1 Phos-2.0* (repleted) Mg-2.0 . COAGS: PT-15.5* PTT-33.9 INR(PT)-1.4* . LFTs: ALT-13 AST-23 LD(LDH)-208 Brief Hospital Course: 89 y.o. F with h/o CAD, s/p CABG '[**14**], PVD, new-onset afib [**11-12**] s/p recent cardioversion, who presented with hyponatremia after beginning HCTZ. Briefly transfered to MICU with hypotension (never on pressors), then back to floor with stable vitals and eunatremic. Hospital course by problem: . # Hyponatremia - Was likely secondary to overdiuresis with new thiazide diuretic. Held HCTZ. Resolved with normal saline IVF, with Na stable in low-normal range at discharge. Euvolemic on exam. At presentation, uOsm was > 300 @ 581, with UNA @ 41 on admission suggesting SIADH, but pt may still have been salt wasting in setting of recent thiazide use. To promote eunatremia, she should continue on a *free water* restriction after discharge (note: not at the expensive of dehydration. fluids with electrolyes are ok) . # Hypotension - Resolved with IVF, so was probably simple hypovolemia. No leukocytosis. No fevers. U/A was negative, urine cx with NGTD by discharge. No blood cx available, but very low likelihood for infection as etiology for hypotension. . # O2 requirment: Only developed briefly after aggressive hydration in MICU. Autodiuresed well with no clinical symptoms of volume overload and had an O2 sat on room at of 96% at discharge. Serial CXRs were largely unchanged. . # Diarrhea: Developed loose stool in the setting of MICU transfer. Stool sent for C Diff but pt was empirically started on Flagyl. Diarrhea has subsequently improved, but this is confounded by the fact that she was put on Flagyl. Meanwhile, first stool sample was negative for C Diff toxin. Given the relatively high (~85%) sensitivity of this assay, it is very unlikely that C diff was the etiology of her diarrhea. d/c Flagyl on day of d/c (day #[**3-15**]) as it was unlikely to be treating a true infection, and also it will greatly complicate achieving a therapeutic INR for her (already on amiodarone!). Patient should have 2 additional stool samples sent for formal C Diff rule out as an outpatient. . # CKD: remained at baseline. Baseline 1.4 to 1.7. . # CAD, s/p CABG - no symptoms. Continued medical CAD regimen of ASA, plavix, statin. After hypotension resolvedm, added low dose beta blocker to CAD regimen . # Atrial Fibrillation - s/p cardioversion in early [**Month (only) 1096**]. Coumadin initially held for initial INR on presentation of 3.7. Monitored on telemetry with NSR throughout. On discharge, INR had dropped to 1.4, so restarted coumadin 2mg. INR to be checked 2 and 4 days after discharge, goal [**2-8**]. INR must be montored carefully as pt is on amiodarone, with dosing to be tapered as per discharge medications. . # Anemia: After placement of R IJ line in MICU stay, persistent oozing was noted. FFP was given. Had slight HCT drop, and was transfused 1 unit of PRBCs on [**12-28**] with a more than appropriate bump in HCT. The drop was likely from oozing from central line site. No other evidence of bleeding. . # Postnasal drip: persists. Continued flonase . # PVD - stable, continued pentoxifyline. . # FEN - Ate a regular, not salt restricted, diet. Initiated free water restriction of 1500cc / day for possible SIADH (low suspicion). Repleted lytes prn . # Full Code . # Communication - Daughter - [**Name (NI) 94817**] [**Name2 (NI) 94818**] cell: [**Telephone/Fax (1) 94819**]; [**Telephone/Fax (1) 94820**] patient's house # where the daughter resides. Medications on Admission: 1. Folic Acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days: Continue taking amiodarone 200mg TID until [**12-11**]. 10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). 11. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 12. Metoprolol Tartrate 25 mg Tablet Sig: one half tablet Tablet PO BID (2 times a day). 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days: Do not start this medicine until [**12-11**]. Continue this medication until [**12-25**]. 14. Amiodarone 300 mg Tablet Sig: One (1) Tablet PO once a day for 14 days: Please start this [**12-25**]. You will continue this until [**1-7**]. 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Please start this [**1-7**]. You will continue this ongong until you follow up and your cardiologist tells you otherwise. 16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual PRN Chest pain as needed for pain. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed for constipation. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). 9. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): continue until [**2128-1-7**]. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: this dose is to begin on [**2127-1-8**] and is ongoing until otherwise instructed by cardiology. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary: Hyponatremia . Secondary: coronary atery disease s/p myocardial infarction and 3-vessel bypass atrial fibrillation s/p recent cardioversion chronic renal infuffiency, baseline creatinine 1.4-1.7 urge incontinence hypertension hypercholesterolemia peripheral vascular disease depression peripheral neuropathy with gait instability Discharge Condition: stable, eunatremic, improved Discharge Instructions: You were admitted to the hospital with a low sodium level ("hyponatremia"), which caused you to feel weak. The hyponatremia was probably due to a new medicine you were taking called hydrochlorothiazide (HCTZ), which dehydrated you. We stopped the medicine and you sodium improved. Your blood pressure was low for a short time, and so we monitored you in our ICU. You never needed any medicines to maintain your blood pressure and it quickly normalized with fluids. . You were also briefly on an antibiotic to treat diarrhea that you developed in the hospital. We checked your stool for a common infection called C Diff, and it was negative. You do not need any further antibiotics but you should have additional stool samples checked for this infection. . Please take all your medicines as prescribed. Please keep all of your followup appointments. If you experience any further fatigue, or if you develope fevers/chills, or any other symptoms which disturb you, please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the emergency room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 60**] Date/Time:[**2128-1-29**] 8:30 . Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10012**] in the next 2 weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**] Name: [**Known lastname 14925**],[**Known firstname **] Unit No: [**Numeric Identifier 14926**] Admission Date: [**2127-12-26**] Discharge Date: [**2127-12-29**] Date of Birth: [**2038-9-9**] Sex: F Service: MEDICINE Allergies: Meperidine Attending:[**First Name3 (LF) 11538**] Addendum: Pt also has stable chronic diastolic heart failure which was not acutely clinically exacerbated during this admission despite radiographic evidence of mild volume overload. Pt autodiuresed and was compensated throughout. Discharge Disposition: Extended Care Facility: [**Hospital3 163**] - [**Location (un) 164**] [**Name6 (MD) 634**] [**Name8 (MD) 635**] MD [**MD Number(1) 636**] Completed by:[**2127-12-29**]

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Discharge summary

report

Admission Date: [**2147-5-11**] Discharge Date: [**2147-6-8**] Date of Birth: [**2071-5-6**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: 76-year-old female with no psychiatric history who was admitted to [**Hospital1 18**] via [**Hospital **] Hospital on [**2147-5-11**] after a 15 foot fall from her porch resulting in a C2-C3 fracture. Since admission, she has been in the TICU where she has been quadriplegic and ventilator dependent. Major Surgical or Invasive Procedure: Placement of 2 lip retrievable IVC filter using intervascular ultrasound at bedside. Procedure [**5-13**] Trach /PEG [**5-15**] Halo [**5-16**] IVC filter . History of Present Illness: 78 F transfer transfer from [**Hospital **] Hosp s/p fall approx 15 feet from deck. +LOC. C2,3,4 fx on CT at OSH. No bleed. . Past Medical History: Seizure disorder, HTN, CRI (baseline 3-3.5) PSH:colon cancer, s/p colectomy, R Port-A-Cath, s/p R nephrectomy, appy, CCY Physical Exam: MS/NEURO: A/O parapleagic HEENT: PERRLA, EOMI CVS RRR Resp:CTA-B Abd: S/NT/ND/+BS Pertinent Results: Click "Import Result" to add to discharge summary. Results from [**2147-5-10**] to Note: For Cytogenetics results see Clinical Information System Blood Urine CSF Other Fluid Microbiology Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2147-6-8**] 02:25AM 7.6 2.69* 7.9* 23.1* 86 29.4 34.2 17.6* 312 Import Result [**2147-6-7**] 02:42PM 26.4* Import Result [**2147-6-7**] 03:08AM 8.1 2.97* 8.4*# 25.0* 84 28.3 33.6 17.6* 332 Import Result [**2147-6-7**] 12:26AM 25.5* Import Result [**2147-6-6**] 03:42AM 6.6 2.48* 6.7* 20.8* 84 27.1 32.3 17.8* 361 Import Result [**2147-6-5**] 04:09AM 5.6 2.67* 7.1* 22.4* 84 26.7* 31.7 17.7* 352 Import Result [**2147-6-4**] 02:00AM 7.5 2.87* 7.6* 23.8* 83 26.4* 31.8 17.5* 351 Import Result [**2147-6-3**] 03:14AM 6.7 2.80* 7.4* 23.5* 84 26.4* 31.4 17.4* 343 Import Result [**2147-6-2**] 02:06AM 7.0 2.79* 7.6* 23.5* 84 27.2 32.3 16.9* 339 Import Result [**2147-6-1**] 08:27AM 7.8 2.93* 8.0* 24.7* 84 27.2 32.3 17.4* 316 Import Result [**2147-5-31**] 02:58AM 7.0 2.62* 7.2* 22.5* 86 27.3 31.9 17.2* 262 Import Result [**2147-5-30**] 04:11PM 8.5 2.78* 7.6* 23.6* 85 27.5 32.4 17.4* 309 Import Result [**2147-5-30**] 03:04AM 6.6 2.64* 7.2* 22.7* 86 27.1 31.5 17.3* 273 Import Result [**2147-5-29**] 03:39PM 23.2* Import Result [**2147-5-29**] 03:28AM 5.5 2.53* 6.9* 21.8* 86 27.1 31.5 17.4* 292 Import Result [**2147-5-28**] 03:45AM 7.1 2.81* 7.6* 24.0* 85 27.0 31.6 17.3* 307 Import Result [**2147-5-27**] 03:37AM 7.8 2.90* 8.0* 25.1* 87 27.7 32.0 16.7* 270 Import Result [**2147-5-26**] 02:15AM 8.4 2.77* 7.5* 23.8* 86 26.9* 31.3 17.4* 265 Import Result [**2147-5-25**] 02:00AM 8.4 2.48* 6.8* 21.4* 86 27.3 31.6 17.2* 238 Import Result [**2147-5-24**] 02:07AM 10.1 2.64* 7.2* 22.6* 86 27.3 31.9 17.5* 231 Import Result [**2147-5-23**] 02:23PM 22.9* Import Result [**2147-5-23**] 01:43AM 10.6 2.48* 6.9* 21.4* 86 27.7 32.0 17.2* 198 Import Result [**2147-5-22**] 05:02PM 24.1* Import Result [**2147-5-22**] 02:38PM 25.2* Import Result [**2147-5-22**] 01:56AM 12.0* 2.81* 7.8* 23.7* 85 27.6 32.7 17.4* 221 Import Result [**2147-5-21**] 01:30AM 13.6* 3.29* 9.0* 28.1* 85 27.4 32.2 17.7* 262 Import Result [**2147-5-20**] 02:01AM 9.8 3.02* 8.5* 26.1* 87 28.2 32.5 17.2* 215 Import Result [**2147-5-19**] 03:00AM 10.1 3.05* 8.6* 26.2* 86 28.2 32.8 17.1* 207 Import Result [**2147-5-18**] 02:49AM 7.3 2.98* 8.2* 25.1* 84 27.4 32.6 17.6* 168 Import Result [**2147-5-17**] 02:01AM 9.7 3.09* 8.7* 26.3* 85 28.1 33.0 17.4* 154 Import Result [**2147-5-16**] 03:09AM 7.1 3.05* 8.4* 26.4* 87 27.5 31.8 17.3* 170 Import Result [**2147-5-15**] 02:08AM 13.4* 3.30* 9.1* 29.2* 88 27.7 31.4 17.5* 196 Import Result [**2147-5-14**] 02:22AM 20.4*# 3.58* 9.9* 30.6* 86 27.6 32.2 17.9* 216 Import Result [**2147-5-13**] 02:14AM 11.4* 3.27* 9.1* 28.3* 87 27.9 32.3 17.5* 200 Import Result [**2147-5-12**] 08:15PM 28.1* Import Result [**2147-5-12**] 04:24PM 27.3* Import Result [**2147-5-12**] 12:08PM 25.6* Import Result [**2147-5-12**] 02:05AM 8.1 3.23* 8.8* 27.7* 86 27.3 31.9 17.1* 167 Import Result [**2147-5-11**] 02:15PM 10.3 4.14* 11.6* 35.1* 85 28.0 33.1 17.5* 223 Import Result DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2147-5-17**] 02:01AM 92.5* 0 3.7* 3.7 0.2 0 Import Result [**2147-5-11**] 02:15PM 84.3* 10.9* 3.5 0.8 0.4 Import Result RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [**2147-5-17**] 02:01AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL Import Result [**2147-5-11**] 02:15PM 1+ 1+ 1+ 1+ Import Result BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2147-6-8**] 02:25AM 312 Import Result [**2147-6-8**] 02:25AM 12.4 46.5* 1.1 Import Result [**2147-6-7**] 08:16PM 11.6 28.2 1.0 Import Result [**2147-6-7**] 03:08AM 332 Import Result [**2147-6-6**] 03:42AM 361 Import Result [**2147-6-6**] 03:42AM 11.9 34.7 1.0 Import Result [**2147-6-5**] 04:09AM 352 Import Result [**2147-6-5**] 04:09AM 11.8 30.8 1.0 Import Result [**2147-6-4**] 02:00AM 351 Import Result [**2147-6-3**] 03:14AM 343 Import Result [**2147-6-2**] 02:06AM 339 Import Result [**2147-6-1**] 08:27AM 316 Import Result [**2147-5-31**] 02:58AM 262 Import Result [**2147-5-30**] 04:11PM 309 Import Result [**2147-5-30**] 03:04AM 273 Import Result [**2147-5-29**] 03:28AM 292 Import Result [**2147-5-28**] 03:45AM 307 Import Result [**2147-5-27**] 03:37AM 270 Import Result [**2147-5-26**] 02:15AM 265 Import Result [**2147-5-25**] 02:00AM 238 Import Result [**2147-5-24**] 02:07AM 231 Import Result [**2147-5-23**] 01:43AM 198 Import Result [**2147-5-22**] 01:56AM 221 Import Result [**2147-5-21**] 01:30AM 262 Import Result [**2147-5-20**] 02:01AM 215 Import Result [**2147-5-19**] 03:00AM 207 Import Result [**2147-5-18**] 02:49AM 168 Import Result [**2147-5-17**] 02:01AM NORMAL 154 Import Result [**2147-5-16**] 03:09AM 170 Import Result [**2147-5-15**] 02:08AM 196 Import Result [**2147-5-14**] 02:22AM 216 Import Result [**2147-5-13**] 02:14AM 200 Import Result [**2147-5-12**] 02:05AM 167 Import Result [**2147-5-12**] 02:05AM 13.6* 28.0 1.2* Import Result [**2147-5-11**] 03:15PM 12.8 25.6 1.1 Import Result [**2147-5-11**] 02:15PM 223 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2147-6-8**] 02:25AM 118* 98* 2.5* 139 3.7 98 30 15 Import Result [**2147-6-7**] 03:08AM 112* 98* 2.5* 140 3.7 100 30 14 Import Result [**2147-6-7**] 12:26AM 131* 3.7 Import Result [**2147-6-6**] 03:42AM 115* 96* 2.6* 140 3.5 100 31 13 Import Result [**2147-6-5**] 04:09AM 136* 97* 2.6* 139 3.5 100 28 15 Import Result [**2147-6-4**] 02:00AM 158* 96* 2.7* 140 3.8 101 27 16 Import Result [**2147-6-3**] 03:14AM 139* 99* 2.9* 141 3.8 102 27 16 Import Result [**2147-6-2**] 02:06AM 146* 98* 3.0* 141 4.2 102 25 18 Import Result [**2147-6-1**] 02:44AM 148* 94* 3.0* 142 3.9 105 25 16 Import Result [**2147-5-31**] 02:58AM 126* 96* 3.1* 144 4.4 108 27 13 Import Result [**2147-5-30**] 04:11PM 121* 95* 3.1* 147* 4.3 110* 26 15 Import Result [**2147-5-30**] 03:04AM 149* 95* 3.2* 146* 4.3 110* 26 14 Import Result [**2147-5-29**] 03:39PM 129* 93* 3.2* 149* 3.2* 110* 26 16 Import Result [**2147-5-29**] 03:28AM 145* 90* 3.3* 150* 3.2* 112* 27 14 Import Result [**2147-5-28**] 03:45AM 149* 88* 3.2* 149* 3.4 113* 26 13 Import Result [**2147-5-27**] 03:37AM 158* 89* 3.3* 147* 3.9 112* 23 16 Import Result [**2147-5-26**] 02:15AM 86 90* 3.2* 147* 3.8 112* 23 16 Import Result [**2147-5-25**] 02:00AM 107* 90* 3.3* 146* 3.6 114* 20* 16 Import Result [**2147-5-24**] 02:07AM 102 98* 3.5* 146* 3.9 112* 21* 17 Import Result [**2147-5-23**] 01:43AM 77 102* 3.6* 144 4.1 109* 21* 18 Import Result [**2147-5-22**] 05:02PM 4.4 Import Result [**2147-5-22**] 01:56AM 100 106* 3.9* 143 4.5 108 24 16 Import Result [**2147-5-21**] 01:30AM 141* 96* 3.7* 143 4.3 108 21* 18 Import Result [**2147-5-20**] 02:01AM 94 81* 3.4* 143 4.2 112* 21* 14 Import Result [**2147-5-19**] 03:00AM 137* 80* 3.5* 144 4.1 112* 20* 16 Import Result [**2147-5-18**] 02:49AM 158* 75* 3.5* 141 4.1 110* 18* 17 Import Result [**2147-5-17**] 02:01AM 104 71* 3.5* 141 4.1 112* 18* 15 Import Result [**2147-5-16**] 03:09AM 97 67* 3.2* 141 3.9 110* 16* 19 Import Result [**2147-5-15**] 02:08AM 240* 65* 3.3* 141 4.3 110* 18* 17 Import Result [**2147-5-14**] 02:22AM 136* 57* 3.1* 148* 4.5 115* 15* 23* Import Result [**2147-5-13**] 02:14AM 197* 50* 3.0* 143 3.9 112* 16* 19 Import Result [**2147-5-12**] 02:05AM 177* 44* 2.2* 143 3.7 116* 15* 16 Import Result [**2147-5-11**] 02:15PM 147* 51* 2.6* 142 4.0 110* 17* 19 Import Result ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2147-5-12**] 02:05AM 206* Import Result [**2147-5-11**] 02:15PM 249* Import Result CPK ISOENZYMES CK-MB cTropnT [**2147-5-12**] 02:05AM 8 <0.01 Import Result [**2147-5-11**] 02:15PM 9 0.02* Import Result CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2147-6-8**] 02:25AM 7.5* 3.5 2.0 Import Result [**2147-6-7**] 03:08AM 7.5* 3.5 2.1 Import Result [**2147-6-7**] 12:26AM 2.1 Import Result [**2147-6-6**] 03:42AM 7.9* 3.5 2.1 Import Result [**2147-6-5**] 04:09AM 7.8* 3.9 2.1 Import Result [**2147-6-4**] 02:00AM 8.0* 3.9 2.2 Import Result [**2147-6-3**] 03:14AM 7.8* 4.2 2.1 Import Result [**2147-6-2**] 02:06AM 7.5* 4.3 2.2 Import Result [**2147-6-1**] 02:44AM 7.4* 4.1 2.2 Import Result [**2147-5-31**] 02:58AM 7.5* 3.9 2.2 Import Result [**2147-5-30**] 04:11PM 7.7* 3.4 2.3 Import Result [**2147-5-30**] 03:04AM 7.6* 3.3 2.3 Import Result [**2147-5-29**] 03:39PM 7.1* 3.6 1.8 Import Result [**2147-5-29**] 03:28AM 7.3* 4.0 1.9 Import Result [**2147-5-28**] 03:45AM 7.5* 3.8 2.0 Import Result [**2147-5-27**] 03:37AM 7.9* 5.1* 2.2 Import Result [**2147-5-26**] 02:15AM 7.9* 5.2* 2.2 Import Result [**2147-5-25**] 02:00AM 7.2* 5.2* 2.2 Import Result [**2147-5-24**] 02:07AM 7.4* 5.8* 2.4 Import Result [**2147-5-23**] 01:43AM 6.9* 6.0* 2.4 Import Result [**2147-5-22**] 05:02PM 6.0* 2.4 Import Result [**2147-5-22**] 01:56AM 2.3* 7.6* 5.8* 2.5 8* Import Result [**2147-5-21**] 01:30AM 7.8* 5.1* 2.4 Import Result [**2147-5-20**] 02:01AM 7.2* 4.4 2.4 Import Result [**2147-5-19**] 03:00AM 7.4* 4.7* 2.5 Import Result [**2147-5-18**] 02:49AM 7.6* 5.1* 2.4 Import Result [**2147-5-17**] 02:01AM 7.6* 5.0* 2.3 Import Result [**2147-5-16**] 09:04AM 69 Import Result [**2147-5-16**] 03:09AM 6.9* 4.3# 2.2 Import Result [**2147-5-15**] 02:08AM 7.5* 6.6* 2.4 Import Result [**2147-5-14**] 02:22AM 2.9* 7.3* 7.0* 1.9 Import Result [**2147-5-13**] 02:14AM 2.8* 7.0* 7.4*# 2.0 Import Result [**2147-5-12**] 02:05AM 6.8* 4.7* 2.2 Import Result [**2147-5-11**] 02:15PM 7.9* 4.4 1.5* Import Result HEMATOLOGIC calTIBC Ferritn TRF [**2147-5-22**] 01:56AM 181* 139* Import Result [**2147-5-16**] 09:04AM 229* 30 176* Import Result LIPID/CHOLESTEROL Triglyc [**2147-5-22**] 01:56AM 228* Import Result PITUITARY TSH [**2147-6-7**] 03:08AM 68* Import Result [**2147-6-2**] 02:06AM 47* Import Result [**2147-5-17**] 02:01AM 16* Import Result THYROID T4 T3 PTH [**2147-6-7**] 03:08AM 2.1* 49* Import Result [**2147-5-15**] 02:08AM 158* Import Result NEUROPSYCHIATRIC Phenyto Phenyfr %Phenyf [**2147-6-1**] 02:44AM 5.6* Import Result [**2147-5-31**] 02:58AM 4.1* Import Result [**2147-5-17**] 02:01AM 9.9* Import Result [**2147-5-16**] 09:04AM 6.8* 2.0 29* Import Result [**2147-5-14**] 02:22AM 9.2* Import Result [**2147-5-13**] 02:14AM 7.5* Import Result [**2147-5-12**] 02:05AM 8.4* Import Result [**2147-5-11**] 02:15PM 6.4* Import Result TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp Barbitr Tricycl [**2147-5-11**] 02:15PM NEG NEG NEG NEG NEG NEG Import Result LAB USE ONLY GreenHd HoldBLu RedHold [**2147-6-7**] 02:42PM HOLD Import Result [**2147-5-22**] 09:52PM HOLD Import Result [**2147-5-11**] 02:15PM HOLD Import Result Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calHCO3 Base XS Intubat Vent [**2147-6-2**] 05:07AM ART 37.1 5 140* 39 7.43 27 2 INTUBATED Import Result [**2147-6-2**] 02:33AM ART 37.0 5 355* 36 7.47* 27 3 INTUBATED Import Result [**2147-5-30**] 08:42AM ART 169* 43 7.42 29 3 Import Result [**2147-5-28**] 03:52AM ART 138* 49* 7.38 30 3 Import Result [**2147-5-27**] 04:03AM ART 151* 48* 7.29* 24 -3 Import Result [**2147-5-26**] 06:20PM ART 35.6 /14 350 5 30 110* 46* 7.28* 23 -4 INTUBATED IMV Import Result [**2147-5-26**] 05:45PM ART 35.7 /14 330 5 30 114* 46* 7.29* 23 -4 INTUBATED Import Result [**2147-5-22**] 02:08AM ART 117* 47* 7.35 27 0 Import Result [**2147-5-21**] 01:33AM ART 119* 42 7.36 25 -1 Import Result [**2147-5-19**] 10:35AM ART 130* 44 7.30* 23 -4 Import Result [**2147-5-18**] 03:21AM ART 133* 33* 7.40 21 -2 Import Result [**2147-5-17**] 10:23PM ART 132* 34* 7.36 20* -5 Import Result [**2147-5-17**] 08:45PM ART 143* 37 7.31* 20* -6 Import Result [**2147-5-17**] 01:05PM ART 135* 38 7.33* 21 -5 Import Result [**2147-5-17**] 02:13AM ART 37.7 12/ 500 5 30 127* 35 7.35 20* -5 ASSIST/CON INTUBATED Import Result [**2147-5-16**] 09:18PM ART 116* 34* 7.35 20* -5 Import Result [**2147-5-16**] 05:45PM ART 36.9 12/ 490 5 30 140* 32* 7.37 19* -5 ASSIST/CON INTUBATED Import Result [**2147-5-16**] 04:10PM ART 36.3 12/ 480 5 40 169* 28* 7.37 17* -7 ASSIST/CON INTUBATED Import Result [**2147-5-16**] 10:55AM ART 36.7 /9 490 5 40 158* 36 7.29* 18* -8 INTUBATED SPONTANEOU Import Result [**2147-5-16**] 09:23AM ART 36.7 /14 300 40 174* 38 7.28* 19* -7 Import Result [**2147-5-16**] 03:27AM ART 142* 34* 7.37 20* -4 Import Result [**2147-5-15**] 07:34PM ART 149* 30* 7.36 18* -6 Import Result [**2147-5-15**] 02:19AM ART 36.1 /19 330 5 50 198* 42 7.28* 21 -6 INTUBATED SPONTANEOU Import Result [**2147-5-14**] 11:09AM ART 195* 35 7.28* 17* -9 Import Result [**2147-5-14**] 02:42AM ART /16 400 5 50 208* 37 7.30* 19* -7 INTUBATED SPONTANEOU Import Result [**2147-5-13**] 03:41PM ART 36.8 5 50 95 34* 7.33* 19* -6 INTUBATED Import Result [**2147-5-13**] 06:02AM ART 153* 36 7.32* 19* -6 Import Result [**2147-5-13**] 02:25AM ART 195* 34* 7.34* 19* -6 Import Result [**2147-5-12**] 08:26PM ART 186* 35 7.33* 19* -6 Import Result [**2147-5-12**] 12:33PM ART 37.9 172* 35 7.36 21 -4 Import Result [**2147-5-12**] 06:06AM ART 36.5 12/ 500 5 35 144* 31* 7.41 20* -3 ASSIST/CON INTUBATED Import Result [**2147-5-12**] 02:31AM ART 36.1 12/ 500 5 35 158* 33* 7.31* 17* -8 ASSIST/CON INTUBATED Import Result [**2147-5-12**] 12:07AM ART 36.1 [**12-17**] 500 50 211* 29* 7.34* 16* -8 ASSIST/CON INTUBATED Import Result WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K [**2147-5-26**] 05:45PM 73 0.8 Import Result [**2147-5-22**] 02:08AM 105 0.8 Import Result [**2147-5-21**] 01:33AM 144* Import Result [**2147-5-19**] 10:35AM 188* Import Result [**2147-5-16**] 09:18PM 91 Import Result [**2147-5-16**] 05:45PM 93 Import Result [**2147-5-16**] 04:10PM 94 Import Result [**2147-5-16**] 10:55AM 99 Import Result [**2147-5-16**] 09:23AM 102 Import Result [**2147-5-16**] 03:27AM 107* Import Result [**2147-5-15**] 07:34PM 129* 1.4 Import Result [**2147-5-14**] 11:09AM 137* Import Result [**2147-5-13**] 03:41PM 112* Import Result [**2147-5-13**] 06:02AM 133* Import Result [**2147-5-12**] 08:26PM 194* 0.8 143 4.1 Import Result [**2147-5-12**] 12:33PM 142* Import Result [**2147-5-12**] 02:31AM 0.9 Import Result HEMOGLOBLIN FRACTIONS ( COOXIMETRY) O2 Sat [**2147-5-28**] 03:52AM 96 Import Result [**2147-5-16**] 09:18PM 97 Import Result [**2147-5-15**] 02:19AM 97 Import Result [**2147-5-12**] 02:31AM 96 Import Result [**2147-5-12**] 12:07AM 98 Import Result CALCIUM freeCa [**2147-6-2**] 02:33AM 0.95* Import Result [**2147-5-30**] 08:42AM 1.08* Import Result [**2147-5-28**] 03:52AM 1.10* Import Result [**2147-5-27**] 04:03AM 1.07* Import Result [**2147-5-26**] 05:45PM 1.09* Import Result [**2147-5-22**] 02:08AM 1.11* Import Result [**2147-5-21**] 01:33AM 1.15 Import Result [**2147-5-19**] 10:35AM 1.08* Import Result [**2147-5-17**] 02:13AM 1.13 Import Result [**2147-5-16**] 03:27AM 1.10* Import Result [**2147-5-15**] 07:34PM 1.03* Import Result [**2147-5-15**] 02:19AM 1.06* Import Result [**2147-5-14**] 11:09AM 1.13 Import Result [**2147-5-14**] 02:42AM 1.09* Import Result [**2147-5-13**] 03:41PM 1.04* Import Result [**2147-5-13**] 02:25AM 1.05* Import Result [**2147-5-12**] 08:26PM 1.07* Import Result [**2147-5-12**] 06:06AM 1.04* Import Result [**2147-5-12**] 02:31AM 1.05* Import Result [**2147-5-12**] 12:07AM 0.95* Import Result Miscellaneous PREALBUMIN [**2147-5-22**] 01:56AM Test Import Result Brief Hospital Course: Injury C-spine [**2-18**] and T-spine 4 fracture . Patiemt was fused by Dr [**Last Name (STitle) 363**], after that she remained stable. The desitionn to perform a tracheosty and gastrostomy was made and corroborated with the family and health proxy.After the gastric tube was placed percutaneously tube feeding could not be advance due to increased residuals then a ct scan of the abdomen was done: [**5-22**] CT [**Last Name (un) 103**]: free air. RE: Pt had g tube placed after pt not tolerating TF tru GT, so ct scan done showed free air wich is a normal finding after this procedure. Since pt failed several attempts to be feed by gt [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1372**] jejunal tube was placed for feeding and, was able to be advanced. Previous studies: [**5-21**] KUB: Increased Intra-abd air [**5-17**] CXR: free air in abdomen unchanged [**5-16**] gastric contrast: no extravasation Summary of radiology studies: [**5-11**] R knee: no fx, effusion+, CT torso: T4 vertebral body fx, CT c-spine: C2 post vertebral body fxs, traverses B neural foramina, C3 spinous process fx, widening of the C2-3 anterior disc space with grade 1 retrolisthesis at C5 and C5-6 MRI spine: cord edema c1-c3, vessels intact, spinal cord stenosis at c3, likely secondary to djd [**6-4**] CXR: increased L effusion, stable retrocardiac effusion; [**5-31**] CT Head: no ICH; [**5-30**] CXR: bilat effusions, intra-abd air; [**5-28**] KUB: Stable intra abdominal air. [**5-22**] CT [**Last Name (un) 103**]: free air; [**5-21**] KUB: Increased Intra-abd air; [**5-17**] CXR: free air in abdomen unchanged; [**5-16**] gastric contrast: no extravasation; [**5-15**] CXR: Free air in Abd; [**5-11**] MRA neck: no stenosis, aneurysm, R knee: no fx, effusion+, CT torso: T4 vertebral body fx, CT c-spine: C2 post vertebral body fxs, traverses B neural foramina, C3 spinous process fx, widening of the C2-3 anterior disc space with grade 1 retrolisthesis at C5 and C5-6, MRI spine: cord edema c1-c3, vessels intact, spinal cord stenosis at c3, likely secondary to djd EEG: no epileptiform activity, ? widespread encephalopathy Drips: none Abx: none Events for the last 24 hours: Transfused RBC on [**6-6**], Hcts stable despite guaic + stools, case management-- has bed at [**Hospital1 **] AND [**Hospital1 **] on [**6-8**] . Procedures [**5-13**] Trach /PEG [**5-15**] Halo [**5-16**] IVC filter . MICRO [**5-29**] MRSA: neg, [**5-29**] VRE: neg [**5-21**] urine: yeast 10-[**Numeric Identifier 4856**] [**5-14**] sputum: GPC, [**5-12**] urine: enterococcus sp. LAST Psy recs; ROS: Discomfort in back. Quadriplegic. Vent dependent. O/w all sx's negative. O/VS: Tmax 98.8 HR 74 BP 150/44 O2 100% MSE: Sitting in chair c halo. Speech soft, but clear through voice trach. Thought process: Paucity of content. No overt hallucinosis or delusional thought content. Mood "good" Affect somewhat withdrawn. Denies SI/HI. COGNITIVE: A&O to person, "[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital" and "[**347-6-1**]" WORLD forward intact. WORLD bkwds DLOROW Labs: WBC 7 Hct 23.5 Plt 339 Na 141 K 4.2 Cl 102 HCO3 25 BUN 98 Cr 3 Glc 146 Ca 7.5 Mg 2.2 Phos 4.3 TSH 47 EEG: [**5-21**] hertz theta background rhythm. Focal [**2-17**] hertz delta slowing in left fronto-temporal region. Imp: 76y/o female s/p C2/C3 frx and resultant complete quadriplegia and vent-dependence. Continued improvement in delirium. For now, plan is to pursue vent rehab. Plan: 1) D/C ambien (deliriogenic). Would use olanzapine as PRN for insomnia. 2) D/C metoclopromide -- often causes akathisia which could contribute to general sense of discomfort which may be difficult to detect given paralysis. 3) Check full thyroid panel and replete given hypothyroidism. Low thyroid may contribute to delirium. Send today to rehab recs followed Medications on Admission: atenolol 50'', verapamil ER 240', lasix 40 qMo/Fr, prevacid 30', dilantin 100/200, sodiumbicarb 650" . Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 4. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 8. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO Q8H (every 8 hours). 9. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 10. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed. 11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Lansoprazole 30 mg Recon Soln Sig: One (1) Intravenous DAILY (Daily). 16. Hydroxyzine HCl 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for itching. 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 18. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 20. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed. 21. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: C-spine [**2-18**] and T-spine 4 fracture Discharge Condition: self feeding Discharge Instructions: Physcal Therapy as needed Followup Instructions: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] [**Hospital Ward Name 23**] ([**Telephone/Fax (1) 11061**] [**Hospital Ward Name 23**] 2 Orthopedics [**Hospital1 18**] 2 weeks Completed by:[**2147-6-8**]

[ "V45.73", "518.5", "599.0", "293.0", "V10.00", "401.9", "584.9", "806.00", "805.2", "805.04", "E884.9", "850.11", "780.39" ]

icd9cm

[ [ [] ] ]

[ "02.94", "99.04", "93.41", "43.11", "38.7", "96.6", "31.1", "88.79", "96.72", "96.04", "38.91" ]

icd9pcs

[ [ [] ] ]

24929, 25029

19121, 20495

613, 773

25115, 25129

1194, 19098

25203, 25435

23124, 24906

25050, 25094

22996, 23101

25153, 25180

1088, 1172

272, 575

801, 929

20504, 22970

951, 1073

29,020

167,786

48941+59124

Discharge summary

report+addendum

Admission Date: [**2159-1-26**] Discharge Date: [**2159-2-1**] Date of Birth: [**2099-11-12**] Sex: F Service: MEDICINE Allergies: Prednisone Attending:[**First Name3 (LF) 348**] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: 59yo woman with 30 year history of multiple sclerosis presents after fall in her bathroom [**1-26**] (the night prior to admission). She reports slipping on the water that had dropped on the tile while brushing her teeth. She denies palpitations, chest pain, or lightheadedness prior to her fall. She hit her right orbit and her chin upon falling, then spent about 12 hours trying to get up. Eventually, a neighbor walked by and she managed to call out and get her attention. She initially presented to an OSH, where she was found to have a small subarachnoid hemorrhage on head CT, prompting transfer to [**Hospital1 18**]. Vitals on presentation to [**Hospital1 18**] ED were: 98.2 93/62 92 16 98% RA. Repeat head CT showed a small SAH in the left frontal lobe; no evidence of midline shift or mass effect. Neurosurgery was consulted, and felt that there was no acute neurosurgical issue, so they signed off. She was given 4L of normal saline per their records, but unclear how much she absorbed. On review of systems, she denies recent illness or flare of her MS, fevers, palpitations, chest pain, headache, dyspnea, dysuria, or loss of consciousness. She does note that her right arm and both legs (R>L) are weak at baseline and that she sometimes has constipation or frequent stools from her MS. She does c/o back pain, knee pain, and elbow pain from where she hit the floor and abdominal pain from using her muscles to try to get up. She reports falling 3 times in the last year, but never as seriously as this. Past Medical History: Multiple sclerosis since her late 20s; followed by Dr. [**Last Name (STitle) 31464**] from "[**Street Address(2) 3375**]" Social History: She lives alone in [**Hospital1 392**]. Uses a cane about 90% of the time; has a walker if she needs it. Walks barefoot at home b/c she feels she is more stable that way. Has 4 other apartments in the building. + tobacco [**1-31**] to 1 PPD x 40 years, quit drinking in her 30s; denies illicit drug use. No pets. She does not have a life alert. Family History: No MS. Mother died of "bone cancer" Physical Exam: 99.2 107/69 98 22 97% RA Pleasant woman with bruised face lying in bed, NAD. Ecchymosis over right orbit and chin. No conjunctival injection. Right eye somewhat swollen, creating ptosis. PERRL; Vertical nystagmus, especially of right eye. Right eye stays midline with extreme right gaze--+INO on R Left face decreased movement with showing teeth. Palate raised equally, tongue midline. Mucous membranes dry, OP clear. Neck supple S1, S2, tachycardic and regular, no murmur. Lungs clear b/l Abdomen soft, NT, ND. Ext: Bruising and redness of both knees; area inferior to right knee somewhat erythematous and warm to touch; +RLE edema; DP easier to palpate on left than right Skin: multiple bruises and abrasions, particularly of knees and feet Neuro: Alert and oriented x 3. CN exam as above. Strength 5-/5 in LUE proximal and distal. 4-/5 in proximal RUE and 4+/5 in distal RUE. Says she cannot move her proximal LE b/l because of weakness and pain. Strength 5/5 in distal LE b/l. Sensation intact to cold and light touch in face and UE b/l. Decreased sensation to light touch and to cold and vibration in RLE as compared with left. Pertinent Results: Labs on admission: WBC 21.1 (82% N), Hct 39.6, Plt 363 K 4.8, Cr 0.9, Glucose 142 Coags not drawn in ED CK 5973 -> 4440 MB 84 -> 41 MBI 1.4 -> 0.9 Trop 1.07 -> 0.89 UA: leuk neg, nitr neg, mod blood, mod bact UCx pending EKG (no baseline available): ED: Sinus tachycardia with normal axis and intervals. Flat T waves in inferolateral leads. ? ST depression in V2-V4. Upon arrival in MICU: NSR, flat T waves in inferolateral leads, ST depressions in V3 and V4. Imaging on admission: CXR [**1-27**]: The lungs are mildly hyperinflated. There is mild cardiomegaly. The lateral view raises the possibility of an infiltrate in the lower lobe posteriorly. However, no focal infiltrate is detected on the frontal view. There is upper zone redistribution, without overt CHF. No frank consolidation or effusion is identified. CT Head without contrast [**1-27**]: A small focus of high attenuation is seen in the left frontal lobe sulcus, most suggestive of trace subarachnoid blood. No hemorrhage is identified elsewhere. There is no hydrocephalus, mass effect or shift of normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved. No major vascular territorial infarct is apparent. The visualized paranasal sinuses and mastoid air cells remain normally aerated. No fracture is identified. Brief Hospital Course: 59 yo woman with h/o multiple sclerosis and multiple falls presents with mechanical fall, on ground x 12 hours. Most likely mechanical in setting of weakness from chronic progressive MS. [**Name13 (STitle) 15110**] to the injury her CK was elevated with peak of 5500 for which she received IV fluids with normal urine output and kidney function. Potassium, Calcium and phosphate were low during the course and needed to be repleted. She also had a difficult to explain elevation of troponin without cardiac symptoms or EKG findings. She was monitored on telemetry overnight for evidence of arrhythmias, which she did not have. She was found to have a small subarachnoid bleed, for which neurosurgery was consulted. Bleed remained stable and no intervention was thought to be necessary. Her neuro exam remained at baseline and unchanged. . Leukocytosis: Most likely secondary to stress of fall, but infectious processes also thought to be possible. She did not have a fever but developed some low grade temperature, without any symptoms. UA and blood culture remained negative, and CXR suggestive of possible infiltrate, but no symptoms of pneumonia. With regard to her MS she was treated with prednisone in the past which she did not tolerate. She currently is not on any medication, which has been confirmed by her [**Name13 (STitle) 850**] Dr. [**Last Name (STitle) 31464**]. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Chronic progressive Multiple Sclerosis Subarachnoidal hemorrhage Rhabdomiolysis Electrolyte abnormalities Discharge Condition: Good Discharge Instructions: You were admitted after fall at home and were found to have small amount of bleed in you head, which is of no concern. You also had severely injured your muscles and were dehydrated, however you received intra venous fluids and your hospital course remained uncomlicated. Followup Instructions: Please follow up with Your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 850**] Dr. [**Last Name (STitle) 31464**] in 2 to 3 weeks Name: [**Known lastname 7020**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 16596**] Admission Date: [**2159-1-26**] Discharge Date: [**2159-2-1**] Date of Birth: [**2099-11-12**] Sex: F Service: MEDICINE Allergies: Prednisone Attending:[**First Name3 (LF) 1775**] Addendum: On the day of her discharge Ms. [**Known lastname **] was found to have a UTI, for which she was started on Cipro 500mg daily for 3 days. She also complaine of urinary retention, which was thought to be multifactorial due to recent foley in the setting of MS, opioids, and UTI. She was straight cathed once for a bladder volume of one liter. Her urinary function will need to monitored in rehab. Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **] [**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**] Completed by:[**2159-2-1**]

[ "078.19", "599.0", "285.9", "728.88", "276.51", "E885.9", "852.01", "788.20", "564.00", "340", "788.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8030, 8285

4976, 6360

275, 282

6781, 6788

3605, 3610

7108, 8007

2378, 2416

6415, 6511

6652, 6760

6386, 6392

6812, 7085

2431, 3586

231, 237

310, 1848

4100, 4953

1870, 1994

2010, 2362

4,904

169,215

50337

Discharge summary

report

Admission Date: [**2193-6-8**] Discharge Date: [**2193-7-4**] Date of Birth: [**2126-2-17**] Sex: F Service: NEUROLOGY Allergies: Dilantin Attending:[**First Name3 (LF) 11344**] Chief Complaint: Mental status changes. Major Surgical or Invasive Procedure: Lumbar puncture. History of Present Illness: 67 yo woman with history of atypical meningioma in [**11-21**], s/p resection and then XRT which was complete in [**2-22**]. Her family says that prior to her tumor resection pt had significant cognitive dysfunction and inattention, most of which resolved after resection. For the past few months she has been improving significantly with regards to her mental status. Was able to take care of her own ADL's and had an improvement in her overall affect. Then [**Name (NI) 1017**], sister says that patient had to suddenly go to the bathroom, and she ran into the bathroom to urinate. When she came out she just was not herself. She seemed more detached and distant. No LOC. No seizure-like activity. Then Monday am had bowel incontinence, when asked about it she did not know that it had happened. Since then she has been a little more fatigued, less active. On Wednesday had worsening of her prior tremors in her arms and mouth. She also became unable to feed herself b/c seemed confused about the food. She had one witnessed mechanical fall, had difficulty getting herself up. No LOC or incontinence with the fall. She was seen in [**Hospital **] clinic this am and there was concern about her deterioration in mental status and therefore she was sent to ED for further workup. . ROS: no fever, cough, diarrhea, vomiting, recent illness, head trauma. no focal weakness or sensory loss. no headache or visual changes. has been taking her trileptal consistently. Past Medical History: thyroidectomy for cancer [**2183-8-29**]; uterine and transverse colon polypectomy for adenoma [**2183**]; basal cell carcinoma nasal bridge and left lower lip [**2188**]; GERD, hypothyroidism, hypertension. Social History: Lives with her husband and daughter, no ETOH or tobacco. Sister very much involved with her care. Family History: Not obtained Physical Exam: Exam upon admission . Vitals: T 100.3, HR 93, BP 168/90, RR 18 98% room air . Gen: smiling, in no distress but overall unwell appearing. HEENT: mmm, OP benign Neck: supple CV: heart RRR no m/r/g Resp: CTA B to bases Abd: soft, NT/ND Ext: warm, well perfused Skin: no rash but some statis changes in her ankles . MS: Very distant, makes intermittnet eye contact and inappropriately smiles, disinhibited and child-like. Awake, oriented to person and month, not year, not place. Unable to do MOYB. Can count to 10. Able to follow simple commands midline and appendicular. Very perseverative with commands, repeats prior commands when the next command is given. Intact to repetition, naming impaired. Able to read. Difficulty writing. More detailed frontal lobe testing difficult due to inattention. . CN: PERRLA, VFFTC, optic disks sharp, no papilledema or hemorrhages. EOMI. no ptosis. Difficult to determine sensation in face. Masseters strong symmetrically. Corneal reflex present. Face symmetric without weakness. Hears finger rub bilaterally. Voice normal, palate symmetric, gag intact. [**6-21**] SS bilaterally. Tongue midline, no atrophy or fasciculation. Tremor of mouth very notable. . Motor: Nl bulk and tone, resting and action tremor R>L, and in jaw. No pronator drift. Strength is roughly [**6-21**] throughout but pt has give-way weakness and will not hold attention to full formal strength testing. . Reflexes: [**Hospital1 **] Tri BR Pat Ach Plantar L 1 1 1 1 1 down R 1 1 1 1 1 down . [**Last Name (un) **]: difficult due to inattention. . Coord: no dysmetria on FNF. Gait not tested. Pertinent Results: [**2193-6-7**] 05:30PM BLOOD WBC-5.4 RBC-4.29 Hgb-13.5 Hct-39.8 MCV-93 MCH-31.4 MCHC-33.9 RDW-14.3 Plt Ct-284 [**2193-6-7**] 05:30PM BLOOD Neuts-59.2 Lymphs-31.0 Monos-6.0 Eos-2.2 Baso-1.6 [**2193-6-8**] 06:30AM BLOOD PT-12.4 PTT-22.9 INR(PT)-1.1 [**2193-6-10**] 03:15PM BLOOD D-Dimer-612* [**2193-6-10**] 03:15PM BLOOD ESR-8 [**2193-6-7**] 05:30PM BLOOD Glucose-136* UreaN-16 Creat-0.7 Na-146* K-3.6 Cl-106 HCO3-28 AnGap-16 [**2193-6-8**] 06:30AM BLOOD ALT-14 AST-13 LD(LDH)-163 AlkPhos-101 TotBili-0.3 [**2193-6-7**] 05:30PM BLOOD Calcium-9.3 Phos-4.1 Mg-1.9 [**2193-6-7**] 05:30PM BLOOD TSH-1.1 [**2193-6-7**] 05:30PM BLOOD T4-9.5 [**2193-6-10**] 03:15PM BLOOD CRP-3.4 [**2193-6-8**] 06:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2193-6-7**] 05:30PM BLOOD Carbamz-<1.0* [**2193-6-7**] 07:14PM BLOOD Lactate-1.2 [**2193-6-7**] 09:17PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019 [**2193-6-7**] 09:17PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2193-6-8**] 05:36PM URINE RBC-0 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [**2193-6-8**] 05:36PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2193-6-8**] 12:00AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-8* Polys-2 Lymphs-54 Monos-44 [**2193-6-8**] 12:00AM CEREBROSPINAL FLUID (CSF) TotProt-64* Glucose-83 BCx ntd CSF Cx NTD --- CXR neg --- Head CT:Postoperative changes seen in the left frontal lobe are stable. Periventricular white matter hypodensity likely represents chronic small vessel infarction. No evidence of new hemorrhage. --- Head MRI:IMPRESSION: No significant interval change since the previous study of [**2193-4-8**]. Craniotomy is seen in the left frontal region with encephalomalacia in the left frontal lobe. Changes of small vessel disease are noted. No acute infarcts, mass effect, or midline shift. No enhancing lesions. --- EEG [**6-25**]:This is an abnormal portable EEG obtained in wakefulness due to the presence of continuous [**2-18**] Hz delta frequency slowing intermixed with slow theta frequency slowing over the left frontal temporal region with intermixed sharp features. This finding suggests a subcortical dysfunction over the entire left frontal temporal region and anatomic correlation is recommended. There were no clear epileptiform discharges recorded. . EEG [**6-26**]: IMPRESSION: This 24 hour EEG telemetry is consistent with a moderate encephalopathy. The previously seen left centroparietal discharges are considerably improved. Repeat EEG pending, preilm results: further improvement. --- LENIs neg --- ECHO cor: Conclusions: 1. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Anterior, distal septal, apical, and distal inferior akinesis is present. 2. The aortic valve leaflets (3) are mildly thickened. 3. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Brief Hospital Course: 67 yo woman with history of meningioma s/p resection in [**2192**] who presented with new evidence of encephalopathy with inattention as well as evidence of some frontal lobe dysfunction (perseveration, inappropriate affect). Considerations for this included toxic/metabolic, infection, tumor recurrence, or seizure. . Upon admission, she had no metabolic or electrolyte imbalances. An infectious work-up, including CXR, UA, CBC, and LP was all normal. The LP did have 2 WBCs, so we did consider HSV encephalitis as a possibility. She had an HSV PCR sent from her CSF (negative). She was emperically treated for multiple days on acyclovir. A complication included severe nephrotoxicity (creat 6). At this point she was transferred to the unit for further management. Following hydration, her renal function returned to baseline (0.5-0.7). . A CT was unremarkable. An MRI was performed which showed no new tumor, no new white matter disease, no evidence of bleeding, or any other changes from her prior MRI. She has no enhancing lesions. No evidence of radiation induced necrosis. The patient had an EEG that showed slowing at the site of her old tumor resection with some sharp features as well. She was initially continued on Trileptal 600-300 which was her home dose. She remained intermittently confused, with a waxing and [**Doctor Last Name 688**] mental status that seemed to change fairly suddenly at times according to her family. Trileptal was increased to 600 [**Hospital1 **]. Non-convulsive status was ruled out per EEG monitoring. Repeated prolonged EEGs showed continued occipital sharp features, but an improvement over time. Further into the admission, trileptal was discontinued and her EEG improved further. No clinical seizures were noted. PLEASE NOTE THAT THE PATIENT [**Month (only) **] HAVE EPISODES WITH RHYTHMICAL MOUTH MOVEMENTS. THESE DO NOT REPRESENT SEIZURES AND DO NOT HAVE A CORRELATE ON EEG. . Her mental status changes were thought to be due to steroid taper, rather than seizures, although no clear adrenal insufficiency was present. Steroids were re-started and the patient improved. Dexamethasone should be continued at 4mg PO q12hrs. Further adjustments per brain tumor clinic. She will need a slow steroid taper, once it is decided that she can come off the steroids. Another factor that may have affected her MS is hypothyroidism (see below). Prior to discharge the patient is oriented to name, place when given several choices. She has sparse speech, and is able to follow simple commands only. She also has a R-hemi. At times she can be agitated. Neurobehavioral testing is recommended after discharge. . Endo: a. Hypothyyroidism: Continued her levoxyl. It is currently dosed iv at 125mcg daily. Once she is able to take PO reliably, she should be given 137mcg PO daily. The endocrine service has been following her. Please check TFT in weekly including free T4 and totalT3. Please do not dose Ca and levoxyl together. TSH 12, free T4 1.0, total T4 6.0, FSH 41. b. Diabetes: induced by steroids. The patient was started on ISS and ajdustments were made as per endocrine service. . CV: Her hypertension was well managed with captopril 6.25mg PO TID; upon discharge at max. 130/75. . ID: The patient's WBC was noted to be elevated. Ucx, Bcx, CSFcx and CXR were all negative. Initially she was treated with acyclovir for possible viral encephalitis (see above). While in the unit, she was emperically treated with piperacillin-tazobactam 4.5gm q8hrs, and vancomycin 1g q12hrs. These medications were discontinued on [**6-30**]. No source of infection was found. . Renal: The patient had acute renal failure (creat 6) due to acyclovir. This completely resolved after aggressive hydration. . Hypernatremia: During the admission, the patient developed hypernatremia due to a deficit in free water. This was slowly corrected via free water boluses. . FEN: Her Vit D and Ca were continued throughout. During the admission, an NGT was placed for increased aspiration risk. She passed a swallow evaluation on [**7-2**] and at that point she was started on a regular diet. . Pulm: She had some swelling in her LEs and ? of pain, so LENIs were done and negative for DVT. She also had some borderline hypoxia eith O2 sats in the low 90s. We considered PE, but her D-dimer was only mildly elevated and her hypoxia resolved. In addition, ESR/CRP were normal. . Prophylaxis included ca carbonate 500mg TID; vit D; heparin xs TID; lansoprazole; senna, colace. Medications on Admission: levoxyl 137 mcg trileptal 600-300 mg atenolol 25 mg qday calcium Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Levothyroxine 200 mcg Recon Soln Sig: One (1) Recon Soln Injection DAILY (Daily): 125mcg in daily until she takes PO's well; then change to 137mcg PO daily. 7. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): please give at least two hours apart form levothyoxin once she takes levothyroxin PO. 12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. s/p atypical meningeoma (s/p resection and radiotion) 2. encephalopathy 3. steroid induced diabetes 4. acute renal failure4 5. hypertension 6. hypothyroidism 7. hypernatremia 8. dysphagia Discharge Condition: Improving mental status, oriented to name and place, sparse spontaneous speech, limited comprehension, R-hemi Discharge Instructions: Please administer medications as insstructed. . Please check TFTs every week including free T4 and total T3 (TSH is not helpful due to her steroids), until her levels have stabilized. Please do not dose Ca and levoxyl together. Once her PO intake is stable, she can be changed from 125mcg iv levothyroxin dialy to 137mcg PO daily, with further adjustments based upon the TFTs. Followup Instructions: Please follow up at the brain tumor clinic. Provider: [**Name10 (NameIs) 5005**] [**Name8 (MD) 78783**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2193-7-29**] 10:00with Dr. [**Last Name (STitle) 104939**]. The office of Dr. [**Last Name (STitle) 4253**] with contact [**Name (NI) **] to let you know whether an MRI will be scheduled prior this appointment. . Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2193-7-24**] 11:00 . Provider: [**Name Initial (NameIs) 326**] (B) BONE DENSITOMETRY [**Name Initial (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2193-7-24**] 11:30 Completed by:[**2193-7-4**]

[ "251.8", "438.82", "486", "V10.87", "285.9", "401.9", "458.29", "584.9", "244.1", "V58.65", "E931.7", "518.81", "599.0", "348.30", "V45.3", "276.0", "E932.0", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "96.6", "03.31", "96.04", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

12741, 12820

6928, 11420

292, 311

13055, 13167

3838, 5273

13592, 14257

2169, 2183

11535, 12718

12841, 13034

11446, 11512

13191, 13569

2198, 3819

230, 254

339, 1805

5281, 6905

1827, 2037

2053, 2153

48,118

115,844

42313+58514

Discharge summary

report+addendum

Admission Date: [**2184-10-8**] Discharge Date: [**2184-10-13**] Date of Birth: [**2126-8-27**] Sex: M Service: NEUROSURGERY Allergies: IV Dye, Iodine Containing Contrast Media / myeclog cream Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: [**2184-10-8**]: Bifrontal craniotomy for tumor resection History of Present Illness: 58M with hx of HTN, HL, GERD presenting with 3-4 weeks of [**Hospital 91670**] from OSH after CT head showed new R frontal mass. He says he first began having headaches about 3-4 weeks ago. They were initially occurring [**1-11**] x per week but within the last week have been occurring daily. He does not usually get headaches so this was unusual for him. He describes the headaches as a throbbing pain over his whole head. Recently they have been present when he awakes in the morning and last all day,fluctuating somewhat in severity. He takes advil occasionally which helps somewhat. He also reports some nausea and decreased appetite when the pain is severe; has not vomited. His wife also notes some cognitive changes over the last 6-9 months including increased forgetfulness, "vagueness," just not quite acting like himself. He saw his PCP today due to the increased frequency of his headaches and was sent to [**Hospital 8641**] Hospital for a CT scan. The scan showed a large R frontal mass and he was transferred to [**Hospital1 18**] for further evaluation. Past Medical History: HTN HL GERD PVD PSH: L knee surgery Umbilical hernia repair Social History: Lives at home with wife and step daughter. [**Name (NI) 1403**] as a machinist for GE. Never smoked, drinks occasional alcohol. Denies illicits. Family History: Mother with [**Name (NI) 11964**] / renal cell carcinoma Father with stroke in 60's Sister with brain tumor - unknown what type, family says it is "deep" and inoperable so she is being monitored, asymptomatic and has been stable. Physical Exam: Upon admission The pt was awake alert and oriented with a non focal neurological exam. His headaches were controlled with oral medication. Upon discharge ************ Pertinent Results: [**2184-10-8**] PATHOLOGY [**2184-10-8**] MRI BRAIN Final Report CLINICAL HISTORY: 58-year-old man with headache. Diagnosed to have right frontal lesion on MRI. Pre-surgical mapping. COMPARISON: MRI without and with contrast dated [**2184-10-1**]. TECHNIQUE: Axial T1 and axial MP-RAGE images were obtained after administration of contrast with sagittal and coronal reconstructions. FINDINGS: Again is noted an enhancing mass in the right basifrontal region measuring 2.6 x 2.4 x 2.2 cm in craniocaudad, AP and transverse dimensions. It is associated significant perilesional edema. It causes mass effect on the surrounding brain parenchyma and the frontal [**Doctor Last Name 534**] of right lateral ventricle. A prominent vessel is noted arising from right supraclinoid internal carotid artery and reaching upto the lesion suggestive of hypervascularity of the lesion. The lesion is more likely intra-axial rather than extra-axial. There is no evidence of new enhancing lesion. The ventricles are stable in size. Brainstem and cerebellum appear normal. The visualized paranasal sinuses and mastoid air cells are clear. Orbits are unremarkable. IMPRESSION: Enhancing right basifrontal mass with surrounding perilesional edema and mass effect which is unchanged since the prior study. The lesion is more likely intra-axial rather than extra-axial. This likely represents metastasis. [**2184-10-8**] CT BRAIN Final Report INDICATION: Right frontal tumor, status post craniotomy for resection. Please evaluate for postoperative changes. TECHNIQUE: Sequential axial images were acquired through the head without administration of intravenous contrast material. COMPARISON: MR head from [**2184-10-8**], at 09:45 a.m. FINDINGS: The patient is status post frontal craniotomy with resection of a right frontal lobe lesion. There is a small quantity of hemorrhage within the resection bed. Mild pneumocephalus is seen overlying both frontal lobes. There is vasogenic edema within the right frontal lobe with associated 9 mm leftward shift of the normally midline structures (2:14), not significantly changed compared to the prior MR. There is no large volume intracranial hemorrhage. There is no evidence of acute large vascular territorial infarction. The ventricles are normal in size. Aerosolized secretions and fluid is seen within the frontal sinuses and middle and anterior ethmoidal air cells. The remainder of the visualized portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: 1. Expected postoperative changes in the right frontal lobe, status post resection of a right frontal lobe mass. 2. Persistent vasogenic edema within the right frontal lobe along with unchanged leftward shift of normally midline structures. 3. No large volume intracranial hemorrhage. 4. Minimal new pneumocephalus overlying both frontal lobes. [**2184-10-9**] MRI BRAIN Final Report EXAM: MRI brain. CLINICAL INFORMATION: Status post resection of brain tumor. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal images acquired following gadolinium. Comparison was made with the MRI of [**2184-10-8**]. FINDINGS: Since the previous study, the patient has undergone resection of right inferior frontal lobe mass. Blood products and air are seen in the region. No definite residual enhancement identified. Linear, somewhat tortuous area of enhancement indicating a vascular structure posterior to the surgical cavity is again identified, unchanged from prior study. There is dural enhancement in the region which could be postoperative in nature. The edema in the right frontal lobe is unchanged. No midline shift or hydrocephalus seen. There is no new area of restricted diffusion to suggest acute infarct. IMPRESSION: Status post resection of right inferior frontal lobe mass with blood products in the region. The enhancement at the margin of the surgical cavity is mostly meningeal and could be postoperative in nature. No definite residual parenchymal enhancement is seen. No evidence of acute infarct, mass effect, or hydrocephalus. The edema is unchanged LENIS [**2184-10-11**] - 1. Superficial thrombosis of the lesser saphenous vein of the right calf, with additional deep venous thrombosis of what is likely the gastrocnemius vein on the right. 2. No evidence of DVT in left lower extremity. Brief Hospital Course: Pt electively admitted and underwent a bifrontal craniotomy with cranialization of the frontal sinus. Plastic surgery was involved with the procedure. The pt awoke from anesthesia without complication and was extubated immediately. He was started on a 7 day course of Ancef for sinus coverage. He remained in the ICU overnight and then was transferred to step down. His post operative imaging was stable. He was seen and evaluated by PT OT. There were no events. Medicine and radiation oncology teams were [**Month/Day/Year 653**] regarding completed treatment. On [**2184-10-11**], pt had a LENIs which demonstrated a right calf DVT. Given that he had a craniotomy, it was demed that patient require a IVC filter. IR was consulted for IR IVC filter placement. Because of a clot in the IVC, a filter was not placed. He is to continue his SQH while in hospital. On [**10-13**], patient is ambulatory and voiding appropriately. Pathology results are still pending and PT has cleared patient safe to go home with PT. His IV antibiotics was changed to PO cephalexin and he will have a slow taper of his decadron. He was discharge home on [**10-13**]. He can also restart his aspirin 81mg today. Medications on Admission: brimonidine-timolol [Combigan]0.2-0.5 % Drops One (1) Ophthalmic three times a day. brinzolamide 1 % Drops, Suspension One (1) Ophthalmic three times a day. dexamethasone 2 mg Tablet Two (2) Tablet by mouth every six (6) hours. 240 Tablet(s) 2 fiorocet 1-2 tabs every six (6) hours as needed for pain. 30 0 hydrochlorothiazide12.5 mg Capsule Two (2) Capsule by mouth DAILY (Daily). latanoprost0.005 % Drops one (1) Drop Ophthalmic HS (at bedtime). levetiracetam750 mg Tablet One (1) Tablet by mouth twice a day. 60 Tablet(s) 2 lisinopril20 mg Tablet Two (2) Tablet by mouth DAILY (Daily). omeprazole20 mg Capsule, Delayed Release(E.C.) Two (2) Capsule, Delayed Release(E.C.) by mouth DAILY (Daily). pravastatin20 mg Tablet Two (2) Tablet by mouth DAILY (Daily). Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Combigan 0.2-0.5 % Drops Sig: One (1) Ophthalmic tid (). 5. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic tid (). 6. latanoprost 0.005 % Drops Sig: One (1) Ophthalmic qhs (). 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. dexamethasone 2 mg Tablet Sig: refer to other instructions Tablet PO refer to other instructions: Please take 3mg (1 [**1-11**] tab) TID for 2 days, then take 2mg (1 tab) TID for 5 days, then 2mg (1 tab) [**Hospital1 **] until seen in follow up. Disp:*100 Tablet(s)* Refills:*2* 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. cephalexin 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 2 days. Disp:*8 Tablet(s)* Refills:*0* 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 34004**] Discharge Diagnosis: Right frontal brain tumor Deep vein thrombosis right gastroc vein Elevated BUN High blood pressure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented for removal of a right frontal brain tumor which was discovered at your last hospital admission. The operation was successful and was a combined procedure with both plastic surgery and neurosurgery involved and the biopsy result from this is awaited. You were also found to have a deep vein thrombosis in your right calf revealed on ultrasound tests of your legs. We discussed treatment options with oncology and given taht interventional radiology felt that placing a filter was unsafe due to vein involvement of your renal cancer. You were therefore started on aspirin. You were also started on anti-seizure medication given the risk of seizures following your brain tumor removal. You did well post-operatively and were deemed safe for discharge on [**2184-10-13**]. You have a brain [**Hospital 91671**] clinic appointment on [**2184-10-25**] with MRI. You also have neuro-oncology follow-up as below. General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair with a mild shampoo, or just wanter run over your incision. ?????? 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, Advil, and Ibuprofen etc for one week post operativly. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**7-18**] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. 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. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 6 weeks. ??????You will need an MRI of the brain with and without gadolinium contrast. YOU HAVE AN APPOINTMENT IN THE BRAIN [**Hospital **] CLINIC ON [**10-25**] with an MRI at 7:55 am [**Hospital Ward Name 23**] 4 and Brain [**Hospital 341**] Clinic at 9:30 / IF YOU ARE UNABLE TO MAKE THIS APPOINTMENT PLS CALL [**Telephone/Fax (1) **] Department: NEUROLOGY When: MONDAY [**2184-10-25**] at 11:30 AM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage If Pathology does show that kidney is your primary lesion, please contact Dr. [**Last Name (STitle) 9449**], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 82797**] to schedule an appointment to be seen. Completed by:[**2184-10-13**] Name: [**Known lastname 855**],[**Known firstname 63**] Unit No: [**Numeric Identifier 14435**] Admission Date: [**2184-10-8**] Discharge Date: [**2184-10-13**] Date of Birth: [**2126-8-27**] Sex: M Service: NEUROSURGERY Allergies: IV Dye, Iodine Containing Contrast Media / myeclog cream Attending:[**First Name3 (LF) 40**] Addendum: Physical Exam on discharge: A&Ox3 PERRL R periorbital ecchymosis, subconjunctival hemorrhage Full strength Incision c/d/i Discharge Disposition: Home With Service Facility: [**Location (un) 7011**] [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2184-10-13**]

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icd9cm

[ [ [] ] ]

[ "83.43", "02.04", "22.42", "01.59" ]

icd9pcs

[ [ [] ] ]

15168, 15359

6650, 7852

329, 389

10193, 10193

2188, 6627

13242, 15021

1752, 1984

8679, 9971

10071, 10172

7878, 8656

10344, 13219

1999, 2169

15049, 15145

281, 291

417, 1488

10208, 10320

1510, 1573

1589, 1736

13,295

170,016

21962

Discharge summary

report

Admission Date: [**2175-8-20**] Discharge Date: [**2175-9-16**] Date of Birth: [**2141-7-25**] Sex: M Service: MEDICINE Allergies: Fentanyl / Flagyl / Cefepime / Valium / Morphine Attending:[**First Name3 (LF) 6169**] Chief Complaint: fevers, night sweats, increasing abdominal girth Major Surgical or Invasive Procedure: Selective splenic artery embolization History of Present Illness: Mr. [**Known lastname **] is a 34 yo [**Male First Name (un) 4746**] with an uncomplicated PMH who is transferred from OSH on [**8-20**] for massive splenomegally and suspicion of splenic hemorrhage in the setting of pancytopenia. Patient states that for the past 5-6 weeks, he has been having symptoms of intermittent night sweat with subjective fevers. He also notes early satiety, decreased appetite associated with a loss of approximately 20lbs over the past 4 months. He has noted some subjective sense of increased abdominal girth associated with some mild LUQ tenderness. Approximately one month ago, he notes that played hockey, inducing a bronchospastic episode. He sought evaluation from his primary care physician and was found on routine blood work to be pancytopenic. He was then evaluated by Dr. [**Last Name (STitle) 57521**] (Hematology)on friday and had a bone marrow biopsy performed (reportedly drytap). That evening, he presented experienced lightheadedness, increased abdominal pain, and near syncope. He reported to the ED at [**Hospital1 **] where his initial labwork revealed wbc 7.6, hgb 8.0, hct 24.2, plts 39, wbc diff 8.9 poly, 27.4 lymphs, 62.3 mono, 1.0 eos, 0.5 baso, PT 15.7, inr 1.7, t. bili 1.5. He appears to have been transfused 2 units of p RBC and 2 units of FFP. He was further evaluated with a CT Abd showing massive splenomegaly with question of masses, ascites with possible hemorrhage in the pelvis, and several small retroperitoneal lymph nodes. Pt. was transferred to the [**Hospital1 18**] due to concern for acute leukemia vs. other myeloproliferative process. He was evaluated by surgery and subsequently transferred to the TSICU for close monitoring due to concern for possible splenic rupture. Past Medical History: 1) excercise induced asthma 2) lactose intolerance 3) rhinoplasty s/p MVA Social History: Denies tobacco. Occasional EtOH. Is a banker in [**Location (un) 1459**], lives with wife [**Name2 (NI) **]. No children. Family History: No history of hematologic malignancies. Mother with hx of endometrial CA. Physical Exam: Gen: alert and oriented male, appears comfortable. HEENT: + icteric sclerae (much improved from prior), no thrush, mucous membranes moist. Lungs: CTA bilaterally CV: RRR, no m/r/g Abd: abdomen massively distended, but less so than before. Nontender. Palpable spleen tip in LLQ. + bs. Ext: no edema. Skin: slightly jaundiced Pertinent Results: [**2175-8-21**] 01:07AM BLOOD WBC-3.5* RBC-2.49* Hgb-7.5* Hct-22.9* MCV-92 MCH-30.1 MCHC-32.8 RDW-19.6* Plt Ct-51* [**2175-9-16**] 12:28AM BLOOD WBC-4.3 RBC-3.08* Hgb-9.8* Hct-29.8* MCV-97 MCH-31.8 MCHC-32.9 RDW-19.9* Plt Ct-220 [**2175-8-21**] 01:07AM BLOOD PT-15.2* PTT-28.4 INR(PT)-1.5 [**2175-9-10**] 12:00PM BLOOD Gran Ct-1720* [**2175-8-28**] 02:30AM BLOOD Gran Ct-570* [**2175-9-16**] 12:28AM BLOOD Glucose-134* UreaN-16 Creat-0.6 Na-138 K-4.1 Cl-105 HCO3-28 AnGap-9 [**2175-8-21**] 01:07AM BLOOD Glucose-84 UreaN-15 Creat-0.9 Na-144 K-3.7 Cl-104 HCO3-31* AnGap-13 [**2175-9-16**] 12:28AM BLOOD ALT-240* AST-74* AlkPhos-167* TotBili-7.9* DirBili-4.5* IndBili-3.4 [**2175-9-15**] 01:30AM BLOOD ALT-292* AST-109* LD(LDH)-507* AlkPhos-206* TotBili-10.4* DirBili-6.1* IndBili-4.3 [**2175-9-10**] 09:00AM BLOOD ALT-412* AST-154* LD(LDH)-945* AlkPhos-186* TotBili-17.1* DirBili-9.0* IndBili-8.1 [**2175-9-5**] 07:30AM BLOOD ALT-201* AST-160* AlkPhos-125* TotBili-23.1* [**2175-8-21**] 01:07AM BLOOD ALT-15 AST-19 LD(LDH)-195 AlkPhos-74 Amylase-60 TotBili-2.0* DirBili-0.5* IndBili-1.5 [**2175-9-5**] 07:30AM BLOOD HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2175-9-4**] 05:00AM BLOOD HAV Ab-NEGATIVE IgM HAV-NEGATIVE [**2175-9-3**] 11:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [**2175-9-3**] 11:00AM BLOOD [**Doctor First Name **]-NEGATIVE [**2175-9-3**] 11:00AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: 1. Heme/Onc: Mr. [**Known lastname **] was admitted to the SICU with an immediate Heme-Onc consult. They reviewed his bone marrow bx results from [**Hospital3 **] and felt his diagnosis was consistent with Hairy Cell leukemia. He underwent a 7 day course of cladribine from [**8-21**] to [**8-28**] which he tolerated well. His splenomegaly was felt to be caused by his leukemia, and his spleen was not removed at that time per the surgery service, as it was felt to be so large it would have been a difficult operation, and it was felt his spleen would shrink from the chemo. However, it was clear that his spleen had ruptured with resultant hemoperitoneum, and on [**8-24**], he underwent a selective splenic artery embolization in Interventional Radiology. He tolerated the procedure well although had some post-procedure pain which was controlled with a Dilaudid PCA. Throughout his hospitalization, he had intermittent abdominal pain which occasionally worsened in severity. At one point this was accompanied by an 8-point hematocrit drop which was concerning for a rebleed in his spleen. At that time he had an abd CT which ruled out an intraperitoneal bleed. He had a total of 3 abdominal CT scans while he was on the BMT service all of which demonstrated lessening intraperitoneal fluid and either stable or less splenomegaly. (Of note, one CT demonstrated possible clot in one of his iliac veins, and so he had negative lower extremity dopplers at that time.) In terms of his leukemia, his pancytopenia improved after the cladribine, and he required little to no transfusion support by the end of his hospitalization. He was instructed on d/c to have labs checked when he returned to see Dr. [**First Name (STitle) 1557**] in clinic. 2. ID: Mr. [**Known lastname **] [**Last Name (Titles) 28316**] continuous fevers throughout his hospitalization. He had numerous negative blood and urine cultures. He did have some greenish nasal d/c and sinus pressure, and a sinus CT demonstrated minimal mucosal thickening. He developed a blackish lesion below his nostrils which was positive for HSV, and so he was treated with a 7-day course of acyclovir. He was placed on a number of different courses of antibiotics while he was here, including vancomycin (which he had due to an erythematous PICC site - PICC was later pulled, cx tip was neg), cefepime (for neutropenic fevers), and flagyl (he developed an erythematous macular eruption over his entire torso after one dose of flagyl, which was immediately discontinued). He also was given Zosyn, due to concern that his iatrogenically infarcted spleen was infected (he did have gas within his spleen seen on the aforementioned CT scans.) It was also felt that his fevers could have been due to either his disease or his chemo, and so he was given Prednisone 20 mg po bid. This controlled his fevers, and his antibiotics were discontinued and he was sent home on Prednisone. 3. Neuro: The night of [**8-28**], his PCA was switched from Dilaudid to Fentanyl and he became delirious. He was switched back to Dilaudid and this completely resolved by the morning. Later that week, he tripped and fell over his IV tubing, and did not hit his head although he wasn't sure. He had an abdominal and head CT at that time (given his massively splenomegaly and thrombocytopenia) which ruled out bleeds in his abdominen and head. A week prior to d/c, he developed an area of numbness over his right lateral thigh. He had no other neurological deficits. He was evaluated by Neurology, who felt that it was likely a superficial nerve injury. They were unsure of the exact etiology, although felt that one possibility was the rapid weight loss he sustained while his spleen shrunk (vs. just positioning from having been bed-bound for so long.) 4. Hepatology: Throughout his initial hospital course he had rising liver enzymes. Initially it was more cholestatic-appearing, with an elevated direct and indirect bilirubin (his bilirubin peaked at 23.) He also later had rising ALT and AST, peaking in the 300s-400s. The source of this was unclear and he had a negative [**Name (NI) 5283**] u/s for any biliary ductal dilatation. He had a positive EBV IgG but negative EBV IgM, and a negative monospot. He had hepatitis serologies that were negative except for Hepatitis B surface antibody. He denied ever having been vaccinated for Hep B. Since all of his other serologies were negative, including a negative viral load, it was felt that he may have acquired this antibody through the FFP that he received while in the SICU. His medication list was extensively reviewed and the only medication that could have caused it was Diflucan, which was discontinued. His liver tests continued to rise after this, and the Hepatology service was consulted. They felt it was likely secondary to drug-induced liver injury although they were also worried about hepatic infiltration from his malignancy, and he underwent an ultrasound guided liver biopsy. This revealed: Moderate hepatocellular and canalicular cholestasis. No bile duct proliferation or damage is seen, Focal mild portal mononuclear cell inflammation, with minimal lobular inflammation and rare apoptotic hepatocytes, no evidence of involvement by lymphoproliferative neoplasm, no viral cytopathic changes or granulomas are seen, and no features of [**Last Name (un) **]-occlusive disease seen. Essentially it was a bland biopsy felt by Hepatology to be c/w drug-induced injury. His bilirubin and alt/ast slowly trended down. 5. Pulmonary: He required O2 by nasal cannula initially, with no evidence on pneumonia on CXR. This was felt to be due to atelectasis [**1-2**] his massive splenomegaly, and eventually resolved with incentive spirometry. He was saturating well on room air at d/c. Medications on Admission: Meds on transfer: Regular Insulin by sliding scale Lansoprazole 30 mg PO QD Morphine Sulfate 2-4 mg IV Q4H:PRN pain Discharge Medications: 1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Protonix 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* 3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day for 2 days. Disp:*6 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*2* 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 6. Nystatin 100,000 unit/mL Suspension Sig: Four (4) ml PO four times a day for 1 weeks: swish and swallow. Disp:*100 cc* Refills:*0* 7. Peridex 0.12 % Liquid Sig: Fifteen (15) cc Mucous membrane twice a day. Disp:*500 cc* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hairy cell leukemia Discharge Condition: Good Discharge Instructions: Please call Dr.[**Name (NI) 6168**] office on Monday to make an appointment for Tuesday [**2175-9-19**]. Please call Dr. [**First Name (STitle) 1557**] (if during office hours) or the page operator (at [**Telephone/Fax (1) 8717**], ask for the Bone Marrow Transplant Physician on [**Name9 (PRE) **]) if you develop a fever >100.5, productive cough, nausea, vomiting, severe abdominal pain, or weakness. Followup Instructions: Call Dr. [**First Name (STitle) 1557**] on Monday to set up a Tuesday appointment.

[ "112.0", "284.8", "576.8", "054.9", "780.6", "202.40", "355.8", "202.43", "289.59", "789.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.05", "99.25", "50.11", "99.04", "99.07", "99.29", "88.47" ]

icd9pcs

[ [ [] ] ]

11123, 11129

4279, 10108

358, 398

11193, 11199

2879, 4256

11650, 11736

2438, 2514

10274, 11100

11150, 11172

10134, 10134

11223, 11627

2529, 2860

270, 320

426, 2182

2204, 2280

2296, 2422

10152, 10251

25,337

116,249

43142

Discharge summary

report

Admission Date: [**2120-1-10**] Discharge Date: [**2120-1-17**] Service: MEDICINE Allergies: Tape II Disposable Liner Adhes / Ciprofloxacin / Glyburide Attending:[**First Name3 (LF) 905**] Chief Complaint: Mental Status Changes Major Surgical or Invasive Procedure: s/p thrombectomy of AV fistula Tunneled Catheter Placement History of Present Illness: Ms [**Known lastname 92981**] is a 81 yo female [**Known lastname 595**] speaking only with history of ESRD on hemodialysis, CHF, CAD / CABG, stroke (Broca's Aphasia) admitted s/p complicated thrombectomy of AV fistula on [**1-11**]. She was also recently hospitalized at [**Hospital1 18**] from [**11-16**] [**11-21**] for GI bleed and mental status changes but she refused further workup. She is known to have a large rectal mass which she also refuses any workup. During this admission, she was admitted for observation post procedure wheh she became unresponsive with complete right sided hemiparesis, and her blood glucose was found to 54. Given 1 amp of D50 with slow resolution of symptoms. She had a head CT that was unchanged from prior and was also seen by the Neuro team who thought this was secondary to hypoglycemia. She was admitted to the ICU for closer monitoring and started on a D50 drip. Her symptoms resolved, and her blood sugars had been running in the 150s. She is currently of her D50 drip, and her mental status is back to baseline. She also was transfused with 2u PRBC but of note, overnight, she pulled her temporary line. She had a R IJ permanent catheter placed in the OR on Monday [**2120-1-15**]. Also found to be C diff positive and currently on Flagyl Past Medical History: 1) CAD: s/p NSTEMI, CABG x 3v, [**10/2115**], course c/b by stroke with aphasia and right hemiparesis, with eventual regain of function. 2) ESRD: hemodialysis on T,Th,Sat, through left arm AV graft 3) h/o GI bleeding 4) Gout 5) Anemia 6) HTN 7) Hypercholesterolemia 8) DM2 9) Stoke in left posterior frontal area [**10/2115**] 10) CHF: EF 30-40% 11) Depression 12) Colon polyps 13) Hemorrhoids 14) Hyperhomocysteinemia Social History: [**Month/Year (2) 595**]-born. Moved to US in [**2104**]. Lives alone at [**Hospital 7137**]. No children. [**Location (un) **] is the health care proxy; no history ETOH or tobacco. [**Name (NI) **] (cousin) [**Telephone/Fax (2) 92985**]Lena ([**Telephone/Fax (2) 802**]) [**Telephone/Fax (2) 92986**]Val (son) [**Telephone/Fax (1) 92987**] Family History: Non-Contributory. Physical Exam: VS: T 98.4, P 72, BP 98/60, RR 12, O2 sat 97% on room air Gen: comfortable, lying in bed, NAD HEENT: PERRLA, EOMI Neck: supple, no JVD noted Lungs: CTA bilateral anteriorly Heart: irregularly irregular, no murmurs, rubs, gallops appreciated Abd: soft, non distended, non tender, no HSM Extrem: no edema, cyanosis, clubbing Pertinent Results: [**2120-1-15**] 03:46AM BLOOD WBC-19.0* RBC-4.01*# Hgb-12.0# Hct-35.2*# MCV-88 MCH-30.0 MCHC-34.2 RDW-16.3* Plt Ct-340 [**2120-1-15**] 03:46AM BLOOD Plt Ct-340 [**2120-1-15**] 03:46AM BLOOD Glucose-103 UreaN-55* Creat-7.4* Na-131* K-4.7 Cl-95* HCO3-22 AnGap-19 [**2120-1-15**] 03:46AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.3 Iron-89 Brief Hospital Course: 81 yo [**Month/Day/Year 595**] speaking female who is being transferred from the ICU after presenting there with MS changes secondary to hypoglycemia in the setting of her glyburide. 1. MS changes - she experienced these changes most likely due re expression of prior stroke in the setting of hypoglycemia given Neuro exam unremarkable, and head CT was unchanged. She was seen by the Neurology team who thought this was from hypoglycemia, and once her sugars improved back to baseline, her MS improved back to baseline as well. 2. Hypoglycemia - likely secondary to glyburide in hemodiaylsis patient as glyburide is contraindicated for patients with a Creat clearance of less than 40. during her hospital course, her fingerstick remained in the low 100s and so we decided to hold off on all oral hypoglycemiscs and cover her with regular sliding scale insulin. Please see attached sheet in d/c paperwork for details of covering for insulin. 3. Anemia - she most likely has anemia secondary to anemia of chronic disease given renal failure. She was transfused with 2u PRBC and her HCT remained stable during the rest of the hospital course. 4. Renal - she has known ESRD and is currently on hemodialysis on Tu, [**Last Name (un) **], Sat. Had tunneled catheter placed in the OR on [**2120-1-15**] and it was used for dialysis during her Tuesday session. 5. Cardiology - she has significant cardiac history but no active issues at this time. We decided to continue on all her outpatient regimen. Also has history of atrial fibrillation for which we are rate controlling and holding off of anticoagulation given history of GI bleed 6. ID - she had some leukocytosis and diarrhea and was found to be C Diff positive. She is being treated with Flagyl 500mg po bid for a total of 2 weeks from discharge. 7. Code - DNR/DNI Medications on Admission: Captopril 100mg po tid Protonix 40mg po daily Lopressor 25mg po tid Clonidine 0.1mg po bid Isosorbide 20mg po tid Aspirin 81mg po daily Colace 100mg po bid Nephrocaps Percocet prn Hydralazine 10mg po q6 Discharge Medications: 1. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for diarrhea. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): Please give insulin as per sliding scale attached with discharge paperwork. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. Hypoglycemia 2. End Stage Renal Disease 3. Coronary Artery Disease 4. Hypertension Discharge Condition: Stable Discharge Instructions: Please take all your medications as directed. Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**2-3**] weeks. Please check fingersticks three times a day and cover with Regular Sliding Scale as shown in the discharge paperwork. Followup Instructions: Please take all your medications as directed. Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**2-3**] weeks [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "99.04", "38.95", "39.95", "39.42" ]

icd9pcs

[ [ [] ] ]

6398, 6468

3212, 5036

288, 349

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2859, 3189

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72,536

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39317

Discharge summary

report

Admission Date: [**2156-6-24**] Discharge Date: [**2156-7-6**] Date of Birth: [**2079-12-29**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Digoxin / Nitrate / Dioxyline Phosphate / Irbesartan / Ethaverine / Nylidrin / Papaverine Attending:[**First Name3 (LF) 8104**] Chief Complaint: Hematemesis and melena Major Surgical or Invasive Procedure: EGD IVC filter placement Central line History of Present Illness: Ms. [**Known lastname **] is a 76 year old lady discharged from the medical service yesterday after a prolonged hospitalization for Upper GI bleed complicated by RUE DVT resulting in discharge on Warfarin, Heparin IV and aspirin. She was found at her LTAC today to be vomiting bright red blood and passing dark stool and transferred to [**Hospital3 **] for further management. . At [**Hospital1 487**], she received 10mg Vit K, Protonix Bolus/gtt, 80mg of Pepcid, 1L NS, what appears to be 2 units PRBCs, 1 unit Whole blood and 2 units FFP, R femoral triple lumen and foley placement. INR 2.9, Hct 23.8. She was transferred to the [**Hospital1 18**] ED for further evaluation. . In the ED, initial vs were: 98.3 134 128/74 16 98. Patient was typed and screened, refused NG lavage and admitted for further management. Gi was consulted and recommended keeping Hct >30 and that they will scope in AM. No additional access was obtained. VS 97.3 130 130/65 22 97% RA 0/10 . On the floor, the patient reports that she has actually had bloody bowel movements for the last few days. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Ischemic Colitis s/p R colectomy ([**2155-8-28**]) CAD s/p CABG Afib SVT s/p ablation PPM COPD DM Carotid Endarterectomy PVD HTN Hyperlipidemia CKD baseline Cr 1.1 Social History: Lives in [**Location **]; quit smoking in [**2125**] after 5 pack yr history; rarely drinks etoh. Family History: Pt father died of heart disease at age 42. Said he had a large heart and not sure exact cause of death. Mother died of meningitis (age could not remember), Both sister died - had heart disease and DM. Physical Exam: On admission to ICU: Vitals: T: 96 BP: 133/92 P: 130 R: 20 O2: 100% RA General: Awake, answers questions HEENT: Sclera anicteric, dry mucous membranes, pale conjunctiva Neck: supple, JVP not elevated, no LAD Lungs: Limited exam, clear laterally/anteriorly CV: S1 & S2 fast, unable to appreciate murmur Abdomen: soft, diffusely tender, non-distended, bowel sounds present, GU: foley in place, R femoral line in place, dressing applied Ext: warm, well perfused, 1+ pulses, no edema Pertinent Results: On admission: [**2156-6-24**] 11:10PM BLOOD WBC-9.4# RBC-3.72* Hgb-11.0* Hct-31.9* MCV-86 MCH-29.5 MCHC-34.4 RDW-15.7* Plt Ct-332 [**2156-6-24**] 11:10PM BLOOD Neuts-67 Bands-2 Lymphs-20 Monos-7 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* [**2156-6-23**] 07:00AM BLOOD PT-22.2* PTT-133.4* INR(PT)-2.1* [**2156-6-23**] 07:00AM BLOOD Glucose-177* UreaN-9 Creat-0.7 Na-135 K-3.4 Cl-97 HCO3-26 AnGap-15 [**2156-6-24**] 11:10PM BLOOD ALT-23 AST-26 AlkPhos-61 TotBili-0.7 [**2156-6-24**] 11:23PM BLOOD cTropnT-0.07* [**2156-6-28**] 03:12AM BLOOD CK-MB-5 cTropnT-0.11* [**2156-6-29**] 05:03AM BLOOD CK-MB-5 cTropnT-0.09* [**2156-6-24**] 11:10PM BLOOD Albumin-2.8* Calcium-7.5* Phos-4.7*# Mg-1.3* [**2156-6-29**] 02:51PM BLOOD TSH-4.1 [**2156-6-24**] 11:20PM BLOOD Glucose-242* Lactate-1.4 K-3.2* On discharge: [**2156-7-5**] 07:10AM BLOOD WBC-8.6 RBC-4.67 Hgb-13.6 Hct-42.0 MCV-90 MCH-29.2 MCHC-32.4 RDW-14.9 Plt Ct-420 [**2156-7-2**] 04:19AM BLOOD PT-11.8 PTT-27.3 INR(PT)-1.0 [**2156-7-5**] 07:10AM BLOOD Glucose-165* UreaN-13 Creat-0.9 Na-136 K-4.0 Cl-92* HCO3-34* AnGap-14 [**2156-7-5**] 07:10AM BLOOD Albumin-2.8* Calcium-8.6 Phos-3.2 Mg-1.6 .. ECG Study Date of [**2156-6-24**] 11:17:02 PM Possible atrial flutter with rapid ventricular response and 2:1 block. Compared to the previous tracing of [**2156-6-15**] the ventricular rate is faster. .. Imaging: CXR [**2156-6-24**]: A dual-lead cardiac pacing device is unchanged with leads in appropriate atrial and ventricular positions. A right peripherally inserted central catheter has been removed. Multiple median sternotomy wires are stable as are vascular clips from coronary arterial bypass grafting. Heart size is stable as are mediastinal and hilar contours. Calcification along the aorta is unchanged. Note is also made of bibasilar subsegmental atelectasis. There is no pulmonary edema. . Tagged RBC scan [**2156-6-25**]: No active GI bleeding through 101 minutes. . TTE [**2156-6-28**]: Suboptimal image quality. Normal left ventricular cavity size with diffuse biventricular systolic dysfunction c/w multivessel CAD, toxin, metabolic, etc. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2156-6-10**], biventricular systolic function is now depressed. LVEF = 30% . U/S of b/l UE's and LE's [**2156-6-29**]: 1. DVT of the right common femoral vein and superficial veins. 2. Extension of prior right upper extremity DVT into the right subclavian vein. 3. Superficial thrombosis of the left upper extremity basilic and cephalic veins. [**7-4**] Head CT: WNL Micro: [**6-30**] Blood culture x 2: enterobacter cloacae (sensitive to ciprofloxacin) [**6-26**], [**6-30**] blood cx x 2: negative [**6-26**] stool culture: C.diff negative Brief Hospital Course: Ms. [**Known lastname **] is a 76 year old woman with PMH s/f UGI bleeding, multiple DVTs, CAD s/p CABG, Afib/flutter, COPD, DM, s/p aortobifem bypass, ischemic colitis s/p colectomy, who was hospitalized at [**Hospital1 18**] from [**Date range (1) 35589**] for UGI bleed and RUE DVT, presented on [**6-25**] with recurrent upper GI bleed, and whose hospital course has included Afib/flutter, persistent tachycardia, RUE and RLE DVT and LUE and LLE superficial thrombophlebitis, worsening CHF, UTI, delirium and diarrhea. . #) GI Bleed: The patient had a recent h/o GI bleed with visualized duodenal ulcers. She initially presented with hematemesis and melana. An EGD showed no active bleeding and 2 healing duodenal ulcers. A tagged red cell scan was negative for active bleeding. She intitially had a hematocrit of 31 and received 4U of PRBCs upon admission. She refused gastric lavage, but it is presumed this was an upper GI bleed. Her hematocrit was stable from [**6-26**] until the day of discharge, when it was 42.7. Her anticoagulation was stopped and should be restarted in 4 weeks to treat her R UE DVT, R LE DVT, and likely PE. She continues on heparin SQ prophylaxis 5000 U TID. She was continued on pantoprazole 40 mg [**Hospital1 **]. . # DELIRIUM: The patient was diagnosed with hypoactive delirium by psychiatry. They recommended environmental modifications for delirium (dark, quiet room with minimal disruptions at night; awake during day), the avoidance of deliriogenic medications (ie, benzos, opiates, Benadryl, etc). B12/folate levels were normal/high. Head CT was negative. The patient was started on olanzipine 2.5 mg qhs. On the day of discharge, the patient was intermittently somnolent, but oriented to person, place, and month. . #. Tachycardia/CAD/AFib: The patient had consistent HR in the 90s-120s. EKG and telemetry showed atrial flutter. This was likely exacerbated hy her DVTs/PE. Her metoprolol was increased to 100 mg QID, which was tolerated by her blood pressure. She has had no recent events of atrial flutter with rapid ventricular response on telemetry. Cardiology followed the patient during admission. . #. Recent C. Diff colitis: For the patient's reported history of C.diff colitis during her last admission in early-mid [**May 2156**], the patient has completed a course of PO vancomycin and flagyl. She did not have diarrhea after transfer to the floor and her C.diff toxin was negative. Her PO vancomycin was stopped. . #. DVTS/PE: Confirmed DVT in 3 of 4 limbs on doppler scan; pt likely with DVTs in [**2-29**] limbs; also with PE by V-Q scan. Unfortunately, the patient cannot currently receive anticoagulation due to her recurrent GI bleeding. An IVC filter was placed and she was continued on subQ heparin for prophylaxis. In 4 weeks, the issue of restarting anti-coagulation should be re-visited (~[**7-27**]), likely with a lower INR goal. . #. CHF: Repeat Echo showed worsening heart failure with an EF of 30%, down from 55%. This was likely a result of her PE/DVTs as well as volume overload. She was aggressively diuresed with Lasix 80 mg [**Hospital1 **], and her electrolytes were carefully followed. On the day of discharge, the patient was thought to be at her dry weight and she was discharged on her home dose of Lasix, 20 mg qd. This medication may need to be up-titrated if she displays signs/symptoms of volume overload. Her electrolytes will need to be followed every 3 days. . #. UTI: The patient had an [**6-30**] urine culture that grew Enterobacter cloacae. She received 4 days of therapy with ciprofloxacin. This was discontinued out of concern for it worsening her delirium. Her foley was removed. . #. DM: For the patient's DM, she received SSI (6-8U per day). Her lantus was discontinued as the patient's appetite had declined. Her sugars were in the 150s to low 200s. . #. Htn: The patient's blood pressure was controlled with metoprolol 100 mg qid (also for rate control. . #HL: The patient received her home statin, rosuvastatin 40 mg qd. . #Poor nutrition: The patient denied nausea but stated that she had little interest in food. She had 1:1 feeds. She declined a feeding tube. . The patient was on SubQ heparin for DVT prophylaxis. She was ordered a regular diet. Communication was with her son, [**Name (NI) **] ([**Telephone/Fax (1) 86943**], and daughter [**Name (NI) **] [**Telephone/Fax (1) 86944**] . [**Name2 (NI) **] code status was DNR/DNI. Medications on Admission: Warfarin 2 mg PO Q1600 Heparin Sliding Scale ASA 81mg PO daily Vancomycin 125 mg PO Q6H until [**2156-7-6**] Miconazole Nitrate 2 % Powder TP QID Metronidazole 500 mg Tablet PO TID Rosuvastatin 40 mg PO DAILY Furosemide 20 mg PO Daily Pantoprazole 40 mg PO Q12 Metoprolol Tartrate 50 mg PO BID Fluticasone-Salmeterol 500-50 mcg/Dose [**11-29**] INH [**Hospital1 **] Ipratropium Bromide 17 mcg 2 Puff INH QID Albuterol Sulfate 90 mcg/Actuation HFA 2 Puffs Q4 PRN wheeze Acetaminophen 650 mg PO/PR Q6 PRN Calcium Carbonate 500 mg PO TID Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 7. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: [**11-29**] inhalation Inhalation twice a day. 8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Country Rehabilitation and Nursing Center - [**Location (un) 5028**] Discharge Diagnosis: Primary: CHF DVT PE GI bleed UTI Hypoactive delirium Atrial flutter w/ SVT Secondary: DVT Ischemic Colitis s/p R colectomy ([**2155-8-28**]) CAD s/p CABG Afib SVT s/p ablation PPM COPD DM Carotid Endarterectomy PVD HTN Hyperlipidemia CKD baseline Cr 1.1 Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: . Ms. [**Known lastname **], it was a pleasure taking care of you at the [**Hospital1 1535**]. You were diagnosed with a Gastrointestinal Bleed that was, in part, due to your taking blood-thinning medication for the known blood clot in your right arm. In addition, you were found to have an abnormal heart rhythm with a fast heart rate that was treated with medication. . Additional studies showed blood clots in your right leg and also in your lung. A filter was placed to help prevent further clots in your leg from reaching your lung. You also had a scope to look into your stomach to try and see the cause of your vomiting blood. No obvious cause was seen, but the bleeding was likely caused by your known ulcers and the blood thinning medication you were on. It was also discovered that you had a urinary tract infection for which you received antibiotics. . The following changes were made to your medication regimen: We STOPPED aspirin, coumadin, and heparin drip. You will be continued on heparin prophylaxis (5000 U SQ TID) We STOPPED vancomycin and metronidazole. We CHANGED metoprolol 50 mg [**Hospital1 **] to 100 mg QID. We STARTED olanzapine 2.5 mg PO qhs We CONTINUED your Lasix 20mg qd (this dose may need to be adjusted if your volume status worsens) We CONTINUED your Sliding Scale Insulin (receiving 6-8U per day) . Your electrolytes will need to be routinely followed after discharge. Recommend checking Chem10 every 3 days and uptitrating Lasix if volume status worsens. . You have a follow-up appointment tomorrow with the gastroenterologist below. If necessary, this can be re-scheduled by calling the number below. . Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2156-7-6**] at 4:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22561**], 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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icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "45.13", "88.51", "38.7" ]

icd9pcs

[ [ [] ] ]

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12,246

182,580

27126

Discharge summary

report

Admission Date: [**2116-5-6**] Discharge Date: [**2116-5-24**] Date of Birth: [**2049-7-1**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Hyperbilirubinemia, cirrhosis, ARF Major Surgical or Invasive Procedure: ERCP History of Present Illness: 66 yo F with h/o HTN and gastritis transferred from [**Hospital 1263**] Hospital for hepatology evaluation and possible ERCP. Pt initially presented to [**Hospital 1263**] Hospital in late [**Month (only) 958**] secondary to increased jaundice, decreased appetite, and emesis. Her bilirubin was found to be elevated but was d/c'd with OP followup when as it started to trend down. She was readmitted on [**2116-4-28**] with c/o increased jaundice and hyperbilirubinemia to 34. Workup was significant for +antismooth muscle antibody 1:160 and +[**Doctor First Name **] 1:160. MRCP did not show evidence of biliary ductal dilation. Viral hepatitis workup was negative. Liver biopsy was performed [**2116-4-30**] was nonspecific showing cirrhosis with cholestasis. She was started on prednisone 60 mg QD on [**5-1**] for presumed autoimmune hepatitis. That day, creatinine rose from 1.5 to 2.8 to 7.9 on [**5-4**]. Pt was noted to be anuric with low BPs to the 80s. She ws thought to be hypovolemic and started on IVF but d/c'd secondary to ?CHF/SOB. She was transferred to the ICU on [**5-2**] for closer monitoring and started on HD by renal through a right femoral catheter placed on [**5-3**]. It was thought that her acute rise in creatinine was c/w ATN secondary to IV contrast from a CT scan and hyperbilirubinemia. She was dialyzed 2 out of the past 3 days by renal. She was kept on lactulose that was started a few days PTA. Anzemet was used for nausea. She was transferred to the [**Hospital1 18**] for further management of her cirrhosis and renal failure. . Per reports, she was in her USOH until [**3-30**] when she began to feel tired, had decreased appetite, and jaundice. She had a bilirubin on [**4-17**] which was 10.8. CT abdomen as an OP showed a normal sized, lobulated liver suggestive of cirrhosis. There was no focal abnormalities or biliary dilation. There was marked hypertrophy of the caudate lobe but no pancreatic masses. There was mild ascites and splenomegaly suggestive of mild portal hypertension. There was mild GB wall thickening without signs of gallstones. She had no c/o of F or abd pain. The patient was electively admitted 4 days later with a bilirubin of 34.4. . In the patient's history, she has had a moderate elevation in her liver enzymes in [**2100**] and had a liver biopsy at the [**Hospital1 10551**]. It showed mild steatosis, patchy portal inflammation without significant piecemeal necrosis or fibrosis. She does report 2 units of PRBCs 34 y ago with the birth of her daughter. She reports drinking 3 ounces of wine twice per week. She has never been a heavy drinker in the past. She is a retired nurse and has had [**1-27**] needle sticks during her career. In [**2101**] she was told that she had a fatty liver and LFTs were being monitored. She takes 500mg-1gm/month for knee pain. Past Medical History: - Upper GI bleed [**9-29**] ?[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, EGD c/w mild gastritis. At that time she also had a gastroenteritis and hematemesis requiring 3uPRBCs and d/c'd on PPI. (ALT 53, AST 29, Alk Phos 157, TB 1.2) - Colonoscopy [**2113**] negative - Sinus Surgery [**8-/2111**] - HTN - Obesity - Anxiety Disorder - Osteoarthritis of knees/valgus deformity of R knee requiring cane for ambulation Social History: - Retired RN working at [**Hospital 66601**] Nursing home until [**2105**] - Husband died of MM in [**2106**] - Daughter [**Name (NI) **] 34 [**Name2 (NI) **] - No tobacco history - Rare ETOH - No illicits Family History: - Mother with breast CA - Father with lupus and anemia - h/o Alcoholism in several family members - Brother with cirrhosis secondary to ETOH - Sister with cirrhosis secondary to ETOH, colon and breast ca - Brother with ETOH abuse - Sister with breast ca Physical Exam: PE: 96.4, 69, 104/34, 20, 96% 4LNC GEN: A+O x 3, NAD, jaundiced HEENT: PERRL, EOMI, scleral icterus, jaundiced frenulum, dry mm CV: RRR, II/VI systolic murmur at LUSB LUNGS: Decreased BS at R base, [**1-28**] of the way up. Minimial crackles at left base. No wheezes ABD: soft, distended, +fluid wave, no HSM palpated, +BS, NT EXT: 1+edema to shins bilaterally, 1+edema at sacrum NEURO: CNII-XII intact, 5/5 strength in all ext, nl sensation, no asterixes Skin: jaundiced, +spider angiomas on chest, no palmar erythema, +eccymoses on arms Pertinent Results: LABS: [**5-6**] - CBC- 7.8/27.3/71, MCV 99, 92N, 4M, 4L Chem 7 - 139/4.6/104/26/41/5.6 Ca/Mag/Phos - 8.6/6.4/2.3 Tot BILI - 27.3 AST 69 ALT 38 TP 5.2 ALB 2.2 PT 14.9, PTT 33.3, INR 1.4 . [**Doctor First Name **]: 1:160 speckled Max Total Bili 34.4 on [**2116-4-28**], with direct 17 Max creatinine 7.9 on [**2116-5-4**] Platelet trend 230 on admit trending down 71 on transfer . [**5-1**] Urine Na <10, Osm 22, Cr 9.7, FeNA 4% 4/8 Urine Na osm 150, cr 80.1, na 16, K 25, cl 17 UA [**5-1**] -1.025, ph 5, prot 30, glu 100, tr ketones, large blood, pos nitrites, large bili, mod LE, [**11-13**] rbc, 20-50 WBC, many urine bacteria, Ucx negative . IMAGING: MRCP [**2116-4-22**]: Atrophy of the right lobe of the liver with hypertrophy of the caudate lobe. No evidence of intrahepatic bile duct dilation and the distal common biled duct is normal in diameter. No evidence of an intraluminal filling defect int eh visulalized portion of the common bile duct. No evidence of a mass in the region fo the head of the pancreas. The GB wall is mildly thickened. No gallstones or hepatic masses. Moderate ascites in the upper abdomen. 5.6 cm simple cyst int he lower pole of the right kidney. . CT Abd with contrast [**2116-4-20**]: Normal sized but very lobulated appearing liver suggestive of cirrhosis. No focal hepatic abnormality shown. No biliary tree dilation or pancreatic mass. Marked hypertrophy of caudate lobe seen. Associated splenomegaly suggesting mild portal hypertension. Ascites. Atherosclerosis. Simple cyst of right kidney. Fundal uterine fibroid. Mild nonspecific GB wall thickening without signs of gallstone. Small pericholescystic lymph node. . RUQ US [**4-28**]: increased echogenicity fo the liver, thickened GB wall without gallstones. Left kidney 13.2 cm, right kidney 12.5 cm. . Liver biopsy [**2101**]: mild steatosis, patchy mild portal inflammation without significant piecemeal necrosis or fibrosis. . Abd US [**8-/2112**]: one or two nonspecific echogenic tubular structures within the left hepatic lobe c/w scars/thrombosed vessels or sludge filled ducts. fatty infiltration of the liver. 1cm angiomyolipoma in the left kideny, 6 cm right kidney cyst. Splenomegaly. Normal GB. . Renal US [**5-2**]: No hydronephrosis or obstruction. CXR R pleural effusion, cardiomegaly . EKG: [**5-4**] NSR, 60 bpm, LAD, IVCD, LAFB, peaked Ts V2-V3 Brief Hospital Course: 66 yo F with PMH significant for HTN and UGIB in the past transferred from OSH with cirrhosis, hyperbilirubinemia, and ARF felt to be due to contrast from abdominal ct and hyperbilirubinemia. She was treated with hemodialysis via a right femoral catheter placed on [**5-3**] at OSH. She was transferred to [**Hospital1 18**] MICU for ercp. Unclear etiology of cirrhosis. DDX included autoimmune hepatitis, biliary cirrhosis, NASH and PSC. Labs from OSH significant for +[**Doctor First Name **] and Anti smooth muscle antibodies concerning for an autoimmune etiology. Liver biopsy was nonspecific. Pt was initially started on prednisone 60 mg. Other etiologies included viral hepatitis, acetaminophen, ETOH, NASH, hemachromatosis. A liver duplex revealed a cirrhotic liver with thrombosis or extremely slow flow within the portal vein. A moderate amount of ascites,splenomegaly and a right renal cyst. Hepatology was consulted. Upon review of her case, a liver transplant consult was initiated by Dr. [**Last Name (STitle) 66602**] and a workup was begun for liver and renal transplant. A MELD score was calculated at 37. Nephrology was consulted. Findings were consistent with HRS with superimposed ARF given urine sodium less than 10 on [**5-1**] superimposed on acute hypotension with dye load from CT. An MRI to evaluate the liver revealed conventional hepatic arterial anatomy. Segment IV hepatic artery arose from the left hepatic artery. A small accessory right lobe hepatic vein was seen draining into the IVC. The portal vein was patent with hepatopetal flow. She continued on prednisone for presumed initially to be autoimmune hepatitis and lactulose daily to prevent encephalopathy. NASH was later suspected and prednisone stopped around the [**5-9**]. On [**5-14**], she was taken to the OR and underwent insertion of right internal jugular Perm-A-Cath by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She continued on hemodialysis. She also had a R pleural effusion with decreased breath sounds at RLL and 4L o2 requirement. A cardiac echo demonstrated (LVEF 70%). No masses or thrombi were seen in the left ventricle. No ventricular septal defect. Right ventricular chamber size and free wall motion were normal. There were focal calcifications in the aortic arch. The aortic valve leaflets (3) were mildly thickened but aortic stenosis was not present. No aortic regurgitation was seen. The mitral valve leaflets were mildly thickened. There was no mitral valve prolapse. Trivial mitral regurgitation was seen. The estimated pulmonary artery systolic pressure was normal. There was no pericardial effusion. She experienced thrombocytopenia: Plt count had decreased since from 230 to 55. DDX included sequestration from splenomegaly, decreased production from low thrombopoietin levels, HIT, DIC. Heparin products were held and a HIT Ab level was checked and negative. a factor V leiden was negative. She was started on epogen for anemia for a hct of 27. MCV high normal at 99. ?ACD secondary to liver failure, B12/folate deficiency, GIB, renal failure. Stools were guaiac'd as stool positive on [**4-29**] at OSH. She continued to complain of nausea for which she was given anzemet and PPI. On [**5-12**] she experienced small amount of BRBPR with straining during a bm. The patient attributed this to hemorrhoids.Hct was 31.5. On admission she was continued on Levofloxacin that started at OSH for unclear reasons. ?+UA, but urine culture negative. Had completed 5 day course. Remained afebrile without an elevated WBC. A repeat urine culture revealed yeast and enterococcus. She was treated with fluconazole and ceftriaxone. Ceftriaxone was switched to vancomycin.Infectious disease was consulted. Recommendations were in agreement with the medicine team. On [**5-15**], she had an episode of chest discomfort described as a dull pain lasting ~ 10 min, substernal with radiation to the left arm anad jaw. EKG revealed t was inversion . She was given an aspirin and nadolol for varices. CK was 25 and trop 0.03. On the AM of ([**2116-5-18**]), her SBP dropped to 65 from a bp of 80 following 200cc ultrafiltrationwhile in dialysis. HD was stopped and CVVHD was recommended. At that time, her Sat was 80% which improved to 97% on NRB. She had hematemsis of 50cc She had mild CP which resolved spontaneously; ECG demonstrated no changes compared to prior from four days before. ICU evaluation was called and the patient was taken urgently to the SICU. There, she had emesis of several hundred cc of blood and was immediately intubated followed by OGT placement. Hct dropped to 17 and inr of 2.0. She was resusitated with 6 PRBCs, 6bags of FFP and 3 bags of plts. An egd was done revealing esophageal varices at the lower third of the esophagus, portal gastropathy, and blood in the fundus likely from portal gastropathy. Octreotide, ppis, and carafate were administered. A cxr revealed edema and chf. CVVHD was continued. She required pressor support and further blood products to stabilize hct and plts. ID was consulted. Cipro was given for SBP prophylaxis. Caspo and zosyn was added for sepsis due to ampi-resistant enterococcus, and yeast. She experienced ARDS with worsening status and ongoing sepsis. It was felt that she would not tolerate transplant surgery. A family meeting was held to disuss critical status and poor prognosis. Propofol was weaned without improvement in mental status. On [**5-23**], she experienced a 1 liter upper gi bleed treated with rapid infusion of crystatlloid, 4 units of PRBC, ffp and factor VII. Emergent EGD revealed clotted blood in the upper, middle and lower esophagus extending into the stomach. Findings consistent with severe portal gastropathy. After discussion with family, the desicion was made to withdraw support. She was made CMO status. In the AM of [**2116-5-23**], she expired. Medications on Admission: OP MEDS: - HCTZ 25 mg daily - Nadolol 20 mg daily - Omeprazole 20 mg daily - Lactulose 30 cc daily - Tylenol 500 mg rarely for OA pain, q1month - Advil 200 mg qmonth . MEDS on TX: - Nexium 40 mg daily - Prednisone 60 mg QD day 6 - Levofloxacin 250 QOD day 5 - Lactulose 30 cc po daily - Anzemet prn - Renagel 800 mg TID - Renavite Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: ESLD, secondary to NASH hepatorenal syndrome Upper GI bleed [**Doctor First Name **]-[**Doctor Last Name **] gastritis anxiety OA Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2116-9-3**]

[ "571.5", "599.0", "785.59", "584.5", "518.81", "112.2", "456.21", "995.92", "038.0", "458.21", "572.3", "286.7", "572.4", "571.8", "401.9", "452", "578.0", "428.0", "278.00", "284.8", "570" ]

icd9cm

[ [ [] ] ]

[ "99.07", "38.93", "39.95", "45.13", "38.95", "99.04", "99.15", "96.72", "54.91", "96.04", "99.05" ]

icd9pcs

[ [ [] ] ]

13435, 13444

7135, 13020

346, 352

13617, 13627

4752, 7112

13680, 13841

3922, 4177

13402, 13412

13465, 13596

13046, 13379

13651, 13657

4192, 4733

272, 308

380, 3216

3238, 3682

3698, 3906

26,239

160,045

6284

Discharge summary

report

Admission Date: [**2149-2-26**] Discharge Date: [**2149-3-10**] Date of Birth: [**2097-7-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Ascites, clogged NG tube Major Surgical or Invasive Procedure: Paracentesis x 5, placement of central line in Left IJ History of Present Illness: 52 M w/ HCV cirrhosis, stage I varices, VL 90k in [**2142**], hx PV thrombosis, polysubstance abuse on methadone, who was previously on transplant list was admitted for evaluation of clogged NJ tube. Pt is malnurished and NJ tube is for nutrition. He had a large volume paracentesis over 1 week ago (>6L) prior to screening colonoscopy (normal) and since then, he had not been taking good PO's and the NJ tube is clogged, resulting in fatigue. He also began to experience abdominal pain a couple of day prior to this admission. He denies f/c/nausea or vomiting/diarrhea. No melena. . On arrival to the floor, the patient's BP 70/p and he was hypothemic [**Age over 90 **]F oral, cold and clammy per report. No visible bleeding from below and guaiac negative. He was taken to the MICU where the BP was found to be 98/76 and temp 97 rectal. Guiac negative. Per report, smelled like alcohol. Past Medical History: 1. Hepatitis C cirrhosis diagnosed ten years ago. Last viral load 90,700 in [**2142**], ascites, status post a liver biopsy. 2. Anxiety/depression. 3. Polysubstance abuse. 4. History of arthroscopic knee surgery. 5. Status post thoracentesis at [**Hospital3 7362**]. Social History: The patient worked in a shipyard, former heavy alcohol, history of intravenous drug abuse, heroin, tobacco use. He reports now one cigarette per day with a fifteen pack year history. The patient is married and lives with his wife and son. Family History: NC Physical Exam: PE: 97.0 84/49 79 94%RA 14 General: Non-toxic, chronically ill, A&O X 2 (negative for place) Heent: EOMI, PERRL, anicteric sclera, dry MM, NJ tube in place. Heart: RRR soft 2/6 SEM, no rg Lungs: Clear Abd: Soft, distended, hypoactive BS Ext: No edema, well perfused. Neuro: Asterixis. + horizontal nystagmus Pertinent Results: Admission Labs [**2149-2-26**] 11:15AM WBC-12.4*# RBC-3.90* HGB-14.0 HCT-40.3 MCV-103* MCH-35.9* MCHC-34.8 RDW-15.6* NEUTS-83* BANDS-6* LYMPHS-2* MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 GLUCOSE-94 UREA N-54* CREAT-2.3*# SODIUM-129* POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-20* ANION GAP-21* ALBUMIN-2.6* CALCIUM-8.8 PHOSPHATE-8.5*# MAGNESIUM-2.4 ALT(SGPT)-50* AST(SGOT)-84* LD(LDH)-225 ALK PHOS-69 TOT BILI-9.1* LIPASE-11 . [**2149-2-26**] 03:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG . ASCITES TOT PROT-1.6 GLUCOSE-82 LD(LDH)-125 ALBUMIN-LESS THAN [**2149-2-26**] 02:39PM ASCITES WBC-5250* HCT-2.0* POLYS-95* LYMPHS-3* MONOS-2* . CT Abd- 1. Extremely limited study due to lack of intravenous contrast [**Doctor Last Name 360**]. Massive ascites as seen previously. No evidence of bowel obstruction. Marked cirrhosis and splenomegaly and evidence of portal hypertension. Please note that evaluation of the liver lesions islimited. . CXR- There has been interval placement of NG tube with tip in the stomach. Again seen are low lung volumes, however, the lungs are otherwise clear. The cardiac and mediastinal contours are stable, accounting for patient rotation. There has been no other significant interval change. Brief Hospital Course: In the MICU, the patient did not respond to fluid boluses and was placed on pressors. Lactate was 6. He was found to have gram negative bacteremia with pan-sensitive klebsiella (2/4 bottles from [**2-26**]) and SBP also with klebsiella in [**1-12**] bottles on [**2-26**]. he was treated with ciprofloxacin and albumin. CXR unremarkable. He became hemodynamically stable and was taken off pressors on [**2-28**]. He was noted to have large ascites on CT but team was only able to take off 0.5L fluid on [**2-28**] due to clotting of paracentesis catheter. He was given albumin, platelets, and ffp post paracentesis. Blood Pressure has remained stable. Hematocrit dropped from 29 on [**2-28**] to 26 on [**3-1**], while it was 31 on admission. Platelets have steadily declined from 61 on admission to 25 on [**3-1**]. INR remained elevated around 2.0. Renal failure improved from Cr 2.7 to 0.7. LFTs prominent for t bili of 9 AST/ALT of 84/50. The patient was transferred to the floor on [**2149-3-1**], and d/c home cmo on [**2149-3-10**]. # Sepsis/Hypotension: Pt presented with a clogged NG tube as well as abdominal pain. His hypotension was likely secondary to a combination of dehydration and septic shock. He was found to be hypotensive, with elevated lactate. Therefore he was given aggressive IVF's. A central line was placed and he was transiently started on dopamine. We held his nadolol. [**Last Name (un) **] stimulation test demonstrated a cortisol level of 99, therefore he was not started on steroids and was quickly weaned off pressors. Pressure slowly responded to this regimen. He was pan cultured and started on broad spectrum antibiotics. Paracentesis and ascites laboratories were consistent with SBP. He grew out gram negative rods from both his ascitic fluid and blood. The cultures were positive for Klebsiella, pan-sensitive. He was initially on ceftriaxone but this was changed to ciprofloxacin due to propensity for Klebsiella to develop into ESBL with 3rd generation cephalosporins. Repeat paracentesis showed WBC trending down in fluid. Ciprofloxacin was switched to PO and the patient developed leukocytosis in both peripheral blood and ascitic fluid. He was put back on IV cipro, then on zosyn and vancomycin as ascitic fluid results became available. The next paracentesis showed fewer numbers of WBCs. The patient remained afebrile during these episodes, and his CXR showed only small lung volumes. Antibiotics were d/c when he was made cmo on [**2149-3-9**]. . #Abdominal Pain: Likely secondary to distention from large volume ascites and SBP. We continued him on lactulose and rifaximin and treated his SBP. In the MICU we attempted a large therapuetic tap however was only able to drain 500cc due to the fibrous nature of the ascitic fluid and clogging of the tubing. However on the floor therapeutic taps yielded 5-6 Liters regularly. Ascitic fluid analysis [**2-26**] with SAAG elevated at 2.6, LDH elevated at 125, and WBC 5250 with >90% neutrophils consistent with bacterial peritonitis. Repeated paracentesis on [**2-28**] with decrease in WBC to 3000 WBC but persistent left shift with >90% neutrophils. GNR in ascites fluid speciated as pan-sensitive Klebsiella; continued to grow on peritoneal culture from [**2-28**]. Given pt's previous paracentesis 1 week prior to this admission and subsequent colonoscopy, there was a question of microperforation leading to secondary bacterial peritonitis (however, would have expected a polymicrobial infection in this case) vs. SBP. SBP was the most likely diagnosis. Treated with vanc/zosyn on [**2-26**] -> changed to ceftriaxone on [**2-28**] -> cipro on [**3-1**]. . #Cirrhosis: he was initially on transplant list but was deactivated due to the severity of his illness and cachexia, as well as overall poor prognosis. He did not have GI bleeding. He was not severely encephalopathic. Known portal vein thrombosis, grade I varicies and thrombocytopenia/coagulopahty. Initially held his nadolol and diuretics in the setting of sepsis, but were able to restart after resuscitation. Continued on lactulose and rifaximin. He received one unit of FFP and one unit of platelets on [**3-1**]. . #ARF: Baseline Cr of 0.7, peaked at 2.3 and subsequently returned to baseline. Likely secondary to pre-renal state in sepsis and dehydration, as resolved with fluids. He did have urinary sodium less than 10 and developed HRS. He was put briefly on octreotide and midodrine, but these medications were d/c when he was made cmo on [**2149-3-9**]. He had low UOP on [**3-3**] so foley was placed with 250 cc UOP. He was given albumin for volume expansion after each paracentesis. His renal function remained normal until discharge. . # h/o IVDU: He received methadone [**Hospital1 **]. . # PANCYTOPENIA: He had h/o thrombocytopenia and coagulopathy secondary to liver disease and splenomegaly. His Hct remained stable throughout this hospitalization. . # FEN: He was malnourished and cachectic; has had feeding tube in place as outpatient but tube was clogged on admission and was pulled in the ICU. A NJ was endoscopically placed on [**3-4**]. Tube feeds were poorly tolerated by the patient. He also maintained PO intake . # PPX: Pneumoboots, PPI, bowel regimen (lactulose) . # CODE: FULL code initially, changed to CMO, DNR-DNI on [**2149-3-9**] according to the patient's wishes. . # DISPO: Home by ambulance [**2149-3-10**] with home hospice arranged, comfort measures only as arranged with wife and patient. Medications on Admission: 1. Docusate Sodium 100 mg Capsule [**Hospital1 **] 2. Rifaximin 400 mg TID 3. Methadone 45 mg QD 4. Alprazolam 0.5 mg [**Hospital1 **] 5. Nadolol 20 mg QD 6. Spironolactone 100 mg QD 7. Furosemide 40 mg QD 8. Lactulose 10 g/15 mL TID 9. Omeprazole 20 mg QD 10. Vitamin D 600mg [**Hospital1 **] Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO Q 1 hr as needed for respiratory distress, pain. Disp:*90 mL* Refills:*0* 2. Ativan 1 mg Tablet Sig: 0.5 - 2 Tablet PO every 4-6 hours as needed for anxiety, restlessness, nausea, vomiting. Disp:*30 Tablet(s)* Refills:*0* 3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch Transdermal every seventy-two (72) hours as needed for airway secretions. Disp:*6 Patch * Refills:*0* 4. Levsin/SL 0.125 mg Tablet, Sublingual Sig: 1-2 tablets Sublingual every 4-6 hours as needed for increased airway secretions. Disp:*10 cc* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Primary diagnosis: SBP Bacteremia Acute renal failure End stage liver disease Hypoxic respiratory failure . Secondary diagnosis: Cirrhosis Hepatitis C Anxiety/depression Discharge Condition: Fair. Being discharged home with hospice. Currently on oxygen. Discharge Instructions: You were admitted and found to have SBP and acute renal failure. You were in the ICU and were treated with medications to support your blood pressure and antibiotics to treat your infection. You were then transferred to the floor once you were stable. You underwent endoscopic placement of an NJT for feeding. You also underwent multiple paracenteses to try to control your ascites, with minimal improvement. Your ascites worsened to the point where it compromised your respiratory function. You discussed your status with Dr. [**Last Name (STitle) 497**] and decided to stop treatment and become comfort measures only. You were discharged home with hospice care. . Please take all medications as advised by hospice. If you have any concerns about medications or symptoms, please call the hospice nurses. Followup Instructions: For any questions or concerns, please call your hospice nurse or Dr. [**Last Name (STitle) 497**].

[ "518.82", "995.92", "276.51", "570", "571.2", "572.4", "452", "284.8", "070.70", "038.49", "286.7", "304.73", "996.59", "261", "567.29", "303.93", "E879.8", "584.9" ]

icd9cm

[ [ [] ] ]

[ "00.17", "99.07", "54.91", "99.05", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

10014, 10065

3546, 9050

339, 395

10279, 10344

2228, 3523

11197, 11299

1879, 1883

9395, 9991

10086, 10086

9076, 9372

10368, 11174

1898, 2209

275, 301

423, 1314

10215, 10258

10105, 10194

1336, 1605

1621, 1863

3,579

191,345

30478

Discharge summary

report

Admission Date: [**2127-4-5**] Discharge Date: [**2127-4-5**] Date of Birth: [**2077-1-22**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2704**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization [**2127-4-5**] History of Present Illness: 50yo M smoker with h/o asthma and fam hx of premature MI p/w to [**Location (un) **] with acute onset of [**3-29**] dull midsternal chest pain at 11 am associated with shortness of breath while working which became progressively worse throughout the day. He finally presented to [**Location (un) **] at 8 PM, and ECG showed ST elevation inferiorly and was started on Aggrastat, heparin, plavix 600mg, lopressor, morphine and nitroglycerin gtt. Chest pain relieve when received meds at [**Location (un) **]. Then, he was transferred to [**Hospital1 18**] for cardiac intervention given his risk factors and ECG changes. He has not seen any physicians in 5 years and takes no medications. His chest pain a lot his previous heartburn but OTC antiacid gave no relief. . Cath revealed R dominant, nomral LV systolic function. Normal LMCA, minimal LAD, Lcx, and RCA and was diagnosed with pericarditis. Because there is no bed in the hospital, pt is admitted to the CCU for observation. . Denies any chest pain, sob currently. Past Medical History: Asthma Social History: Smokes 1.5 ppd currently. Drinks 4-5 beers per day. Family History: + family history of premature coronary disease. Father died age 52. No history of sudden death. Physical Exam: VS - 98.3, 94, 138/86, 20, 95% on 5L 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 difficult to assess due to supine postion s/p cath. 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. Mild diffuse wheezes anteriorly. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ R sheath getting pulled currently Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [**2127-4-5**] 02:57AM PT-12.6 PTT-32.8 INR(PT)-1.1 [**2127-4-5**] 02:57AM PLT COUNT-202 [**2127-4-5**] 02:57AM WBC-11.5* RBC-4.96 HGB-15.1 HCT-42.6 MCV-86 MCH-30.4 MCHC-35.4* RDW-14.0 [**2127-4-5**] 02:57AM NEUTS-68.7 LYMPHS-24.3 MONOS-5.2 EOS-1.6 BASOS-0.3 [**2127-4-5**] 02:57AM TRIGLYCER-164* HDL CHOL-50 CHOL/HDL-4.5 LDL(CALC)-144* [**2127-4-5**] 02:57AM CK-MB-3 [**2127-4-5**] 02:57AM ALT(SGPT)-43* AST(SGOT)-20 LD(LDH)-142 CK(CPK)-102 ALK PHOS-95 TOT BILI-0.9 [**2127-4-5**] 02:57AM GLUCOSE-96 UREA N-10 CREAT-0.7 SODIUM-135 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-26 ANION GAP-12 . Cardiac Catheterization [**2127-4-5**]: **preliminary report** revealed R dominant, nomral LV systolic function. Normal LMCA, minimal LAD, Lcx, and RCA . Echocardiogram [**2127-4-5**]: 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 with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . CXR Pa/L [**2127-4-5**]: **preliminary report** The heart, lungs and mediastinum are within normal limits. No evidence of focal consolidation, effusion, or CHF. Brief Hospital Course: The patient is a 50 yo M with a family hx of premature coronary disease, current tobacco use, presents with chest pain with ECG showing ST elevations, found to have minimal coronary disease on cardiac cath . 1) Chest pain: C.Cath revealead minimal disease in LAD, LCX, RCA. No significant CAD to suggest coronaries as a culprit. Etiology was felt to be likely pericarditis vs Asthma exacerbation. TTE with minimal LVH, normal valves and EF, and physiologic pericardial effusion. Pa/L CXR was negative for pneumonia. The patient was given ibuprofen and nebs for asthma. He was counseled to quit smoking and expressed a plan to stop. He will follow up with his primary care physician. . 2) RHTYHM- NSR. no acute issues . 3) PUMP- no acute issues, euvolemic. Echo was done and was essentially normal. . 4) Asthma: Pt with a history of Asthma but has not seen a physician [**Last Name (NamePattern4) **] 5 years. O2 saturation was initially 87% on room air, but inproved to 94% on room air after several albuterol and ipratropium nebulizer treatments. Peak flow was 225 initially but improved to 350 by the time of discharge. He was started on a short course of steroids, 40mg prednisone x 5 days. He will be discharged with a prescription for albuterol inhaler, and follow up with his primary care physician. [**Name10 (NameIs) **] was strongly encouraged to quit smoking. . 5) FEN- cardiac diet. He received fluids post catheterization. . 6) PPX: Pneumoboots and then ambulation. Bowel regimen. Po intake. . CODE: FULL Medications on Admission: None Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puffs Inhalation four times a day as needed for shortness of breath or wheezing: For the next 3 days, use your inhaler four times a day. Disp:*2 inhalers* Refills:*1* 2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*30 Patch 24HR(s)* Refills:*2* 3. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 4 days. Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Chest pain, non-coronary 2. Asthma exacerbation 3. Possible pericarditis Discharge Condition: Stable, saturating well on room air. Discharge Instructions: You were admitted with chest pain which is NOT felt to be due to a blockage in your heart. Your cardiac catheterization revealed minimal disease in your coronary arteries. The pain you were feeling is most likely due to an Asthma exacerbation or some mild inflammation in the lining around your heart. . Please take your medications as directed. You are strongly encouraged to stop smoking. . Please be sure to call your primary care physician for an appointment in one week. . Call your doctor or return to the hospital if you have worsening chest pain, bleeding from the site of the catheterization, shortness of breath, or any other symptom that concerns you. Followup Instructions: Please call your primary care physician ([**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 2479**], phone [**Telephone/Fax (1) 72414**]) for a follow up appointment in 1 week. Completed by:[**2127-4-5**]

[ "420.90", "305.1", "V17.3", "786.50", "305.00", "493.92" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.53", "88.56" ]

icd9pcs

[ [ [] ] ]

6288, 6294

4228, 5761

305, 345

6414, 6453

2544, 4205

7167, 7389

1516, 1615

5816, 6265

6315, 6393

5787, 5793

6477, 7144

1630, 2525

255, 267

373, 1400

1422, 1430

1446, 1500

82,222

151,125

48546

Discharge summary

report

Admission Date: [**2129-12-7**] Discharge Date: [**2129-12-18**] Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 86 yo female with a history of vascular dementia, HTN, HLD, recurrent UTIs presents from home with altered mental status and hypoxia. The patient was found by her VNA today to be more confused than normal. Per her daughter, she can get confused easily with UTIs. VNA found her to be hypoxic to the 80s thus called EMS. . In the ED, initial vs were 99.2 84 118/74 40 97% 15. On exam, the patient was confused, combative, crackles bilaterally, old healing superficial lacerations around ankle (concerning for elder abuse) guaiac positive with vesicles on her rectum. She was placed on a non-rebreather with improvement of O2 sat to 96-97% (Pa02 89). CXR revealed bilateral infiltrates concerning for pulmonary edema vs. multifocal pneumonia. Initially the patient was treated for pulmonary edema with nitroglycerin drip and lasix 80mg IV. Her blood pressures dropped to the 90s systolic. Labs then returned with non-elevated BNP (although no prior) so she was treated empirically for hospital associated pneumonia with vanco/levofloxacin/zosyn. Her labs were significant for leukocytosis (with a left shift), hemolyzed specimen, hyponatremia, normal lactate, normal pH, negative UA, blood and urine cultures were sent. Her mental status improved and oxygen saturation stabilized so the decision was made not to intubate her at this time. She received a total of 2L NS. On transfer VS 77 116/90 22 99% on NRB. She is a full code confirmed by the patient's daughter in the [**Name (NI) **]. . On the floor, patient did not complain of any pain. She denied SOB. She did not want her daughters to leave. . Review of systems: Obtained via daughters who denied sick contacts although patient spends days at adult day care so could have been exposed, denies fevers. + for cough over the last week. Past Medical History: HTN hypercholesterolemia arthritis glaucoma h/o colon polyps h/o pulmonary nodule GERD h/o pancreatitis osteopenia anxiety Social History: Lives in [**Hospital3 **]; attends elderly day care. Son and daughter nearby and help with shopping. No tobacco, occ EtOH. Family History: noncontributory Physical Exam: Vitals: Tmax: 35.1 ??????C (95.1 ??????F) Tcurrent: 35 ??????C (95 ??????F) HR: 81 (80 - 99) bpm BP: 108/64(76) {93/52(66) - 108/80(83)} mmHg RR: 28 (16 - 32) insp/min SpO2: 93% Heart rhythm: SR (Sinus Rhythm) General: Alert, oriented, no acute distress but upset when her daughters try to leave [**Name (NI) 4459**]: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diminished BS bilaterally with crackles on right side. UInable to auscultate posteriorly. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops but difficult exam because patient yelling for daughters 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: I. Microbiology [**2129-12-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2129-12-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2129-12-9**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2129-12-8**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT [**2129-12-7**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2129-12-7**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2129-12-7**] URINE URINE CULTURE-FINAL {KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **] [**2129-2-7**] 7:50 pm URINE Site: CATHETER **FINAL REPORT [**2129-12-9**]** URINE CULTURE (Final [**2129-12-9**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2129-12-7**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] II. Radiology A. CT Chest IMPRESSION: Central extensive symmetric consolidation with associated traction bronchiectasis and volume loss. The appearance is suggestive of cryptogenic organizing pneumonia or chronic eosinophilic pneumonia, an infectious etiology is less likely. B. CXR ([**2129-12-12**]) FINDINGS: In comparison with the study of [**12-11**], there is persistent diffuse bilateral pulmonary opacifications consistent with the CT appearance of widespread symmetric consolidations. Moderate enlargement of the cardiac silhouette and small left effusion persist. III. Labs A. Admission [**2129-12-7**] 07:45PM BLOOD WBC-17.8*# RBC-5.34# Hgb-14.8 Hct-43.9 MCV-82# MCH-27.8 MCHC-33.8 RDW-14.3 Plt Ct-441*# [**2129-12-7**] 07:45PM BLOOD Neuts-76.2* Lymphs-14.8* Monos-4.3 Eos-4.1* Baso-0.7 [**2129-12-7**] 07:45PM BLOOD PT-14.7* PTT-33.0 INR(PT)-1.3* [**2129-12-7**] 07:45PM BLOOD Glucose-96 UreaN-30* Creat-1.3* Na-126* K-7.3* Cl-91* HCO3-25 AnGap-17 [**2129-12-8**] 04:28AM BLOOD ALT-16 AST-25 AlkPhos-46 TotBili-0.8 [**2129-12-7**] 07:45PM BLOOD cTropnT-<0.01 proBNP-555 [**2129-12-8**] 04:28AM BLOOD Albumin-3.4* Calcium-8.4 Phos-3.8 Mg-1.8 [**2129-12-7**] 09:09PM BLOOD Type-ART pO2-89 pCO2-35 pH-7.46* calTCO2-26 Base XS-1 [**2129-12-7**] 07:55PM BLOOD Lactate-1.5 K-5.7* Brief Hospital Course: Hospital course: 86-year-old female with history of vascular dementia, hypertension, hyperlipidemia, recurrent UTIs that presented with altered mental status and hypoxia with imaging suggesting non-infectious pneumonia with extensive symmetric consolidation. Hospital course complicated by agitation likely secondary to hypoxemia with respiratory distress and delirium in setting of underlying dementia. . #Hypoxemic respiratory distress: Patient had likely multifocal pneumonia on chest CT suggestive of cryptogenic organizing pneumonia or chronic eosinophilic pneumonia. Of note, the patient has no home oxygen requirement and no prior pulmonary issues with prior imaging reviewed with no apparent pathology related to current episode. She was treated empirically with a brief course of vancomycin, zosyn with negative infectious work-up for pulmonary process. She was also placed on high-dose steroids for ? pulmonary fibrosis (?cryptogenic organizing pneumonia or chronic eosinophilic pneumonia) with poor response. In early morning of [**12-12**], patient agitated with desaturations to low 80s despite maximal oxygen therapy. Patient eventually became less agitated with morphine and zydis but may have had component of aspiration and flash pulmonary edema worsening already poor respiratory status. After ongoing discussions with family, it was decided to start her on a morphine drip and focus on comfort. She expired on the morning of [**2129-12-18**]. . # Agitation: Patient at baseline with moaning as primary communication in setting of dementia. Patient had issues with agitation throughout hospitalization likely given elderly, dementia at baseline, Russian-speaking, and in unfamiliar environment with likely some contribution from hypoxemia. She was continued on aricept and sertraline. In addition to medical therapy with ativan, zydis, and morphine, attempts made to frequently re-orient and family visitations. . # Goals of care Given patient's comorbidities and poor response to steroids for inflammatory pneumonia, family decided to change patient's code status to DNR/DNI. Palliative care consulted, eventually transitioned to comfort measures. . # Leukocytosis Patient with marked leukocytosis with negative infectious work-up except UTI and negative C. diff x 3. Favored likely secondary to steroid therapy. Leukocytosis eventually trended downward. . # K. Pneumoniae urinary tract infection Patient was treated with ciprofloxacin for 7-day course. Medications on Admission: Aricept 5 mg Tab QHS Vit D 3 1000mg daily M-Vit 27 mg-1 mg daily Tricor 48 mg daily Timolol 0.5 % Eye Gel 1 drop(s) both eyes q AM Simvastatin 20 mg once a day Ranitidine 150 mg by mouth qd to [**Hospital1 **] prn Metoprolol tartrate 25mg [**Hospital1 **] lorazepam 0.5 mg [**Hospital1 **] nitrofurantoin 50 mg QHS sertraline 50 mg Daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

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36523

Discharge summary

report

Admission Date: [**2158-3-18**] Discharge Date: [**2158-4-22**] Date of Birth: [**2096-1-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3913**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Thoracentesis Chest Tube Placement History of Present Illness: 62 year old male with a history of refractory biphenotypic leukemia, disseminated fusarium [**First Name3 (LF) 2**], on chemo and with neutropenia, recent enterococcal empyema finishing treatment with long course of vancomycin through PICC line, now presents with worsening [**First Name3 (LF) **] and fevers to 102. Over the past 2 months he has been at home, able to walk many blocks without dyspnea; he has been eating and drinking well, without nausea, vomiting, diarrhea, chest pain, shortness of [**First Name3 (LF) 1440**], headache or malaise. Mild sore throat, but no [**First Name3 (LF) **] or other URI symptoms. No myalgias or joint pain. On the evening of this admission, he developed chills and his wife took his temperature and found it to be 101, rising later to 102.5. He called his oncologist who recommended he go to the ED. He denied any other symptoms at this time. . He has a history of biphenotypic leukemia currently on dacogen (last administration on [**3-17**]) who continues to be transfusion dependent with blasts in periphery, neutropenia, and thrombocytopenia. He has also had multiple complications secondary to his leukemia including congestive heart failure, recurrent pleural and pericardial effusions, and infectious complications including disseminated fusarium which is currently controlled. His IV vancomycin course for enterococcal empyema was due to complete on [**3-16**]. . In the ED he received 2 L of fluid; his atrial fibrillation was at a rate of 100-120. He was initially on a non-rebreather but was quickly weaned off. Chest x-ray was obtained which revealed bibasilar opacities. He was transferred to the MICU for further management. Past Medical History: Hematologic History: 1) followed since [**2154**] for an autoimmune pancytopenia treated with steroids and IVIG. 2) In [**3-/2157**] his cytopenias worsened and he was noted to have about 90% blasts and he was transferred to [**Hospital1 18**]. Preliminary bone marrow biopsy was suspicious for a biphenotypic leukemia 3) therapy was initiated with hyperCVAD. His day 14 marrow showed persistent disease 4) Regimen was changed to 7+3. Day 14 and 2 subsequent marrows all continued to show persistent involvement with leukemia. 5) Further chemotherapy was held as MR. [**Known lastname 1005**] was found to have disseminated fusarium [**Known lastname 2**] in the setting of prolonged neutropenia and was treated with a prolonged course of AmBisome with voricoanzole before transitioning to voriconazole alone. 6) He has subsequently been treated with Dacogen with refractory disease; 7) He has had several admissions for pericardial effusions with tamponade physiology, treated medically; 8) He has had periodic pleural effusions requiring thoracentesis with transudative to exudative chemistries; cell blocks and flow cytometry have not been suggestive of leukemic infiltration, and work up for infectious causes including viral, fungal and AFB have remained unrevealing. 9) admission for VRE bacteremia presumed to be of line origin though line tip cultures were unrevealing and completed a prolonged course of linezolid. 9) admission in late [**Month (only) 956**] 2012for acute shortness of [**Month (only) 1440**], fevers and found to have an enterococcal empyema. 10) Prior HBV [**Month (only) 2**], on lamivudine prophylaxis. Other Medical History: 1. Biphenotypic leukemia CLL/AML (s/p hyper [**Last Name (LF) **], [**First Name3 (LF) **]/Ara, MEC, two cycles of Decitabine) 2. Autoimmune pancytopenia 3. Disseminated fusarium [**First Name3 (LF) 2**], treated with Ambisome and Voriconazole for four and half months. Ambisome was stopped on [**10-20**]. Last voriconazole level was 1.0 on [**10-8**] 4. HBV, on Lamivudine 5. VRE bacteremia/cellulitis 6. Pericardial effusion of unknown etiology 7. s/p appendectomy 8. s/p umbilical hernia repair 9. a-fib, MVR Social History: Currently on disability. Wife is a retired physician. [**Name10 (NameIs) **] from [**Country 5976**]. Nonsmoker, no EtOH, no IVDU. Family History: One brother died of ALL. Denies DM, CAD, strokes, other CAs. Physical Exam: GEN: Cachectic appearing man in NAD [**Country 4459**]: [**Country 3899**], NCAT, temporal wasting, MMM, no mucositis or thrush Neck: Supple CV: Irreg/irreg, normal s1/s2, no s3/s4, no m/r/g PULM: Rales at the bases, diminished [**Country 1440**] sounds in dependent lung fields, no wheezes, no increased WOB, no accessory muscle use ABD: Flat, soft, NTND, NABS, no rigidity, rebound or guarding EXT: WWP, no c/c/e NEURO: A/O x3, CN II-XII intact, sensory and motor exam non focal Pertinent Results: Admission Labs: [**2158-3-18**] 01:30AM [**Month/Day/Year 3143**] WBC-5.4# RBC-3.17* Hgb-9.1* Hct-27.3* MCV-86 MCH-28.6 MCHC-33.3 RDW-13.9 Plt Ct-12* [**2158-3-18**] 01:30AM [**Month/Day/Year 3143**] Neuts-0* Bands-0 Lymphs-4* Monos-0* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Promyel-0 Blasts-96* [**2158-3-18**] 09:47AM [**Month/Day/Year 3143**] PT-18.8* PTT-34.4 INR(PT)-1.8* [**2158-3-29**] 12:00AM [**Year/Month/Day 3143**] Fibrino-384 [**2158-3-26**] 12:00AM [**Year/Month/Day 3143**] Gran Ct-140* [**2158-3-18**] 01:30AM [**Month/Day/Year 3143**] Glucose-120* UreaN-28* Creat-0.9 Na-138 K-4.8 Cl-103 HCO3-25 AnGap-15 [**2158-3-18**] 09:47AM [**Month/Day/Year 3143**] ALT-89* AST-122* LD(LDH)-330* AlkPhos-144* TotBili-0.5 [**2158-3-18**] 01:30AM [**Month/Day/Year 3143**] Calcium-8.6 Phos-3.6 Mg-1.8 [**2158-3-18**] 09:47AM [**Month/Day/Year 3143**] Cortsol-31.4* Discharge Labs: [**2158-4-22**] 12:00AM [**Month/Day/Year 3143**] WBC-0.4* RBC-2.27* Hgb-6.7* Hct-19.1* MCV-84 MCH-29.4 MCHC-35.0 RDW-13.7 Plt Ct-22* [**2158-4-22**] 12:00AM [**Month/Day/Year 3143**] Neuts-0 Bands-0 Lymphs-23 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-77* [**2158-4-22**] 12:00AM [**Month/Day/Year 3143**] PT-14.6* PTT-33.5 INR(PT)-1.4* [**2158-4-22**] 12:00AM [**Month/Day/Year 3143**] Plt Smr-VERY LOW Plt Ct-22* [**2158-4-22**] 12:00AM [**Month/Day/Year 3143**] Glucose-125* UreaN-17 Creat-0.7 Na-135 K-4.4 Cl-100 HCO3-28 AnGap-11 [**2158-4-22**] 12:00AM [**Month/Day/Year 3143**] ALT-32 AST-20 AlkPhos-110 TotBili-0.3 CXR [**2158-4-20**] Stable chest findings, there is no evidence of new pulmonary parenchymal infiltrates as can be excluded on this single AP portable chest view examination. [**2158-3-28**] CT CHEST 1. Multiloculated, bilateral, pleural effusion, with the largest individual collection in the right lower lung with enhancing visceral pleura which is concerning for empyema. This largest collection has decreased in size since [**2158-3-20**] and may be related to prior thoracocentesis (PER OMR). Second largest loculated collection on right side along the paramediastinal aspect has increased, while on the left side is overall unchanged, except in the left lung apex where it shows minimal interval decrease. 2. Right lower lung pneumonia. 3. Borderline sized and other smaller mediastinal lymph nodes, unchanged since [**2158-3-20**]. 4. Splenomegaly [**2158-3-21**] ECHO The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Primary Reason for Admission: 62 yo M with a history of biphenotypic leukemia, disseminated fusarium [**Month/Day/Year 2**], recent diagnosis of enterococcal empyema, admitted to MICU green with septic shock and GNR bacteremia growing E.Coli. Then transferred to BMT service. # Septic Shock ?????? [**Month/Day/Year **] cultures grew E. coli on [**3-18**]. Initially was febrile and hypotensive requiring MICU admission. He was covered with broad spectrium antibiotics which were narrowed to meropenem. When pressures improved he was transferred to BMT service. He was continued on Linezolid (recent Enterococcal empyema, concern for VRE), Meropenem (E Coli sepsis) and Voriconazole (disseminated fusarium). Prior to discharge, he was given a single dose of Ertapenem. He will have VNA services at home and will continue [**Last Name (un) **]/Erta/Vori for at least 2 weeks. He will follow up with [**Hospital 3242**] clinic [**2158-4-24**]. . # Pleural effusions - He had bilateral pleural effusions, with left greater than right as well as significant ascites. His left effusion was tapped by IP, and pleural fluid showed no growth. A chest tube was kept in place to allow for drainage until it stopped. Effusions remained but they were loculated and could not be drained further. He was aggressively diuresed with IV lasix, and his dyspnea improved significantly. He was then switched to maintenance dosing of PO lasix. He was switched from Vanc to Linezolid for treatment of known Enterococcal empyema due to concern for VRE. . # Biphenotypic Leukemia - His leukemia is treatment refractory, after receiving hyperCVAD, decitabine, MEC and dacogen. He remained pancytopenic requiring [**Month/Day/Year **] and platelet transfusions nearly daily. His blast count began to climb, with WBC count up to 6000 with 60+% blasts. He was started on hydrea with improvement of blast counts. His dose was eventually lowered to 500mg daily where he was maintained. He was transfused 1U pRBC and 1U platelets the day of discharge. He will follow up with [**Hospital 3242**] clinic on [**2158-4-24**] for count check and PRN transfusions. . # Atrial fibrillation ?????? History of paroxysmal atrial fibrillation. Rate control difficult in ICU, with hypotension on beta blockade requiring pressors. On transfer to BMT he was kept on digoxin, metoprolol and diltiazem with a heart rate in the low 100s. His BP on the BMT service was 90s/50s, occasionally in the 80s while sleeping. However, he was never symptomatic from his hypotension. Pt requested 50mg Metoprolol Succinate [**Hospital1 **] instead of 100mg po qday at time of discharge. . # Hepatitis B - Continued on Lamivudine . Transitional Issues: Pt spiked a fever to 100.4 the evening before discharge. However, the patient and his wife continued to express a clear desire to go home. Per pt and his wife, if his health deteriorates at home, they will initiate home hospice. Bridge to hospice was arranged. He will have counts check in [**Hospital 3242**] clinic on [**2158-4-24**]. Medications on Admission: ACYCLOVIR - (Dose adjustment - no new Rx) - 400 mg Tablet - 1 (One) Tablet(s) by mouth three times a day DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day DILTIAZEM HCL - 120 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) Solution - 1 Solution(s) inhaled every four (4) hours as needed for shortness of [**Date Range 1440**] or wheezing LAMIVUDINE [EPIVIR HBV] - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) LEVOFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth every twenty-four(24) hours LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth every four (4) hours as needed for nausea/anxiety/insomnia METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day OXYCODONE - 5 mg Tablet - [**11-21**] Tablet(s) by mouth every four (4) hours as needed for pain RAISED TOILET SEAT - - ICD9: 208.0 SHOWER RAIL - - ICD9: 208.0 SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day VANCOMYCIN - (Prescribed by Other Provider) - 500 mg Recon Soln - 1 Recon(s) twice a day VORICONAZOLE - (Dose adjustment - no new Rx) - 200 mg Tablet - 1.5 (One and a half) Tablet(s) by mouth every twelve (12) hours Medications - OTC MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. oxygen 2-4L continuous, pulse dose for portability dx: VRE empyema and PNA 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every four (4) hours as needed for shortness of [**Month/Day (2) 1440**]. Disp:*180 neb* Refills:*0* 4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 5. DILT-XR 120 mg Capsule,Ext Release Degradable Sig: One (1) Capsule,Ext Release Degradable PO once a day. Disp:*30 Capsule,Ext Release Degradable(s)* Refills:*0* 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 10. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 11. ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection once a day. Disp:*30 Recon Soln(s)* Refills:*0* 12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. Disp:*180 Tablet(s)* Refills:*0* 13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*300 Tablet(s)* Refills:*0* 14. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 15. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 17. benzonatate 100 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:*30 Capsule(s)* Refills:*0* 18. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Disp:*180 Tablet(s)* Refills:*0* 19. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 20. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO twice a day. Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Praimry Diagnoses: E Coli Sepsis VRE Emypema [**Hospital1 **]-Phenotypic Leukemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 1005**], It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for a serious [**Hospital1 2**] in your [**Hospital1 **]. We treated you with antibiotics and anti-fungal medications and you improved. In accordance with your wishes, you will return home with VNA care. During this admission, we made the following changes to your medications: STARTED Ertapenem STARTED Linezolid STARTED Hydroxyurea STARTED Omeprazole STARTED Benzonatate STARTED Zofran STOPPED Levofloxacin It will be important for you to keep your BMT appointment to have your [**Hospital1 **] and platelets checked. Thank you for allowing us to participate in your care. Followup Instructions: Department: BMT/ONCOLOGY UNIT When: MONDAY [**2158-4-24**] at 10:00 AM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[ "34.04", "38.93", "34.91", "99.25" ]

icd9pcs

[ [ [] ] ]

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74,955

189,532

51334

Discharge summary

report

Admission Date: [**2201-5-21**] Discharge Date: [**2201-5-24**] Date of Birth: [**2115-1-13**] Sex: M Service: SURGERY Allergies: Indomethacin Attending:[**First Name3 (LF) 1390**] Chief Complaint: Abdominal Pain, nasuea, cessation of bowel function Major Surgical or Invasive Procedure: R / L abdominal drain placed under CT guidance [**2201-5-22**] History of Present Illness: Pt is an 86M with a hx of gastric cancer who is known to the ACS service after undergoing exploratory laparotomy, partial transverse colectomy, resection of prior gastrojejunostomy, Billroth II anastomosis w/roux-en-y reconstruction and feeding jejunostomy replacement for residual gastric cancer that had caused a GI bleed and transverse colonic perforation & abscess by Dr. [**Last Name (STitle) **] on [**2201-4-30**]. He was discharged in good condition to rehab on [**2201-5-8**] and was seen in clinic on [**2201-5-14**]. He has continued to have some R-sided abdominal pain and nausea and he presents today from rehab with one episode of emesis yesterday and 3d hx of constipation, for which he was given a suppository at rehab. He did prodice a small stool from the suppository but has not pass flatus in 3d. Pt reports that he has been in pain since [**4-30**] and is nauseated every day. He endorse poor appetite. He denies CP/SOB. Past Medical History: Past Medical History: gastric cancer, GI bleeds, severe AS, cholangitis s/p sphincterotomy w/ stenting ([**2189**]), CAD with NSTEMIs in [**2181**] and [**2199**], CVA in [**2195**], HTN, dyslipidemia, BPH, gout, anemia, dysphagia resulting from prolonged intubation in [**2200**] after emergent aortic valvuloplasty Past Surgical History: exploratory lap, resection of prior GJ and BII anastamosis, roux-en-y with partial transverse colectomy and feeding J-tube placement ([**Doctor Last Name **] - [**2201-4-30**]), partial gastrectomy and BII ([**2178**]), aortic valvuloplasty ([**2201-1-8**]), CABG Social History: Romanian-Russian. He is married lives with wife who is 84 yo. He has 2 [**Month/Day/Year **], [**Name (NI) 24006**] (HCP) who helps with care and [**Name (NI) **]. Had recent VNA which he has been refusing help and tube feeds. Has 40+ pack-year hx, quit [**2179**]. Since [**2201-1-23**] D/C (for severe ARDS requiring emergent valvuloplasty of AS) has been at [**Hospital1 1501**] and walking independently with walker and close supervision. Family History: Father died of MI and age 78 Mother died of liver cancer at age 81 Physical Exam: Physical Exam on Admission: Vitals: T 98.8; HR 72; BP 124/54; RR 24; POx 100% on 3LNC GEN: Thin elderly gentleman, NAD HEENT: No scleral icterus, mucus membranes dry CV: RRR, 4/6 SEM PULM: Coarse/rhonchorous b/l throughout lung fields ABD: Grossly distended, tympanic R>L, exquisitely TTP R abdomen w/tenderness to light percussion, no rebound or guarding, absent bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood, no formed stool in vault, minimal liquid stool Pertinent Results: ADMISSION LABS: - CBC: 10.9 > 34.1 < 322 ∆ [N:87.7 L:5.8 M:5.6 E:0.4 Bas:0.4] 139 / 102 / 32 - Chem: ---------------< 113 5.0 / 27 / 1.0 - Lactate: 1.9 - UA: ?UTI MICRO: Urine ([**5-21**]): mixed flora c/w fecal contamination Blood ([**5-21**]): pending R abdominal drain ([**5-22**]): Gram stain 4+ PMN, GPR, GNR, GPC in pairs, chains and clusers, cx pending L abdominal drain ([**5-22**]): Gram stain 4+ PMN, no micro-organisms, cx pending IMAGING: CT pelvis w/ contrast ([**5-21**]): 1. massive extraluminal air/fluid/foodstuffs collections, - likely communicating throughout abdomen, largest anteriorly in RUQ with perihepatic extension - the collections have a defined enhancing capsular margin suggesting an element of organization and therefore chronicity - enteric contrast opacifies continuously from tiny gastric remnant pouch through G-J and J-J anastomoses (widely patent) throughout remaining SB to cecum w/o evidence for extravasation - site of perforation/fistulazation not identified though small discontuity suggested in anterior mid transv colon (300b:40) which may be site of contained perf/fistula 2. lg bilat plerual effusion; 3. J-tube clearly intraluminal with no obvious extraluminal or intraperitoneal course; 4. enlarged prostate, lg left bladder diverticulum CT A/P non con and con through Jtube [**5-22**]: unchanged collections, no extravasation to help locate the source of the leak, contrast goes to descending colon Brief Hospital Course: - Mr [**Known lastname 2262**] presented to the [**Hospital1 18**] ED [**2201-5-21**]. He had a grossly distended abdomen and CT confirmed extra-luminal massive extraluminal air/fluid/foodstuffs collections. He was admitted to the TSICU. On admission he stated "I have come here to die. How long will it take for me to die?" Antibiotics were d/c'd overnight at request of patient. - [**5-22**]: Pt and family were initially refusing blood pressures, medications, interventions. Family wanted to take pt to hospice or home. Palliative care and SW consults were placed. After meeting with Dr. [**Last Name (STitle) **], family and patient agreed to antibiotics and drain placement. CT showed continued abdominal collections but no extravasation from anastamoses or Jtube site. R pigtail placed w/purulent output 630cc, L pigtail placed w/non-purulent output 170cc. Pt was stable overnight, BP and UOP adequate w/2 fluid boluses of 500cc for low UOP. Cr rose to 1.3 from 1.0, FeNa 0.2. Pt was agitated and confused overnight, received 1mg Haldol with good effect. He was started on trophic TFs at 10cc with blue dye to see if it exits the drains. - [**5-23**]: methylene blue from TF not seen in abd drains, decreased UOP and falling BP, given albumin in am for total of 37.5g with adequate response. PM pt had sudden onset dyspnea and hypoxia to high 70s, flash pulmonary edema on CXR, given albuterol neb, 20mg Lasix IV, placed on CPAP with improvement in oxygenation, however developed tachycardia to 150s and CP, EKG with sinus tach, no acute ischemia apparent, also given morphine and haldol, patient's daughter arrived and after discussion it was decided to make CMO. He expired 5min after comfort measures were in place. Medications on Admission: - Milk of Magnesia 400mg/5mL 30mL via J-tube prn - Remeron 15mg qHS via J-tube - finasteride 5mg daily via J-tube - Senna Powder [**Hospital1 **] via J-tube - Simvastatin 40mg daily via J-tube - metoprolol tartrate 12.5mg [**Hospital1 **] via J-tube - docusate sodium 50mg/5mL 10mL [**Hospital1 **] via J-tube - Zofran 4mg/5mL q6h prn nausea via J-tube - Albuterol sulfate q4h prn - Robitussin Chest Congestion 10mL TID x1wk - Trazodone 12.5mg [**Hospital1 **] via J-tube - Trazodone 12.5mg Q6H PRN via J Tube - Acetaminophen 1000mg TID via J Tube Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Bowel perforation s/p s/p ex-lap, resxn of prior GJ, BII anastamosis, roux-en-y w/partial transverse colectomy and feeding J-tube placement [**2201-4-30**] Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2201-5-24**]

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icd9cm

[ [ [] ] ]

[ "96.6", "54.91" ]

icd9pcs

[ [ [] ] ]

6918, 6927

4562, 6291

325, 390

7127, 7137

3059, 3059

7190, 7226

2466, 2535

6889, 6895

6948, 7106

6317, 6866

7161, 7167

1724, 1990

2550, 2564

233, 287

418, 1361

3076, 4539

2578, 3040

1405, 1701

2006, 2450

20,362

137,891

4246

Discharge summary

report

Admission Date: [**2143-12-23**] Discharge Date: [**2144-2-4**] Date of Birth: [**2093-3-10**] Sex: M Service: MICU ADMISSION DIAGNOSES: 1. Fournier's gangrene. 2. Necrotizing fasciitis. DISCHARGE DIAGNOSES: 1. Fournier's gangrene. 2. Necrotizing fasciitis. 3. Status post multiple debridements. 4. Status post multiple skin grafts. 5. Status post diverting colostomy. 6. Status post scrotal reconstruction. 7. Status post completion split thickness skin graft. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old male who was transferred from the [**Last Name (un) 4068**] with progressive right lower extremity erythema and groin induration. The patient first noticed right thigh pain on the Friday prior to admission after playing soccer with his kids. The patient reported groin and thigh pain and, on Sunday, went to [**Hospital3 1196**] where patient was ruled out for lower extremity deep venous thrombosis. He was discharged with a diagnosis of muscle strain. On [**2143-12-24**], the patient had increasing pain and swelling and was seen at the [**Last Name (un) 4068**] by his primary care physician and transferred to the [**Hospital1 69**]. In the Emergency Department of [**Hospital1 69**], the patient was evaluated with MRI and seen to have erythema in the thigh progressing to involve the scrotum and severe edema and ecchymosis as well as near necrotic appearance of the scrotum. The patient also was generally malaised. The patient was admitted for treatment of his rapidly progressing edema, ecchymosis and gangrene of his scrotal area. PAST MEDICAL HISTORY: Depression. PAST SURGICAL HISTORY: Right inguinal hernia repair with mesh. MEDICATIONS: Zoloft. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: 97.7 degrees Fahrenheit, heart rate 126, blood pressure 89/69, respirations 16, 97% on room air. Generally, the patient is a middle-aged man who appears unwell. HEENT is atraumatic, normocephalic. Pupils equal, round and reactive to light. Extraocular movements intact. Anicteric. Throat is clear. Neck is supple, midline. No masses or lymphadenopathy. Chest is clear to auscultation bilaterally. Cardiovascular is slightly tachycardic. S1, S2 are noted. There is no murmur, rub or gallop. Abdomen is soft, non-tender, non-distended. Extremities are warm, noncyanotic and nonedematous. The groin and perineal area is notable for scrotum which is edematous and ecchymotic with dark regions. Bilateral thighs are very edematous and indurated diffusely. Neuro is grossly intact. ADMISSION LABORATORIES: CBC 4.3/39.0/178 with 43% bands. Coags: PT 14.5, INR 1.4, PTT 34.2. Chemistries: 133/4.4/102/19/36/1.6/165. HOSPITAL COURSE: The patient was admitted for his aggressive and rapidly spreading cellulitis/necrotizing fasciitis. On [**2143-12-24**], the patient was taken to the Operating Room for aggressive scrotal and perineal debridement. The patient had extensive debridement performed in conjunction with the Plastic Service service, Dr. [**Last Name (STitle) **]. Postoperatively, the patient was returned to the Intensive Care Unit for close monitoring. The patient had some difficulties with metabolic acidosis and was maintained on a bicarb drip as well as multiple pressors. Approximately 12 hours later, the patient was taken back to the Operating Room for further debridement by both the Plastic Service and General Surgery services in conjunction. Again, the patient was felt to have adequate debridement, however, the debridements were taken all the way down to the muscular fascia including the right buttock area. At that point, the infection did not cross over to the left buttock or left peroneal area. The patient again was taken back to the Operating Room in very serious condition. The patient was treated with broad spectrum antibiotics and full ventilatory support as well. The Urology service was consulted and Dr. [**Last Name (STitle) 9125**], in addition, performed a cystoscopy which revealed normal appearing urethra and bladder. Necrosis was seen to have continued along the scrotum and further debridement was performed. Effort was made to preserve the testicles. The patient was returned to the Intensive Care Unit for close monitoring. The patient did have some positive developments regarding his renal function and resolution of his acidosis. Due to his improved clinical area, he was brought back for his third trip to the Operating Room on [**2143-12-26**], for further debridement. Exploration revealed minimal to no remaining necrosis. The wounds appeared fairly clean. The patient was taken to the Operating Room on [**2144-1-4**], for the first of multiple skin grafts. These were performed by the Plastic Surgery service and performed on [**2144-1-4**], [**2144-1-8**], with completion split thickness skin grafting performed on [**2144-1-22**]. In the interim, the patient had a diverting colostomy performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] of the Colorectal Surgery service on [**2144-1-8**]. This was done to divert the fecal stream as well as from potentially contaminated areas. The patient also had scrotal reconstructions performed on [**2144-1-15**], [**2144-1-17**], and [**2144-1-22**]. 1. Neurological: The patient was initially maintained under sedation and on ventilatory support in the Intensive Care Unit. He was gradually weaned appropriately off of these as his ventilatory status returned. He had no significant neurological issues through the course of his hospital stay. 2. Cardiovascular: Initially, the patient had been maintained on multiple pressors in the Intensive Care Unit and required this for hemodynamic support. He was found to be quite septic but was appropriately weaned off of these pressors and continued to do well. 3. Respiratory: The patient initially was maintained on full ventilatory support in the Intensive Care Unit. Upon his transfer to the floor he had no significant respiratory problems. 4. Gastrointestinal: The patient had done well from a gastrointestinal standpoint. He had a diverting colostomy performed in conjunction with the Colorectal service, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**], on [**2144-1-8**]. Subsequent to this, the patient's ostomy was seen to be working well. The patient had excellent bowel function and was stable from this standpoint. 5. Hematology: The patient initially had required multiple blood product transfusions but was otherwise hemodynamically stable. 6. Infectious Disease: The Infectious Disease service was involved early and frequently and initially had placed the patient on penicillin-G and clindamycin. The patient was subsequently switched to meropenem and vancomycin for multiple catheter infections growing out MRSA. In addition, secondary to his extensive necrotizing fasciitis, this was done in order to prevent any other possible neocolonial infections. The patient's most significant recent cultures including a VRE screen on [**2144-2-1**], which was positive, a negative Clostridium difficile assay on [**2144-1-18**], negative Clostridium difficile on [**2144-1-15**], positive catheter tip culture on [**2144-1-14**], for MRSA, and a wound culture on [**2144-1-13**], which grew out Pseudomonas, Enterococcus as well as coag negative Staph. Under the recommendation of Infectious Disease, the patient completed his antibiotic course on [**2144-1-27**], and subsequently found to be afebrile and having no Infectious Disease complications. He had no gross evidence of any infection cutaneous or otherwise on his discharge. 7. Fluids, Electrolytes and Nutrition: The Nutrition service was consulted in regard to maintaining adequate caloric and protein support. The patient was found to be doing well and had an excellent appetite on the floor and this was supplemented by protein shakes t.i.d. Ultimately, the patient was discharged on [**2144-2-4**], tolerating a regular diet, having begun his physical therapy on [**2144-2-3**], without complication and generally doing quite well. He has multiple skin grafts in the perineal and scrotal area. Of note, his right testicle has been reimplanted into the right inguinal area. Multiple scrotal revisions have been viewed by the Plastics team and seem to be doing well although they continue to have a small amount of nonpurulent drainage. Multiple split thickness skin grafts, both donor and recipient sites, are healing well. The patient does have an ischemic pressure ulcer region on his right wrist which is healing well with Santyl and normal saline wet-to-dry changes b.i.d. The patient also has a peristomal wound which is granulating in well and being addressed with just normal saline wet-to-dry b.i.d. changes. PHYSICAL EXAMINATION ON DISCHARGE: General: Patient appears well. He has well-healing skin grafts in multiple areas. Vital signs are stable, afebrile. Chest is clear to auscultation bilaterally. Cardiovascular is regular rate and rhythm without murmur, rub or gallop. Abdomen is soft, non-tender, non-distended. There is a functioning colostomy in the left lower quadrant. Immediately left lateral to this, there is a small 3 x 4 cm open granulating wound which is healing nicely with no evidence of infection. Extremities: On the patient's right wrist there is a small approximately 2 x 3 cm open area which is being treated by Santyl b.i.d. as well as normal saline wet-to-dry changes b.i.d. This is healing nicely with no evidence of infection. The patient's scrotum and perineal area are recipients of scrotal revisions as well as multiple skin grafting. The scrotal and testicular area, in particular, has some daily drainage although this is nonpurulent in nature. The right testicle has been reimplanted into the right inguinal area. All these grafts are seen to be doing well and require Xeroform dressing changes b.i.d. The patient's right leg is significant for multiple donor sites which are healing well and should be treated with bacitracin q.i.d. Up closer to the groin and perineal area, there are some areas of recipient skin graft sites. These along with the scrotal area should be changed with Xeroform b.i.d. The patient's left leg has a donor site with old Xeroform still attached to it. This should be allowed to fall off on its own and treated with bacitracin q.i.d. subsequent to that. The patient has other donor sites on his left leg which are being treated with bacitracin q.i.d. As with the right leg, the area close to the perineum is significant for the most recent skin graft recipient and should be treated with Xeroform b.i.d. Neuro is grossly intact. CONDITION AT DISCHARGE: Stable. DISPOSITION: To rehabilitation facility. DIET: Ad lib with Boost and protein shake supplements t.i.d. DISCHARGE MEDICATIONS: 1. Vitamin C 500 mg b.i.d. 2. Zoloft 50 mg q. day. 3. Zinc sulfate 220 mg q. day. 4. Santyl b.i.d. to right wrist wound. 5. Ativan 0.5 to 1 mg p.o. q. 8h. p.r.n. 6. Percocet 5/325 one to two q. 4h. p.r.n. 7. Morphine sulfate sustained release 30 mg q. 12h. 8. Multivitamin q. day. 9. Bacitracin ointment topical q.i.d. to healed skin graft sites which are on the distal legs. 10. Reglan 10 mg q.i.d. a.c. and h.s. 11. Ambien 5 to 10 mg q. hs. p.r.n. for insomnia. 12. Tylenol 325 to 650 mg q. 4h. p.r.n. 13. Colace 100 mg b.i.d. DISCHARGE INSTRUCTIONS: The patient has a Foley catheter to gravity. This may be discontinued in two to three days' time as his mobility allows. The patient has a right wrist wound which should be changed with Santyl topical b.i.d. as well as normal saline wet-to-dry b.i.d. The patient has a peristomal wound which is normal saline wet-to-dry b.i.d. dressing changes. The patient's scrotal, testicular, perineal and non-healed skin graft areas should be changed with Xeroform b.i.d. The right leg and left leg donor sites seem to be well-healed. There is an old Xeroform dressing on the left leg which should be allowed to fall off on its own. Bacitracin should be applied q.i.d. to all healed skin graft areas. The patient should continue p.o. intake and be supplemented with protein shakes and Boost t.i.d. From a physical therapy standpoint, the patient has significant progress to be made. He needs gait, balance, transfer training as well as conditioning and generalized strengthening of both upper and lower body. His anticipated goals are the activities of daily living. The patient rehabilitation potential is excellent. Patient should follow up with Dr. [**Last Name (STitle) 468**] in three to four weeks' time. The patient should follow up with Dr. [**Last Name (STitle) **] of Plastic Surgery in two weeks' time. The patient will ultimately need another scrotal revision at the discretion of Dr. [**Last Name (STitle) **]. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern1) 5745**] MEDQUIST36 D: [**2144-2-4**] 09:58 T: [**2144-2-4**] 09:13 JOB#: [**Job Number 18457**]

[ "785.4", "995.92", "996.64", "996.79", "785.59", "682.6", "728.86", "707.0", "996.69" ]

icd9cm

[ [ [] ] ]

[ "83.82", "83.45", "61.49", "83.39", "86.75", "86.69", "54.3", "83.14", "83.09", "86.22" ]

icd9pcs

[ [ [] ] ]

232, 494

10951, 11490

2757, 8903

11515, 13200

1662, 1785

158, 211

10812, 10928

8918, 10797

523, 1602

1800, 2739

1625, 1638

13,929

197,118

44192

Discharge summary

report

Admission Date: [**2161-11-10**] Discharge Date: [**2161-11-12**] Date of Birth: [**2125-8-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: heroin overdose Major Surgical or Invasive Procedure: No major surgical or invasive procedures. History of Present Illness: cc:[**CC Contact Info **]. hpi: 36 yo m w/ h/o hepatitis c who presents to the ICU following overdose. Patient reports that he began using heroine last night when he noted some blurry vision then awoke in the ED. Denies other preceding symptoms. No headache/cp/sob/aura. Unclear how long he was down for. Wife found patient on floor in bathroom -> called EMS. again, after being clean for approx 2 years. Triggered by splitup with wife. Also states he has been taking valium (from friend) over the last several days. Denies recent illness. Specifically no f/chills/rash/sore throat/sob/cough/problems w/ urination. States that his daughter has had several bouts of strep throat and that he and his wife have been ill, most recently approx 1 mo ago characterized by lethargy, and flu like symptoms. Denies SI. . In ED, initial VSS stable, pt arousable and oriented. Noted to desat to 89% when his resp rate dropped to approx 7. Given Narcan 0.2 mg x2, followed by 0.4 mg x2, with improvment in rr. Started on narcan drip, transferred to ICU for further monitoring. Past Medical History: hepatitis c, x several years, acquired by needle sharing. no h/o jaundice/ruq pain/dk urine. depression Social History: h/o IV heroin, previously clean for 2 years. denies etoh. +tobacco use Family History: Non-contributory Physical Exam: 98.0, bp 122/65, hr 98, rr 12, 98% ra on narcan gtt Easily arousable, well appearing male in NAD. PERRL. anicteric OP clr. MMM neck supple. Regular s1,s2. no m/r/g LCA b/l +bs. soft. nt. nd. no [**Doctor Last Name **] sign. liver 7cm in mcl. spleen not palpable. no le edema/clubbing/cyanosis Alert and oriented x3. Pertinent Results: EKG: 100bpm, nl axis, nl intervals, no st-tw changes. [**2161-11-10**]: CHEST PORTABLE: Prior studies are not available for comparison. The heart is normal in size. The mediastinal, hilar contours are unremarkable. The pulmonary vasculature is normal. The lungs are clear. IMPRESSION: No acute intrathoracic process. [**2161-11-10**] 11:53PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2161-11-10**] 10:20PM GLUCOSE-349* UREA N-20 CREAT-1.4* SODIUM-141 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-27 ANION GAP-20 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG WBC-13.9* RBC-4.44* HGB-14.4 HCT-40.6 MCV-92 MCH-32.4* MCHC-35.4* RDW-13.1 NEUTS-90.2* BANDS-0 LYMPHS-7.9* MONOS-1.3* EOS-0.2 BASOS-0.3 Brief Hospital Course: Impression: 36 yo m w/ history of IV drug use, recent heroin use, found down, low respiratory rate in ED, improved w/ narcan. . 1) heroin overdose- Pt was administered narcan in the ED with immediate response. He was transferred to the [**Hospital Unit Name 153**] for further observation, monitoring of vital signs. He was maintained on a narcan drip which was titrated off. The pt's vital signs remained stable with good oxygenation. On arrival to [**Hospital Unit Name 153**], he was mentating normally, appropriate in conversation. No suspicion for infectious etiologies (i.e. meningitis- elev wbcc likely [**3-4**] demargination). A social work consult was placed and psychiatry evaluated the patient as well. He was discharged from the ICU in stable condition. . 2) Hepatitis c- little history known by patient LFTs were checked to rule out a hepatic component to his change in mental status. He had only mildly elevated AST and ALT, with a normal total bilirubin. . 3) [**Name (NI) 20191**] unclear etiology. It was not documented if pt received D50 on presentation to ED. However, his glucose was elevated on both his chem 7 and urine. An AM fasting glucose was checked, and it was within normal limits. His HgbA1C was normal. . 4) Elevated anion gap- mild at 15, then closed. This was thought likely secondary to ketones if patient was down for some time (although not noted in urine). Also concern for ingestion, although patient denies. The gap was re-checked on AM labs and was normal. . 5) Depression- We continued his prozac. Psychiatry was involved in the care of this pt. He will need to follow up as an outpatient. . 6) Benzodiazepine use- He did not require a CIWA scale after he was titrated off narcan gtt. . 7) full code Medications on Admission: Prozac 20mg qday Multivitamin 1 tab po qd Discharge Medications: 1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Heroin overdose 2. Depression with suicidal ideations 3. Benzodiazepine use Discharge Condition: Stable. Discharge Instructions: If you develop shortness of breath, chest pain, confusion, headache, vision changes, please call your PCP or go to the emergency room. If you develop suicidal or homicidal thoughts, please go to the emergency room. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **] [**2-1**] weeks. Completed by:[**2161-11-27**]

[ "311", "965.01", "300.9", "276.52", "305.40", "E850.0", "070.70", "305.50" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4843, 4849

2869, 4626

332, 375

4972, 4982

2083, 2846

5245, 5357

1713, 1731

4718, 4820

4870, 4951

4652, 4695

5006, 5222

1746, 2064

277, 294

403, 1480

1502, 1609

1625, 1697

9,477

180,368

29546

Discharge summary

report

Admission Date: [**2134-2-10**] Discharge Date: [**2134-3-12**] Date of Birth: [**2076-9-8**] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 2597**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [**2134-2-24**] right AK [**Doctor Last Name **]/pedal bypass with GSV [**2134-3-1**] R heel ulcer debridement (Podiatry) w/ primary closure [**2134-3-7**] Temporary HD line placement [**2134-3-10**] Tunnelled HD line placement; peritoneal dialysis line placement History of Present Illness: Mr. [**Known lastname **] is a 57 year old man with a history of chronic renal insufficiency (baseline Cr [**4-4**]), cardiomyopathy and type II diabetes who presents to the [**Hospital1 18**] ED complaining of shortness of breath. . Over the past year, he has been diagnosed with coronary artery disease after being found to have had a silent AMI, which likely happened in early [**2133**] during a trip in [**Country 3399**]. He has had fractionated care between [**Country 3399**], [**Country 651**], [**Location (un) 6847**] and [**State **]. The AMI was found during a routine echocardiogram in [**Month (only) 205**], along with an apicla thrombus. Most recently, he was hospitalized in [**Location (un) 6847**] for a right heel ulcer. He was discharged without antibiotics and has travelled back to the US for an appointment at the [**Hospital **] Clinic. While he usually has a strict diet, during the prolonged plan trip, he was unable to adhere to his diet. Early in the trip he felt okay, but after about 7 hours, he began feeling short of breath with exertion. He got off the plan at 3pm yesterday and had difficulty ambulating. He went home, and he believes that his dyspnea would improves when he is lying flat. Overnight, he presented to [**Hospital1 18**] and was found to be hypoxic. In the ED he was bolused with lasix 40mg IV and nitro, and was placed on CPAP. EKG showed lateral ST depressions. Cardiac enzymes were mildly elevated. His potassium was elevated so calcium and insulin we administered. Past Medical History: Hypertension Diabetes, Type II complicated by nephropathy and retinopathy. A1C 6.6 in [**9-/2133**] Hypercholesterolemia, LDL 160 [**8-6**] AMI w/ LV thrombus ([**2133-9-1**]) with EF 41% Fatty Liver Cholecystitis Peripheral vascular disease Wet gangrene R heel [**2133-12-27**] w/ reported MRSA, got 10d course of pip-taz/clinda Social History: Retired pharmacist. He does not and has never smoked, and does not drink alcohol Family History: n/c Physical Exam: VS: T HR 105 BP 123/87 RR 24 SAT 94% Gen: Pleasant asian man in bed on CPAP via facemask HEENT: OP clear, MMM, PERRL Neck: JVP to earlobes when sitting up at 60 degrees. CV: Normal s1/s2, RRR, no m/r/g Pul: Crackles throughout both lung fields Abd: Soft, NT, ND +BS Ext: 2x2cm by about 1cm deep ulcer in R heel, dry appearing. Neuro: A&Ox3 Pertinent Results: CARDIOLOGY REPORTS Echo [**2133-8-26**] LV concentric hypertrophy AK of distal septum, apex, anteroapical segment LV apical thrombus EF 40-45% Trace TR and AR, normal PASP No effusion . EKG on arrival to CCU: loss of anterior R waves, lateral ST depressions/TWI likely due to LVH. ~~~~~~~~~~~~~~~~~~~~~~~~ Follow-up Stress & Echo . Cardiology Report STRESS Study Date of [**2134-2-16**] INTERPRETATION: This 57 year old type 2 NIDDM man with a history of CHF was referred to the lab for evaluation. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no significant ST segment changes. The rhythm was sinus with no ectopy. Appropriate hemodynamic response to the infusion. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. Cardiology Report ECHO Study Date of [**2134-2-23**] Conclusions: The left atrium is mildly dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with akinetic apex. Overall left ventricular systolic function is mildly depressed. Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The remaining left ventricular segments are hypokinetic. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ LABORATORY Admission laboratory [**2134-2-10**] 02:20AM BLOOD WBC-15.3* RBC-3.37* Hgb-10.5* Hct-30.8* MCV-91 MCH-31.1 MCHC-34.1 RDW-15.3 Plt Ct-250 [**2134-2-10**] 02:20AM BLOOD Neuts-82.5* Lymphs-13.2* Monos-3.9 Eos-0.3 Baso-0.2 [**2134-2-10**] 02:20AM BLOOD PT-30.5* PTT-35.4* INR(PT)-3.2* [**2134-2-10**] 02:20AM BLOOD Glucose-242* UreaN-87* Creat-4.9* Na-135 K-5.8* Cl-104 HCO3-15* AnGap-22* [**2134-2-10**] 02:20AM BLOOD ALT-96* AST-100* LD(LDH)-514* CK(CPK)-470* AlkPhos-88 TotBili-0.3 [**2134-2-10**] 02:20AM BLOOD CK-MB-17* MB Indx-3.6 proBNP-[**Numeric Identifier 70856**]* [**2134-2-10**] 07:05AM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE [**2134-2-10**] 02:20AM BLOOD Triglyc-99 HDL-48 CHOL/HD-2.9 LDLcalc-73 ~~~~~~~~~~~~~~~~~~~~~ Discharge laboratory [**2134-3-11**] 05:40AM BLOOD WBC-8.8 RBC-2.78* Hgb-8.5* Hct-25.4* MCV-92 MCH-30.6 MCHC-33.4 RDW-16.5* Plt Ct-197 [**2134-3-12**] 05:35AM BLOOD PT-18.0* PTT-30.4 INR(PT)-1.7* [**2134-3-12**] 05:35AM BLOOD Glucose-132* UreaN-42* Creat-3.7*# Na-136 K-4.2 Cl-98 HCO3-30 AnGap-12 [**2134-3-12**] 05:35AM BLOOD Calcium-7.9* Phos-2.9# Mg-1.7 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Please see individual reports for results of radiology studies Brief Hospital Course: Mr. [**Known lastname **] is a 57 year old man with a history of type II diabetes, diabetic nephropathy, coronary artery disease, s/p anterior mi with apical thrombus, preserved EF, presenting with shortness of breath. BNP elevated to >25,000. . 1) Cardiac: a) Pump: Presented with florid CHF requiring 100% NRB. He had h/o anterior MI with apical thrombus, apical akinesis, LVH. Repeat eccho showed EF 35-40% no apical thrombus + apical akinesis. He was started on a nitro drip and diuresed aggressively 1.5-2L/d with lasix (and put out well to 100mg bolus). This was bridged to imdur + lasix with the addition of metoprolol to improve his filling time. . b) Ischemia: Mr [**Known lastname **] presented with lat STD and NSTEMI; his CK peaked at 470. It was thought that he likely had demand ischaemia from hypoxia/CHF. His metoprolol was titrated up to 100mg po tid, he was kept on aspirin, and his anticoagulation was continued (for LV thrombus). He was kept on high-dose statin. . c) Rhthym: NSR throughout stay. Mr [**Known lastname **] was tachycardic in the 90-100 range, he was begun on metoprolol which was quickly increased to 100mg metoprolol tid. . 2) Diabetes, type II: Likely diagnosed late given his nephropathy and retinopathy would be incosistent with the short duration of his diagnosis and his relatively good [**Name (NI) **] (6.9). His glyburide was d/c'd b/c of renal insufficiency and he was started on an insulin regimen. . 3) R foot ulcer: pt with post-tibial disease; s/p debridement with non-healing. Dr. [**Last Name (STitle) **] (vascular surgeon) was consulted and performed an above-knee popliteal to dorsalis pedis artery bypass with reverse saphenous vein and angioscopy on [**2134-2-23**]. He also underwent a right heel debridement with primary closure on [**2130-3-1**] by Dr. [**Last Name (STitle) **] of podiatry. He tolearated both of these procedures well. Please see operative notes for procedural details. He recovered well with evidence of improved distal blood flow. His graft remained palpable and distal pulses dopplerable throughout his hospital course. His heel wound progressed well with primary closure. Levofloxacin was continued for a 2 week course and discontinued on the day of discharge to rehab for GNR (NON-FERMENTER non-pseudomonas) from his wound. He remained non-weight bearing on the right due to his heel wound. This will remain his status until clearance from podiatry. Sutures and staples remain from the operations and will be taken out at follow-up visits. . 4) Acute on Chronic Renal failure: with hyperkalemia on presentation. This continued without evidence of resolution. Nephrology recommended intiation of dialysis. The patient initially refused to begin dialysis despite recommendations, however he eventually decided on this course. A temporary HD line was placed [**2-4**] and HD was initiated on a daily basis for 3 days. The line was exchanged in the OR for a tunnelled line and he also received a peritoneal dialysis catheter. He will be converted to a TIW dialysis schedule at rehab and PD will be taught and initiated at rehab as well. . 5) Anemia: Likely due to chronic kidney disease. Stable. It is the recommendation of vascular surgery to maintain a HCT of approximately 30. . 6) HIT+: Heparin antibody positive on [**2134-2-26**]. Patient anticoagulated for this with argatroban converted to coumadin. Goal INR>2.0. He should follow-up with his PCP or [**Name Initial (PRE) **] hematologist for duration of therapy guidelines. . 7) Elevated LFT's on admission, resolved on discharge. History of steatohepatitis by report. - RUQ showed tumorfactive sludge w/o GB wall thickening; no liver dz. Pt should have repeat US in [**3-6**] months per medical team. - hepatitis serologies w/ +HAVAb only. Negative HepB & HepC studies. . 8) F/E/N: fluid restricted renal diet, diabetic, cardiac diet. . 9) Access: peripheral IV, tunnelled HD line RIJ . 10) PPX: Heparin SQ, no need for PPI for now. . Contact: His sister/pcp, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70857**], at [**Telephone/Fax (1) 70858**] Medications on Admission: Simvastatin 40mg daily Norvasc 10mg daily Dologesic 1 tab qid:prn Metoprolol 25mg [**Hospital1 **] (also has been on metoprolol 100mg [**Hospital1 **]) Lasix 40mg daily Glyburide 5mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please adjust dosing per INR. 7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Iodine 10 % Solution Sig: One (1) Appl Topical ASDIR (AS DIRECTED): To right plantar foot wound dressings. 10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 32674**] Discharge Diagnosis: Peripheral vascular disease Acute renal failure Myocardial infarction Heparin antibody positive Discharge Condition: Good Discharge Instructions: Please see d/c summary. Please transfuse 1unit PRBC with HD Saturday for HCT=25. Goal HCT=30 given CAD. Followup Instructions: Please f/u with Dr. [**Last Name (STitle) **] 1 week for evaluation of heel. ([**Telephone/Fax (1) 4335**] Please f/u with Dr. [**Last Name (STitle) **] in 1week. Call for appointment. ([**Telephone/Fax (1) 18181**] Follow-up with your cardiologist, nephrologist, and your PCP.

[ "799.02", "250.40", "425.4", "410.71", "276.7", "583.81", "585.6", "403.91", "285.21", "682.7", "287.4", "730.27", "584.9", "707.14", "E934.2", "440.23", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.95", "77.68", "39.95", "99.07", "54.93", "93.90", "39.29", "99.04" ]

icd9pcs

[ [ [] ] ]

11995, 12047

6402, 10525

281, 548

12187, 12194

2947, 6379

12347, 12631

2566, 2571

10776, 11972

12068, 12166

10551, 10753

12218, 12324

2586, 2928

234, 243

576, 2098

2120, 2452

2468, 2550

31,360

144,432

32118

Discharge summary

report

Admission Date: [**2153-9-26**] Discharge Date: [**2153-10-10**] Date of Birth: [**2111-9-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Fall, alcohol intoxication Major Surgical or Invasive Procedure: Paracentesis x 2 History of Present Illness: Mr. [**Known lastname **] is a 42 year-old man with past medical history significant for extensive alcohol abuse with alcoholic cirrhosis and ascites, who presented to an outside hospital after falling subsequent to heavy drinking. He stated that he fell back, hit his head, blacked out for a brief period, awoke and called 911. He denies having had any chest pain prior to falling, no syncope or seizure like activity. He has had black-outs in the past from his heavy alcohol abuse. The patient denied drinking in excess of his usual dose of 1L whiskey per day, but called 911 after falling due to inability to get up. He does not recall what medications he's taking but takes [**4-9**] meds daily. He denies using any illicit drugs. He was admitted to the outside hospital for further evaluation after his fall with symptoms of nausea, back pain. He was found to have acute renal failure, marked tense ascites, and history of poor PO intake. . OSH Course: Initial WBC 10.3, LFTs elevated, Cr increased at 2.4 (baeline 0.7-1.0), Na 112, Albumin 1.8. Renal followed the pt and thought he had hepatorenal syndrome. Pt was diuresed with Bumex 3mg, kept on aldactone 50mg [**Hospital1 **], and fluid restricted to 1L/day. GI also evaluate pt for ETOH cirrhosis, recommended octretide, albumin, and protamine. Plan was to do an Abdominal U/S to evaluate ascites and do a therapeutic paracentesis, which was not done prior to transfer. He was diuresed, kept on lactulose 30ml [**Hospital1 **] but no BM. He was noted to have BP in the 80s, transferred him to the ICU and placed on Neosynephrine transiently. He was weaned off Neo prior to transfer. He was given 30mg Serax for ETOH withdrawal prior to transfer. He was transferred to [**Hospital1 18**] for further management. . Past Medical History: -Alcohol Abuse -Alcoholic Cirrhosis, complicated by ascites, s/p paracentesis 8L [**7-12**] -Hepatic encephalopathy -Pancytopenia -s/p multiple falls and black-outs in the past -Hyponatremia Social History: - Lives alone, 2 daughters-twins age 16 live in [**State 108**] with kid's mother. Disabled. - Alcohol Abuse; drinks 1 liter of whiskey per day, last rehab admission 1 year ago-unsuccessful. - Smokes 2/3 packs per day for 20years. Family History: NC Physical Exam: ADMISSION EXAM: VS: 96.8 HR 102 BP 101/45 RR 15 99%2L NC GEN: NAD, Comfortable lying in bed cachetic/emaciated appearing speaking in short sentences HEENT: dry MM, minimally icteric sclera with pale conjunctiva RESP: CTABL no crackles, no wheezing, no use of accessory muscles CV: Reg Nml S1,S2, no M/R/G ABD: Soft, very distended, +Fluid wave, non tender +BS, liver unable to palpate, unable to appreciate splenomegaly, caput medusa EXT: no peripheral edema, warm 2+DP pulses b/l NEURO: A&O x2 self and time, confused about hospital, no focal deficits, strength 4/5 upper and lower extremeties, mild asterixis/tremor SKIN: Spider telangiactasia on upper chest . Pertinent Results: LABS: [**2153-9-26**] WBC-7.6 HGB-8.9 HCT-25.3 PLT COUNT-144 [**2153-9-26**] NEUTS-81.0 LYMPHS-15.3 MONOS-3.2 EOS-0.4 BASOS-0.1 [**2153-9-26**] PT-13.4 PTT-29.6 INR(PT)-1.2 [**2153-9-26**] GLUCOSE-118* UREA N-23* CREAT-2.3* SODIUM-113* POTASSIUM-4.2 CHLORIDE-85 TOTAL CO2-25 [**2153-9-26**] ALT(SGPT)-33 AST(SGOT)-62* LD(LDH)-243 ALK PHOS-164 TOT BILI-1.3 [**2153-9-26**] ALBUMIN-2.6* CALCIUM-8.2* PHOSPHATE-4.6* MAGNESIUM-2.6 [**2153-9-27**] Retic-2.3 Fibrino-187 calTIBC-70 VitB12-1083 Folate->20ng/mL Ferritn->[**2146**] TRF-54 [**2153-9-27**] TSH-1.1 [**2153-9-27**] AFP-1.0 [**2153-10-2**] HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-NEGATIVE HCV Ab-NEGATIVE [**2153-10-2**] tTG-IgA-9 . URINE STUDIES: [**2153-9-27**] urine tox screen: benzo-POS opiates-POS [**2153-9-27**] urine electrolytes BUN-394 Creat-255 Na-<10 K-20 TP-25 Prot/Cr-0.1 Albumin-2.2 Alb/Cre-8.6 Osmolal-321 . [**2153-9-27**] urinalysis: Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG pH-5.0 Leuks-SM RBC-0-2 WBC-0-2 Bact-FEW Eos-NEGATIVE [**9-27**] urine culture: negative . [**2153-10-3**] urinalysis: Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG pH-6.5 Leuks-NEG [**10-3**] urine culture: negative . ASCITIC FLUID STUDIES: [**2153-9-27**]: WBC-52* RBC-8* Polys-21* Lymphs-39* Monos-16* Mesothe-24* TotPro-1.2 Glucose-122 LD(LDH)-59 Amylase-16 Albumin-<1.0 [**9-27**] culture: no growth . [**2153-10-2**]: WBC-130* RBC-970* Polys-60* Lymphs-20* Monos-15* Mesothe-4* Macroph-1* TotPro-1.1 Glucose-115 LD(LDH)-51 Albumin-<1.0 [**10-2**] culture: no growth . [**9-27**] and [**10-1**] blood cultures: negative . IMAGING [**2153-9-26**] CXR: Opacification at the medial aspect of the right lung base could be consolidation or atelectasis in either the middle or lower lobe, and may also represent small right pleural effusion, largely subpulmonic. Left lung is clear. Tip of the left subclavian line projects over the mid SVC. No pneumothorax or upper mediastinal widening. Heart size is normal. Lateral displacement of the left paraspinal line just above the diaphragm could be due to distended esophagus or esophageal varices. There is at least a mild degree of intestinal distention seen in the upper abdomen, but no subdiaphragmatic free air. . [**2153-9-27**] RUQ ULTRASOUND W/DOPPLERS: 1. Abundant ascites. Patient's skin marked in left lower quadrant for paracentesis. 2. Cirrhosis. 3. Patent hepatic vasculature. . [**2153-10-1**] EGD: Granularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Erythema and erosion in the antrum compatible with gastritis (biopsy) Atrophy in the duodenum (biopsy) Otherwise normal EGD to second part of the duodenum . [**2153-10-1**] GASTROINTESTINAL MUCOSAL BIOPSIES: A. Antrum: No diagnostic abnormalities recognized. B. Duodenum: No diagnostic abnormalities recognized. . Brief Hospital Course: . Mr [**Known lastname **] was transferred directly to the MICU. Below is a brief summary of his hospital course. Was fluid-restricted to 1 L per day for persistent hypoNa. Started on lactulose for hepatic encephalopathy ppx. He was also put on CIWA and received diazepam, and pt never showed frank signs of withdrawal. . ASSESSMENT/PLAN: 42 yo M with extensive ETOH abuse, ETOH Cirrhosis, hyponatremia, malnourished presents s/p fall in setting of ETOH intoxication found to have ARF. Underwent 6L paracentesis in ICU, had . # ETOH cirrhosis: When he initially presented, he had tense ascites secondary to his EtOH cirrhosis. In the [**Hospital1 **] MICU, he had 6L paracentesis. He had a second paracentesis with 5L removed on the floor. Studies of the ascitic fluid were not consistent with SBP but was still started on cipro for SBP prophylaxis. He was strated on lactulose for hepatic encephalopathy prophylaxis. He also had an elevated INR. He was followed by the liver consult service. EGD was performed and was consistent with portal hypertensive gastropathy, showing gastritis in the antrum and atrophy in the duodenum. No abnormalities were found on biopsy of antrum and duodenum. Esophagus was normal without varicies. Hepatitis serologies were negative. . # ETOH abuse: He has an extensive history ETOH abuse and blackouts secondary to drinking. He also has a history of DTs. He appeared very malnourished with significant ascites as above. His last drink was 48 hours prior to admission. He was placed on CIWA scale with valium administered as needed. He also received thiamine, folate, and multivitamin. He was evaluated by psychiatry, who felt he remained at significant risk for EtOH relapse with limited insight into the medical complications of resuming drinking. They felt he did not appear acutely depressed, that his overall flattened affect and cognitive slowing appeared more related to longer term effects of EtOH. It was recommended that he be discharged to a dual diagnosis facility but placement was difficult due to his insurance coverage. He was discharged home with plans for close follow-up at an outpatient rehab center. . # ARF: On admission he was in acute renal failure, with creatinine 2.3. It was felt most likely to be prerenal given his concurrent ascites and decreased PO intake. His renal failure resolved with IVF. . # Abdominal wall cellulitis: During his hospitalization, the patient developed cellulitis on his left abdomen extending around to the back and the left groin. He was treated with a 10-day course of PO keflex and the cellulitis had completely resolved by the day of discharge. . # Hyponatremia: He was hyponatremic with Na on admission of 113. The etiology was felt to be multifactorial-- partly a chronic problem from ETOH cirrhosis and diuretic use and also hypovolemic secondary to worsening ascites and decreased PO intake. His Na level improved slightly after IVF repletion to 119. He was then fluid-restricted and his Na came up to the mid-120s. He was poorly compliant with fluid restriction, however his Na had normalized to 135 by the day of discharge. . # Thrombocytopenia: He was noted to be thrombocytopenic, which is chronic for him and likely from marrow suppression secondary to ETOH abuse. . # Anemia: Unclear baseline but most likely from ETOH abuse and marrow suppression. No history of GI bleed per patient or records. Hemolysis work-up was negative. Iron studies were consistent with anemia of chronic disease. B12 level was normal. He received one unit RBC on [**10-3**] with appropriate hematocrit bump 24.4-27.8. Hematocrit remained stable afterwards between 26-30. . # CODE: He was full code but established that he did not want long-term artificial support. Medications on Admission: MEDS at home but not taking: -Lasix 20mg daily -Lactulose 30mg [**Hospital1 **] -ThiaminE 100mg daily . Discharge Medications: 1. Lactulose 10 g/15 mL Solution Sig: Thirty (30) ML PO twice a day. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days: continue for 2 more days-- last day is [**10-10**]. 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO X1 (ONE TIME) as needed for insomnia. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Primary: 1)Acute renal failure 2)Alcoholic cirrhosis . Secondary: 1) Alcohol abuse 2) Abdominal wall cellulitis 3) Anemia of chronic disease 4) Hypovolemic hyponatremia Discharge Condition: Stable, ascites stable, satting well on room air. Discharge Instructions: You were admitted to the hospital after falling while intoxicated with alcohol. You were found to have acute renal failure as well as tense ascites from your alcoholic cirrhosis. You were initially admitted to the ICU where your acute renal failure was treated. You underwent two paracenteses (belly taps) and a total of 11L of ascitic fluid was removed. Fluid studies did not show infection, however you were started on antibacterial prophylaxis with ciprofloxacin. You were also followed by the Liver service. You were also started on antibiotics for an infection on your abdominal skin. . Please take all medications as directed. You have been prescribed medications for your liver failure. . While you are now medically stable for discharge from the hospital, it is strongly recommended that you seek further care for your alcohol abuse. You should STOP drinking alcohol. You have an appointment with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 75166**] at Bayview Associates in [**Hospital1 392**] at [**2153**] tomorrow morning at 11 a.m. . If you develop chest pain, shortness of breath, fever, severe nausea and vomiting, or other symptoms similar to those that brought you into the hospital, please go to the nearest emergency room. Followup Instructions: You have an appointment with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 75166**] at Bayview Associates in [**Hospital1 392**] at [**2153**] tomorrow morning at 11 a.m. . Follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10543**], in the next week. His office number is ([**Telephone/Fax (1) 24747**]. . Please also follow-up with Dr. [**Last Name (STitle) **], your liver doctor, on [**2153-10-17**] at 1:50 p.m. Call [**Telephone/Fax (1) 2422**] as needed. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "276.1", "682.2", "584.9", "285.9", "303.91", "572.3", "263.9", "571.2", "287.5", "789.5" ]

icd9cm

[ [ [] ] ]

[ "54.91", "45.16" ]

icd9pcs

[ [ [] ] ]

11266, 11272

6255, 9999

341, 359

11484, 11535

3342, 6232

12850, 13499

2640, 2644

10153, 11243

11293, 11463

10025, 10130

11559, 12827

2659, 3323

275, 303

387, 2162

2184, 2376

2392, 2624

28,844

167,271

32108

Discharge summary

report

Admission Date: [**2150-9-19**] Discharge Date: [**2150-9-25**] Date of Birth: [**2084-5-11**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: Struck by motor vehicle Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 66 year-old man who was found down in the street stating that he had been struck by a motor vehicle. He was reported to have had a systolic blood pressure of 50 in the field. He reported sharp back pain on arrival to the trauma bay. Past Medical History: Seasonal allergies Social History: Reports occasional alcohol use and states he had several drinks on the day prior to being struck. Lives with girlfriend at home. Family History: Non-contributory Physical Exam: Physical Exam on Admission: Vitals: HR 60 BP 62/Palp left, 138/105 right RR: 32 O2: 90% RA Gen: Awake, alert and oriented. No acute distress. HEENT: PERLL. Neck: Trachea midline. Chest: CTA bilaterally. No crepitus. CV: RRR. Abdomen: Soft. NT/ND. Rectal: Normal tone. + gross blood. Guaiac +. Extremities: Bilateral knee abrasions. Back: No step-offs. Pertinent Results: Non-contrast Head CT [**2150-9-19**]- No evidence of acute intracranial hemorrhage or mass effect. Evidence of remote infarction or prior traumatic injury of the right frontal lobe. NOTE AT ATTENDING REVIEW: There are bilaterally symmetric oval-shaped regions of low density in both subinsular regions, which may also be areas of infarction, subacute to chronic in age. Neurology consultation is suggested to assess if there are indications of possible acute brain ischemia. Also, there are fracture deformities of the left zygomatic arch, as well as the lateral orbital and maxillary sinus walls. Please obtain history, where possible, for prior trauma. Dr. [**Last Name (STitle) 2026**] is informing ED staff re: these additional findings. . CT Chest/Abdomen/Pelvis [**2150-9-19**]- 1. Minimally displaced fracture of the left inferior pubic ramus, without evidence of significant adjacent hematoma or active arterial extravasation. 2. Hematoma of the subcutaneous tissues of the right hip. 3. Fluid-filled esophagus makes patient at risk for aspiration. . CT C-spine [**2150-9-19**] Minimally displaced fracture of the left transverse process of C7. No spondylolisthesis. The fracture, noted above, involves the left lateral mass of C7, and extends to both the superior and inferior articular facet surfaces. It is mildly distracted, as judged from the axial view. Moderate degenerative changes of the atlantodental articulation are also seen. . Echo [**2150-9-19**]- Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. IMPRESSION: Dynamic left ventricular function with small chamber size. Hypovolumia should be considered in the setting of hypotension . Chest X-ray [**2150-9-19**] Single View- No evidence of traumatic injury of the thorax. . Left elbow X-ray [**2150-9-19**]- No fracture identified. If there is continuing clinical concern for fracture, then CT may be helpful for further evaluation. Right Femur (AP +lateral) -Two extremely limited views performed in the AP plane of the proximal and distal femur obtained. No gross fracture identified. There are degenerative changes about the hip and knee joint Left Knee Film 2 views [**2150-9-19**]- 1. Complex comminuted fracture of the patella. 2. Fractures of the medial femoral condyle and medial tibial plateau. 3. Comminuted fracture of the fibular head and styloid. 4. Fracture suspected of the lateral femoral condyle. MRI left Knee [**2150-9-20**]- 1. Extensive fractures about the left knee, as delineated in the prior CT report, including comminuted patellar, lateral femoral condyle, bilateral femoral trochlea. 2. Findings consistent with severe posterolateral corner injury, including tears of both menisci, rupture of the ACL, strain of the PCL, rupture of the LCL, high-grade partial tear of the popliteus tendon, fracture/avulsion of the fibular styloid, fracture of the posterolateral tibial plateau. 3. Avulsion of the MCL from its femoral attachment. CT Sinus/Mandible/Maxilla [**2150-9-22**]- Fracture deformities of the left zygomatic arch, left lateral orbital wall, left lateral maxillary sinus wall, without soft tissue swelling, most likely representing old trauma are again seen. No new fractures identified. Minimal mucosal thickening in the ethmoid, sphenoid, and maxillary sinuses. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the trauma surgical ICU with the following injuries: non-displaced C7 transverse process fracture externding to superior and inferior articular facets, a minimally-displaced left inferior pubic ramus and a moderate-sized hematoma of the right thigh. He was transferred to the surgical floor on hospital day 5. #) Hypotension- Mr. [**Known lastname **] was given IV fluids and admitted to the ICU and a central line was placed. Levophed was started but was weaned after 8 liters of fluid. A discrepancy between blood pressures in the left and right arm was noted both with in invasive and non-invasive blood pressure readings. He remained normotensive from hospital 2 onwards. . #) Metabolic Acidosis- Mr. [**Known lastname **] had a severe metabolic acidosis (pH 7.11 initially, bicarbonate of 6) which was thought to be secondary to ethanol intoxication and dehydration. His blood ethanol level on admission was 285. ABG's worsened after admission to the ICU and his lactate rose from 3.8 on admission to a peak of 10.6 but returned to 1 by hospital day 3. pH returned to [**Location 213**] by hospital day 2 and remained normal for the duration of his hospital course. . #) Anemia- Mr. [**Known lastname 75141**] hematocrit dropped from 39.6 to 25.8 throughout the course of hospital day 1 for which he received 2 units of packed red blood cells and has ranged between 25 and 27 for the remainder of his hospital course. . # Hypoxemia- After resuscitation he demonstrated signs of fluid overload with a CVP of 21 and pulmonary congestion. Mr. [**Known lastname **] was requiring supplemental oxygen administration to maintain his oxygen saturation. He was started empirically on vancomycin and Zosyn and furosemide for fluid overload in the setting of an extensive fluid resuscitation after trauma. He was treated with chest physical therapy, incentive spirometry, and nebulizer treatments. He was saturating 99% on room air on the day of discharge. . # Atrial Fibrillation- Mr. [**Known lastname **] [**Last Name (Titles) 75142**] from sinus rhythm to atrial fibrillation with a rate of 160. Potassium was found to be low and was repleted. He was given IV lopressor. He had intermittent atrial fibrillation prior to discharge. He also experienced intermittent episodes of bradycardia to HR 40s-50s without symptoms that resolved spontaneously. He is being discharged on metoprolol 25mg PO BID. . #) ID- he was started empirically on vancomycin and Zosyn for and these antibiotics were discontinued once all blood cultures were found to be negative. Final blood and urine cultures were negative. . #) Non-displaced C7 Transverse Process Fracture- Spine/Neurosurgery was consulted and recommended a cervical collar for at least 6 weeks and follow-up with neurosurgery. . #)Old Infarct on Head CT- Neurology was consulted and did not find evidence of acute cerebral ischemia but noted that per patient's history of angina, he has risk factors for stroke. It was recommended to check Hemoglobin A1c (goal < 7) which was found to be 6.4. and a fasting lipid panel (LDL goal < 70) and was within normal limits (LDL 60). . #) Orthopedic Injuries- Orthopedics was consulted for Mr. [**Known lastname 75141**] left patella fracture, left lateral condyle fracture, posterior tibial plateau fracture, and ACL tear. These injuries were deemed non-operative. A long leg cast was placed in external rotation and Mr. [**Known lastname **] was advised to be non-weight bearing on the left lower extremity for 12 weeks. He should follow-up with Dr. [**First Name (STitle) **] in clinic 2 weeks after discharge. . #) Zygomatic Arch Fracture- Plastic surgery was consulted for a left zygomatic arch fracture and recommended a CT of the sinuses/maxilla/mandible. The study was performed and revealed dracture deformities of the left zygomatic arch, left lateral orbital wall, left lateral maxillary sinus wall, without soft tissue swelling, most likely representing old trauma. No surgical intervention was recommended and the Mr. [**Known lastname **] should follow-up in plastic surgery clinic as necessary. . #) Thrombocytopenia- Mr. [**Known lastname **] had a platelet count of 154 on admission which decreased to a nadir of 48 on hospital day 3 which was thought to be dilutional in nature. Platelet count prior to discharge was 93. . #)Agitation: Mr. [**Known lastname **] had episodes of agitation in the intensive care unit for which he was given PRN Haldol. Haldol was weaned and discontinued on the day prior to discharge. . #) Ethanol use- Social work was consulted and Mr. [**Known lastname **] [**Last Name (Titles) **] information for alcohol rehabilitation services. Medications on Admission: Benadryl PRN Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (Titles) **]: One (1) ML Injection TID (3 times a day). 2. Multivitamin,Tx-Minerals Tablet [**Last Name (Titles) **]: One (1) Cap PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2 times a day): hold fro SBP <110; HR <60. 7. Percocet 5-325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every 4-6 hours as needed for pain. 8. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day: hold for loose stools. 9. Milk of Magnesia 800 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30) ML's PO twice a day as needed for constipation. 10. Dulcolax 10 mg Suppository [**Last Name (STitle) **]: One (1) Rectal once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: s/p ?Fall Non-displaced C7 transverse process fracture Let inferior pubic ramus fracture Right thigh hematoma Discharge Condition: Good Discharge Instructions: You must continue to wear your cervical collar per recommendations of Neurosurgery for the next 6 weeks. Followup Instructions: Follow up with Dr. [**First Name (STitle) **], Orthopedics in 2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with Neurosurgery in 4 weeks for a repeat c-spine CT scan, call [**Telephone/Fax (1) 1669**] for an appointment.

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icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

11091, 11168

5009, 9738

337, 343

11322, 11329

1251, 4986

11482, 11734

843, 861

9801, 11068

11189, 11301

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274, 299

371, 638

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660, 680

696, 827

15,685

191,259

10817

Discharge summary

report

Admission Date: [**2179-3-10**] Discharge Date: [**2179-3-16**] Date of Birth: [**2106-6-8**] Sex: F Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: The patient was originally admitted to the Medical service on [**2179-3-10**] with a complaint of chest pain. She is a 72-year-old female with a history of hypercholesterolemia, hypertension, family history of coronary artery disease, who presented with chest pain to the Emergency Room. PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, lacunar infarcts, syncope, appendectomy, cholecystectomy, total abdominal hysterectomy for fibroids. MEDICATIONS: Include atenolol 12.5 mg once a day, Lipitor 10 mg once a day, Klonopin .5 mg twice a day, vitamin E, folate, aspirin. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She never used tobacco, never drank, never used intravenous drugs. She lives with her husband. She is a former restaurant worker. FAMILY HISTORY: Significant for multiple paternal uncles who died of myocardial infarctions between the ages of 50 and 60. HOSPITAL COURSE: Cardiac catheterization showed high-grade left anterior descending and right coronary artery stenosis. The patient was on the Medical service. The patient, on [**2179-3-10**], the day before coronary artery bypass graft, developed a recurrent chest pain and electrocardiogram changes with T wave downgoing in V3 and V4, ST segment depressions in II, III and F. The patient was taken to surgery for insertion of an intra-aortic balloon pump and started on intravenous heparin. The patient was transferred to the Coronary Care Unit, where a 7 French 30 cc arrow balloon was placed without complications. The patient was in the Coronary Care Unit postoperatively. Just preoperatively, she was transferred and was stabilized on intra-aortic balloon pump on pressors. She was taken to the operating room on [**2179-3-11**] for a coronary artery bypass graft under Dr. [**Last Name (STitle) **], and postoperatively was transferred to the Cardiothoracic Intensive Care Unit with an intra-aortic balloon pump and nitroglycerin drip. She was slowly weaned off the balloon pump. She was on Captopril. Chest tubes were in place, and the patient was intubated. The patient had a few episodes of low blood pressure, continuing the intra-aortic balloon pump. On [**2179-3-14**], the patient looked much improved, and was better after being weaned off all drips and the intra-aortic balloon pump being discontinued. However, a hematocrit of 21.4 was noticed on this date, and the patient was transfused two units of packed red blood cells. The patient was seen by Rehabilitation services, and was doing well with regards to her movement and independence. On postoperative day number four, the patient actually achieved a Level IV to V with respect to her ability to move, one and a half days after being transferred out of the Intensive Care Unit and onto the floor. Her wires and Foley were discontinued. Her chest tube had previously been discontinued. Rehabilitation evaluated her formally and discontinued their involvement. On [**2179-3-16**], the patient was discharged home after thorough physical examination, which was inconsequential for any significant abnormal findings. The patient was discharged home on the following medications: K-Dur 20 mEq by mouth twice a day for ten days, Lopressor 12.5 mg by mouth twice a day, Lipitor 10 mg by mouth once daily, lasix 20 mg by mouth twice a day for ten days, Captopril 6.25 mg by mouth three times a day, percocet 5/325 tablets one to two tablets by mouth every four to six hours as needed for pain, Colace 100 mg by mouth twice a day, and aspirin 325 mg by mouth twice a day. Upon discharge, the patient's condition is good, and she is to follow up with Dr. [**Last Name (STitle) **] for all surgical issues, and with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**], with regards to any cardiac and medical issues. The patient, upon discharge, is in good condition, and understands the discharge plan. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2179-3-16**] 00:11 T: [**2179-3-16**] 01:37 JOB#: [**Job Number **]

[ "411.1", "790.01", "300.00", "V10.05", "401.9", "272.4", "V12.59", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61", "37.22", "97.44", "37.61", "88.53", "36.15", "88.56" ]

icd9pcs

[ [ [] ] ]

983, 1091

1109, 4419

172, 462

486, 814

832, 965

60,797

198,434

44958

Discharge summary

report

Admission Date: [**2190-2-6**] Discharge Date: [**2190-2-8**] Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Gantrisin Attending:[**First Name3 (LF) 1253**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: None History of Present Illness: 86 yo f with h/o schizophrenia, DM, HTN, CHF (EF unknown), who has a h/o of a GI bleed approx 1 year ago presents with BRBPR. Per [**Hospital1 1501**] report the BRBPR started on [**2190-2-2**]. She had increased bleeding per rectum this morning and she was noted to be less animated and interactive than usual. She has not had any other complaints or any vital sign abnormalities. . In the ED, initial vs were: 98.5 77 142/45 18 100%ra. In the ED, she was hemodynamically stable, alert and oriented to person only. Her belly exam revealed a ventral hernia, but was non-tender and rectal exam showed maroon colored stools that were guaiac positive. Her Hct was down to 23, last Hct in our system was 30 in [**6-13**]. Surgery was consulted to evaluate for strangulated hernia. Surgery felt there was no evidence of ischemic gut or strangulated hernia. CT a/p was also negative for bowel ischemia. She was seen by GI consult who felt that doing a colonoscopy in the AM would be reasonable if consistent with patient's goals of care. Patient was given protonix 80mg IV x1, Zyprexa 2.5mg PO for agitation, 2 units of PRBCs and 1L of IVF. VS prior to transfer 101 152/72 16 99% ra. . In the ICU, she appears comfortable. Her speech is garbled, likely has dentures at [**Hospital1 1501**]. She answers questions appropriately. She does not know why she is in hospital. She denies any particular complaints. Past Medical History: DM Congestive Heart Failure, EF unknown Paranoid schizophrenia Urinary incontinence Dementia HTN Chronic renal failure, baseline Cr 1.5 Anemia, has refused colonoscopy in the past. Hypercholesterolemia History GI bleed approx 1 year ago at [**Hospital3 5097**], per guardian, managed conservatively. Social History: Lives in a nursing home. At baseline alert and talkative though delusional, more lethargic and sleepy. Guardian uncertain of whether she is independent of ADLs or what her ambulatory status is. - Tobacco: none - Alcohol: none - Illicits: none Family History: Unknown. Physical Exam: General: Alert, oriented x2 (person & hospital), 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, large umbilical hernia. GU: foley in place. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN grossly intact, MAE. Pertinent Results: Admission labs: [**2190-2-6**] 09:00AM BLOOD WBC-6.0 RBC-2.82* Hgb-7.7* Hct-23.5* MCV-83 MCH-27.1 MCHC-32.5 RDW-14.4 Plt Ct-161 [**2190-2-6**] 09:00AM BLOOD PT-12.6 PTT-22.8 INR(PT)-1.1 [**2190-2-6**] 09:00AM BLOOD Glucose-258* UreaN-59* Creat-1.7* Na-142 K-5.1 Cl-113* HCO3-18* AnGap-16 [**2190-2-6**] 06:19PM BLOOD Calcium-9.6 Phos-2.9 Mg-1.9 [**2190-2-6**] 09:54AM BLOOD Lactate-2.7* Interval Changes: [**2190-2-6**] 06:19PM BLOOD WBC-7.1 RBC-3.17* Hgb-9.2* Hct-27.2* MCV-86 MCH-29.2 MCHC-33.9 RDW-14.4 Plt Ct-152 [**2190-2-6**] 09:55PM BLOOD Hct-28.0* [**2190-2-7**] 05:06AM BLOOD WBC-7.5 RBC-3.03* Hgb-8.7* Hct-25.5* MCV-84 MCH-28.7 MCHC-34.2 RDW-15.0 Plt Ct-154 [**2190-2-7**] 05:06AM BLOOD Glucose-240* UreaN-46* Creat-1.5* Na-145 K-4.4 Cl-119* HCO3-18* AnGap-12 [**2190-2-6**] 06:43PM BLOOD Lactate-1.9 [**2190-2-8**] 06:15AM BLOOD WBC-5.9 RBC-3.44* Hgb-9.7* Hct-28.8* MCV-84 MCH-28.3 MCHC-33.8 RDW-15.2 Plt Ct-150 [**2190-2-8**] 06:15AM BLOOD Glucose-177* UreaN-32* Creat-1.2* Na-146* K-4.3 Cl-116* HCO3-22 AnGap-12 [**2190-2-6**] 06:43PM BLOOD Lactate-1.9 U/A negative. Studies: CT ABD & PELVIS W/O CONTRAST Study Date of [**2190-2-6**] 10:07 AM IMPRESSION: 1. Large periumbilical ventral hernia containing large bowel and fluid. No evidence for obstruction or incarceration. 2. Diverticulosis. 3. Probable left renal simple cyst. 4. Small 5-mm right lower lobe pulmonary nodule. This may have been seen on the prior study. Attention on follow-up. 5. Unchanged L3 compression fracture. Brief Hospital Course: 86 yo f with h/o schizophrenia, DM, HTN, CHF (EF unknown), who has a h/o of a GI bleed approx 1 year ago presents with BRBPR. . # Acute blood loss anemia: Most probably a lower GIB given hematochezia for 3 days prior to admission. She was monitored in the MICU overnight and she remained hemodynamically stable making it likely a slow bleed. The possible etiologies include diverticuli, hemorrhoids, AVM and colon cancer. Her baseline Hct was uncertain. Prior value in our system was 30 6 months ago, and on admission her HCT was 23. Per her guardian, she has had GIB managed conservatively in the past. She received 2 units of PRBCs overnight with an appropriate bump from 23 to 28, and subsequently dropped to 25.5 and was given an additional unit of PRBCs prior to transfer to the general medical floor (total 3 units PRBC). IV access was established with 2 PIVs. . # Ventral Hernia: Long standing. Surgery was consulted initially out of concern for possible strangulation or incarceration. However, on exam she denied pain and did not exhibit tenderness. A CT abd/pelvis was done that showed no evidence of strangulation or obstruction. . # Schizophrenia: She was alert and tangential in the MICU. Her speech was slightly garbled, however she has dentures at which were not with her, and oral thrush that was likely contributing to the picture. She followed commands and answered questions appropriately. Standing zyprexa QHS was continued and a smaller dose prn for agitation was added. . # Cardiomyopathy: EF unknown, she appeared dry to euvolemic. lasix, aspirin, and atenolol were held for potential instability. Her statin was restarted. . # DM: While in the ICU she was covered with ISS. Held prandin and glipizide. . # Acute on Chronic kidney disease (Stage III): Baseline cr not entirely clear, but improvements in Cr suggest ARF on admission. Her Cr peaked at 1.7 (admission), and improved to 1.2 at the time of discharge. Given her improvements in renal failure and unclear baseline, and the probable ARF on admission, her lasix was continued to be held at the time of discharge, but would recommend resuming in another 1-2 days as her clinical condition continues to improve. # Urinary incontinence: Her Detrol was held during this hospitalization, as foley was initially in place. Her Detrol was held on discharge to see if she can remain off of this medication, as the anticolinergic effects have the potential to be problem[**Name (NI) 115**] in this elderly female with cognitive and psychiatric impairments. # Pulmonary nodule: noted incidentially on CT scan. She will need outpatient follow-up. # Osteoporosis: continued calcium, vit D and calcitriol. # Patient & Guardian, [**Name (NI) **] [**Name (NI) 29768**], c: [**Telephone/Fax (1) 29770**] or w: [**Telephone/Fax (1) 29769**]. Code: Full (discussed with guardian; per guardian, she does not have legal authority to make patient DNR/DNI). Medications on Admission: # ATENOLOL 25 mg Tablet - 1 Tablet(s) by mouth once a day # ATORVASTATIN [LIPITOR] 20 mg by mouth once a day # CALCITRIOL 0.25 mcg by mouth every Monday, Wednesday and Friday # FUROSEMIDE 20 mg Tablet by mouth daily # GLIPIZIDE 12.5 mg Tablet by mouth Ext release once daily # LACTULOSE 10 gram/15 mL 30 ml by mouth once a day # OLANZAPINE [ZYPREXA] 8.75 mg Tablet by mouth at bedtime # TOLTERODINE [DETROL LA] 2 mg Ext Release by mouth at bedtime # PRANDIN 2mg TID # ACETAMINOPHEN 325 mg Tablet, 2 Tablet(s) by mouth once a day # ASPIRIN 81 mg Tablet by mouth once a day # CALCIUM CARBONATE-VITAMIN D3 600 mg-400 unit by mouth twice a day # DOCUSATE SODIUM 100 mg by mouth twice a day # MULTIVITAMIN 1 Tablet by mouth once a day # SENNA 8.6 mg Tablet - 2 Tablet(s) by mouth at bedtime PRNS: Bisacodyl, Fleet enema, combivent inhaler, guaifenesin, acetaminophen, duonebs. Discharge Medications: 1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR (Monday -Wednesday-Friday). 4. glipizide 10 mg Tablet Extended Rel 24 hr Sig: 12.5 mg PO once a day. 5. olanzapine 2.5 mg Tablet Sig: 3.5 Tablets PO HS (at bedtime): (8.75 mg). 6. Prandin 2 mg Tablet Sig: One (1) Tablet PO three times a day. 7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. 11. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: # Lower GI Bleed; possibly diverticular # Acute blood loss anemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with GI bleed. We suggested colonoscopy, but you and your guardian preferred to not to have the procedure. Your bleeding stopped, and your blood levels remained stable after transfusion of blood. Followup Instructions: Pt is currently off of her lasix; please follow her volume status. Her lasix can likely be resumed within the next [**12-6**] days. . Small 5-mm right lower lobe pulmonary nodule, recommend outpt follow up.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9208, 9291

4450, 7379

270, 276

9401, 9401

2925, 2925

9789, 9999

2327, 2338

8303, 9185

9312, 9380

7405, 8280

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224, 232

304, 1722

2941, 4427

9416, 9527

1744, 2046

2062, 2311

53,734

176,182

26013+57476

Discharge summary

report+addendum

Admission Date: [**2131-2-19**] Discharge Date: [**2131-4-30**] Date of Birth: [**2060-5-10**] Sex: F Service: SURGERY Allergies: Augmentin / Oxycodone Attending:[**First Name3 (LF) 2777**] Chief Complaint: Fever, swelling, pain and drainage from L BKA stump Major Surgical or Invasive Procedure: [**2131-2-20**] OPERATION PERFORMED: 1. Ultrasound-guided puncture of right common femoral artery. 2. Contralateral second-order catheterization of left external iliac artery. 3. Abdominal aortogram. 4. Serial arteriogram of the left lower extremity. 5. Debridement of massive soft tissue infection of the left lower extremity. [**2131-3-2**] Right Heart Catheterization/ Left Heart Catheterization/ Coronary Catheterization. [**2131-3-13**] PROCEDURE: Re-exploration of below-knee amputation and above- knee amputation. History of Present Illness: Patient is a 70F with severe PVD s/p left BKA [**4-23**] by Dr. [**Last Name (STitle) **] with pain, redness, and discharge in left stump since Sunday. Fever to 101F. Pt was in usual state of health until saturday when the 1 cm ulcer that appears intermeittently on the bottom of her otherwise well-healed stump opened up and began to drain purulent fluid. On Sunday the stump became firey red and warm to touch which prompted her to present to the ED Today. No n/v/c/d. All other ROS negative. Past Medical History: PMH: vascular history as below, CAD s/p angioplasty 92, HTN, high lipids, s/p appy, s/p colon resection, s/p lumpectomy, GI bleed Vascular Procedures: [**4-19**]: L BKA [**4-15**]: Angio - Occlusion of the L [**Doctor Last Name **] and peroneal art, unable to reenter the distal limb [**4-11**]: Left second toe amputation [**4-7**]: Angio - Dx abd aortogram & L lower extrem arteriogram, PTA of the tibioperoneal, [**Doctor Last Name **] and SFA and stenting of the tibioperoneal BK-[**Doctor Last Name **] and AK-[**Doctor Last Name **] art for residual stenosis. Social History: neg drinker neg smoker Family History: unknown Physical Exam: PE: 96.8 74 128/42 18 100%RA Pain [**6-25**] Gen: NAD, appears comfortable Pulm: CTAB Chest: RRR. no murmurs Abd: Soft, NT/ND LLE: Purulent discharge along medial well healed incision of BKA stump; significant TTP from stump to proximal knee; significant blanching circumferential erythema from stump to proximal knee; pain with active and passive ROM of knee; no significant edema appreciated RLE: 3+ pitting edema to knee pulses fem [**Doctor Last Name **] dp pt r 1+ d d d l 1+ d - - Pertinent Results: [**2131-2-19**] 07:00PM BLOOD WBC-25.0*# RBC-3.58* Hgb-11.1* Hct-32.8* MCV-91 MCH-30.8 MCHC-33.7 RDW-18.9* Plt Ct-358 [**2131-2-21**] 03:05AM BLOOD WBC-12.7* RBC-3.18* Hgb-9.8* Hct-27.6* MCV-87 MCH-31.0 MCHC-35.7* RDW-18.1* Plt Ct-174 [**2131-2-22**] 03:27AM BLOOD WBC-10.0 RBC-2.84* Hgb-8.7* Hct-24.8* MCV-87 MCH-30.5 MCHC-34.9 RDW-18.1* Plt Ct-113* [**2131-2-23**] 03:30AM BLOOD WBC-13.0* RBC-4.33# Hgb-12.9# Hct-38.4# MCV-89 MCH-29.7 MCHC-33.5 RDW-17.5* Plt Ct-107* [**2131-3-13**] 07:26PM BLOOD WBC-30.1*# RBC-2.85* Hgb-8.6* Hct-25.9* MCV-91 MCH-30.1 MCHC-33.2 RDW-17.5* Plt Ct-341 [**2131-3-14**] 04:20AM BLOOD WBC-16.3* RBC-3.44* Hgb-10.4* Hct-29.8* MCV-86 MCH-30.3 MCHC-35.0 RDW-17.5* Plt Ct-259 [**2131-3-15**] 04:07AM BLOOD WBC-11.8* RBC-3.54* Hgb-10.4* Hct-30.3* MCV-85 MCH-29.5 MCHC-34.5 RDW-17.0* Plt Ct-217 [**2131-2-20**] 08:10AM BLOOD PT-15.0* PTT-47.7* INR(PT)-1.3* [**2131-3-11**] 06:50AM BLOOD PT-11.9 PTT-30.6 INR(PT)-1.0 [**2131-2-19**] 07:00PM BLOOD Glucose-183* UreaN-44* Creat-1.4* Na-135 K-5.0 Cl-102 HCO3-18* AnGap-20 [**2131-2-20**] 06:56PM BLOOD Glucose-194* UreaN-26* Creat-0.8 Na-144 K-3.8 Cl-120* HCO3-17* AnGap-11 [**2131-2-22**] 03:27AM BLOOD Glucose-96 UreaN-18 Creat-0.6 Na-143 K-3.7 Cl-114* HCO3-23 AnGap-10 [**2131-3-14**] 04:20AM BLOOD Glucose-85 UreaN-13 Creat-0.5 Na-138 K-4.0 Cl-108 HCO3-24 AnGap-10 [**2131-3-15**] 04:07AM BLOOD Glucose-79 UreaN-14 Creat-0.4 Na-140 K-3.6 Cl-109* HCO3-27 AnGap-8 [**2131-2-21**] 03:05AM BLOOD ALT-9 AST-23 AlkPhos-51 Amylase-200* TotBili-0.8 [**2131-3-14**] 04:20AM BLOOD ALT-4 AST-18 AlkPhos-62 TotBili-1.0 [**2131-2-20**] 06:56PM BLOOD CK-MB-7 cTropnT-0.02* [**2131-2-26**] 10:49PM BLOOD CK-MB-NotDone cTropnT-0.08* [**2131-2-27**] 03:35AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2131-2-27**] 10:38AM BLOOD CK-MB-NotDone cTropnT-0.13* [**2131-2-27**] 06:12PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2131-3-14**] 04:20AM BLOOD cTropnT-0.02* Portable TEE (Complete) Done [**2131-3-13**] at 2:33:04 PM The left atrium is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. Brief Hospital Course: [**2131-2-19**] Admitted from home to Vascular Surgery, fever, pain w/ L below knee amputaion stump erythema and drainage. X-ray showed-likely a deep ulcer extending to the cortical surface of the remnant tibial stump. Started broad spectrum antibiotics. Remained febrile 101.5. Pre-oped for exploration and drainage of infected L BKA stump. NPO post MN and IV hydration. [**2131-2-20**] Remained febrile T 102- blood cultures sent. Triggered for hypotension SBP down to 60's and desaturation down to 88%. Given NS boluses, responded briefly but continued to become hypotensive. Transferred to the VICU, more fluid boluses given, given O2/NC 4l- O2 sats came up to 98-100%. Persistently hypotensive. Foley inserted, additional preipheral IV access, central line, a-line placed. Started on Dopamin to keep SBP>90's. Taken to OR for exploration and drainage of infected L BKA stump. Post-operatively, remained intubated and sedate, transferred to CVICU. Presumed to have necrotizing fascitis- started on Meropenem, Clindamycin and Gentamycin. Post-operatively the ID team was consulted who recommended continuing therapy with clindamycin and meropenem, vancomycin was added in addition. Cultures taken from the operating room were followed. Daily wound care was performed with wet->dry dressings TID. [**2-21**] Dopmaine was required to maintain adquate SBP's. [**2-22**] Pressors were weaned off, 1 U PRBC transfused and a plastic surgery consult was obtained. [**2-23**] The patient was weaned from mechanical ventilation, transitioned from AC to CPAP, a wound VAC was placed over the left BKA stump. [**2-24**] The patient was extubated without incident, began spiking fevers, c-diff was sent along with blood cultures. [**2-25**] Wound cultures from the OR were positive for beta-hemolytic strep and MSSA. [**2-27**] pt with increasing SOB, desaturations, CXR consistent w/volume overload, diuersis initiated. T-wave inversions noted on EKG [**3-2**] Persistently increasing troponins, Cardiac cath, negative for significant flow limiting coronary lesions. Pt transfered to VICU [**3-3**] - [**3-7**] The patient was progressively diuresed, nutrition recommendations were obtained and implemented, TTE was repeated showing improved systolic function (50-55%) [**3-9**] Pt cleared by cardiology to return to OR for completion AKA [**3-13**] Pt returned to operating room for above knee amputation with primary closure. The procedure was without complication. Chronic pain service continued to follow [**3-14**] 2 Units PRBC were transfused for a drop in Hct, no obvious source of bleeding aside from oozing at the amputation site. Enzymes were cycled to r/o for MI, negative x3. Antibiotics were continued [**3-15**] The dressing was taken down, amputation site appeared in good condition, meropenem was discontinued. [**3-16**] Pt was deemed fit for discharge. At the time of discharge pain was well controlled with oral medications, pt was voiding without difficulty, tolerating a regular diet and working with physical therapy. [**3-18**] CVL d/c'd Physical therapy continued to work with patient for transitioning to chair. Medial aspect of left AKA wound slightly opened in multiple subcentimeter areas with no evidence of infection or necrosis, pt kept in house for wound monitoring. Incision closing appropriately with dry dressing changes. No sign of infection. Medications on Admission: atenolol 25', folic acid 1', lasix 20', vicodin prn, lisinopril 10', methotrexate 17.5 mg q week, methyprednisolone 4', omeprazole 20', opium tincture 10mg/ml 2 drops [**Hospital1 **], simvastatin 20', MVI, calcium 500", imodium 80' Discharge Medications: 1. Methylprednisolone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for distension. 5. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Methotrexate Sodium 2.5 mg Tablet Sig: Four (4) Tablet PO 1X/WEEK (FR). 15. Methotrexate Sodium 2.5 mg Tablet Sig: Three (3) Tablet PO 1X/WEEK (SA). 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 18. Opium Tincture 10 mg/mL Tincture Sig: Two (2) Drop PO BID (2 times a day) as needed for Diarrhea. Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: Infected L BKA stump Sepsis Hypotension Non STEMI CHF- Left ventricular systolic dysfunction, EF 30% Discharge Condition: Improved Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION . This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are restrictions on activity. On the side of your amputation you are non weight bearing until cleared by your Surgeon. You should keep this amputation site elevated when ever possible. . You may use the other leg to assist in transferring and pivots. But try not to exert to much pressure on the amputation site when transferring and or pivoting. Please keep knee immobilizer on at all times to help keep the amputation site straight. . No driving until cleared by your Surgeon. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Redness in or drainage from your leg wound(s) . . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . Exercise: . Limit strenuous activity for 6 weeks. . Do not drive a car unless cleared by your Surgeon. . Try to keep leg elevated when able. . BATHING/SHOWERING: . You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. . WOUND CARE: . Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. . When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. . MEDICATIONS: . Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. . CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid pressure to your amputation site. . No strenuous activity for 6 weeks after surgery. . DIET : . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. . FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**12-19**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**1-17**] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-3-30**] 11:00 Provider: [**Name10 (NameIs) **], [**Name8 (MD) **] MD (Vascular Surgery):([**Telephone/Fax (1) 44777**] [**2131-4-5**] - 11:00 AM [**Last Name (un) 2577**] Building [**Location (un) 442**] Name: [**Known lastname 11406**],[**Known firstname 1647**] Unit No: [**Numeric Identifier 11407**] Admission Date: [**2131-2-19**] Discharge Date: [**2131-4-30**] Date of Birth: [**2060-5-10**] Sex: F Service: MEDICINE Allergies: Augmentin / Oxycodone Attending:[**First Name3 (LF) 839**] Addendum: Chief Complaint: Following transfer to medical service: Hypernatremia, delirium, dysphagia Major Surgical or Invasive Procedure: Following transfer to medical service: None History of Present Illness: Upon transfer to the medical service on [**2131-3-29**]: 70 yo F with history of CAD, hypertension, hyperlipidemia, PVD s/p multiple amputations and vascular interventions. Is now hospital day 38 following presentation for on [**2131-2-19**] for debridement of gangrenous L BKA site. Since that time has had a complicated course including performance of a left above knee amputation. At this time the patient's major outstanding issues that have prompted a transfer to the medical service are hypotension and anemia requiring recent blood transfusion, urinary tract infection, delerium, candidal esophagitis, question of recent aspiration, anemia, lack of vascular access. At time of interview the patient's main complaints are throat and mouth pain as well as the inability to eat or drink anything at this time. Denies fever or chills. Denies chest pain or dyspnea. REVIEW OF SYSTEMS: (+)ve: throat pain, dry mouth, mouth pain (-)ve: chest pain, dyspnea, leg pain, diarrhea, constipation Past Medical History: 1) CAD s/p angioplasty '[**13**] 2) Rheumatoid arthritis -on MTX/steroids 3) Hx staph aureus left hand and arm and right hand and arm, [**2122**] and [**2124**] respectively. History of heel infection, [**2126**]. 4) Hx GIB [**2129**] [**12-18**] ulceration 5) Hypertension 6) Hyperlipidemia 7) Peripheral vascular disease -s/p L AKA [**2131-3-13**] -s/p R ant tib, [**Doctor Last Name **], SFA angioplasty [**2130-9-26**] -s/p L BKA [**2130-4-19**] -s/p L second toe amputation [**2130-4-11**] c/b MSSA bacteremia [**2130-4-15**], s/p 2 wk vanco, TTE neg -s/p L PTA of the tibioperoneal, [**Doctor Last Name **] and SFA and stenting of the tibioperoneal BK-[**Doctor Last Name **] and AK-[**Doctor Last Name **] art for residual stenosis [**2130-4-7**] 8) s/p colon resection c/b CVA 9) s/p lumpectomy '[**09**] 10) s/p bilateral hernia repairs '[**15**], 11) s/p bilateral cataracts '[**18**] 12) s/p left finger amputation 13) s/p appendectomy Allergies: Augmentin / Oxycodone Social History: Lives with husband, two daughters one in TN, one in [**Name (NI) 42**] who is [**Name8 (MD) **] MD. Tobacco: Denies EtOH: Denies Family History: Reviewed and noncontributory Physical Exam: Upon transfer to medical service on [**2131-3-29**]: VS: T 97.0, BP 119/66, HR 90, O2Sat 94% RA GEN: thin and frail appearing elderly woman HEENT: PERRL, oral mucosa strikingly dry with cracked and bleeding lips, oropharynx with dried secretions and slight erythema NECK: Supple, no [**Doctor First Name **] PULM: CTAB anteriorly CARD: RR, nl S1, nl S2, no M/R/G ABD: BS+, soft, NT, ND EXT: Left AKA with stiched surgical incision appears to be healing well with no surrounding erythema or exudates. Right LE with 2+ pedal edema and poor muscle tone. Right upper ext with muscle wasting multiple confluent ecchymoses SKIN: Skin is thin and fragile accross entire body NEURO: Oriented to person and clinical situation, not oriented to date PSYCH: Affect blunted Physical exam at time of discharge: Pertinent Results: Following transfer to medical service on [**2131-3-29**]: Portable TTE (Complete) Done [**2131-3-29**]: LVEF >55%, Grade I diastolic dysfunction. VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2131-3-29**]: IMPRESSION: Silent aspiration and ineffective clearing of residuals. US ABD LIMIT, SINGLE ORGAN Study Date of [**2131-3-31**]: IMPRESSION: 1. No ascites. 2. Bilateral pleural effusions, right greater than left. 3. Right likely renal cyst. VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2131-4-5**]: RESULTS: Flash laryngeal penetration with thin liquid that did not result in aspiration. CT HEAD W/ & W/O CONTRAST Study Date of [**2131-4-7**]: CONCLUSION: Prior infarcts of the brain. Air-fluid levels within the maxillary sinuses may correlate with the patient's symptoms, and suggests an acute infection. Multiple extracranial calcifications, unusual in appearance and distribution. The finding could be representative of a disorder of calcium- phosphorus metabolism and less likely be post-inflammatory in nature. See above report for additional findings. CT CHEST, ABDOMEN, AND PELVIS W/CONTRAST Study Date of [**2131-4-7**]: IMPRESSION: 1. No source of infection identified to account for neutropenic fever. 2. Right lower lobe pulmonary edema. 3. Moderate right and small left nonhemorrhagic pleural effusions with adjacent atelectasis. 4. Liver hypodensity, likely representing a hemangioma. 5. Status post colectomy. 6. Bulky uterus with rounded masses arising, but also showing enhancement. Findings could represent fibroid uterus; however, slightly unusual for the patient's age. Also 1.3 cm left ovarian cyst is also slightly unusual for the patient's age. Correlation with hormonal use is recommended, and if clinically indicated, ultrasound could be performed for further assessment after treatment of acute symptoms. BILAT LOWER EXT VEINS Study Date of [**2131-4-7**]: IMPRESSION: Bilateral lower extremity DVTs. VENOUS DUP EXT UNI (MAP/DVT) RIGHT Study Date of [**2131-4-12**]: IMPRESSION: Cephalic vein phlebitis. No evidence of right upper extremity DVT. PELVIS, NON-OBSTETRIC Study Date of [**2131-4-14**]: IMPRESSION: Transabdominal scanning reveals a bulky fibroid uterus, with a 1.6 x 1.3 x 1.3 cm anechoic cyst located superiorly to the left of the fundus, consistent with findings on recent CT scan. This may represent a simple ovarian versus paraovarian cyst. CT HEAD W/O CONTRAST Study Date of [**2131-4-15**]: IMPRESSION: 1. No evidence of acute extra- or intra-axial hemorrhage. 2. Remote right temporal and left occipital infarcts with encephalomalacia. 3. Mucosal thickening and aerosolized secretions within the maxillary and sphenoid sinuses, with similar appearance compared to prior study, which may indicate an acute inflammatory component. 4. Prominence of ventricles and sulci, likely age related. SELECTED HEMATOLOGY: [**2131-3-28**] 04:22AM BLOOD WBC-6.5 RBC-3.66* Hgb-10.8* Hct-32.1* MCV-88 MCH-29.6 MCHC-33.8 RDW-16.2* Plt Ct-267 [**2131-3-30**] 05:04AM BLOOD WBC-3.4* RBC-3.08* Hgb-9.0* Hct-27.2* MCV-88 MCH-29.3 MCHC-33.2 RDW-15.5 Plt Ct-138* [**2131-4-2**] 02:47AM BLOOD WBC-0.8* RBC-2.98* Hgb-8.9* Hct-26.0* MCV-87 MCH-30.0 MCHC-34.3 RDW-15.4 Plt Ct-35* [**2131-4-3**] 04:42AM BLOOD WBC-1.8*# RBC-3.40* Hgb-10.1* Hct-29.4* MCV-87 MCH-29.7 MCHC-34.4 RDW-15.5 Plt Ct-24* [**2131-4-7**] 03:00AM BLOOD WBC-3.1* RBC-2.81* Hgb-8.4* Hct-24.4* MCV-87 MCH-29.9 MCHC-34.3 RDW-17.0* Plt Ct-252 [**2131-4-13**] 05:38AM BLOOD WBC-37.1* RBC-2.71* Hgb-7.8* Hct-24.2* MCV-90# MCH-28.9 MCHC-32.2 RDW-16.4* Plt Ct-729* [**2131-4-17**] 09:00AM BLOOD WBC-16.0* RBC-3.84* Hgb-11.3* Hct-34.1* MCV-89 MCH-29.5 MCHC-33.3 RDW-18.1* Plt Ct-509* ANC TREND: [**2131-4-1**] 02:30AM BLOOD Gran Ct-240* [**2131-4-5**] 05:00AM BLOOD Gran Ct-100* [**2131-4-8**] 02:00AM BLOOD Gran Ct-[**2108**]* SELECTED CHEMISTRIES: [**2131-3-29**] 02:46AM BLOOD Glucose-121* UreaN-46* Creat-1.3* Na-144 K-3.5 Cl-116* HCO3-20* AnGap-12 [**2131-3-25**] 06:53AM BLOOD Glucose-88 UreaN-47* Creat-2.6*# Na-141 K-5.5* Cl-107 HCO3-24 AnGap-16 [**2131-3-26**] 11:53AM BLOOD Glucose-115* UreaN-56* Creat-2.6* Na-142 K-4.6 Cl-112* HCO3-20* AnGap-15 [**2131-4-10**] 04:12AM BLOOD Glucose-86 UreaN-34* Creat-1.0 Na-142 K-5.3* Cl-108 HCO3-26 AnGap-13 [**2131-4-17**] 09:00AM BLOOD Glucose-124* UreaN-28* Creat-0.7 Na-141 K-3.6 Cl-109* HCO3-25 AnGap-11 [**2131-4-2**] 02:47AM BLOOD ALT-9 AST-13 LD(LDH)-142 AlkPhos-74 TotBili-0.3 [**2131-4-11**] 05:49AM BLOOD ALT-7 AST-23 LD(LDH)-393* AlkPhos-135* TotBili-0.2 MISCELLANEOUS: [**2131-4-15**] 04:23AM BLOOD calTIBC-138* Hapto-282* Ferritn-1569* TRF-106* [**2131-4-8**] 09:29AM BLOOD CEA-4.9* CA125-69* METOTREXATE TREND: [**2131-4-2**] 02:47AM BLOOD mthotrx-LESS THAN [**2131-4-3**] 04:42AM BLOOD mthotrx-<0.02 [**2131-4-7**] 03:00AM BLOOD mthotrx-LESS THAN MICROBIOLOGY: [**2131-4-12**] CATHETER TIP-IV WOUND CULTURE-FINAL (NO GROWTH) [**2131-4-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL (NEGATIVE) [**2131-4-10**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-4-8**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY (NO GROWTH) [**2131-4-8**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-4-8**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-4-8**] URINE URINE CULTURE-FINAL (NO GROWTH) [**2131-4-7**] STOOL FECAL CULTURE, CAMPYLOBACTER CULTURE, CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL (NEGATIVE) [**2131-4-7**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-4-6**] MRSA SCREEN MRSA SCREEN-FINAL (NEGATIVE) [**2131-4-6**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-4-6**] URINE URINE CULTURE-FINAL {YEAST} [**2131-4-6**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-4-4**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP, VANCOMYCIN RESISTANT} [**2131-4-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL (NEGATIVE) [**2131-4-2**] Blood (CMV AB) CMV IgG ANTIBODY, CMV IgM ANTIBODY-FINAL (NEGATIVE) [**2131-4-1**] Blood (EBV) [**Doctor Last Name 1897**]-[**Doctor Last Name **] VIRUS VCA-IgG AB-FINAL; [**Doctor Last Name 1897**]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name 1897**]-[**Doctor Last Name **] VIRUS VCA-IgM AB-FINAL (CONSISTENT WITH PAST INFECTION) [**2131-4-1**] Immunology (CMV) CMV Viral Load-FINAL (NEGATIVE) [**2131-3-31**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP, VANCOMYCIN RESISTANT} [**2131-3-31**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL (NEGATIVE) [**2131-3-30**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-3-30**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2131-3-30**] URINE URINE CULTURE-FINAL {YEAST, PROBABLE ENTEROCOCCUS} Brief Hospital Course: Hospital course starts on [**2131-3-29**], following transfer of patient to Internal Medicine service: #. Dysphagia / Nutrition: Upon transfer to medicine service on [**2131-3-29**], patient was noted to have dysphagia, odynaphagia, hoarse voice, oral ulcers, and oral pain. Her video swallowing study and speech pathology evaluation on [**2131-3-29**] revealed that she had silent aspiration likely due to generalized weakness and complicated by mucositis and pharyngitis. This had been presumed to be due to [**Female First Name (un) **] esophagitis and patient was being treated with nystatin. Due to her dysphagia and identified aspiration risk patient was made strict NPO. She was switched from oral nystatin to IV fluconazole on [**2131-3-30**]. Over the next few days her odynaphagia improved and hoarseness resolved. Patient was started on TPN on [**2131-4-2**]. A repeat swallowing eval on [**2131-4-5**] cleared her to have a dysphagia diet with aspiration precautions. Patient continued on combination of full TPN with small amount of oral dysphagia diet. From [**4-12**] through [**4-14**] a calorie count for her oral intake was performed. Patient was noted to only be consuming 60% of her recommended oral caloric intake. On [**2131-4-16**] her TPN was reduced to supplemental level and she was approved to start a full regular diet given that she had done well on dysphagia diet and given that part of her inadequate caloric intake could have been due to patient not having adequate choices for dietary intake. Given patient's poor PO intake, patient was evaluated for PEG placement, but given patient's fever/bacteremia, it was decided to defer this procedure indefinitely. Patient was taking regular solids with Ensure supplementation on dischage. # Fevers/Bacteremia: On [**4-20**], patient was noted to be febrile. Blood and urine cultures were obtained. Blood cultures peripherally on [**4-20**] (1/2 bottles) grew Clostridium Perfringens. Blood cultures from PICC and peripheral cultures thereafter were negative. Urine culture by straight cath grew Vancomycin Resistant Enterococcus, sensitive to linezolid. Patient was also found to have C Diff in her stool. Patient was treated for these with IV Flagyl, PO Vancomycin, and PO linezolid. - Continue PO Vancomycin/IV Flagyl for 14 day course (starting [**4-24**]) - Continue PO Linezolid for 7 day course (starting [**4-24**]) # Pancytopenia attributed to methotrexate toxicity: Morning after transfer to medicine service, patient noted to have decreased WBC count as well as decreased platelet count. This result was confirmed on repeat testing on evening of [**2131-3-30**]. Methotrexate was held at this time due to concern for further toxicity to bone marrow. Through use of hematology consult on [**2131-4-1**], methotrexate was identified as likely primary cause of pancytopenia and leucovorin rescue was started. Methotrexate level was obtained on [**2131-4-2**]; however was already less than assay at this time. This indicates that the damage had likely been done following patient receiving methotrexate on [**3-23**] and [**3-24**]. There was no measured creatinine on those days and on [**3-25**], patient was discovered to have acute kidney injury. The lingering methotrexate levels due to renal failure likely first caused the mucosits and pharyngitis as above that was identified on [**2131-3-29**]. As methotrexate toxicity continued, pancytopenia followed the mucositis and was noted first on [**2131-3-30**]. As counts were trended, the patient's ANC nadir was 100 on [**4-3**] and platelet nadir was 23 on [**4-5**]. Patient received filgrastim on [**2131-4-7**] while patient was in the MICU. Patient's WBC count recovered to normal range at 4.1 on [**4-8**]. Leucovorin was discontinued on [**2131-4-8**]. WBC count subsequently raised to peak of 37.1 and platelets peaked at 729 on [**2131-4-13**]. - Plan to discontinue Methotrexate indefintitely #. Febrile neutropenia: Patient was first recognized at being neutropenic on [**2130-3-31**] and she spiked a fever later than day. She received full set of blood and urine cultures and a CXR was obtained. She was put on neutropenic precautions and started on cefepime. She had already been started on Vancomycin on [**3-30**] for probable VRE UTI. Due to persistent high fevers while neutropenic, on [**4-5**] patient was started on metronidazole and switched from vancomycin to daptomycin. On [**4-6**] patient was still spiking fevers and thus cefepime was discontinued and meropenem as well as micafungin was added to her antimicrobial regimen. Patient on [**4-6**] became delerious in setting of her febrile neutropenia and she was transferred to the MICU with a final antibiotic regimen of daptomycin, meropenem, metronidazole, fluconazole, and micafungin. Patient's urine cutlure cleared on enterococcus on [**4-6**]. In the MICU, patient's neutropenia resolved on [**4-8**] and all antibiotics were ceased. Patient did not have a positive blood or urine culture from that time through to time of discharge from the hospital. In all, she never had a positive blood culture during the hospitalization. #. Leukocytosis: Starting on [**4-9**] after administration of minimum allowed dose of G-CSF (later realized to be approximately 2.5 times recommended dose for her body weight), patient developed a leukocytosis with peak WBC count of 37 on [**2131-4-13**]. From [**4-7**] to time of discharge patient had two negative stool c. diff assays, 3 negative blood cultures, a negative urine culture, and a negative culture for central venous catheter tip. Patient later ([**4-20**]) became febrile and then developed CDiff/Clostridium Perfringes Bacteremia/VRE UTI, which she was treated for. WBC on discharge was 16.8. #. Pulmonary embolism and DVT: On [**4-7**] chest CT patient was incidentally noted to have bilateral pulmonary embolisms. Extensive bilateral lower extremity DVTs were noted on [**4-8**] LE doppers while patient in ICU. Likely related to prolonged hospitalization and immobility, though patient had been on appropriate prophylaxis with Heparin subcutaneous. She was started on a heparin drip on [**4-7**] with a bridge to warfarin started on [**4-12**]. Patient was started on lovenox in anticipation of discharge on [**4-18**]. Patient was re-started on coumadin on [**4-25**]. Patient had been refusing coumadin intermittantly on discharge and INR was not therapeutic. - Continue Lovenox 40mg [**Hospital1 **], until INR therapeutic - Continue coumadin 3mg daily - Check INR daily #. Pelvic CT scan abnormalities: [**2131-4-7**] CT scan with note of "Bulky uterus with rounded masses arising" thought to be unusual for her age. Also note of 1.3 cm left ovarian cyst inconsistent with her age. Poor visualization of pelvic mass on [**4-11**] as patient refused transvaginal ultrasound. Patient had repeat ultrasound yesterday that reported bulky fibroid uterus as well as anechoic cyst consistent with simple cyst or paraovarian cyst. Given this result, we are unlikely to need to pursue additional imaging as this is not consistent with malignant process; however, radiology reported that if additional imaging were to be pursued, MRI would be the study of choice. #. Headache: Patient reporting moderate headache on [**4-14**] and [**2131-4-15**]. Concerning in setting of anticoagulation. No focal neuro deficits on exam and no additional confusion above baseline. Head CT on [**2131-4-15**] was without concern for acute ICH. Headache was able to be controlled with tylenol #. Anemia: Patient's HCT had slowly trended down to 20.7 on [**2131-4-15**] from 29.1 on [**2131-4-5**]. Stool was guaiac negative, patient without focal pain complaints aside from head. Likely all late result of methotrexate toxicity, though may consider anemia of chronic disease as possibility along with frequent phlebotomy as possibility. Hemolysis labs were negative. HCT has jumped from 20.7 yesterday morning to 31.9 on [**2131-4-16**] following transfusion of 2 units PRBCs. Iron studies from [**4-15**] had low iron and low TIBC with high ferritin, which was consistent with anemia of chronic disease. Medications on Admission: atenolol 25 folic acide 1 lasix 20 vicodin prn lisinopril 10 methotrexate 17.5 mg qweek methylprednisolone 4 omeprazole 20 opium tincture 10 mg/mL 2 drops [**Hospital1 **] simvastatin 20 MVI calcium 500 [**Hospital1 **] immodium 80 Discharge Medications: 1. Simethicone 80 mg Tablet, Chewable [**Hospital1 1649**]: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for distension. 2. Quetiapine 25 mg Tablet [**Hospital1 1649**]: 0.5 Tablet PO QHS (once a day (at bedtime)). 3. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 1649**]: One (1) ML Mucous membrane TID (3 times a day). 4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 1649**]: One (1) Tablet PO BID (2 times a day). 5. Methylprednisolone 2 mg Tablet [**Hospital1 1649**]: Two (2) Tablet PO DAILY (Daily). 6. Enoxaparin 40 mg/0.4 mL Syringe [**Hospital1 1649**]: One (1) Subcutaneous [**Hospital1 **] (2 times a day). 7. Warfarin 2 mg Tablet [**Hospital1 1649**]: One (1) Tablet PO Once Daily at 4 PM: Please adjust dose based on INR. 8. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Hospital1 1649**]: One (1) Intravenous Q8H (every 8 hours) for 9 days. 9. Heparin Flush (10 units/ml) 2 mL IV PRN PICC flush 10. Linezolid 600 mg Tablet [**Hospital1 1649**]: One (1) Tablet PO Q12H (every 12 hours) for 1 days. 11. Vancomycin 125 mg Capsule [**Hospital1 1649**]: One (1) Capsule PO four times a day for 7 days. 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 13. Ondansetron 4 mg IV Q8H:PRN nausea 14. Citalopram 20 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO DAILY (Daily). 15. Haloperidol 0.5 mg Tablet [**Last Name (STitle) 1649**]: Two (2) Tablet PO HS (at bedtime) as needed for agitation. 16. Opium Tincture 10 mg/mL Tincture [**Last Name (STitle) 1649**]: Five (5) Drop PO Q4H (every 4 hours) as needed for loose stool: Start once patient's is finished w/ treatment for CDiff. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] Discharge Diagnosis: Infected L BKA stump Sepsis Hypotension Non STEMI CHF- Left ventricular systolic dysfunction, EF 30% UTI Bacteremia C Diff Colitis Hypertension Discharge Condition: Afebrile, vitals stable. Discharge Instructions: You were admitted to the hospital for an above the knee amputation. You had a long hospital course that was complicated. During this hospitalization you were found to have a blood clot in your legs and lungs. In addition, you were found to have a C.diff infection in your stool, a urinary tract infection, and an infection in your blood. For this, you were given antibiotics. In addition, you had difficulty with your nutrition; you were given IV nutrition for a while. You were felt to require rehab prior to returning home. If you feel like you have a fever, have chills, please follow up with the physician at the rehab center. . Avoid pressure to your amputation site. Followup Instructions: Vascular Surgery Please follow up with vascular surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**5-16**] at 1:45. Address is [**Hospital Unit Name 11408**], [**Location (un) 42**], MA. Phone number is ([**Telephone/Fax (1) 4685**]. Rheumatology Please follow up with Dr. [**Last Name (STitle) 11409**] in [**Hospital1 **] on [**6-6**] at 2:30pm. His phone number is ([**Telephone/Fax (1) 11410**]; Address is: [**Last Name (NamePattern1) 11411**] [**Apartment Address(1) 11412**]; [**Hospital1 **], [**Numeric Identifier 11413**]. Please follow up with the physician at the Rehabilitation center. If she decides to pursue MRI for pelvic mass following her discharge, she should call Dr.[**Name (NI) 11414**] office for an appointment: [**Telephone/Fax (1) 10513**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 841**] Completed by:[**2131-4-30**]

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icd9cm

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icd9pcs

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39545, 39691

37450, 37683

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17830, 18378

21506, 22305

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21315, 21445

808

197,130

3780

Discharge summary

report

Admission Date: [**2181-11-16**] Discharge Date: [**2181-11-23**] Date of Birth: [**2126-6-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 13621**] is a 55 year old woman with adenocarcinoma of unknown primary (s/p six cycles of gemcitabine/irinotecan and two cycles of Xelox, last cycle [**2181-11-14**]) who developed acute shortness of breath this morning. EMS was called and found her to have tachycardia to 180-200; she was given 6mg adenosine with some slowing, and they determined the rhythm to be atrial flutter. She was given an additional 5mg lopressor with rates decreased to the 130-150. On oxygen 4L at baseline. . In the ED, her heart rate was in the 150's, and she did not receive any further rate control. Bedside [**Month/Day/Year 113**] revealed a moderate pericardial effusion with no signs of tamponade or RV strain. She received a dose of ceftriaxone, clindamycin, and azithromycin for CAP + post-obstructive pneumonia, as well as nebulizers and solumedrol x 1. . Of note, she underwent her second cycle of Xelox on [**11-14**]. She was recently discharged from [**Hospital1 18**] on [**11-11**] after right chest thoracentesis and placement of chest tube for pneumothorax s/p throacentesis. She had been off her Lovenox for approximately 6 days. . Oncologic history: Initially had syncope, and pericardial/pleural effusion discovered [**2181-5-10**]. Fluid revealed metastatic adenocarcinoma and pericardial fluid revealed well-differentiated mucinous adenocarcinoma. She has had multiple admissions for dizziness/syncope and dyspena. She had pericardiocentesis and balloon pericardiotomy with removal of 520cc of bloody fluid on [**6-6**]. Given location of effusions, a subtle gastric or pancreatico/biliary tumor was suspected, and she underwent 6 cycles of gemcitabine/irinotecan. She has had bilateral pleurex catheters. She has a history of DVT/PE in [**Month (only) **] [**2180**]. Past Medical History: - Tuberculosis treated in [**2145**] with normal chest x-ray at [**Hospital1 2025**] in [**2162**]. - GYN: G2 P2. Tubal ligation [**2156**]. Stopped menstruating at age 50, normal pap's per patient - Hypertension. - History of mild asthma, inhalers not used for several years. - normal mammogram less than one year ago. - normal colonoscopy 2/[**2178**]. - recent pericardial effusion/tamponade - right pleural effusion - large common femoral DVT - adenocarcinoma of unclear primary Social History: She worked as a nursing assistant. Lives with her husband. [**Name (NI) **] 2 Children. Family History: Her father died of stomach cancer at age 72. Mother died of colon cancer at age 63. She is the 10th of 13 children. She has lost 3 siblings to motor vehicle accidents. Physical Exam: VITALS: T96.9F, BP 101/78, HR 138, RR 26, Sat 100% VENT: BiPap 8/4 GENERAL: Respiratory distress, audible wheezing HEENT: BiPap in place NECK: No JVD appreciated, cannot lay patient flat CARD: Tachycardic, no murmurs RESP: Expiratory wheezing throughout, tachypneic, decreased breath sounds at bases bilaterally ABD: Mildly distended and tympanic, nontender, decreased bowel sounds EXT: Warm, well-perfused, 2+ DP pulses bilaterally; 2+ edema in both legs bilaterally NEURO: Alert & appropriate Pertinent Results: ABG: 7.40/39/79/25 on 100%NRB . [**2181-11-16**] 09:59AM GLUCOSE-155* UREA N-13 CREAT-0.8 SODIUM-136 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13 [**2181-11-16**] 09:59AM ALT(SGPT)-18 AST(SGOT)-22 LD(LDH)-161 CK(CPK)-72 ALK PHOS-67 TOT BILI-0.5 [**2181-11-16**] 09:59AM WBC-6.2 RBC-4.08* HGB-13.5 HCT-40.5 MCV-99* MCH-33.0* MCHC-33.2 RDW-19.0* [**2181-11-16**] 09:59AM NEUTS-94.3* BANDS-0 LYMPHS-2.8* MONOS-2.5 EOS-0.3 BASOS-0.1 ATYPS-0 METAS-0 MYELOS-0 Brief Hospital Course: Summary 55yF with adenocarcinoma of unknown primary presenting with tachycardia and shortness of breath. . #) Dyspnea. This was felt to be due to known pleural and pericardial effusions with associated SVT. At the time of admission, there was no evidence of tamponade or worsening pleural effusion on CXR. The patient has a history of DVT/PE from earlier this year, but did not have evidence of right heart strain on [**Month/Day/Year 113**], was continued on her home anticoagulation and has an IVC filter in place. She was treated with azithromycin and ceftriaxone for a possible CAP and nebs plus short steriod taper as she has a history of asthma. The patient's shortness of breath responded well to supplemental O2 and low-dose morphine. Her rate was controlled at her baseline of 115-120. She was discharged to home with azithromycin to complete a 14 day course. . #) Tachycardia. The patient is tachycardic at baseline around 115-120. On the day of admission and again on [**2181-11-18**], the patient had an additionally elevated rate to the 160s. This responded in a moderate fashion to IV adenosine, metoprolol and diltiazem; the patient was transitioned to PO diltiazem. The patient's tachycardia was thought to be related to her shortness of breath, pleural effusion and advanced disease state. . #) Adenocarcinoma. The patient's primary oncologist, Dr. [**Last Name (STitle) **], was involved in her care from the time of admission. Xeloda was initially while in intensive care an was restarted when returning to the oncology service. She was discharged to home with services and plan for follow up with Dr. [**Last Name (STitle) **]. . #) CODE: DNR/DNI Medications on Admission: Xeloda TID Lovenox 60mg [**Hospital1 **] (restarted yesterday after being off x 1 week) Calcium/Vitamin D Multivitamin Compazine/Zofran PRN Morphine 15mg PRN pain Fentanyl 25mcg patch Lidocaine Patch Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours). 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 6. Capecitabine 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID:PRN as needed: After loose bowel movement. Do not exceed 8 tabs per day. 8. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 4 days. Disp:*4 Capsule(s)* Refills:*0* 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. 11. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO DAILY (Daily). 12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 13. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 14. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: Three (3) ML Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing for 2 weeks. Disp:*QS ML(s)* Refills:*6* 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing for 2 weeks. Disp:*QS NEB* Refills:*6* 16. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:*30 Capsule, Sustained Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: PRIMARY: Atrial flutter SECONDARY: Adenocarcinoma of unknown primary Discharge Condition: Good, afebrile, shortness of breath at baseline Discharge Instructions: YOu were admitted to the hospital for shortness of breath. Your heart rate was elevated and you were given medications to slow it down. . You were started on steroids as we were concerned your shorntess of breath may have been related to asthma. YOu should continue to take this medication for four more days at 10mg. . You should follow up with your regularly scheduled appointments. . If you develop any worrisome symptoms such as shortness of breath, chest pain, fluttering in your chest, lightheadedness, please contact your doctor or return to the emergency room. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2181-11-29**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-12-5**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-12-5**] 2:00

[ "401.9", "420.90", "199.1", "493.90", "427.32", "427.89", "518.81", "197.2", "486" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7664, 7742

3987, 5655

337, 343

7855, 7905

3493, 3964

8522, 9004

2793, 2962

5905, 7641

7763, 7834

5681, 5882

7929, 8499

2977, 3474

278, 299

371, 2166

2188, 2672

2688, 2777

63,017

193,864

46034

Discharge summary

report

Admission Date: [**2141-10-20**] Discharge Date: [**2141-10-30**] Date of Birth: [**2083-5-4**] Sex: M Service: NEUROLOGY Allergies: Dilantin Attending:[**First Name3 (LF) 5018**] Chief Complaint: Variceal bleeding Major Surgical or Invasive Procedure: EGD History of Present Illness: 58 year old male with past medical history of alcoholic cirrhosis complicated by gastric varices and recurrent GI bleeding, myelodysplastic syndrome, radiation proctitis after XRT for prastate cancer and JRA presented to [**Location (un) 2274**] today for screening endoscopy and colonoscopy. Colonoscopey was not done but endoscopy showed hypertensive gastropathy and villous mucosa/?Barrett's at GE junction. A biopsy was taken but complicated by profuse bleeding which was not amenable to epinephrine injection or clipping due to poor visualization. . He was subsequently transferred to [**Hospital1 18**] ED for further management. In the ED, he was intubated for airway protection. Initial vitals were 177/72 87 100% on FiO2 100% PEEP of 5 RR: 14 and Vt: 500. OG tube suction showed dark blood. He was given octreotid bolus. Intubated. Pulse: 87. RR:14. FiO2100% BP:177/72. Bolused octreotide and started on 2 units of O negative blood transfusion. He was subsequently transferred to MICU. . In the MICU he received 2 units of pRBC, 1 unit of platelets and 1 unit of FFP. Right IJ trauma line was placed without any complications. EGD showed clotted of bleed at GE junction which could be variceal or arterial. Past Medical History: Alcoholic cirrhosis complicated by gastric varices and encephalopathy Myelodysplastic syndrome Radiation proctitis Total hip replacement Juvenile rheumatoid arthritis Seizures Social History: Unable to obtain as he was intubated. Per Atrius records never smoked. Family History: Not obtained as he was intubated/sedated Physical Exam: ADMISSION EXAM: Tmax: 38.1 ??????C (100.6 ??????F) Tcurrent: 38.1 ??????C (100.6 ??????F) HR: 78 (62 - 78) bpm BP: 151/64(86) {96/47(61) - 158/68(90)} mmHg RR: 16 (13 - 29) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 76.7 kg (admission): 76.7 kg General: Intubated. Sedated. Anicteric sclera. PERRLA. EOMI. Neck: JVP not elevated. Trauma line in place at RIJ 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 GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neurologic: Tone: less rigid and less hypertonic. Still Upgoing babiski bilaterally. Not following commands, withdraws to pain on L>R DISCHARGE PHYSICAL EXAM: VS: 96.9, 130/60, 60, 16, 98%RA GEN: mildly paranoid, but interactive, somewhat cooperative HEENT: OP clear, MM mildly dry CV: RRR PULM: CTA-B ABD: soft, NT, ND EXT: no edema NEURO EXAM: MS - didn't know his location, the month or date, but knew the year. CN - mild L facial droop, EOMI but needs lots of encouragement to look past the midline to the L MOTOR - antigravity in all 4 extremities, will not cooperate with a more formal exam SENSORY - intact to LT throughout, but mildldy diminished on L-side REFLEXES - upgoing toe bilaterally COODRINATION - able to reach for examiners hand accurately bilaterally GAIT - deferred Pertinent Results: ADMISSION LABS [**2141-10-20**]: CBC: WBC-3.7* RBC-2.39* Hgb-7.2* Hct-23.0* MCV-96 MCH-30.4 MCHC-31.5 RDW-13.7 Plt Ct-63* Diff: Neuts-80.4* Lymphs-12.7* Monos-5.8 Eos-0.8 Baso-0.3 Coags: PT-14.6* PTT-28.6 INR(PT)-1.4* Chemistries: Glucose-119* UreaN-13 Creat-0.6 Na-145 K-2.3* Cl-115* HCO3-16* AnGap-16 Calcium-5.8* Phos-2.4* Mg-1.1* DISCHARGE LABS: [**2141-10-30**] 04:45AM BLOOD WBC-3.8* RBC-2.95* Hgb-8.6* Hct-26.9* MCV-91 MCH-29.3 MCHC-32.1 RDW-15.3 Plt Ct-87* [**2141-10-27**] 08:35AM BLOOD Neuts-82* Bands-0 Lymphs-9* Monos-5 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2141-10-30**] 04:45AM BLOOD Glucose-99 UreaN-17 Creat-0.9 Na-141 K-3.4 Cl-111* HCO3-23 AnGap-10 [**2141-10-30**] 04:45AM BLOOD ALT-34 AST-50* LD(LDH)-261* AlkPhos-75 TotBili-0.8 [**2141-10-24**] 12:18AM BLOOD Lipase-442* [**2141-10-30**] 04:45AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.8 Mg-1.5* [**2141-10-26**] 04:30AM BLOOD %HbA1c-5.0 eAG-97 [**2141-10-26**] 04:30AM BLOOD Triglyc-60 HDL-59 CHOL/HD-2.2 LDLcalc-60 CXR: Low lung volumes accentuate prominence of the pulmonary vasculature. Endotracheal tube in appropriate location. CT Head: No CT evidence for acute intracranial hemorrhage. CT C-spine: Degenerative changes of the cervical spine without evidence for for fracture, normal alignment. RUQ U/S: 1. Markedly dilated, but patent portal vein with biphhasic, helical flow. 2. Patent paraumbilical vein and varices due to portal hypertension. 3. Patent hepatic veins. 4. Gallstone, but no acute cholecystitis. 5. 4.6 x 4.3 cm anechoic cystic lesion at the porta hepatis, likely represents a liver cyst off the caudate lobe. . [**10-23**] MRI: IMPRESSION: 1. Early subacute infarcts in bilateral frontal, parietal, right posterior temporal and occipital lobes, right thalamus and right superior cerebellar vermis. These are of different chronicity and likely thromboembolic in etiology. 2. Generalized cerebral atrophy with extensive changes of chronic small vessel ischemic disease. 3. The right temporalis muscle is slightly enlarged in size and appears hyperintense on FLAIR images, this may represent edema or myositis. EEG [**2141-10-24**]: IMPRESSION: This EEG continues to show an exceptionally active paroxysmal epileptiform abnormality in the right occipital pole in the context of a continuous focal delta disturbance suggestive of a large structural lesion in that region. There are superimposed fairly frequent electrographic seizures that are now spreading to the left homolygous hemipsheric regions but with no obvious clinical accompaniment. EEG [**2141-10-25**]: IMPRESSION: This is an abnormal continuous ICU video EEG study due to paroxysmal at times periodic epileptiform discharges in the right occipital pole in the context of a continuous focal delta activity suggestive of a large structural lesion in that region. There are superimposed intermittent electrographic seizures that occasionally spread to the left homologous hemispheric regions but with no obvious clinical accompaniment. The seizures decreased in frequency and amplitude towards the end of the recording. Background was asymmetric with delta slowing and suppression on the right and [**6-27**] Hz posterior dominant rhythm on the left. EEG [**2141-10-26**]: IMPRESSION: This is an abnormal continuous ICU video EEG study due to paroxysmal and, at times, periodic epileptiform discharges in the right occipital pole in the context of a continuous focal delta activity suggestive of a large structural lesion in that region. There are superimposed intermittent electrographic seizures but with no obvious clinical accompaniment. The seizures stopped after 17:52. Background was asymmetric with delta slowing and suppression on the right and [**6-27**] Hz posterior dominant rhythm on the left. MR HEAD [**2141-10-26**]: IMPRESSION: Limited study due to motion artefacts. 1. Multiple areas of restricted diffusion with associated FLAIR and T2 hyperintensity in bilateral frontal, parietal, right posterior temporal and occipital lobes, right thalamus and right superior cerebellar vermis. The distribution of the lesions make the possibility of these being infarcts more likely than being due to seizures. These have not significantly changed since the prior study. No evidence of hemorrhagic transformation of the infarcts. 2. Generalized cerebral atrophy with extensive changes of chronic small vessel ischemic disease. CTA HEAD AND NECK [**2141-10-27**]: IMPRESSION: Moderate atherosclerotic calcifications of the cervical carotid bifurcations with no evidence of critical stenosis. There is no evidence of critical stenosis or aneurysms in the circle of [**Location (un) 431**]. Evolution of the bilateral parietal infarction, with associated vasogenic edema, producing effacement of the sulci on the right parietal lobe as described above, there is no evidence of hemorrhagic transformation. Brief Hospital Course: Mr. [**Known lastname 4027**] is a 58 year old male with past medical history of alcoholic cirrhosis complicated by gastric varices, encephalopathy and recurrent GI bleeding admitted for concern for variceal bleeding after biopsy of mass at the gastroesophageal (GE)junction, found to have R MCA and PCA territoty infarcts once awakened from sedation. . ACTIVE ISSUES BY PROBLEM: # GE junction bleed: Endoscopy by hepatology showed clotted off lesion which could be hematoma at the site of arterial bleed or variceal bleed. No intervention was made during the endoscopy. The patient had a trauma line placed, and serial HCTs were monitored. While in the MICU, his HCTs remained stable and he was hemodynamically stable. The patient was initially on pantoprazole and octreotide drips. After the endoscopy, the octreotide drip was discontinued, and the patient was switched to IV PPI [**Hospital1 **]. He was also started on ceftriaxone for spontaneous bacterial peritonitis (SBP) prophylaxis. The patient's HCTs were checked q8h, with goal HCT maintained between 25 and 30. Hepatology followed the patient and on [**10-27**] felt that ASA 81mg was ok to give, which was started for secondary stroke prevention (see below) . # New right hemispheric stroke: As sedation was weaned, it became apparent that the patient had left hemiparesis and loss of leftward gaze. Additionally, he continued to have focal occipital seizures even after increasing antiepileptics. The patient also had evidence of upper motor neuron signs, with upgoing Babinski, hyperreflexia, and rigid tone on the left side. CT head/neck without contrast was negative for acute process. EEG showed abnormal epileptiform discharges (the patient has a history of seizures). MRI showed early subacute infarcts in bilateral frontal, parietal, right posterior temporal and occipital lobes, right thalamus and right superior cerebellar vermis; there are of different chronicity and likely thromboembolic in etiology. TTE showed aortic regurgitation and aortic stenosis and bubble study was done showing no PFO. However, saline was only injected at rest, as patient could not perform any maneuvers. Social work, PT/OT, and speech and swallow were all consulted. Neurology was consulted, and then patient was transferred to the neurology service once he was stable enough to leave the ICU. We started him on ASA 81mg QD on [**10-27**]. He received a CTA to see if his blood vessels were patent, which they were. Therefore the asymmetrical appearance of his infarcts is unlikely to be caused by hypotension, as this would be more symmetrical in appearance. . # Seizures: The patient has a history of alcohol withdrawal and post-op seizures. EEG showed abnormal epileptiform discharges; hundreds of briefly sustained electrographic seizures from the right occipital area with occasional spread to the left occiput. He was started on IV Keppra 2 grams [**Hospital1 **]. His EEG improved to show less frequent seizures, but they were still occurring. He was then started on lacosamide, and his seizures further decreased. However, he continued to have no clinical correlate and was awake and interactive during his sublclinical seizures. We stopped his lacosamide, and his EEG did not become more active, so we slowly tapered down the keppra to 1000mg [**Hospital1 **]. This can be further tapered down in the future as long as his exam doesn't worsen with each subsequent decrease. . # Fevers: The patient started spiking fevers while in the MICU. No infectious source was found, but there was a possible RLL infiltrate on CXR and the patient was empirically started on cefepime. His sputum cultures were also growing out Gram negative rods. The patient was never ill-appearing, however, and it was thought that his fevers could be medication related or neurogenic fevers, given his new onset stroke. However, given his recent intubation, he will complete a 15 day course for presumed VAP. . #. Alcoholic cirrhosis complicated by cirrhosis and encephalopathy: Hepatology was following the patient, and he was continued on PPI [**Hospital1 **], and was started on ceftriaxone for SBP prophylaxis. Social work was consulted. The patient was also initiated on CIWA protocol. On transfer from the unit, the patient was not requiring any ativan for withdrawal. The patient's home lasix, spironolactone, propranolol were in the setting of the UGIB, but eventually were restarted with no issues. . # Hypernatremia: The patient was hypernatremic and we increased free water flushes through the patient's NGT. PENDING RESULTS: Final EEG read [**10-27**], [**10-28**] and [**10-29**] TRANSTIONAL CARE ISSUES Patient is Rh neg and received RH + plt. If a candidate for liver transplant, he needs to get WinRho (Rh immunoglobulin). His LFTs will need to be monitored frequently as he was just started on simvastatin on [**2141-10-30**]. In addition, his platelets will need to be monitored while he is on aspirin to ensure that they do not drop below 50. Medications on Admission: Tramadol 50 mg po QID Lasix 40 mg po qdaily Spironolactone 100 mg po qdaily Propranolol 20 mg po BID Folic acid 1 mg po qdaily MVA Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection TID (3 times a day). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Do not exceed 2 grams of tylenol in 24 hours. 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) as needed for agitation. 12. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. cefepime in D5W 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous every eight (8) hours for 10 days: Last day = [**11-8**] to finish a 15 day course. 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 15. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right sided MCA and PCA territory infarcts Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. NEURO EXAM: rambling, mildly paranoid speech, L arm > L leg weakness, extinction to DSS on L Discharge Instructions: Dear Mr. [**Known lastname 4027**], You were seen in the hospital because you need an EGD, but during this procedure you had some bleeding, that led to you needing to be intubated. Once you woke up, it was found that you had had a stroke that caused you difficulty moving your left side. We made the following changes to you medications: 1) We STOPPED your TRAMADOL. 2) We STARTED you on SUBCUTANEOUS HEPARIN 5,000 units three times a day to prevent DVTs while you are at rehab. 3) We STARTED you on TYLENOL 500mg every 6 hours. You are not to exceed more than 2 grams of tylenol in a given 24 hour period as this can cause liver damage. 4) We STARTED you on OXYCODONE 5mg every 6 hours as needed for pain. 5) We STARTED you on ASPIRIN 81mg once a day. 6) We STARTED you on SEROQUEL 12.5mg every 12 hours as needed for agitation. 7) We STARTED you on SIMVASTATIN 10mg once a day. Your liver function tests will need to be monitored while you are on this medication. 8) We STARTED you on CEFEPIME 2 grams every 8 hours. You will continue this antibiotic until [**2141-11-8**]. 9) We STARTED you on PANTOPRAZOLE 40mg every 12 hours. 10) We STARTED you on KEPPRA 1,000mg twice a day. Please continue to take yout other medications as previously prescribed. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: You have a follow-up appointment with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 3614**] on [**11-27**] at 8:30am. His office is located at 26 City [**Doctor Last Name **] Mall in [**Location (un) 1468**], MA. If you have any questions about thia appointment you can call his office on [**Telephone/Fax (1) 97983**] Department: NEUROLOGY When: TUESDAY [**2141-12-5**] at 3:00 PM With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

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icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "45.13", "96.72", "89.19", "94.62" ]

icd9pcs

[ [ [] ] ]

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289, 294

14985, 14985

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