ChanBeDu/relevant_section_length · Datasets at Hugging Face

69,398

193,849

45464

Discharge summary

report

Admission Date: [**2154-9-12**] Discharge Date: [**2154-9-14**] Service: MEDICINE Allergies: Hay fever / sensitive to sedation Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] y/o female with a history of systemic amyloidosis (Kidney, autonomic, presumed heart), Aortic stenosis, CHF, IDDM, and frequent falls [**12-20**] autonomic dysfunction presenting to the emergency department with brief episode of syncope admitted to the ICU for tachycardia. This morning, the patient was using the commode and was getting back to the bed. The daughter witnessed that the patient LOC for about 30 secs and caught her. No fall occurred. There was no bowel/stool incontinence, tongue biting, jerking movement. Patient was not thought to have confusion like post-ictal state. She cannot recall if she has any numbness/tingling or focal weakness. Currently she has generalized weakness and some chest discomfort but not pain/tightness. Had an admission [**7-/2154**] for syncope/fall, including an episode concerning for possible seizure with post-ictal state. MRI brain was negative for infarct or hemorrhage. EEG showed no seizure. Her lasix was uptitrated during that admission. Cardiology was consulted and thought that if patient has dCHF from amyloid that avoiding fluid shifts would be important. Patient has f/u with cardiology in [**Month (only) **]. Patient was sent to rehab for about 3 weeks given the left humerus fracture. Patient just returned home from rehab yesterday. On arrival to the ED 97.7 130 87/63 16 96%/RA. Given ceftriaxone for presumed UTI. CT head and chest xray negative. Started IV heparin for presumed PE. Received 10mg IV diltiazem which dropped pressures to 80s systolic for presumed afib with RVR. Felt to be high risk for PE. Heme negative brown stool. Mentating with daughter at bedside. In the ICU, vitals are 98.3, 124, 87/61, RR 21, O2 sat 98% on RA. Daughter states that patient is normally on midodrine and BP has been low. It used to be in the 100-110 about a year ago, but her normal over the last month or two has been in the upper 80s-90s. Past Medical History: Diabetes mellitus, type 2 Hypothyroidism dyslipidemia depression Arthritis Urinary incontinence and prolapse s/p sling suspension surgery Spinal stenosis s/p decompression/laminectomy/fusion [**2147**] s/p hysterectomy [**2109**] Total hip replacement -left SAH in [**2151**] after fall peripheral neuropathy Social History: Lived alone until recently. no smoking, etoh. Family History: Sisters living 90-100's. One recently died at [**Age over 90 **] yrs of age. Sister with [**Name (NI) **] Ca. Physical Exam: ADMISSION EXAM: Vitals: 98.3, 124, 87/61, RR 21, O2 sat 98% on RA. General: Alert, oriented x 3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP at 2 cm, no LAD CV: irregular, tachycardic, normal S1, soft 2/6 systolic ejection murmur without radiation to the carotids best heard at the RUSB, no rub or gallops Lungs: RLL crackles but otherwise clear to auscultation, no wheezes or rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: + foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 4/5 strength upper/lower extremities, grossly normal sensation, gait deferred DISCHARGE EXAM: Deceased Pertinent Results: ADMISSION LABS: [**2154-9-12**] 04:23AM BLOOD WBC-5.1 RBC-3.86* Hgb-10.7* Hct-35.4* MCV-92 MCH-27.8 MCHC-30.3* RDW-16.5* Plt Ct-453* [**2154-9-12**] 04:23AM BLOOD Plt Ct-453* [**2154-9-12**] 04:23AM BLOOD Glucose-187* UreaN-69* Creat-3.4* Na-135 K-4.4 Cl-99 HCO3-22 AnGap-18 [**2154-9-12**] 04:23AM BLOOD CK(CPK)-99 [**2154-9-12**] 04:23AM BLOOD CK-MB-6 [**2154-9-12**] 04:23AM BLOOD TSH-9.6* [**2154-9-12**] 04:31AM BLOOD Lactate-1.2 MICRO: [**2154-9-12**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2154-9-12**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2154-9-12**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2154-9-12**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] IMAGING: [**9-13**] Renal ultrasound [**9-12**] CXR: IMPRESSION: Chronically elevated hemidiaphragm. [**9-12**] CT Head: IMPRESSION: No acute intracranial process or trauma. Brief Hospital Course: [**Age over 90 **] y/o female with a history of systemic amyloidosis (Kidney, autonomic, ? heart), aortic stenosis, CHF, T2DM on insulin, and frequent falls [**12-20**] autonomic dysfunction presenting to ED with fall and admitted to MICU for tachycardia. Patient and family initially decided to transition from aggressive care to home hospice, and plans were made to dicharge patient with home Hospice on [**9-14**]. Patient died on the evening of [**9-13**]. ACTIVE ISSUES: 1. Atrial fibrillation: Hypotensive on arrival with rate 130s. Initially thought to be regular, but on further review of the EKGs from the ED, it seems that patient has been having irregular borderline narrow complex tachycardia, which is more consistent with atrial fibrillation. Patient does have underlying structural heart disease and suspected amyloidosis of the heart, which can make her more prone to having conductive abnormalities, such as the 1st/2nd/3rd degree block, intraventricular conduction delay, AF, A flutter, and even ventricular tachycardia. TSH was only mildly elevated in [**Month (only) **], making hyperthyroidism less likely the cause of the AF. Patient is a non-alcohol drinker. Clinical exam and CXR do not suggest significant volume overload or infectious etiology. CHADS2 score is 3. ED had concern about PE and started heparin gtt empirically pending VQ scan (unable to get CTA chest given CKD), although clinical suspicion of PE is low based on her [**Doctor Last Name 3012**] criteria is low prob. A TEE with cardioversion was planned for [**9-13**]. However, after discussion of goals of care with patient and her three daughters, the decision was made to avoid further invasive procedures and discharge patient home with home hospice on [**9-14**]. Patient died on the evening of [**9-13**]. 2. Syncope: Symptoms were primarily concerning for underlying arrhythmia given tachycardia on admission, but orthostatic hypotension was also high in the differential given patient is on midodrine due to underlying autonomic dysfunction. An acute coronary syndrome was considered as was high sensitivity to volume status due to underlying cardiac amyloidosis. A seizure was felt to be less likely given differences between current presentation and prior seizure and given that patient has been on keppra as an outpatient. Keppra was continued. 3. Elevated troponin. Patient had elevated troponins that were likely due to demand in the setting of tachycardia and CKD. Could also be secondary to amyloidosis. Patient was continued on ASA and simvastatin and placed on telemetry. Goals of care were transitioned to Hospice as above. 4. Acute on chronic renal insufficiency: Patient's baseline creatinine in last 2 months has been low 2.0's from mid to high 1's in [**2152**]. A renal biopsy in [**3-/2154**] was positive for amyloidosis. The acute elevation was most likely due to progression of amyloid vs. prerenal azotemia, possibly in the setting of low perfusion (low BP) and poor forward flow (AF). Patient received IVF bolus (500cc) in the ED. Per renal, c/w cardiorenal syndrome + poor forward flow (sodium avid per urine). 5. dCHF, no evidence of acute exacerbation. Given likelihood of amyloid cardiomyopathy and the potential sensitivity to fluid shift, fluid status was monitored closely. Her baseline weight is about 163 lb per the daughter but more recently has been 175 lb. 6. T2DM, on insulin. Last HgbA1C 6.8. Patient was initially continued on home lantus and ISS. 7. Autonomic dysfunction. Baseline SBP now in the upper 80s to 90s per family despite being on midodrine. Midodrine was continued. 8. Hypothyroidism. Last TSH 4.6. Now 9. Most likely subclinical at this time. Patient was continued on ue current home dose levothyroxine 88 mcg daily 9. Systemic amyloidosis. Currently off [**Year (4 digits) **] and dexamethasone. 10. Possible UTI: In the ED, there was concern for a UTI based on UA; however, leuk and nitrite were negative. Patient is not complaining of urinary symptoms. Antibiotics were discontinued. TRANSITIONAL ISSUES: - Patient died in the intensive care unit on the evening of [**9-13**]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 162 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Glargine 15 Units Bedtime 4. Midodrine 10 mg PO TID 5. Paroxetine 30 mg PO DAILY 6. Simvastatin 20 mg PO DAILY 7. Furosemide 60 mg PO DAILY 8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze 9. LeVETiracetam 250 mg PO BID Discharge Medications: N/a Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9045, 9054

4466, 4928

260, 267

9106, 9116

3515, 3515

9168, 9310

2641, 2753

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209, 222

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3532, 4378

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2576, 2624

13,329

103,551

51847

Discharge summary

report

Unit No: [**Numeric Identifier 107381**] Admission Date: [**2181-9-25**] Discharge Date: [**2181-10-4**] Date of Birth: Sex: Service: REASON FOR ADMISSION: Living related kidney transplant. PROCEDURE PERFORMED: Renal transplant ultrasound and MR contrast of the kidney. HISTORY OF PRESENT ILLNESS: [**Known firstname 7232**] [**Known lastname 106665**] is a 69 year-old, African-American female with end stage renal disease who has been on [**Known lastname 2286**] for a long time. She underwent a pretransplant evaluation and was found to be a suitable candidate for organ transplantation. Her nephew presented as a potential live donor and underwent evaluation and completed his work-up. HOSPITAL COURSE: On [**2181-9-25**], she underwent a left sided live donor renal transplant. The kidney was somewhat slow to reperfuse, taking about 20 to 25 minutes before it completely pinked up but did not make urine in the operating room. Her postoperative course was complicated by delayed graft function, slow graft function, although she did not require [**Date Range 2286**]. She did not make much urine. She underwent ultrasound of the transplanted kidney on [**2181-9-25**], the day after surgery, that demonstrated a normal flow and somewhat reduced arterial wave forms. Ultrasound was repeated on postoperative day number 3 which was also performed and demonstrated a very small fluid collection around the kidney but the resistive indices remained low. She completed her induction immunosuppression which included 4 doses of thymoglobulin and steroid injection, in conjunction with Prograf and CellCept maintenance therapy. Steroids were discontinued on postoperative day number 5. On [**2181-10-2**], she underwent a MRA due to continued poor renal function. The MRA demonstrated a 5 x 9 cm perinephric fluid collection. She also demonstrated mild stenosis in the left common iliac and no evidence of anastomotic stenoses in the renal artery. Ms. [**Known lastname 106665**] was started on a liquid diet after surgery, which was advanced over 3 days to a regular diet. She had no other hospitalized complications. She eventually began making more substantial quantities of urine 2 days prior to discharge and was discharged home on [**2181-10-4**] with follow-up instructions with the transplant office. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern4) 3433**] MEDQUIST36 D: [**2181-12-12**] 15:18:12 T: [**2181-12-12**] 15:39:03 Job#: [**Job Number 107382**]

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icd9cm

[ [ [] ] ]

[ "55.69", "99.04", "39.95", "00.91" ]

icd9pcs

[ [ [] ] ]

747, 2629

334, 729

45,599

195,826

3230

Discharge summary

report

Admission Date: [**2113-2-26**] Discharge Date: [**2113-3-2**] Date of Birth: [**2065-7-6**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 4373**] Chief Complaint: chest pain, SOB Major Surgical or Invasive Procedure: Chemotherapy on [**3-2**], FLOX regimen. History of Present Illness: 47yo M with PMHx metastatic colon CA to liver and lungs, hereditary telangiectasias complicated by chronic nosebleeds, a TIA, and a large pulmonary AVM repaired in [**12/2106**] who presented on [**2113-2-25**] with chest and calf pain and fever. Patient has been followed by Dr. [**Last Name (STitle) **] in pulmonary who embolized his AVM but felt that the AVM may still be leaking. Of note, his diagnosis of metastatic colon cancer came only several weeks prior to this hospitalization. He is on FLOX chemotherapy (5-FU, oxaliplatin, leucovorin), and is cycle 1, week 2; last dose was on [**2-23**]. He also had a power port placed without complications on [**2-24**]. . Per patient was in his usual recent state of health until [**2-23**] when he developed left calf pain and swelling. On [**2-25**] he had the onset of CP, localized to the center of his chest, which was exacerbated with taking deep breaths. He also experienced some SOB. Denies having jaw or arm pain, diaphoresis, palpitations, or N/V/D. This prompted him to be evaluated further in the ED. . In ED initial VS: T:100.0 HR:117 BP:154/84 RR:20 O2Sat:97on 2LNC. He was febrile to 100.8 and noted to have a WBC of 12.5. The recent port-a-cath placement site in left chest did not look infected. He was started prophylactically on vanc/zosyn in ED. His exam was benign aside from a nose bleed but CTA showed small subsegmental PEs. O2 sats remained stable at 92% on RA and 98% on 2L NC with HRs and BPs stable. However, with the need for anticoagulation in setting of AVMs in his lung and nose it was thought he would be better served by close monitoring in the ICU on heparin gtt. Moreover, given his h/o metastatic cancer he needed a head CT prior to hep gtt; preliminary read is negative for acute intracranial process. . On arrival to the ICU, the patient was quite overwhelmed and tearful with all of the recent events. He reported continued CP, similar as described above, worse with deep inspiration. Vital signs were notable for HR of 97. His oxygen saturation was 99% on 3L NC with RR of 17. He was hemodynamically stable with a BP of 132/73. He had 2 episodes of <1tsp bright red hemoptysis, but stated that this was consistent with his usual nosebleeds and stated that it was coming from his nose and not coughed up from his chest. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Hereditary Telangectasia with pulmonary arterial venous malformations - pulmonary shunts s/p two previous closure procedures. pt reports his pulmonologist is thinking about another closure procedure for another shunt - nosebleeds - systemic emboli - TIA - iron deficiency anemia Social History: Patient is originally from [**Country 13622**] Republic; he just recently returned from there, cutting a 3 week vacation short, after a CT scan of his abdomen showed liver lesions. His wife lives in DR [**Last Name (STitle) 151**] their 3 yo daughter. [**Name (NI) **] lives in the same building as his mother in [**Name (NI) 86**]. He has a girlfriend in [**Name (NI) 6607**]. He also has an ex-girlfriend in [**Name (NI) 86**], with whom he had a daughter. His ex-girlfriend and daughter were with him in the room. He works as a case manager at [**Location 1268**] [**Location **]. Does not exercise, has cut down substantially on his alcohol, and does not smoke. Family History: Mother had well-controlled HTN and [**Name (NI) 2320**]. Nobody in his family has hereditary telangectasia or epistaxis. No family history of cancer, except for a paternal aunt with cancer (not of the colon, pt unsure of type). Physical Exam: Vitals: T: 98.4 BP: 132/73 P: 97 R: 17 18 O2: 99% 3L NC General: Alert, oriented, no acute distress, but tearful HEENT: Sclera icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No asymmetrical swelling. Pt reports ttp of the L calf, but there is no palpable cord. Pertinent Results: Admission labs: [**2113-2-26**] URINE OSMOLAL-396 [**2113-2-26**] PT-15.9* PTT-50.5* INR(PT)-1.4* [**2113-2-26**] NEUTS-85.0* LYMPHS-11.0* MONOS-2.7 EOS-1.1 BASOS-0.3 [**2113-2-26**] WBC-12.5* RBC-3.73* HGB-7.2* HCT-25.5* MCV-68* MCH-19.2* MCHC-28.2* RDW-23.1* [**2113-2-26**] OSMOLAL-270* [**2113-2-26**] ALBUMIN-2.8* [**2113-2-26**] LIPASE-35 [**2113-2-26**] ALT(SGPT)-44* AST(SGOT)-70* ALK PHOS-369* TOT BILI-1.1 [**2113-2-26**] GLUCOSE-100 UREA N-9 CREAT-0.7 SODIUM-132* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-27 ANION GAP-13 [**2113-2-26**] LACTATE-1.4 . CT Head prelim read: no acute intracranial process. . CTA: subsegmental filling defects in the right apical pulmonary arteries,consistent with pulmonary embolisms. metastatic pulmonary nodules and hilar adenopathy as before. . [**2-27**] bilateral LE u/s: IMPRESSION: No evidence of DVT. . [**2-26**] ECG: Sinus tachycardia. Low limb lead QRS voltage. Leftward axis. Findings are non-specific and unstable baseline makes assessment difficult. Since the previous tracing of [**2106-5-19**] sinus tachycardia is now present. . Discharge labs: [**2113-3-2**] WBC-9.0 RBC-3.50* Hgb-6.9* Hct-25.0* MCV-71* MCH-19.6* MCHC-27.5* RDW-24.2* Plt Ct-454* [**2113-3-2**] PT-15.6* PTT-108.3* INR(PT)-1.4* [**2113-3-2**] Glucose-105* UreaN-6 Creat-0.5 Na-137 K-4.0 Cl-101 HCO3-29 AnGap-11 [**2113-3-1**] Calcium-8.7 Phos-3.2 Mg-2.1 . Urine culture: no growth Blood cultures: pending . Urine: [**2113-2-26**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2113-2-26**] URINE Hours-RANDOM UreaN-271 Creat-46 Na-62 Uric Ac-35.1 [**2113-2-26**] URINE Osmolal-396 Brief Hospital Course: 47yo M with h/o metastatic colon CA, pulmonary and nasal AVMs with continuous nosebleeds admitted with fever, calf and chest pain and found to have subsegmental PEs admitted for anticoagulation. . # PE: Likely secondary to underlying malignancy, and given that the patient has a high risk of bleed from AVM's and telangiectasias, he was monitored in the ICU during initiation of anticoagulation with weight based Heparin gtt. LENI's were ordered to evaluate LE clot burden, they were negative. After stable anticoagulation with heparin gtt while in the ICU, patient transferred to floor on heparin gtt. Patient had nosebleeds, but at less than his baseline amount he reported. Hct stable, no other evidence of bleed. Patient started on coumadin; heparin gtt discontinued and started on lovenox. Patient discharged with plans for lovenox bridge to coumadin with close INR follow-up in the outpatient setting. Patient resistant to the idea of injections long-term so would prefer coumadin as outpatient with simply a short lovenox bridge. Patient's chest pain and inspiratory discomfort resolved, as did his calf discomfort. Ambulatory SpO2 95% on room air at discharge. . # AVMs: Stable. Patient was monitored closely for bleeding without any decrease in Hct during his stay. He had nosebleeds that he reported to be at or below his typical baseline for nosebleeds. Afrin nasal spray provided to help with this issue. Patient instructed to hold pressure and to call if the nosebleeds worsen or become uncontrollable. Concern that this might be an issue as the patient is being anti-coagulated long term, but was stable with AVM's and anticoagulation during hospitalization. . # Hyponatremia: Patient with a serum Na of 132 on admission. His baseline is 136, and he did not receive IVF's on admission, so the etiology was unclear. It was posited that it could be secondary to SIADH given lung mets/stress response and with urine electrolytes that supported SIADH. With free water restriction, Na improved to within normal range. Restriction lifted the day prior to discharge. # Metastatic colon CA: Patient on FLOX chemotherapy regimen, now cycle 1, week 2, on admission. Patient treated with another day of FLOX chemotherapy and tolerated this without incident, on [**3-2**]. Suggest to consider genetic testing for family members (especially children) given the early age of onset of metastatic colon cancer; this is suggested in the outpatient setting. # Constipation: patient required aggressive bowel regimen to relieve constipation and associated abdominal discomfort. patient takes multiple opiates for abdominal pain, and so medication and disease likely both contribute to his constipation. patient discharged with opiates for abdominal pain (home pain regimen) and with bowel regimen. # Fever: Believed secondary to PE & known malignancy. The patient demonstrated no localizing source of infection and was not neutropenic so no antibiotics were started. Fever resolved. Leukocytosis resolved too. # Anemia: Patient's HCT on admission was stable at 25.5, compared to HCT at time of cancer diagnosis ~27. He was placed on q8H HCT checks given his Heparin gtt and an active T&S was maintained throughout his stay. At the time of transfer to medicine, his HCT was 24.4. On the floor, HCT remained stable, even in the setting of nosebleeds. # Coagulopathy: Thought to be [**1-10**] liver dysfunction from liver metastases. # Coping with metastatic cancer: patient was seen by social work. # Access: port, left chest Code: Full (confirmed with patient in the ICU) Communication: Patient and ex-girlfriend, [**Name (NI) 6303**] ([**Telephone/Fax (1) 15107**]) Medications on Admission: Acetaminophen 325-650 mg Q6H prn pain, fever. Oxycodone 5 mg Q4H prn pain. Docusate 100 mg PO BID Senna 8.6 mg Tablet PO BID Polyethylene Glycol 3350 17 gram/dosePO DAILY Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Rectal QID Iron 325 mg PO TID Lactulose 10 gram/15 mL TID prn Discharge Medications: 1. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four (4) 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) as needed for constipation. 4. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 5. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) application to the rectal area Rectal four times a day. 6. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 7. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed for constipation. 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed 2gm per day. 9. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours): Please take until instructed to discontinue by your oncologist. Disp:*14 syringes/administrations* Refills:*1* 10. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day) for 3 days: Patient has bottle with him upon discharge. 11. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. MS Contin 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every twelve (12) hours. 13. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime: This medication dose will likely be adjusted based on your blood level and your oncologist's recommendation. Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Metastatic colon cancer Pulmonary embolism Hereditary telangiectasias Chronic nosebleeds Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [**Hospital1 18**] from [**2-26**] to [**3-2**], [**2112**]. Here at [**Hospital1 18**] you were found to have blood clots in your lungs, likely related to your colon cancer. To prevent further clots you were treated medically, with heparin and then with lovenox and coumadin (also known as warfarin). You will take lovenox injections and coumadin pills at home temporarily, and then you will be transitioned to just taking the coumadin pills, as instructed by your oncologist. . You had a fever, and this resolved - perhaps this was because of the blood clots or the colon cancer; no infection was found. You had leg pain that resolved, this could have been the site of the original blood clot. You had chest pain, also believed to be because of the blood clot, and this resolved too. . You were constipated and had abdominal pain, and were treated with medications to resolve this. At home, be sure to take medications to help move your bowels, because the pain medication you take can cause constipation. . You had chemotherapy on [**3-2**] without incident. . If you are having nosebleeds that are worsening or that you cannot adequately control, call your physician. . Changes to your medications include: - START LOVENOX INJECTIONS twice a day, until instructed to stop by your oncologist - START COUMADIN (also known as WARFARIN) every evening Followup Instructions: Please come to the Hematology-Oncology infusion area on Monday [**3-6**] at 10am to get an INR check (blood check) and IV fluids. You will also have an appointment at that time with [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2113-3-6**] at 10:00. . Colorectal surgery appointment. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2113-3-9**] at 9:00 AM. . You will have an appointment with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 11309**] on [**2113-3-9**]; their clinic will call you with the precise time (likely 10 AM or 11 AM). ([**Telephone/Fax (1) 5562**]. . You have an appointment with Dr. [**Last Name (STitle) **] on [**2113-3-15**] for another round of chemotherapy; his clinic will call you with the precise time. ([**Telephone/Fax (1) 5562**]. Completed by:[**2113-3-3**]

[ "415.19", "784.7", "564.09", "448.0", "197.0", "280.9", "197.7", "286.7", "153.9", "253.6" ]

icd9cm

[ [ [] ] ]

[ "99.25" ]

icd9pcs

[ [ [] ] ]

12228, 12234

6642, 10313

282, 325

12367, 12367

4955, 4955

13911, 14872

4069, 4298

10642, 12205

12255, 12346

10339, 10619

12515, 13888

6054, 6619

4313, 4936

227, 244

2690, 3062

353, 2672

4971, 6038

12382, 12491

3084, 3367

3383, 4053

7,327

153,888

52989

Discharge summary

report

Admission Date: [**2117-5-29**] Discharge Date: [**2117-5-31**] Date of Birth: [**2066-6-11**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 3984**] Chief Complaint: Syncope, GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: 50m with HTN, Hypercholesterolemia, OSA who presented to the ED after 3 syncopal episodes on the day of admission. His symptoms began when he awoke on the morning of admission drenched in sweat with chills and mild nausea. He went to the bathroom and had a bm that was normal, no melena/hematochezia. He then stood up and tried to induce vomiting, thinking that would make him feel better; the next thing he remembers, he was waking up on his bathroom floor, no pre-syncopal prodrome, feeling groggy and confused. He crawled into bed and went to sleep, waking later to get the phone, walking into his kitchen, and again waking up on the floor groggy. It happened one more time, and he called EMS. In the ED he passed a large dark stool in the ED that was guaiac positive. An NG lavage attempted and during the attempt he vomited a large amount of coffee grounds. BP remained stable (orthostatics negative after one liter IVFs), but he was tachycardic to the 130s. In ED, given 5 liters IVFs. . Patient denies ETOH use, only rare NSAID use. He denied chest pain, palpitations, dizziness, or other prodrome prior to the syncopal episodes. . Also, foley placed in ED. Patient w/ gross hematuria upon arrival in ICU. Past Medical History: HTN Hyperchol OSA Depression Social History: Lives with his dog, works as a real-estate broker, has 2 kids, one at Vanderbilt, pre-med. Fairly active, golfs, no limitations to physical activity. No tobacco, but exposed to heavy tobacco as a child. Rare etoh. Family History: Mother, heavy [**Name2 (NI) 1818**], died MI at 61, sister, heavy [**Name2 (NI) 1818**], died of PE at 54, father died of sepsis post-op at 79. Physical Exam: t 99.6, BP 126/64, HR 109-13 rr 18, O2SAT 96%ra GEN- pleasant, well-appearing male, NAD HEENT- anicteric, PERRL, OP clear, Dry MM, right forehead hematoma, small scratch under right eye NECK- no jvd/lad/thyromegaly CV- tachycardic, regular, normal s1 s2, no m/r/g PULM- CTAB/l ABD- soft, nt, nd, nabs +BS, guiaic pos black stool per ED BACK- no cva/vert tenderness EXT- no cyanosis/edema, warm/dry NEURO- a&ox3, no focal cn/motor/sensory deficits Pertinent Results: . 141 / 107 / 30 gluc 116 --------------- 4.4 / 23 / 1.0 . WBC 12.9 HCT 44.4 --> 38.5 PLT 352 N:88.9 L:7.3 M:3.3 E:0.3 Bas:0.2 . PT: 12.6 PTT: 22.4 INR: 1.1 . D-Dimer: 112 . Trop-*T*: <0.01 . CK: 69 MB: Notdone . Sinus CT: No fx, fluid r maxillary sinus, soft tissue promn over r frontal . MIBI [**7-/2116**]: Normal, done for screening purposes . Colonoscopy [**12/2114**]: Grade 3 internal hemorrhoids. Otherwise normal colonoscopy to cecum and terminal ileum. . ECG: NSR at 94, NML axis, intervals, Qwave II, II, avF (old), no change from prior . EGD: Medium hiatal hernia Grade 3 esophagitis in the lower third of the esophagus Erythema in the antrum Brief Hospital Course: 1) Upper GI bleed: Patients HCT went from 44 on admission to a low of 32. He was given 1 unit of PRBCs during his hospital course. He remained hemodynamically stable throughout although he was tachycardic initially to 110. On the morning of hospital day #2, he underwent EGD. EGD revealed a hiatal hernia, Grade 3 esophagitis in the lower third of the esophagus, and erythema in the antrum. There was no active bleeding. GI recommended [**Hospital1 **] proton pump inhibitor (PPI) and Sucralfate. They felt the esophagitis was due to GERD. A H-pylori serology was sent. His aspirin was held and will need to be restarted as an outpatient when deemed appropriate by his PCP. [**Name10 (NameIs) **] remained stable with stable hematocrits. His diet was advanced. His anti-hypertensives were restarted. He was discharged on hospital day # 3 with GI and PCP [**Last Name (NamePattern4) 702**]. . 2) Syncope: Felt to be hypovolemia due to GI bleed and hypovolemia. He was ruled out for MI with serial enzymes and was watched on telemetry without any events. He has had a recent stress MIBI that was normal. . 3) Hematuria: Patient with gross hematuria following foley placement in ED. It is lkely due to foley trauma. It cleared quickly and the foley was discontinued. He will need a follow-up UA as an outpatient. . 4) Depression: Sertraline, Buproprion were held initially and restarted at time of discharge. Medications on Admission: Lisinopril 20mg daily Sertraline 50mg daily Bupropion XL 300mg daily Atorvastatin 10mg daily ASA 81mg daily Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*6* 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bupropion 300 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QAM (once a day (in the morning)). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Upper GI Bleed Anemia, blood loss Esophagitis GERD Syncope Discharge Condition: good, tolerating POs, HCT stable Discharge Instructions: You will start on 2 new medications, Protonix and Sucralfate. You need to follow up with your PCP and GI physician. stools, black stools, abdominal pain, nausea, vomiting, fever, lightheadedness, or further episodes of passing out. Please do not take aspirin until your PCP or GI physician tell you to restart it. Followup Instructions: Follow up with your gastroenterologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**] within 4 weeks of discharge. Call ([**Telephone/Fax (1) 12401**] to schedule an appointment. . Please follow up with Dr [**Last Name (STitle) 311**] within 1-2 weeks [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "867.0", "272.0", "285.1", "780.57", "E879.6", "530.81", "578.9", "599.7", "401.9", "276.52", "780.2" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

5415, 5421

3193, 4621

314, 320

5524, 5559

2503, 3170

5924, 6329

1875, 2020

4779, 5392

5442, 5503

4647, 4756

5583, 5901

2035, 2484

257, 276

348, 1572

1594, 1624

1640, 1859

55,579

173,431

53916

Discharge summary

report

Admission Date: [**2199-5-1**] Discharge Date: [**2199-5-5**] Date of Birth: [**2136-3-6**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Percodan Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [**2199-5-1**] Coronary artery bypass grafting x5, left internal mammary artery to left anterior descending artery and reverse saphenous vein grafts to the posterior descending artery, the left posterior left ventricle branch artery, obtuse marginal artery, diagonal artery. History of Present Illness: 63 year old male was seen by Dr [**Last Name (STitle) **] in follow-up for his worsening angina at rest which is improved with the addition of isosorbide mononitrate 30 mg daily. He recently had two episodes of chest discomfort at rest while watching TV in the last few weeks. He was referred by Dr [**Last Name (STitle) **] for left heart catheterization. Upon catheterization he was found to have coronary artery disease and is now being referred to cardiac surgery for revasularization. Past Medical History: Coronary artery disease s/p atherectomy [**2175**], angioplasty [**2179**] Diabetes mellitus type 2 Hypertension Hyperlipidemia Past Surgical History: Left Knee surgery [**2180-3-1**] Exploration of the femoral artery and drainage of hematoma Past Cardiac Procedures: s/p atherectomy [**2175**], angioplasty [**2179**] Social History: Race:Caucasian Last Dental Exam:edentulous Lives with:Alone Contact:[**Name (NI) 402**] (daughter) Phone #[**0-0-**] Occupation:retired Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [x] [**1-8**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- Grandfather had myocardial infarction at age 72. Mother and brother had hypertension. Physical Exam: Pulse:73 Resp:16 O2 sat:99/RA B/P Right:109/61 Left:104/61 Height:5'9" Weight:210 lbs General: 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: 2 Left:2 DP Right: 2 Left:2 PT [**Name (NI) 167**]: 2 Left:2 Radial Right: 2 Left:2 Carotid Bruit Right: x Left:x Pertinent Results: [**2199-5-1**] LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal regional LV systolic function. Low normal LVEF. RIGHT VENTRICLE: Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. No MS. Moderate (2+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions PRE BYPASS The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricle displays borderline normal free wall function. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is at least moderate (2+) mitral regurgitation which occasionally borders on moderate to severe. There are at least two distinct jets of mitral regurgitation. They are predominantly centrally directed and the more significant one is betwwen the A2-P2,P3 scallops. The etiology appears to be most consistent with leaflet restriction. There is no pericardial effusion. POST BYPASS The patient is in sinus rhythm. There is normal biventricular systolic function. The mitral regurgitation may be slightly improved but remains in the moderate range. The rest of valvular function appears unchanged. The thoracic aorta is intact after decannulation. [**2199-5-2**] 02:03AM BLOOD WBC-9.4 RBC-3.25* Hgb-9.3* Hct-28.6* MCV-88 MCH-28.8 MCHC-32.6 RDW-13.5 Plt Ct-161 [**2199-5-1**] 09:59PM BLOOD Hct-29.2* [**2199-5-2**] 02:03AM BLOOD Glucose-78 UreaN-13 Creat-0.8 Na-138 K-4.4 Cl-108 HCO3-25 AnGap-9 [**2199-5-1**] 03:27PM BLOOD UreaN-13 Creat-0.6 Na-139 K-4.1 Cl-112* HCO3-24 AnGap-7* [**2199-5-5**] 06:30AM BLOOD WBC-5.8 RBC-2.97* Hgb-8.8* Hct-26.2* MCV-88 MCH-29.6 MCHC-33.5 RDW-13.6 Plt Ct-179 [**2199-5-1**] 02:19PM BLOOD WBC-6.9 RBC-3.10* Hgb-8.9* Hct-27.8* MCV-90 MCH-28.7 MCHC-32.0 RDW-13.2 Plt Ct-188 [**2199-5-1**] 03:27PM BLOOD PT-13.4* PTT-27.5 INR(PT)-1.2* [**2199-5-5**] 06:30AM BLOOD UreaN-20 Creat-0.7 Na-138 K-4.3 Cl-103 [**2199-5-1**] 03:27PM BLOOD UreaN-13 Creat-0.6 Na-139 K-4.1 Cl-112* HCO3-24 AnGap-7* Brief Hospital Course: Mr.[**Known lastname 916**] was admitted to the hospital and brought to the operating room on [**5-1**] where he underwent Coronary artery bypass grafting x5, left internal mammary artery to left anterior descending artery and reverse saphenous vein grafts to the posterior descending artery, the left posterior left ventricle branch artery, obtuse marginal artery, diagonal artery with Dr.[**Last Name (STitle) **]. Please refer to operative report for further surgical details. Overall he tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. Mr.[**Known lastname 916**] was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker, Statin,and aspirin was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD#4 he was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with VNA services in good condition with appropriate follow up instructions. Medications on Admission: LIPITOR 40 mg Daily GLIPIZIDE 10 mg Daily ISOSORBIDE MONONITRATE 30 mg Daily LISINOPRIL 20 mg [**Hospital1 **] METFORMIN 1000 mg [**Hospital1 **] TOPROL XL 100 mg Daily NITROGLYCERIN 0.4 mg Tablet PRN ACTOS 30 mg Daily ASPIRIN 325 mg Daily GLUCOSAMINE-CHONDROITIN Dosage uncertain Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 5 days. Disp:*5 Tablet Extended Release(s)* Refills:*0* 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care Discharge Diagnosis: Primary Diagnosis 1. Coronary artery disease. 2. Moderate mitral regurgitation. Secondary Diagnosis: Coronary artery disease s/p atherectomy [**2175**], angioplasty [**2179**] Diabetes mellitus type 2 Hypertension Hyperlipidemia Left Knee surgery Exploration of the femoral artery and drainage of hematoma Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**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 Wound CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2199-5-9**] 10:00 Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2199-6-6**] 1:15 Cardiologist: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2199-5-28**] at 1:30 Please call to schedule appointments with your Primary Care Dr. [**First Name (STitle) **] in [**3-7**] weeks [**Telephone/Fax (1) 2010**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2199-5-5**]

[ "424.0", "272.4", "285.1", "414.01", "250.00", "V45.82", "401.9", "413.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9260, 9299

6227, 7660

301, 578

9649, 9866

2565, 6204

10706, 11477

1763, 1886

7992, 9237

9320, 9400

7686, 7969

9890, 10683

1271, 1441

1901, 2546

244, 263

606, 1098

9421, 9628

1120, 1248

1457, 1747

49,854

128,831

35164

Discharge summary

report

Admission Date: [**2136-9-24**] Discharge Date: [**2136-9-26**] Date of Birth: [**2084-9-25**] Sex: F Service: MEDICINE Allergies: Percocet / Morphine And Related Attending:[**First Name3 (LF) 1973**] Chief Complaint: Suicidal Ideation, Suicidal Ingestion Major Surgical or Invasive Procedure: none History of Present Illness: 51 year old woman with h/o bipolar disorder and prior suicide attempts with overdoses, found in bed by daughter minimally responsive, found to have 41 missing tabs of 0.5mg xanax in her newly refilled bottle, taken at unclear time. Could have also been other medicine ingested but not witnessed. Daughter was called by the patient's therapist on afternoon of admission when patient missed her 2pm appt which prompted daughter to check on patient. Noted that in days leading up to overdose, the patient was increasingly depressed with labile mood swings. Patient with history of prior suicide attempts by overdose on sleeping pills requiring 3 hospitalizations in past 10 years. No prior ICU stays or intubations. Patient is followed by psychiatrist and therapist and may have had recent psych medications changes. Initial vitals were T97.3, HR 88, 126/72, RR 12, O2 sat of 100% on RA. On exam, patient somnolent, only grimacing to sternal rub. Pupils reactive 3->2mm, positive gag reflex. Withdrew to nailbed pressure in all extremities. Had hypotension of 78/42, but went back up to SBP 100s with sternal rub and fluids. Positive tox screen with benzos, tricyclics. Received 0.2mg IV narcan without response. Toxicology saw patient in ED and no need for charcoal because protecting airway. Toxicology team was consulted on the patient on the floor. EKG normal with normal intervals. Received 2L fluids in ED. On transfer, vitals were HR 89, BP 116/68, RR 15, O2 sat of 100% on 4L. On arrival to floor, patient somnolent but able to open eyes to light sternal rub, move upper extremities to command. Maintaining airway and with good O2 sat on room air. Past Medical History: [**2-17**]: had gastric balloon with complications; removed in [**Country 149**] this summer Schizoaffective d/o= Psycyiatrist Dr [**Last Name (STitle) **] ?Histrionic Borderline Personality h/o mania [**2-11**] diet pills- h/o breast cancer s/p lumpectomy and XRT - no recurrent in last 6 years Hypothryoidism h/o DM on metformin, pt states no longer needed it after wt loss surgery. endometriosis s/p hyterectomy Social History: She lives in [**Location **]; currently her husband requested a divorce. She has 2 children. She teaches spanish at [**Location (un) **] high school but lost job in [**Month (only) 958**]. Smokes 1ppd cigarettes. Family History: No history of mental illness. History of breast cancer in family Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: Stable and Afebrile GEN: NAD Pain: 0/0 HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Non-Focal Pertinent Results: [**2136-9-24**] 05:52PM BLOOD WBC-7.0 RBC-5.07 Hgb-13.9 Hct-42.0 MCV-83 MCH-27.4 MCHC-33.1 RDW-14.6 Plt Ct-347 [**2136-9-26**] 07:20AM BLOOD WBC-7.2 RBC-4.59 Hgb-13.0 Hct-37.9 MCV-83 MCH-28.3 MCHC-34.2 RDW-14.5 Plt Ct-282 [**2136-9-24**] 05:52PM BLOOD Neuts-52.0 Lymphs-37.9 Monos-6.1 Eos-3.5 Baso-0.5 [**2136-9-24**] 05:52PM BLOOD Plt Ct-347 [**2136-9-25**] 05:56AM BLOOD PT-13.0 PTT-28.0 INR(PT)-1.1 [**2136-9-24**] 05:52PM BLOOD Glucose-74 UreaN-13 Creat-0.8 Na-144 K-4.3 Cl-108 HCO3-30 AnGap-10 [**2136-9-26**] 07:20AM BLOOD Glucose-80 UreaN-14 Creat-0.8 Na-142 K-3.9 Cl-106 HCO3-26 AnGap-14 [**2136-9-24**] 05:52PM BLOOD ALT-18 AST-16 CK(CPK)-90 AlkPhos-81 TotBili-0.1 [**2136-9-25**] 05:56AM BLOOD ALT-15 AST-11 LD(LDH)-142 AlkPhos-66 Amylase-73 TotBili-0.2 [**2136-9-26**] 07:20AM BLOOD ALT-15 AST-13 AlkPhos-79 TotBili-0.2 [**2136-9-24**] 05:52PM BLOOD Lipase-32 [**2136-9-24**] 05:52PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2136-9-24**] 05:52PM BLOOD Albumin-4.4 Calcium-10.0 Phos-4.6* Mg-2.5 [**2136-9-26**] 07:20AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.2 [**2136-9-25**] 05:56AM BLOOD %HbA1c-5.6 [**2136-9-25**] 05:56AM BLOOD TSH-0.72 [**2136-9-24**] 05:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-POS [**2136-9-24**] 11:51PM BLOOD Lactate-0.8 [**9-24**] CXR:FINDINGS: No previous images. There is an area of increased opacification right base and possibly also at the left base. In view of the clinical history, these could represent sites of aspiration pneumonia. The upper zones are clear. [**9-25**] CXR: FINDINGS: In comparison with study of [**9-24**], the area of suspected opacification at the right base has effectively cleared. The opacification at the left is again seen, again consistent with aspiration or atelectatic changes. Upper zones are clear. EKG Study Date of [**2136-9-26**] 7:30:32 AM Sinus rhythm with borderline prolonged P-R interval Vertical axis, Possible inferior infarct - age undetermined Since previous tracing of [**2136-9-25**], no significant change Brief Hospital Course: #. Delirium due to suicidal Ingestion of tranquilizers due to Suicidal Ideation: - Pt took a total of approximately 20mg of Xanax in a suicide attempt. Tox screen was positive for benzos and tricyclics. PT was sommolent on arrival and was briefly hypotensive which responded to painful stimuli and IVF. Toxicolgy was consulted and did not reccomend further intervention. The patient was monitored in the MICU and remained stable. She was transfered to regular medical floor where VS remained stable, EKG was stable, no events on telemetry, Chem 7, LFTs, CBC normal. Currently medically stable s/p overdose; stable for transfer to psych bed. - Clonazepam for CIWA was continued given possible withdrawal per psych. - Patient continues to be actively suicidal, threatening to kill herself if allowed to leave. Per psychiatry consultation, needed inpatient psychiatry admission. - We continued a 1:1 sitter until transfer. - Further intensive treatment of depression is needed. # Schizoaffective, Histrionic Borderline Personality: - diagnoses as per inpatient pysch evaluation. - Further treatment defered in medical hospital setting. - She has a history of following with psychiatry in [**Location (un) 7349**] and [**Country 149**] and has been on Respiridal, Effexor, tegretol, xanax, trazadone, and prozac in the recent past. Medication regimen should be clearified at inpatient psych facility. She also appears to be getting medications from multiple sources. # Abnormal EKG: - Serial EKGs show NSR with isolated q wave in III, no TWI or ST changes. Qtc within normal limits. Poor R wave progression. - Changes are not accompanied with cardiac symptoms, VS stable, no events on telemtry. - Medically stable for pyschiatry transfer. - Follow up EKG by PCP in future is warrented. # Hypothyroidism: - Patient on levothyroxine as outpatient. TSH wnl in hosptial. #. Hyperglycemia: - Patient with no stated history of diabetes per daughter, however, has filled prescription for metformin in past. She says she has not needed metformin since her wt loss procedure in [**Country **]. HgbA1c within normal limits, fingersticks normal, no need for Insulin or metformin #. Code - Full code confirmed with daughter on admission #. Comm - daughter - [**Name (NI) 10827**] [**Telephone/Fax (1) 80260**] Medications on Admission: alprazolam 0.5mg 1 tab [**Hospital1 **] - 60 tabs filled [**2136-9-20**] fluoxetine 20mg 1 tab daily - 30 tabs filled [**2136-9-20**] levothyroxine 137mcg 1 tab daily - 30 tabs filled [**2136-9-11**] trazodone 50mg 1 tab daily - 30 tabs filled [**2136-7-19**] metformin 750mg PO BID - 60 tabs filled [**4-/2136**] Effexor- from [**Country **] Risperdone- from [**Country **] Tegretol-from [**Country **] Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for CIWA>10 or aggitation. 3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] Discharge Diagnosis: Suicidal Ideation Depression Borderline Personality Disorder Discharge Condition: Stable but with ongoing risk for harm to self. Discharge Instructions: You were admitted to the hospital because you attempted to hurt yourself by taking an large quantity of xanax. This was not safe and you were found to be sleep. You were admitted to the intensive care unit for close monitoring. You were evaluate by the medical service and felt to be medically cleared from injury. You were seen by psychiatry who felt that you were a threat to yourself and required additional treatment in an inpatient psychiatric facility. You are being transferred to the care of a psychiatry unit. You will no longer need to take Metformin. This is a medicine for diabetes and it was felt you do not have diabetes. Your Synthroid was continued for your hypothyroidism. You were given a nicotine patch to help alleviate your desire to smoke cigarettes. All of your other medications were stopped and you should discuss with your psychiatrist what medications to continue before going home. If you feel that you want to harm yourself or others, please call 911 or go the emergency room. Followup Instructions: You were directly transferred to a psychiatric unit for ongoing care Completed by:[**2136-9-26**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

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253, 292

364, 2020

2042, 2459

2475, 2691

79,330

106,537

54704

Discharge summary

report

Admission Date: [**2148-6-15**] Discharge Date: [**2148-6-21**] Date of Birth: [**2064-2-1**] Sex: M Service: MEDICINE Allergies: aspirin Attending:[**Doctor Last Name 1857**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: This is a 84 yo man with H/O ESRD on HD, hypertension, renal cell carcinoma s/p radiofrequency ablation, atrial fibrillation on Coumadin, and CAD who presented to [**Hospital3 3583**] on [**6-13**] with severe chest pain and nausea. EKG on admission notable for atrial fibrillation with rapid ventricular rate without ischemic changes. Initial troponin-I 0.06 was attributed to renal disease and atrial fibrillation, however troponin-I peaked at 17.45, consistent with NSTEMI. He had a diagnostic catheterization showing 50% ostial LMCA, 100% occlusion of OM3, 90% PDA, moderate LAD disease, lateral wall abnormalities on ventriculogram; no intervention was performed. He was started on a heparin gtt, Plavix, and beta-blockade. The cardiologist at [**Hospital3 3583**] planned to transfer to [**Hospital1 18**] on Monday for intervention (coronary angioplasty with stents vs. CABG), however, he experienced a run of tachycardia (HR 120s) with nausea and vomiting with troponin re-elevation and oyxgen desaturation. Temp was 102.5 and chest X-ray showed LLL pneumonia for which he received 1 dose of vancomycin and Zosyn for aspiration pneumonia. He was pan-cultured. [**6-14**] dipyridamole-MIBI reportedly showed a fixed inferolateral defect. He was transferred to [**Hospital1 18**] for additional medical management. Vitals on transfer notable for HR 80s and SaO2 100% on 2 Lpm nasal cannula. Past Medical History: ESRD on HD MWF Atrial fibrillation, on Coumadin Renal cell carcinoma s/p RFA [**2143**] at [**Hospital1 2025**] Glaucoma Anemia Hypertension R TKR R AV fistula for HD Mild/moderate dementia BPH Social History: Lives with Wife [**Name (NI) **] in [**Location (un) 3320**]. 3 grown children, daughters very involved. Retired manager for telephone laboratories company. Family History: Both parents deceased, mother renal cell carcinoma; father pulmonary embolus. Physical Exam: Admission GENERAL: Well-appearing elderly Caucasian man in NAD, comfortable, appropriate. VS: T 97.7 BP 122/69 HR 79 RR 20 SaO2 100% on 2 Lpm NC HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: irregularly irregular rhythm, normal rate; no murmurs, rubs or gallops; nl S1-S2. LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement, resp unlabored. ABDOMEN: Soft, non-tender, not distended, no masses or HSM, no rebound/guarding. EXTREMITIES: warm and well-perfused; no clubbing, cyanosis or edema; 2+ peripheral pulses. SKIN: No rashes or lesions. Mild erythema at old PIV site. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact Discharge exam Good O2 saturation on room air. LUE PICC clean, dry and intact. Regular rate and rhythm. Examination otherwise unchanged. Pertinent Results: Admission Labs [**2148-6-16**] 12:04AM BLOOD WBC-11.9* RBC-2.97* Hgb-10.2* Hct-31.4* MCV-106* MCH-34.2* MCHC-32.3 RDW-13.5 Plt Ct-171 [**2148-6-16**] 12:04AM BLOOD PT-20.8* PTT-34.7 INR(PT)-2.0* [**2148-6-16**] 12:04AM BLOOD Glucose-79 UreaN-41* Creat-5.7* Na-136 K-4.8 Cl-94* HCO3-26 AnGap-21* [**2148-6-16**] 06:45AM BLOOD CK(CPK)-198 CK-MB-3 cTropnT-3.85* [**2148-6-16**] 12:04AM BLOOD Calcium-7.9* Phos-6.7* Mg-2.0 Pertinent Labs [**2148-6-16**] 06:45AM BLOOD CK-MB-3 cTropnT-3.85* [**2148-6-16**] 05:20PM BLOOD CK-MB-4 cTropnT-4.24* [**2148-6-16**] 11:57PM BLOOD CK-MB-2 cTropnT-4.69* [**2148-6-17**] 07:12AM BLOOD CK-MB-2 cTropnT-5.09* [**2148-6-17**] 07:40PM BLOOD CK-MB-2 cTropnT-5.02* [**2148-6-18**] 06:55AM BLOOD CK-MB-1 cTropnT-5.37* [**2148-6-19**] 07:15AM BLOOD ALT-20 AST-23 LD(LDH)-230 AlkPhos-93 TotBili-0.4 [**2148-6-17**] 07:12AM BLOOD VitB12-1288* Folate-GREATER TH [**2148-6-16**] 12:04AM BLOOD TSH-0.96 [**2148-6-17**] 12:30PM BLOOD PTH-332* Discharge labs: [**2148-6-21**] 05:48AM BLOOD WBC-6.4 RBC-2.70* Hgb-9.2* Hct-28.2* MCV-105* MCH-34.2* MCHC-32.7 RDW-14.2 Plt Ct-194 [**2148-6-21**] 05:48AM BLOOD PT-22.4* PTT-36.8* INR(PT)-2.1* [**2148-6-21**] 05:48AM BLOOD Glucose-90 UreaN-35* Creat-6.3*# Na-137 K-5.1 Cl-97 HCO3-26 AnGap-19 [**2148-6-21**] 05:48AM BLOOD Calcium-8.6 Phos-5.1* Mg-2.0 Micro: Blood cultures ([**6-16**], [**6-17**], [**6-18**]): no growth Stool ([**6-20**]): c. diff negative ECG [**2148-6-16**] 4:49:52 PM Atrial flutter versus atrial tachycardia with variable conduction pattern. Left anterior fascicular block. Intraventricular conduction delay. Non-specific anterolateral ST-T wave changes. No previous tracing available for comparison. Echocardiogram [**2148-6-17**]: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. 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%). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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. Significant pulmonic regurgitation is seen. There is no pericardial effusion. There are bilateral pleural effusions. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved regional and low normal global systolic function. Dilated ascending aorta. Mild pulmonary artery hypertension. Left atrial enlargement. These findings are c/w hypertensive heart. Video Swallow [**2148-6-18**]: Video swallow fluoroscopy was completed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. Barium passed freely through the oropharynx without evidence of obstruction. There was intermittent trace aspiration of thin liquids, nectar-thick liquids, and pureed solid consistencies and risk of aspiration with all other consistencies due to laryngeal penetration. Left Upper Extremity Non-invasive [**2148-6-18**]: Focused son[**Name (NI) 493**] evaluation demonstrates a small thrombus along the course of the left cephalic vein at the level of the left elbow joint. There are no fluid collections identified in this region. The cephalic vein above and below the level of the left elbow is patent. Brief Hospital Course: 84 yo man with H/O ESRD on HD, hypertension, renal cell carcinoma s/p radiofrequency ablation, and [**Hospital **] transferred from [**Hospital3 3583**] for further management of NSTEMI and pneumonia. # Bacteremia: Fever spiked to 102.5 on [**6-15**] and found to have gram positive cocci in clusters in 2 of 2 bottles at [**Hospital1 3325**], subsequently speciated as MSSA. Patient noted to have thrombophlebitis in left antecubital from IV placed at [**Hospital1 3325**], which is the suspected source. He was initially on vancomycin, but once sensitivities showed MSSA, he was transitioned to nafcillin q4 hrs. He will need 2 weeks total (last day [**6-29**]). TTE was negative for vegetation. PICC line was placed with blood culture from [**Hospital3 3583**] on [**6-13**] no growth on final report. Six sets of blood cultures at [**Hospital1 18**] were negative. # Aspiration pneumonia: Evidence of evolving LLL pneumonia on portable chest X-ray taken prior to transfer at [**Hospital3 3583**] in setting of fever and hypoxia. Patient asymptomatic now but given recent vomiting (on arrival), highest concern was for aspiration pneumonia. He was placed on levofloxacin for planned 10 days total (last day [**6-25**]). The patient was on RA with good O2 saturation at time of discharge. # Abnormal swallowing: Video swallow study confirmed aspiration. The risks related to this were explained to patient and family, but he stated his wishes to continue eating (as opposed to nutrition solely via feeding tube). Recommendations on safest food consistencies were provided by the Speech and Swallowing Service. # NSTEMI: Patient already on medical management. Peak TnT 5.37 (in setting of hemodialysis) with normal CK-MB at [**Hospital1 18**]. There was initial reluctance to proceed with any type of revascularization given aspiration pneumonia and bacteremia. As patient had history of anaphylaxis to aspirin, aspirin desensitization in the CCU would be required prior to planned PCI. The patient had no symptoms suggestive of ischemia since his infarct. His dipyridamole-MIBI images were reviewed with the nuclear cardiologist at [**Hospital1 18**] and felt to show a fixed inferolateral wall defect (likely due to the abrupt occlusion of the OM3 seen on angiography). As the patient was asymptomatic with no objective evidence of post-infarct ischemia (spontaneous or inducible), it was decided not to proceed with either angioplasty or bypass surgery. He was initially changed from atenolol to metoprolol to avoid build-up of atenolol and its metabolites given his renal failure. Although he was bradycardic, low dose metoprolol was attempted for secondary prevention post-MI. He was also given long-acting nitrates for treatment of his residual CAD. We continued lisinopril 20 mg, Plavix 75 mg, and atorvastatin 80 mg daily. He was desensitized to ASA in the CCU and tolerated the desensitization process without incident; he will need to be on uninterrupted ASA for life to avoid recurrence of his allergy. The plan to continue triple therapy with low dose aspirin and Plavix for CAD (dual anti-platelet therapy as medical therapy for MI for at least a few weeks) and Coumadin (for atrial fibrillation) was discussed with his outpatient cardiologist, Dr. [**First Name (STitle) **]. He agreed with a brief triple therapy regimen with subsequent discontinuation of Plavix to lessen the bleeding risk associated with dual anti-platelet plus anti-coagulant therapy. # Atrial fibrillation: Episodes of RVR on arrival and prior to transfer likely precipitated by NSTEMI and evolving pneumonia. His TSH was normal at 0.95. Patient reverted to NSR and was in sinus bradycardia at discharge. He was bridged back on Coumadin with a heparin gtt. The patient was therapeutic at time of discharge with an INR of 2.1. # ESRD on HD: MWF schedule. The patient was continued on his home Phoslo. Transitional Issues: - The patient will need to complete 10 days total of Levaquin (last day [**6-25**]) and 14 days total of nafcillin (last day [**6-29**]) - The pt will need to see his outpatient cardiologist about changes in his anticoagulation and antiplatelet therapy as appropriate. - The rehabilitation facility will need to schedule a follow-up appointment with his PCP Medications on Admission: Aricept 5 mg [**Hospital1 **] Mom[**Name (NI) 6474**] 1 inh daily Avodart 0.5 mg daily (Coumadin, on hold) Flomax 0.4 mg daily Flonase inh daily Hydroxyzine 25 mg TID Lexapro 10 mg daily Namenda 5 mg daily Nephrocaps 1 cap daily Clopidogrel 75 mg daily Vit D and C Preservision softgel 1 tab [**Hospital1 **] Prontonix 40 mg IV daily Prostat liquid 30 mg TID Sensipar 30 mg daily Ultram 50 mg daily prn Xalatan 0.005% solution 2 drops both eyes qhs Zestril 20 mg daily Atenolol 50 mg daily Heparin gtt at 1200 u/hr Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 3. donepezil 5 mg Tablet Sig: One (1) Tablet PO twice a day. 4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 6. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 17. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:*90 Tablet(s)* Refills:*2* 18. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 19. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 4 days: administer after HD on HD days; last dose [**2148-6-25**]. 20. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 8 days: last dose [**2148-6-29**]. 21. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Patient may refuse. Hold if patient has loose stools. 22. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): Patient may refuse. Hold if patient has loose stools. 23. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed 4g in 24hrs. 24. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for SBP < 100 and HR < 60. 25. Asmanex Twisthaler 110 mcg (7 [**Month/Day/Year 4319**]) Aerosol Powdr Breath Activated Sig: One (1) puff Inhalation once a day. 26. Namenda 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Location (un) 3320**] Discharge Diagnosis: Non-ST segment elevation Myocardial Infarction Coronary artery disease Methicillin sensitive Staphylococcus aureus Bacteremia Left upper extremity thrombophlebitis, presumed septic Aspiration Pneumonia Recurrent aspiration with abnormal video swallowing study Aspirin allergy, now status post successful desensitization Atrial fibrillation End-stage renal disease on hemodialysis Atrial fibrillation on long term use of anti-coagulants Glaucoma Anemia Hypertension Mild-moderate dementia Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were transferred from another hospital for management of your heart attack. After reviewing your studies, our cardiologists felt it would be appropriate for you to be managed medically instead of pursuing surgery or cardiac catheterization. Your medications were adjusted appropriately and you were densensitized to aspirin. Do not stop taking aspirin unless specifically instructed to do so by a physician. You were also found to have aspiration pneumonia. You were started on antibiotics for treatment. Speech and swallow evaluated you, and found that you were indeed aspirating silently. The risks were explained to you in detail about eating, but you chose to continue eating despite the ongoing risk for aspiration pneumonia. You were also found to have bacteria in your bloodstream. You will be continued on IV antibiotics with the PICC line for treatment. While at rehab, an appointment with your PCP will need to be scheduled. Medications: CHANGE Coumadin 7mg to 3mg once daily CHANGE Metoprolol to 12.5mg [**Hospital1 **] START Aspirin 81mg daily (do NOT miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]) START Nafcillin 2g IV every 4 hours (last day [**2148-6-29**]) START Levofloxacin 500 mg PO every 48 hours administer after HD on HD days (last day [**2148-6-25**]) START Atorvastatin 80mg once daily START Isosorbide Dinitrate 10 mg PO three times daily If you experience any fevers, chills, chest pain, increased shortness of breath, or any other symptoms concerning to you, please call or come into the ED for further evaluation. Thank you for allowing us at the [**Hospital1 **] to participate in your care. Followup Instructions: Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 111869**],MD SPECIALTY: Cardiology Address: [**Apartment Address(1) 43403**], [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 26647**] When:Tuesday,[**7-2**] at 10:45am [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2198-9-7**] Discharge Date: [**2198-9-11**] Date of Birth: [**2117-12-20**] Sex: F Service: MEDICINE Allergies: Codeine / Penicillins / Erythromycin Base / Morphine Attending:[**First Name3 (LF) 800**] Chief Complaint: hypotension s/p syncope Major Surgical or Invasive Procedure: none History of Present Illness: 80 year old woman with a history of COPD, HTN, CRI who presents with syncope and hypotension. She reports a recent over the past 5 days with whitish phlegm which turned green 1 day prior to admission. She denies fevers, chills or night sweats. According to the patient she awoke this morning to the sound of someone knocking on the door and the phone ringing. She went to get up and slid from her bed to the floor. She denies hitting her head or losing consciousness. She states her legs gave out on her. She report her legs given out 2 other times in the past. She denies dizziness, lightheadedness, palpitations. According to her daughter she was found by the concierge at her home on the floor with vomit and urine and her fall was not witnessed. She denies losing her urine and does not recall if she vomited. EMS was called. Initial vitals by EMS were BP 120/70 O2 sats 95% on NRB. . In the ED, initial vs were: T97.4 HR77 BP71/31 RR20 O2sats 93 on 4L NC. Patient was given 4L NS for resuscitation. A FAST scan was done showing a 3.8cm AAA. Given her AAA and hypotension, a vascular surgery consult was called. She underwent non-contrast CT torso which showed a LLL infiltrate. Vascular surgery was not concerned about the AAA. She was given 1gm CTX, 750mg Levofloxacin and 500mg Flagyl. Blood pressures improved to the mid-90s but then started to trend down. A R femoral CVL was placed and she was started on Levophed. Lactate was 2.2. She was found to be in acute renal failure with a creatinine of 2.6. Potassium was 5.6. Her WBC was 19.1 with 13% bands. INR was noted to be 4.3. Blood cultures were obtained. . On arrival to the ICU she complains of cough without significant shortness of breath. She is otherwise comfortable without pain. She denies nausea, headache, chest pain, dysuria. Pressors were weaned, and the patient was transferred to the floor after being afebrile. . Review of sytems: (+) diarrhea in the past week. she reports diarrhea on and off for her lifetime. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Pulmonary Embolism [**2-25**] on coumadin - Hypertension - Hypercholesterolemia - Monoclonal gammopathy - COPD - Arthritis - Gastrointestinal ulcers - Gastric esophageal reflux disease - Kidney stones 55 years ago in the setting of pregnancy - Elevated PTH - Chronic renal insufficiency with baseline 1.1 to 1.5 - Abdominal aortic aneurysm measuring 4.2 cm - Possible pons lacune infart noted on [**1-24**] MR [**Name13 (STitle) 2853**] - Peripheral Neuropathy of unclear etiology Social History: The patient lives alone. She is divorced and her former husband is now deceased. She has five children. She previously worked as a laboratory technician at [**Location (un) 86**] State Hospital and an office manager. She has a 50 pack year smoking history but quit greater than 25 years ago. She drinks [**2-17**] glasses of wine per day. She denies use of illicit drugs. Family History: The patient's mother died from a myocardial infarction at age 60. Her mother had hyperthyroidism. The patient's father had a myocardial infarction at age [**Age over 90 **] and a benign brain tumor. She has a sister with breast cancer. Her daughter has juvenile rheumatoid arthritis. There is no family history of gastric disorders or kidney stones. Physical Exam: Vitals: T: 98.4 BP: 118/80 P: 81 R: 18 O2: 93% on RA General: Alert, oriented, elderly female, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: decreased breath sounds on left side, otherwise clear CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic ejection murmur at the LUSB 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, 1+ peripheral edema bilaterally, former site of femoral catheter (now withdrawn) on the right is C/D/I Neuro: A&O x 3, CNII-XII grossly intact. Pertinent Results: Labs On admission: [**2198-9-7**] 07:31PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2198-9-7**] 07:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2198-9-7**] 07:31PM URINE RBC-0-2 WBC-[**7-26**]* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2198-9-7**] 06:30PM URINE HOURS-RANDOM CREAT-96 SODIUM-27 POTASSIUM-98 CHLORIDE-62 [**2198-9-7**] 06:30PM URINE OSMOLAL-440 [**2198-9-7**] 03:51PM K+-5.6* [**2198-9-7**] 12:42PM LACTATE-2.2* [**2198-9-7**] 12:20PM GLUCOSE-144* UREA N-49* CREAT-2.6*# SODIUM-137 POTASSIUM-7.0* CHLORIDE-105 TOTAL CO2-25 ANION GAP-14 [**2198-9-7**] 12:20PM estGFR-Using this [**2198-9-7**] 12:20PM ALT(SGPT)-47* AST(SGOT)-69* ALK PHOS-65 TOT BILI-0.3 [**2198-9-7**] 12:20PM LIPASE-18 [**2198-9-7**] 12:20PM cTropnT-<0.01 [**2198-9-7**] 12:20PM ALBUMIN-3.4* [**2198-9-7**] 12:20PM WBC-19.1*# RBC-3.84* HGB-10.9* HCT-33.2* MCV-87 MCH-28.5 MCHC-32.9 RDW-14.7 [**2198-9-7**] 12:20PM NEUTS-81* BANDS-13* LYMPHS-1* MONOS-4 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2198-9-7**] 12:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2198-9-7**] 12:20PM PLT SMR-NORMAL PLT COUNT-248 [**2198-9-7**] 12:20PM PT-40.5* PTT-41.4* INR(PT)-4.3* On Discharge: [**2198-9-11**] 05:15AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.0* Hct-29.9* MCV-84 MCH-28.1 MCHC-33.5 RDW-14.3 Plt Ct-260 [**2198-9-11**] 05:15AM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-138 K-4.0 Cl-103 HCO3-29 AnGap-10 [**2198-9-11**] 05:15AM BLOOD ALT-31 AST-17 [**2198-9-11**] 05:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.4* Radiology: CHEST (PORTABLE AP) Study Date of [**2198-9-7**] 12:18 PM IMPRESSION: Mild central vascular congestion without overt failure. Bibasilar atelectasis. Increased opacity of the retrocardiac left lower lobe may reflect underlying pneumonia or aspiration. Correlate clinically. CT CHEST W/O CONTRAST Study Date of [**2198-9-7**] 12:34 PM LUNG BASES: There is consolidation and ground-glass opacification of the superior segment of the left lower lobe, as well as portions of the posterior basal segment of the right lower lobe. CT HEAD W/O CONTRAST Study Date of [**2198-9-7**] 12:33 PM IMPRESSION: No acute intracranial process. CT ABDOMEN W/O CONTRAST Study Date of [**2198-9-7**] 12:34 PM IMPRESSION: 1. No evidence of rupture of the patient's 3.8-cm abdominal aortic aneurysm. Stability in size maintained. 2. Area of density within the left breast has a lucent center, and may represent an intramammary lymph node, fat necrosis, or oil cyst. Recommend correlation with mammogram. 3. Stable appearance of adrenal nodule over 5 years, described above. 4. Status post cholecystectomy, with stable and expected dilatation of the common bile duct. 5. Diverticulosis with no evidence of diverticulitis. US ABD LIMIT, SINGLE ORGAN PORT Study Date of [**2198-9-8**] 1:54 PM IMPRESSION: Stable common bile duct at approximately 9 mm. The liver echotexture is normal and there is no underlying suggestion of cirrhosis or other parenchymal disease. No mass lesion identified. There is no intrahepatic biliary dilatation. There has been interval development of a small right pleural effusion. Known abdominal aortic aneurysm is stable in size since yesterday. BILAT UP EXT VEINS US Study Date of [**2198-9-8**] 1:54 PM IMPRESSION: No DVT in either upper extremity. Brief Hospital Course: 80 year old woman with a hx of PE on coumadin, HTN who presents with syncope, hypotension and likely PNA concerning for sepsis. . 1. Hypotension: Likely from sepsis given her chest CT findings of PNA, elevated WBC and cough. She had no fevers. She received 4L NS in the ED but continued to appear clinically dry. Volume resuscitation was continued in the MICU along with levophed which was weaned over 24 hours. PNA treatment was begun with with ceftriaxone and levofloxacin, but was later switched to cefpodoxime and levofloaxin, for a total 8 day course. Patient's blood pressure on the floor was normotensive, although we continued to hold her home medications of HCTZ, Amlodipine, and Benzepril, and discharged her with instructions to follow-up with her PCP if she should resume this medications. . 2. Acute Renal Failure: Prior kidney function 1.2. Patient made good urine throughout her hospitalization. Her creatinine peaked at 2.6 and trended down to a nadir of 1 upon discharge with volume resuscitation and holding nephrotoxic meds. 3. UTI: On [**2198-9-7**], the patient was noted to have a UTI on urine culture from E. Coli, which was sensitive to ceftriaxone. As the patient was being treated for PNA with ceftriaxone and levofloxacin, we did not change her antibiotic regimen, which should appropriately cover her for an uncomplicated UTI. . 3. Hyperkalemia: Felt to be secondary to acute renal failure in the setting of taking potassium and triamterene and benazepril. ECG without peaked T waves. Offending meds were held during the hospitalization, and were held until patient can follow-up with her primary care physician. [**Name10 (NameIs) **] patient's hyperkalemia improved with aggressive IV fluid resusitation, and her discharge K was 4.0. . 4. Syncope: Likely from hypotension, hypovolemia. It is concerning that the patient lost urine but not other signs of seizure activity during her stay in the MICU or on the floor. The patient was monitored on tele without event. An EEG was not done. . 5. Elevated INR: Likely due to infection and coumadin use. No signs of active bleeding. Would expect INR to rise with recent antibiotics. Coumadin was initially held and then restarted prior to discharge, with an INR on discharge of 2.7. . Code: Full (discussed with patient) Medications on Admission: Hydrochlorothiazide 25 mg Tab PO daily Bisoprolol Fumarate 2.5 mg Tab PO daily Omeprazole 40 mg Cap, Delayed Release 1 tab PO Daily Klor-Con 8 mEq Tab 1 tab PO BID Amlodipine 5 mg Tab 1 tab PO daily Benazepril 40 mg Tab PO daily Multivitamin Tab 1 tab PO daily Triamterene 50 mg PO daily Simvastatin 80mg PO daily Trazadone 100-150mg PO qHS PRN - has not taken this in the past few day but perhaps monday, tuesday and wednesday Coumadin alternating 1.5mg with 2mg this week Gabapentin 100mg PO TID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Sepsis secondary to Community Acquired Pneumonia Urinary Tract Infection . Secondary Diagnoses: Hx Pulmonary Embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU for low blood pressure in the setting of pneumonia. You were treated with IV fluids and antibiotics and your symptoms improved. You should complete a total of 8 days of antibiotics, and follow-up with your PCP. . We made the following changes to your home medications: -Start Cefpodoxime - continue for 6 more days to end on [**2198-9-16**] -Start Levofloxacin - continue for 6 more days to end on [**2198-9-16**] (this is an every-other-day medication). -STOP Hydrochlorothiazide, Amlodipine, Benazepril, Triamterene and Klor-Con until you see your PCP on [**Name9 (PRE) 2974**]. He will decide if you should resume this medications. -CHANGE Coumadin to 1.5 Mg daily for this week - please have your INR drawn tomorrow, Wednesday the 28th at your PCP's office. Followup Instructions: Please have your INR drawn tomorrow at your PCP's office. You have an appointment to see your PCP on [**Name9 (PRE) 2974**]: Name: [**Last Name (LF) 7726**],[**First Name3 (LF) 177**] A. When: FRIDAY, [**2198-9-14**]:30 AM Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 7728**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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icd9cm

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icd9pcs

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40472

Discharge summary

report

Admission Date: [**2110-5-26**] Discharge Date: [**2110-5-31**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: Code stroke Major Surgical or Invasive Procedure: intravenous tPA History of Present Illness: [**Known firstname **] ([**Doctor First Name **]) [**Known lastname 88664**] is a [**Age over 90 **] yo righthanded owman with a history of atrial fibrillation who presents for evaluation following sudden onset of left sided weakness. Per the patient's grandson [**Name (NI) **], the patient was woken from her nap at 1pm and given lunch. She seemed in her usual state of heatlh until 3pm when she was being transferred from a chair. The patient was apparently able to hold onto her grandsone has he assister her to stand/pivot. When she sat down, he noticed that she was week on the left side. 911 was called and the patinet's vitals were initially 110/70, HR 70 and FSG 155. She was taken to [**Hospital1 18**] for immediate evaluation. Neurologic review of systems could not be completed due to patient cooperation. Family denies any recent complaints. Past Medical History: - Afib on ASA - Stroke in [**2108**] with babbling speech, resolved without deficits - Colon Ca [**2106**] - Hip fracture (l) s/p repair - HOH - "Legally blind" Social History: Lives with her son, daughter and grandson. family [**Name2 (NI) 88665**] very remote smoking use, no alcohol. At baseline, the pateint is a+ox1. She does not ambulate but can stand to transfer. Family History: No family hx stroke that is known. Physical Exam: T 98.8 BP 162/85 HR 75 RR 20 O2% 100% 2L NIH SS: 1a. Level of Consciousness: 0 1b. LOC questions: 2 1c. LOC commands: 2 2. Best gaze: 2 3. Visual:3 4. Facial palsy: 0 5a. Motor arm, left: 2 5b. Motor arm, right: 0 6a. Motor leg, left: 2 6b. Motor leg, right: 0 7. Limb ataxia: 0 8. Sensory: 0 9. Best language: 1 10. Dysarthria: 1 11. Extinction and inattention: 1 General: cachetic and ill appearing Head and Neck: no cranial abnormalities,mm dry Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs clear to auscultation bilaterally Cardiac: regular rate and rhythm Abdomen: soft, normoactive bowel sounds Extremities: 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: The patient is awake, moaning and yelling. Does not repeat or answer questions. Head and eyes are turned to the right and there appears to be neglect of left space. PERRL. She does not make good eye contact and does not appear to track. Right gaze deviation cannot be fully overcome with dolls eye maneuver. Left facial droop. There is no spontantous antigravity movement of the left arm or leg, but both withdraw appropriately to noxious stim. Right amd and leg move against gravity. Reflexes 1+ and toes upgoing bilaterally. Pertinent Results: Labs on admission: [**2110-5-26**] 04:37PM BLOOD WBC-7.7 RBC-4.53 Hgb-13.6 Hct-41.1 MCV-91 MCH-30.0 MCHC-33.1 RDW-14.6 Plt Ct-229 [**2110-5-26**] 04:37PM BLOOD Glucose-156* UreaN-13 Creat-0.6 Na-141 K-4.8 Cl-107 HCO3-23 AnGap-16 [**2110-5-26**] 04:37PM BLOOD CK(CPK)-23* [**2110-5-26**] 04:37PM BLOOD Lipase-21 [**2110-5-26**] 04:37PM BLOOD CK-MB-2 cTropnT-<0.01 [**2110-5-28**] 02:21AM BLOOD CK-MB-3 cTropnT-<0.01 [**2110-5-26**] 04:37PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.2 [**2110-5-26**] 05:52PM BLOOD %HbA1c-5.4 eAG-108 [**2110-5-26**] 04:38PM BLOOD Lactate-2.9* [**2110-5-28**] 02:47AM BLOOD Lactate-1.6 [**2110-5-28**] 02:47AM BLOOD freeCa-1.16 [**2110-5-26**] 08:08PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.048* [**2110-5-26**] 08:08PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [**2110-5-26**] 08:08PM URINE RBC-16* WBC-40* Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1 . Labs on discharge: XXXX . Imaging: [**2110-5-29**] UNILAT UP EXT VEINS US: No DVT in the right upper extremity. [**2110-5-29**] MR HEAD W/O CONTRAST: final read pending [**2110-5-28**] CT HEAD W/O CONTRAST: 1. Unchanged size of the right frontal lobar parenchymal hemorrhage, degree of associated edema, and mild leftward shift of normally-midline structures. No evidence of central herniation. 2. No new intracranial hemorrhage. 3. Decreased quantity of intraventricular blood, layering in the occipital [**Doctor Last Name 534**] of the right lateral ventricle and unchanged quantity of blood layering in the occipital [**Doctor Last Name 534**] of the left lateral ventricle. The ventricular size and configuration is unchanged. [**2110-5-27**] CT HEAD W/O CONTRAST: 1. Hemorrhagic transformation of a previously seen right frontal/anterior parietal MCA territory infarct. Intraventricular extension of the hemorrhage into both lateral ventricles. No new hydrocephalus. 2. Mild leftward shift of midline structures. [**2110-5-27**] ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. There is asymmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. No cardiac source of embolus identified (cannot definitively exclude) other than atrial fibrillation. [**2110-5-26**] CTA HEAD/NECK W&W/O C & RECON: 1. Matched MTT/CBV/CBF defect of the right frontal/pareital region compatible with MCA territory infarct. No infarct is appreciated on the noncontrast portion of the study, likely because the infarct is acute. 2. No evidence of intracranial hemorrhage. 3. Extensive calcific arteriosclerosis, particularly intracranially, with regions of moderate-to-severe narrowing but no evidence of large vessel occlusion and no aneurysm. 4. No flow-limiting disease within the neck. A thin linear filling defect within the left internal carotid artery origin, may represent a focal dissection or complex atheromatous plaque. 5. Multinodular thyroid. Consider followup ultrasound if not already evaluated elsewhere. [**2110-5-26**] ECG: Atrial fibrillation with rapid ventricular response. Leftward axis. Low voltage throughout. No previous tracing available for comparison. Clinical correlation is suggested. Rate PR QRS QT/QTc P QRS T 126 0 72 328/443 0 -14 65 Brief Hospital Course: [**Known firstname **] [**Known lastname 88664**] is a [**Age over 90 **] year old right handed woman with a history of paroxsysmal atrial fibrillation who presents with sudden onset of left sided weakness this afternoon. The patient has a very limited functional baseline and so her presenting exam is also difficult. At admission, the patient has a clear left facial droop, left arm and leg weakness. She also appeared to respond to noxious stimuli thoughout. CT of the head showed multiple, likely chronic infarcts. CTA is without a clear occlusion (though recons pending) but perfusion studies show a possible increased MTT in the right temporal/parietal region. Likely source of clot is atrial fibrillation or cardiac atheroemboli. The risks and benefits of tPA were discussed with the family and the decision was made to give tPA. She was unable to tolerate MRI, so repeat head CT [**5-27**] obtained, which showed hemorrhagic transformation of stroke w. intraventricular bleed, a repeat head CT with less blood in ventricles, no hydrocephalus. On admission exam demonstrated L sided weakness (upper and lower extremity), L facial droop, dysarthria but fluent speech; facial droop improved. On the floor she can lift and hold LUE, withdraws BLE, clear but nonsensical, perseverating speech. . Cardiovascular: - Held aspirin she should follow up in 8 weeks with Dr. [**Last Name (STitle) **] to determine if she can be restarted and possible repeat imaging to examine for stability of the bleed She was started on metoprolol for rate control. . Stroke Risk Factors: - LDL: 93 - HgBA1c: 5.4 - TTE: No cardiac source of embolus identified (cannot definitively exclude) other than atrial fibrillation Pulmonary: - A CXR demonstrated Ill-defined right upper lobe opacity is not fully characterized but could potentially represent a neoplastic mass. Chest CT would more fully characterize this region. This was discussed with the family, however goals of care were addressed. The family did not wantt to persue further imaging and wanted her to be comfortable. . Gastrointestinal / Abdomen: - Speech and swallow eval [**5-28**]: Nutrition: PO diet: thin liquids, pureed solids. 2. Meds crushed with applesauce. 3. TID oral care. 4. 1:1 supervision with all PO intake. 5. We will f/u at the end of the week to determine if further upgrade may be appropriate based on improvement in mental status. Hematology: - Underwent TPA [**5-26**] at 530pm, now has hemorrhagic transformation. She also had some left upper extremity swelling and an ultrasound negative for DVT. . Endocrine: - No active issues and HgbA1C was 5.4. . Infectious Disease: - urine cx c/w w. evidence of contamination on repeat UA there was 55 WBCs and therefore was given a Week supply of Bactrim. . Dispo: Discussion with the family was held about placement. The family felt strongly about taking her home. They were trained by PT on how to lift and repositioning prior do discharge. An ambulance was ordered for transport home. Medications on Admission: Asa 325 daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for afib. Disp:*90 Tablet(s)* Refills:*0* 2. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Stroke Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [**Known lastname 88664**], You were admitted for a stroke and were given IV tPA. You had some bleeding in your brain after this. This stroke was thought to be secondary to your atrial fibrillation. Your aspirin was held for bleeding risk, and you should restart it in about 4 weeks after follow up imaging and follow up with Dr. [**Last Name (STitle) **]. Your stroke risk factors were checked. You should not smoke. Your cholesterol was an LDL of 93. You were checked for blood glucose control with a HgB A1c. The level was 5.4. You need to continue your blood pressure control. You should continue to eat a low fat healthy diet, and follow up with your primary care physician and stroke Neurology. It was a pleasure taking care of you. Followup Instructions: Home Care Facility: [**Location (un) 86**] VNA PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 37165**] in 7 - 10 days for post hospitalization follow up. Neurology: In about 4 weeks. [**Last Name (LF) **], [**First Name3 (LF) **] Office Phone: ([**Telephone/Fax (1) 7394**] Office Location: W/[**Location (un) **] 1 Department: Neurology Organization: [**Hospital1 18**] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2110-5-31**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2145-7-23**] Discharge Date: [**2145-7-26**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine Attending:[**First Name3 (LF) 5893**] Chief Complaint: nausea, vomiting, and abdominal pain Major Surgical or Invasive Procedure: Central venous catheter History of Present Illness: Mr. [**Known lastname 21822**] is a 32 year old male with history of poorly controlled DM1 c/b ESRD on dialysis and hypertension who presented to the ED with N/V and abdominal pain x 24 hours. Patient was in usual state of health until day of presentation. He woke up with some abdominal pain and nausea/vomitting. Subjective chills, no documented fever at home. He had one episode of non-bloody, watery diarrhea and was unable to take any of his PO meds. He went to HD and initially felt better, then nausea/vomitting returned. Vomiting is non-bloody. He went to the ED for eval. He states he has been compliant with his insulin regimen. The only additional symptom he has had is a runny nose over the past 2-3 days. He denies headache, cough, sore throat, shortness of breath, chest pain, palpitations, peripheral edema. . In the ED, initial vs were: T 100.2 P 125 BP 167/102 R 18 O2 sat 98%. Initial labs showed hyperkalemia and an anion gap of 19, however bicarbonate of 26 and glucose of 410. CBC with WBC of 10.6 and 84.5% neutrophils. He was given zofran and IV protonix. He also recieved Vancomycin and Levofloxacin. He was placed on an insulin gtt and given 2L of NS with KCl and transferred to the ICU for further monitoring. . On the floor, initial vitals were 98.9 187/111 118 15 100% RA. Patient does not have any abdominal pain, but complains of hiccups and some nausea. He is tired and thirsty. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - HTN - DM I since age 19, seen at [**Last Name (un) **]. Complicated by nephropathy, gastroparesis, and possibly retinopathy. - ESRD/CKD: [**2-9**] HTN and DM1; hemodialysis T/Th/Sat. On kidney/pancreas transplant wait list since 4/[**2144**]. - Anemia on epo with dialysis - Depression - s/p appendectomy [**7-/2144**] Social History: States that he previously drank heavily (30-40 drinks/week) but has not used alcohol since [**2144-11-14**]. +h/o tobacco use, quit in [**2142**], relapsed, quit last year and denies tobacco currently. Denies other drugs. Neg PPD [**2145-2-26**]. Lives with girlfriend. Family History: No FH of pancreatitis. Diabetes and heart trouble in grandfather. Physical Exam: Vitals: T: 98.9 BP: 187/111 P: 118 R: 15 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear with no erythema or exudate, nasal mucosa without obvious lesion Neck: supple, JVP not elevated, no LAD. Right IJ in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: alert, oriented x 3, spontaneously moves all 4 extremities, no facial asymmetry or droop. . Pertinent Results: Admission labs: [**2145-7-23**] 12:05AM BLOOD WBC-10.6# RBC-4.53* Hgb-12.6* Hct-35.6* MCV-79*# MCH-27.7 MCHC-35.2*# RDW-14.3 Plt Ct-231 [**2145-7-23**] 12:05AM BLOOD Glucose-410* UreaN-24* Creat-7.8*# Na-133 K-6.4* Cl-88* HCO3-26 AnGap-25* [**2145-7-23**] 05:20AM BLOOD Calcium-9.3 Phos-1.5*# Mg-1.6 . Discharge labs: [**2145-7-26**] 04:15AM BLOOD WBC-4.7 RBC-3.15* Hgb-8.8* Hct-26.3* MCV-83 MCH-28.1 MCHC-33.7 RDW-14.3 Plt Ct-154 [**2145-7-26**] 04:15AM BLOOD Glucose-51* UreaN-21* Creat-8.9*# Na-136 K-3.7 Cl-96 HCO3-32 AnGap-12 [**2145-7-26**] 04:15AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.1 . [**2145-7-24**] 08:26PM URINE Blood-NEG Nitrite-NEG Protein->600 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG Brief Hospital Course: 32 year old male with history of DM1, ESRD on HD, HTN presented to ED with 24 hours of abdominal pain and N/V and found to have DKA. He was managed in the [**Hospital Unit Name 153**] with IV insulin and transitioned to SQ insulin. He was discharged to home with good glucose control on glargin insulin plus a humalog sliding scale. . # Diabetic Ketoacidosis - Presented with DKA with anion gap and hyperglycemia. Anion Gap 19 in ED. Patient recieved HD the day of admission, so possibilty metaboloic acidosis was corrected during HD session. Trigger for DKA unclear, however, infection can not be ruled out given subjective chills. No steroid use. Initially on an insulin drip. Weaned off with improvement in anion gap. Blood and urine cultures were negative, and CXR was not consistent with infection. Once he was tolerating POs, had WNL blood sugars, and a normal anion gap he was discharged home with close follow up. . # Hypertension - History of hypertension. Maintained on PO medications as outpatient (Toprol XL, amlodipine, lisinopril). BP's in 150's in ED, elevated on admission to [**Hospital Unit Name 153**]. EKG with no ischemic changes. Improved with home regimen. . # Metabolic Alkalosis - Likely mixed picture of metabolic acidosis from DKA and metabolic alkalosis from renal HD replacement of bicarb, however this is assumption in setting of no HD records. Improved with improved DKA and HD. . # ESRD - On dialysis T-Th-Sa. Recieved dialysis on [**7-22**] and in the FIC on [**7-24**]. Will resume HD as an outpatient the day after discharge. . # Diabetes - in DKA, see section above. Discharged on glargin 15 units QAM and a Humalog sliding scale (See DC paperwork). . FULL CODE Medications on Admission: Amlodipine 10 mg qday Vitamin D 50,000 units qweek Lasix 80 mg PO qday Glargine 15 units daily Lisinopril 30 mg qday Toprol XL 200 mg qday Sertaline 25 mg qday Sevelamer 800 mg TID Discharge Medications: 1. Amlodipine 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 2. Vitamin D 50,000 unit Capsule [**Month/Year (2) **]: One (1) Capsule PO once a week. 3. Lasix 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 4. Lisinopril 30 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 5. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr [**Month/Year (2) **]: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Sevelamer Carbonate 800 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO three times a day. 7. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen [**Month/Year (2) **]: Fifteen (15) units Subcutaneous once a day. 8. Humalog Pen 100 unit/mL Insulin Pen [**Month/Year (2) **]: 1-10 units Subcutaneous four times a day: Per sliding scale. Please see discharge paperwork. . Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic ketoacidosis . Secondary: Diabetes type I, hypertension, chronic renal failure on HD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for diabetic ketoacidosis. This is a life threatening complication of not taking enough insulin. It is very important that you take your insulin and other medication. We treated you with IV insulin, and transitioned you to injected insulin. You improved, and are being discharged home. It is very important that you check your finger stick blood sugars before every meal and before bed. If your blood sugar is less than 80, please eat a snack. If your blood sugar is >380, please call your doctor or come to the emergency room. . This is the insulin regimen that we recommend for you: In the morning: - Glargin insulin (Lantus) 15 units in the morning Before meals: - Glucose 80-130 2 units of Humalog insulin - Glucose 130-180 3 units of Humalog insulin - Glucose 180-230 4 units of Humalog insulin - Glucose 230-280 5 units of Humalog insulin - Glucose 280-330 6 units of Humalog insulin - Glucose 330-380 7 units of Humalog insulin - Glucose over 380 come to the emergency room or call your doctor Before bed: - Glucose 200-250 1 unit of Humalog insulin - Glucose 250-300 2 units of Humalog insulin - Glucose 300-350 3 units of Humalog insulin - Glucose 350-400 4 units of Humalog insulin - Glucose >400 call your doctor or come to the emergency room . Please attend dialysis tomorrow. Followup Instructions: Provider: [**Name10 (NameIs) **],DIALYSIS SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2145-7-27**] 12:00 Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2145-9-22**] 1:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24385**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2145-10-11**] 2:10 Completed by:[**2145-7-26**]

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icd9cm

[ [ [] ] ]

[ "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

7201, 7207

4410, 6110

350, 375

7353, 7353

3664, 3664

8834, 9241

2835, 2904

6342, 7178

7228, 7332

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1834, 2183

274, 312

403, 1815

3680, 3966

7368, 7479

2205, 2528

2544, 2819

31,112

198,071

5493

Discharge summary

report

Admission Date: [**2175-8-3**] Discharge Date: [**2175-8-9**] Date of Birth: [**2110-7-26**] Sex: F Service: MEDICINE Allergies: Captopril Attending:[**First Name3 (LF) 45**] Chief Complaint: Hyperglycemic, hyperosmolar state. Major Surgical or Invasive Procedure: Cardiac catheterization. History of Present Illness: Ms. [**Known lastname 22204**] is a 65 yo female with h/o TypeI DM w/ insulin pump, who brought herself to the ED for elevated blood glucose. Yesterday evening she noted that her blood sugars were > 600. She c/o general malaise, but otherwise has no specific complaints. She states that she changed her pump yesterday morning and had the feeling that it was not inserted correctly. She attempted to change it again last night when she noted her BS were high. She thought it was working and went to bed. She woke up this morning feeling generally lousy and nauseated. She denies CP, SOB, abd pain, fevers, chills, vomiting, increased urinary frequency and dysuria. She reports not thinking clearly at the time. She did not think she needed to give herself a SC injection of insulin. Patient has not been hospitalized with DKA frequently - last admission may have been at diagnosis at aged 18. She believes her last HbA1c was around 8. . In the ED, VS were T 97.2, BP 105/48, HR 90, O2 sat 99% on RA. CXR and UA were negative. She was placed on an insulin drip given IV Fluids and tranfered to the ICU. Past Medical History: - Type I DM-- for over 40 years, on insulin pump, followed at [**Last Name (un) **] - Diabetic retinopathy - Diabetic neuropathy with Charcot joints - Multiple sclerosis-- dx [**2169**]; c/b neurogenic bladder; no longer ambulates (uses wheelchair) - Peripheral vascular disease - Depression -- weaning off celexa and titrating effexor. - s/p right [**Doctor Last Name **]-pedal bypass [**2174**] - Essential tremor - History of syncope - Hypertension. - Status post PTCA [**2166-3-3**] for coronary artery disease - Status post bladder suspension surgery for stress incontinence - Chronic anemia. Social History: She lives alone, she is not married. She has a brother in [**Name (NI) 620**] and a sister in [**Name (NI) **]. She is quite close with her sister. [**Name (NI) **] tobacco or alcohol. Family History: Counsin with MS; mother died of MI at age 80; Father had epilepsy Physical Exam: VS: T 99.0 BP 123/52 HR 80 RR 18 O2 97% RA General:thin woman, NAD with mild resting tremor affecting face & hands. HEENT:sclera white, 0.5cm raised area of erythema below left eye and involving left lower eyelid. another 0.5cm area of erythema with eschar on left cheek. pharynx has moist mucosa. Lungs: CTAB Card: RRR, 2/6 SEM @ USB Abd: soft, NT, ND, no masses or organomegaly Extremities: warm, dry, right foot with charcot deformity. mild bilat LE edema. Pertinent Results: Labs on admission: [**2175-8-3**] WBC-9.7# RBC-3.98* Hgb-12.4 Hct-38.4 MCV-97 MCH-31.2 MCHC-32.3 RDW-13.8 Plt Ct-212 [**2175-8-3**] Neuts-90.0* Bands-0 Lymphs-7.4* Monos-2.4 Eos-0.1 Baso-0 [**2175-8-4**] PT-13.1 PTT-115.4* INR(PT)-1.1 [**2175-8-3**] Glucose-629* UreaN-30* Creat-0.9 Na-134 K-5.2* Cl-95* HCO3-22 AnGap-22 [**2175-8-3**] ALT-20 AST-26 AlkPhos-82 Amylase-34 TotBili-0.4 [**2175-8-3**] Lipase-15 [**2175-8-3**] Calcium-9.7 Phos-4.8* Mg-2.0 Cholest-149 [**2175-8-5**] %HbA1c-7.6* [**2175-8-5**] Triglyc-49 HDL-56 CHOL/HD-2.0 LDLcalc-47 [**2175-8-3**] Type-[**Last Name (un) **] pO2-51* pCO2-50* pH-7.31* calTCO2-26 Base XS--1 . . Labs on discharge: [**2175-8-9**] WBC-5.0 RBC-3.43* Hgb-10.7* Hct-32.2* MCV-94 MCH-31.3 MCHC-33.3 RDW-14.3 Plt Ct-246 [**2175-8-9**] PT-11.7 PTT-24.9 INR(PT)-1.0 [**2175-8-9**] Glucose-280* UreaN-18 Creat-0.8 Na-140 K-4.9 Cl-102 HCO3-30 AnGap-13 [**2175-8-9**] Calcium-8.6 Phos-4.0 Mg-2.0 . Cardiac enzymes: [**2175-8-3**] CK-MB-4 [**2175-8-3**] cTropnT-0.02* [**2175-8-4**] CK-MB-6 cTropnT-0.08* [**2175-8-4**] CK-MB-6 cTropnT-0.11* [**2175-8-4**] CK-MB-6 cTropnT-0.13* [**2175-8-5**] CK-MB-5 cTropnT-0.09* . . CXR [**2175-8-3**]: 1. Persistent elevation of the right hemidiaphragm. 2. No evidence of pneumonia or CHF. . EKG on admit: NSR, nl axis, STE aVR, STD I, aVL, II, V4-V6 EKG following am: NSR, Nl axis, slight STD V4-V5. . Cardiac Cath [**2175-8-7**]: COMMENTS: 1. Coronary angiography of this right dominant system revealed two vessel coronary artery disease with diffuse atherosclerosis with a patent prior RCA stent. The LMCA was a short vessel with almost dual ostia. The LAD was heavily calcified proximally and had a proximal 40-50% stenosis and diffuse plaquing to 50% in the mid-distal vessel. The LCx had heavy calcification. There was mild diffuse plaquing throughout to 30-40% with tortouous terminal branches of a single major OM. The RCA had diffuse plaquing throughout with mild in-stent restenosis of the mid-distal RCA [**Doctor First Name 10788**] stent with a 35% distal edge restnosis. The distal RCA was tortuous. The origin of the R PDA (<2 mm diameter by QCA) had a 70% stenosis. There were multiple RPLs. 2. Resting hemodynamics revealed severe systemic systolic arterial hypertension (SBP 189 mm Hg) and moderately elevated LV filling pressure(LVEDP 19 mm Hg). 3. Left ventriculography was not performed. . FINAL DIAGNOSIS: 1. Two vessel coronary artery disease with diffuse atherosclerosis. 2. Patent prior mid-RCA [**Doctor First Name 10788**] bare metal stent. 3. Severe systemic systolic arterial hypertension. 4. Moderate LV diastolic heart failure. . . ECHO [**2175-8-7**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >65%) The estimated cardiac index is normal(>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2174-6-10**], biventricular systolic function remains preserved. Borderline pulmonary artery systolic hypertension is now identified. Brief Hospital Course: 65 yo Female with Type I DM who presented with hyperglycemic hyperosmolar state after her insulin pump malfunctioned. There did not appear to be an infectious cause that precipitated this. . # CAD: The patient had known CAD, with known PCI in [**2166**] to RCA. Since then no cardiac cath. Stress (P MIBI) in [**6-7**] and Echo in [**6-7**] were normal (with the exception of focal calcifications of the aortic arch). The patient has been chest pain free and on this admission but was found to have EKG changes in V5/V6 TWI / ST depressions and mildly elevated troponins. Given the patient's high risk (known CAD, multiple risk factors, age, + enzymes, EKG changes) and TIMI score of 5, it was felt she would benefit from early angiography for NSTEMI. She was started on aspirin 325 daily and heparin IV. Given the high risk and STE in aVR leading to ? LM disease, plavix was held in case CABG would be needed. Her lopressor was increased to 25mg po bid. Her lipid panel came back normal. She received a cardiac catheterization on [**2175-8-7**] which did show diffuse disease (see report) but nothing that was deemed intervenable. Her post-precedure course was unremarkable. Given her MS and difficulty ambulating (she currently uses a wheelchair), she requested transfer to rehab and was evaulated by PT/OT. She was discharged on [**2175-8-9**]. . #hyperglycemia: She has had DM typeI from age 18. The gap was closed, and the cause was felt to be due to a malfunctioning insulin pump. [**Last Name (un) **] was consulted and the patient was advised to restart her pump after the catheterization procedure. Until that time, she was covered with sliding scale insulin. Her pump was restarted on [**2175-8-8**] and [**First Name8 (NamePattern2) **] [**Last Name (un) **], her sensitivity for correction was switched from 1:45 to 1:30. She was discharged after monitoring her pump to ensure it was properly functioning. . #skin lesion - The patient was maintained on an antibiotic regimen (keflex) recommend by Dr. [**Last Name (STitle) 21210**] for possible cellulitis. . #burn - The patient had sustained superficial skin burns to her back in an accident about one week prior to admission. She was given routine wound care for this. . #Multiple sclerosis - The patient was maintained on outpatient meds including meds for neurogenic bladder. . #Depression - The patient was maintained on outpatient meds. Medications on Admission: Effexor 25mg PO BID Celexa 40 mg Qam and 20 mg QPM Desonide cream Dextroamphetamine 5 mg [**Hospital1 **] Neurontin 300 mg [**Hospital1 **] Novolog Lactulose PRN Ketoconazole cream-- ears, nose Metoprolol 12.5 mg [**Hospital1 **] Omeprazole 20 mg QD Trileptal 150 mg [**Hospital1 **] Oxybutynin 10 mg QHS Primidone 150 mg [**Hospital1 **] Simvastatin 40 mg QHS Tramadol 50 mg Q6-8 hours PRN MVI Folic acid Discharge Medications: 1. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 2. Lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO BID (2 times a day) as needed. 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for heartburn. 4. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Oxybutynin Chloride 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO at bedtime. 6. Primidone 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO qam. 12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO three times a day. 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO q6to8hr:PRN as needed for pain. 14. Desonide 0.05 % Cream Sig: - Topical -: Use on affected area up to twice a day. 15. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 16. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 17. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 18. Dextroamphetamine 5 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Non-ST elevation myocardial infarction. Hyperglycemic, hyperosmolar state. Discharge Condition: stable. afebrile. chest pain free. Discharge Instructions: You were admitted to [**Hospital1 69**] with hyperglycemic, hyperosmolar state. You were treated with insulin drip. Your were found to have a Non-ST elevation myocardial infarction. You had a procedure called cardiac catheterization to look at the arteries supplying your heart. There were no intervenable lesions found. . Your METOPROLOL was increased to 25 mg twice a day. Aspirin was also added to your medications (please take 81 mg daily). Please take the remaining medications as written. . Please adhere to your follow-up appointments. They are important for managing your long-term health. . Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: Primary care follow up: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2175-8-10**] 11:40 . Cardiology follow up: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2175-8-23**] 2:00 . Other previously scheduled appointments are: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2175-8-18**] 2:20 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22205**] Date/Time:[**2175-10-6**] 10:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**] Completed by:[**2175-8-14**]

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icd9cm

[ [ [] ] ]

[ "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

10818, 10888

6351, 8757

302, 329

11007, 11044

2873, 2878

11937, 11950

2308, 2375

9213, 10795

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8783, 9190

5273, 6328

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3823, 5256

227, 264

3534, 3806

357, 1468

2892, 3515

1490, 2089

2105, 2292

26,027

159,497

7491

Discharge summary

report

Admission Date: [**2206-2-6**] Discharge Date: [**2206-2-10**] Date of Birth: [**2166-7-13**] Sex: M Service: MEDICINE Allergies: Gabapentin / Trazodone / Codeine Attending:[**Attending Info 8238**] Chief Complaint: EtOH intoxication, gait instability Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 27389**] is a 39y/o gentleman who is well known to [**Hospital1 18**] for multiple alcohol-related admissions, who was BIBA for being intoxicated with unsteady gait. He reports a hx of seizure disorder, but also EtOH w/d seizures and DTs in the past. Last seizure was 2 weeks ago and he injured his right knee so he is using a cane these days. His last drink was at night on [**2-5**]. Recently, he has been drinking with his wife [**Name (NI) **] for the past week, ~[**1-16**] of vodka daily. Last drink was late at night on [**2206-2-5**]. Of note, he has had multiple recent ICU and ED Obs admissions for EtOH intoxication (see below for timeline). He has been fired from [**Hospital3 **] for threatening a resident, and has been banned from receiving outpatient meds from here as well given his history of abuse and self-destructive behavior. . In the ED, initial VS were T 97.1, HR 68, BP 136/80, RR 12, POx 96%RA. Labs were notable for AG 20 with lactate 3.4. No osmolar gap. He was agitated but exam was nonfocal and he was going to be observed overnight for sobriety. On routine vitals, he was found to have a HR of 144. BP at the time was stable and the patient was mentating fine, but his O2 sat dropped to 91%RA. CXR was unremarkable. He was given 2L IVF and due to CIWA up to 15 he was also treated for EtOH withdrawal with Diazepam 5mg PO, Lorazepam 2mg IV x3. On EKG he was noted to have new TWI in V2-V4 so he was given ASA 325 - denied any chest pain. The ED felt he was inappropriate for the floor and admitted him to the MICU given his high level of nursing need. VS prior to transfer were BP 140/74, HR 112, RR 19, POx 98%3L NC. On arrival to the MICU, and later in his hospital course as well, patient requested detox and indicated desire to achieve sobriety. Review of systems: (+) Per HPI. Also reports recent abdominal cramping and loose brown stools "because of what I was drinking." Had fevers/chills >3 weeks ago but not recently. No current chest pain, but admits to mild left-sided chest discomfort whenever he eats spicy food. He can climb 6 flights of stairs with no complaints. Says "I always feel a little short of breath because I am a smoker." (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies palpitations or weakness. Denies nausea, vomiting, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: * Alcohol and polysubstance abuse * Hepatitis C virus infection, untreated * Subdural hematoma ([**2204-4-12**]) from fall * Mood disorder with multiple suicide attempts * Migraines * Chronic lower back pain * MVA s/p chest tube placement in [**2200**] * Seizure disorder since [**08**] yo, alcohol withdrawal seizures (Please see note from [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] [**2205-12-7**] which calls into question the veracity of this history) * Aspiration pneumonia treated at [**Hospital1 2177**] from [**Date range (1) 27397**] Social History: Patient states he is homeless. For the last week has been staying with his aunt. Smokes 1/2ppd and drinks 1/5th daily of hard liquour. History of cocaine, heroin, opiates, benzodiazepines documented in [**Date range (1) **], but patient denies any use for the past few years. Patient is on Suboxone. Family History: Father was an alcoholic. Physical Exam: ADMISSION EXAM Vitals: T 99, HR 104, BP 145/71, RR 12, POx 99%RA General: Alert, oriented to person, day/date (but thinks it is [**2205**] and this is [**Hospital1 3278**]), no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI (3mm), PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmur Lungs: Clear to auscultation bilaterally, mild end-expiratory wheezes throughout Abdomen: soft, non-tender, (+)bowel sounds, no hepatomegaly and no RUQ tenderness GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE EXAM VS - 96.1 BP 128/82 HR 95 RR18 , O2-sat 93% RA GENERAL - comfortable, appropriate, eating breakfast HEENT -EOMI, sclerae anicteric, no tongue tremor LUNGS - CTA bilat, no r/rh/wh, resp unlabored HEART - RRR, no MRG ABDOMEN - soft/NT/ND EXTREMITIES - WWP, no c/c/e. no tremor. normal gait. Pertinent Results: ADMISSION LABS: ([**2206-2-6**] 11:02PM) WBC-4.5 RBC-4.29* Hgb-12.9* Hct-38.9* MCV-91 MCH-30.1 MCHC-33.2 RDW-16.4* Neuts-40* Bands-0 Lymphs-52* Monos-7 Eos-1 Baso-0 Atyps-0 Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Target-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 27402**]65* UreaN-9 Creat-0.5 Na-144 K-3.4 Cl-103 HCO3-21* AnGap-23* Osmolal-398* BLOOD ASA-NEG Ethanol-418* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2206-2-6**] 11:02PM BLOOD cTropnT-<0.01 [**2206-2-7**] 07:16AM BLOOD cTropnT-<0.01 [**2206-2-7**] 02:13AM BLOOD Lactate-3.4* [**2206-2-7**] 02:10PM BLOOD Lactate-1.4 . DISCHARGE LABS: ([**2206-2-10**]) WBC-4.9 RBC-3.85* Hgb-11.5* Hct-35.3* MCV-92 MCH-30.0 MCHC-32.7 RDW-16.3* Plt Ct-129* Glucose-82 UreaN-8 Creat-0.6 Na-141 K-4.3 Cl-104 HCO3-28 AnGap-13 ALT-38 AST-39 AlkPhos-85 TotBili-0.6 . CXR [**2206-2-7**] IMPRESSION: Elevation of the right lung base and hemidiaphragm has been pronounced since at least [**2205-7-12**], accounting for atelectasis at the lung base. The right upper lung and the entire left lung are clear and the left lung is hyperinflated suggesting airway obstruction or emphysema. Heart is normal size. There is no pneumonia or pulmonary edema. No pleural effusion or pneumothorax. Brief Hospital Course: BRIEF HOSPITAL COURSE: Mr. [**Known lastname 27389**] is a 39y/o gentleman with EtOH abuse and history of seizure disorder (possible EtOH w/d seizures) who presented with tachycardia, volume depletion, and symptoms of EtOH withdrawal after a week-long EtOH binge. He was stabilized in the MICU on CIWA scale benzodiazepines and he was transferred to the floor. The patient eloped on [**2-10**]. At that point, he had not received any benzodiazepines for 24 hours and was agitated at times but not showing signs of withdrawal. He was awaiting referral to outpatient substance abuse programs. He wasnot given any medications. His IV had been taken out previously. . ACTIVE ISSUES . #. EtOH abuse/withdrawal: Though he reported that his last drink was hours ago and his serum EtOH level was ~400, he appeared to be in clinical EtOH withdrawal. Tox also positive for [**Month/Year (2) **]/[**Month/Year (2) **] but he is prescribed these. He was started on Diazepam 10mg PO PRN CIWA >10. After transfer to the floor, he was requesting valium frequently for agitation. On evaluation, the clinical impresion was that he was not withdrawing. His valium was discontinued. He was not restarted on his clonazepam. . #. Acidosis/alkalosis: AG 20 and metabolic alkalosis. This resovled with IVF resusciation. . #. Tachycardia: sinus tach. First EKG was consistent with prior but a repeat from when he became tachycardic shows sinus tach with PACs, but possibly MAT. With IV fluids his HR went down to 90. . #. TWI on EKG: consistent with prior. His initial EKG showed some anterior TWI so he received ASA, but these are consistent with a prior EKG. He had no chest pain. He was ruled out for MI. . #. O2 sat 90%: baseline is 90-94%RA. Per old discharge summaries, his O2 sat has been in the low 90's. He is on Albuterol - has a long cigarette history so may have component of COPD. He also appeared to be sedated on medications at times which may have caused hypoventilation. . #. ?Seizure disorder: stable. He was continued on Divalproex (was recently filled at his pharmacy). . #. Psych issues: currently stable. He was continued on Amitroptyline, Olanzepine, Mirtazepine, Risperdal. He was not continued on clonazepam. . #. h/o opiate dependence: on Suboxone. Continued Suboxone this admission. He was not given a prescription and we were in the process of referring to oupatient substance abuse when he eloped. . TRANSITIONAL ISSUES . # Note that per recent discharge summary, upon d/c he is not to be given any Rx's for medications . Medications on Admission: Confirmed with CVS at [**Location (un) 5492**]. Prescribed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27403**] & [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 27404**] ([**Telephone/Fax (1) 27405**]) Divalproex DR 1000mg [**Hospital1 **] Clonazepam 0.5mg TID Olanzepine 10mg every morning, 15mg at bedtime Mirtazepine 30mg at bedtime Chlorylhydrate 500mg/5mL 2tsp bedtime Phenobarbital 5mg every day PRN Amitriptylline 100mg QHS Risperidone 4mg daily PRN Lisinopril 10mg daily Ventolin HFA 90: 2 puffs Q4H PRN Prilosec 20mg daily Ibuprofen PRN Fioricet 1 tab every 4 hours PRN Suboxone [**8-14**]: 1 tab every morning Thiamine 100mg daily Vitamin D3 1000IU daily Folate 1mg daily MTV daily Discharge Medications: MEDICATION LIST BELOW IS THE INPATIENT LIST ON DAY OF DISCHARGE. HE WAS NOT GIVEN ANY PRESCRIPTIONS WHEN HE ELOPED. . 1. olanzapine 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 2. olanzapine 5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 3. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 6. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 8. buprenorphine-naloxone 8-2 mg Tablet, Sublingual Sig: One (1) Tablet Sublingual DAILY (Daily). 9. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as needed for headache for 1 doses. Tablet(s) 12. phenobarbital 15 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication Alcohol abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Patient eloped. Followup Instructions: Patient was scheduled a primary care appointment with Health Care for the Homeless on Friday, [**2206-3-14**]. located at [**Location (un) 27406**] (across from [**Hospital1 2177**]) [**Telephone/Fax (1) 27407**] However, patient eloped.

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2162-7-12**] Discharge Date: [**2162-7-25**] Date of Birth: [**2092-6-23**] Sex: M Service: MEDICINE Allergies: Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 134**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Cardiac catheterization, no intervention performed Esophagogastroduodenography (EGD) Foley cath placement History of Present Illness: This is a 70 y/o male from [**Location (un) 4708**], h/o HTN, HL, DM, s/p recent ACA infarct, on the neuro service at [**Hospital1 18**] from [**Date range (1) 72843**], who now presents from [**Hospital1 **] with coffee-ground emesis + some blood x 1 this AM. Patient not able to provide history. Per patient's son and [**Name (NI) **] records, patient was having intermittent nausea/vomiting since his discharge from [**Hospital1 18**] in [**Month (only) 116**]. He has not been doing well from a rehab perspective and has been very weak with decreased po intake. Today, he had sudden onset of n/v with abdominal pain and a low-grade fever. Abdominal u/s done at [**Hospital1 **] without any pathology preliminary. U/A + with large amount of WBC's. He was noted to then have emesis with coffee-ground material around 6pm and was transferred to [**Hospital1 18**] ED for further evaluation. . Per patient's son, the patient is not coversant and it is not clear whether this is [**3-12**] to his recent CVA (which left residual right hemiparesis and a non-fluent aphasia) or depression. . In the ED, VS were Tm 103.4, BP 120/71, HR 115, RR 20, SaO2 97%/2L NC. Exam significant for grossly positive NGL, no clearance after 1 L of fluid. Also guiac positive. He was given PPI 40 mg IV, Levofloxacin 500 mg IV, Flagyl 500 mg IV, and Tylenol 650 mg. Also received 2 L NS for transient hypotension to SBP's 80, with improvement to low 100's. GI made aware of patient, plan for EGD in AM. Incidentally noted to have new ST depressions inferiorly on telemetry, cards consulted and per ED, no intervention possible. Patient admitted to MICU for further management. Past Medical History: 1. HTN 2. DM2 3. Hyperlipidemia 4. s/p cholecystectomy 5. s/p recent left ACA infarct with residual right hemi-paresis and nonfluent aphasia Social History: SH: quit smoking 3yrs ago. No etoh/drugs Family History: FH: brother with cardiac disease Physical Exam: VS: Tc 101.8, Tm 103, BP 143/72, HR 120, RR 22, SaO2 96%/40% FiO2 General: Elderly male, non-conversant, appears ill. HEENT: NC/AT, PERRL, EOMI. MM dry. Neck: supple, no LAD Chest: few bibasilar crackles CV: RR tachy s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS, no HSM Ext: no c/c/e, wwp Neuro: Non-conversant. Patient not cooperative with rest of the exam. Pertinent Results: [**2162-7-12**] 06:55PM BLOOD WBC-16.9*# RBC-4.19* Hgb-11.9* Hct-34.3* MCV-82 MCH-28.4 MCHC-34.7 RDW-14.1 Plt Ct-180 [**2162-7-16**] 05:30AM BLOOD WBC-8.9 RBC-4.08* Hgb-11.7* Hct-33.1* MCV-81* MCH-28.6 MCHC-35.2* RDW-14.3 Plt Ct-164 [**2162-7-12**] 06:55PM BLOOD Neuts-91.7* Bands-0 Lymphs-4.4* Monos-3.4 Eos-0.4 Baso-0.1 [**2162-7-16**] 05:30AM BLOOD PT-14.6* PTT-31.8 INR(PT)-1.3* [**2162-7-12**] 06:55PM BLOOD Glucose-191* UreaN-24* Creat-1.7* Na-135 K-4.7 Cl-101 HCO3-23 AnGap-16 [**2162-7-16**] 05:30AM BLOOD Glucose-94 UreaN-18 Creat-1.3* Na-140 K-3.9 Cl-107 HCO3-22 AnGap-15 [**2162-7-12**] 06:55PM BLOOD ALT-41* AST-27 CK(CPK)-21* AlkPhos-36* Amylase-109* TotBili-0.5 [**2162-7-13**] 03:43AM BLOOD CK(CPK)-293* [**2162-7-13**] 09:09AM BLOOD CK(CPK)-377* [**2162-7-14**] 03:42AM BLOOD CK(CPK)-376* [**2162-7-14**] 04:57PM BLOOD CK(CPK)-164 [**2162-7-12**] 06:55PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2162-7-13**] 09:09AM BLOOD CK-MB-34* MB Indx-9.0* cTropnT-1.26* [**2162-7-14**] 03:42AM BLOOD CK-MB-46* MB Indx-12.2* cTropnT-1.90* [**2162-7-14**] 04:57PM BLOOD CK-MB-26* MB Indx-15.9* cTropnT-1.68* [**2162-7-15**] 05:30AM BLOOD cTropnT-1.96* [**2162-7-13**] 05:04AM BLOOD Type-ART Temp-39.3 pO2-95 pCO2-37 pH-7.41 calTCO2-24 Base XS-0 [**2162-7-13**] 05:04AM BLOOD Lactate-0.9 . [**2162-7-12**] CXR: IMPRESSION: No definite consolidation or CHF. NG tube coiled in the gastric body; its tip is out of the field of view. . [**2162-7-12**] EKG: Sinus tachycardia. Non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2162-6-17**] heart rate is now faster. . [**2162-7-12**] EKG: Sinus tachycardia. Marked inferolateral ST segment depression with T wave inversions, consider an acute ischemic process. Compared to the previous tracing of [**2162-7-12**] heart rate is now faster with marked ischemic type repolarization abnormalities. . [**2162-7-13**] LE U/S: IMPRESSION: No DVT. . [**2162-7-14**] ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%).There may be mild focal basal inferolateral hypokinesis (views suboptimal). Right ventricular chamber size and free wall motion are normal. 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. Compared with the prior study (images reviewed) of [**2162-6-17**], views are technically suboptimal for comparison of regional wall motion. . [**2162-7-16**]: Cardiac cath: - LMCA short but patent - LAD origin 40-50% stenosis with mild diffuse dz - LCX origin 70-80% followed by diffuse dz up to 80% involving origins of both mod large OMs - RCA mid 60% - No intervention performed to LCX due to risk of jailing LAD because part of stent would need to be in left main Brief Hospital Course: This is a 70 y/o male with HTN, HL, DM, s/p recent CVA, now p/w hematemesis, tachycardia, fever, and leukocytosis. . # Sepsis - patient fit sepsis criteria on admission, with fever, leukocytosis, tachycardia and positive u/a and urine culture. He was initially hypotensive in the ED with response to 2 L NS and upon arrival to the MICU, had no further hypotensive episodes. He was bolused with IVF for his tachycardia, which improved and resolved within 12 hours. He was started broadly on ciprofloxacin, flagyl, zosyn, and vancomycin initially, which was tapered to zosyn, ciprofloxacin, and vancomycin as urine cx returned as >100,000 GNR, and then to just cipro after his UCx came back as E coli sensative to all but ampicillin. CXR was without infiltrates and blood cx x 2 have been NGTD. He has been hemodynamically stable x 24+ hours and has never required pressors or further fluid boluses since initial admission. . # Urinary retention - since his CVA, the patient has suffered from bladder distention which was not a problem for him beforehand, suggesting a neurogenic bladder. Urology evaluated the patient in house, and felt that this was the most likely cause of his distention, not his BPH. They recommend that he keep his Foley in place indefinitely, and that he follow up with them in resident clinic on a Wednesday AM sometime in 6 weeks from his discharge. He will likely require the Foley on a continuing basis, but they can re-evaluate him at that time in clinic. . # Renal insufficiency - Baseline Cr 1.3-1.6, within baseline; possible contribution from retention as above. . # Elevated biomarkers - patient had concerning EKG changes on admission, notably deep ST depressions in the inferior and lateral leads. He also had a positive troponin and CK, which has since trended upwards. This was initially thought to be secondary to demand ischemia as the EKG changes occured while he was tachycardic to the 120's; however, given the continued rise of the biomarkers, there was concern for an NSTEMI. Management was limited given the GI bleed. He was started on BB and underwent EGD for evaluation of bleed. He was found to have Barretts esophagus and erosions from NGT trauma. He underwent cardiac cath the following day that showed: -- LMCA short but patent - LAD origin 40-50% stenosis with mild diffuse dz - LCX origin 70-80% followed by diffuse dz up to 80% involving origins of both mod large OMs - RCA mid 60% - No intervention performed to LCX due to risk of jailing LAD because part of stent would need to be in left main Medical management was optimized with increase of BB and he was continued on aspirin, statin. . # Hematemesis - concerning for UGIB source, such as PUD vs gastritis vs AVM's. LGIB also possible, but less likely. He received only 1 U PRBCs on admission and since then his Hct have remained stable and there has not been anymore active bleeding. He was continued on IV PPI [**Hospital1 **] and had a NGT to suction, which was d/c'd today. GI performed EGD which showed Barrett's and erosions from NGT, and he was cleared for catheterization. He will be dischaged on PPI [**Hospital1 **]. . # Diarrhea - patient had diarrhea intermittently during his hospitalization, and he has a C diff toxin pending at the time of his discharge. He has not had any abd discomfort, and his WBC has come down since admission though is still elevated. Pt will need to have his C diff toxin result followed up on [**2162-7-18**] at the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **], [**Telephone/Fax (1) 4645**], and if positive will need to start a course of metronidazole. . # s/p recent CVA - ASA initially held, but restarted after EGD. Continued on beta blocker, diabetes control, lipid control. . # HTN - Beta blocker, uptitrate as needed. . # Hyperlipidemia - continued lipitor . Medications on Admission: 1. Heparin SC tid 2. Atorvastatin 10 mg qd 3. Protonix 40 mg qd 4. Lisinopril 10 mg qd 5. Aspirin 325 mg qd 6. Bisacodyl 10 mg qd prn 7. Senna 8.6 mg [**Hospital1 **] prn 8. Tamsulosin 0.4 mg qd 9. Zofran prn 10. Vitamin D 400 mg qd 11. Lactulose 20 gm qd 12. Reglan 10 mg tid 13. Remeron 7.5 mg qhs . Discharge Medications: 1. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg IV Q12H 3. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 4. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once a day. 6. Senna 8.6 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day as needed. 7. Vitamin D 400 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 8. Lactulose 20 g Packet [**Hospital1 **]: One (1) PO once a day. 9. Reglan 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day. 10. Remeron 15 mg Tablet [**Hospital1 **]: 0.5 Tablet PO at bedtime. 11. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 12. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 13. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: per sliding scale Injection three times a day. Discharge Disposition: Extended Care Discharge Diagnosis: Sepsis from urinary source Chronic urinary retention, likely neurogenic bladder Myocardial infarction S/P Stroke with residual hemiparesis Hematemesis Renal insufficiency Discharge Condition: Stable. Patient at baseline function with right sided hemiparesis. Discharge Instructions: Please take all of your medications as prescribed. Please call your PCP or return to the ED if you have chest pain, shortness of breath, nausea, bloody emesis, or other symptoms that are of concern to you. Followup Instructions: You have the following Cardiology appt set up: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2162-7-30**] 10:30 Please call to arrange follow up in the Wednesday AM [**Hospital 72844**] [**Hospital 159**] clinic in 6 weeks ([**Telephone/Fax (1) 772**]. Keep your Foley in place until that appointment, otherwise you will continue to retain urine. You have had diarrhea recently, and given your recent antibiotic use, this is concerning for C difficile infection. A test for C diff toxin was sent and is pending at the time of your discharge. Please have your healthcare provider at [**Name9 (PRE) **] call the [**Hospital1 18**] [**Hospital1 **] [**Hospital1 **] [**Telephone/Fax (1) 4645**] on Sunday [**2162-7-18**] to find out the results of your C diff test. Name: [**Known lastname 12123**],[**Known firstname 12124**] Unit No: [**Numeric Identifier 12125**] Admission Date: [**2162-7-12**] Discharge Date: [**2162-7-25**] Date of Birth: [**2092-6-23**] Sex: M Service: MEDICINE Allergies: Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 296**] Addendum: Mr. [**Known lastname **] remained in the hospital for several more days for disposition planning. It was decided that he would return home with his family, with the plan to return to [**Location (un) 804**] the following week. He was told to continue his medications as per the discharge planning. He will continue to have a Foley catheter in place until he can follow up with a doctor [**First Name8 (NamePattern2) **] [**Location (un) 12126**] within the next 4 weeks. He completed treatment of his UTI. His C. diff stool test returned negative. He had no recurrence of GI bleeding. He and his family had intensive training with Physical Therapy to facilitate his care at home. He remained medically stable throughout this time. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale units Injection three times a day: Please see sliding scale. Disp:*200 units* Refills:*2* 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Insulin Syringe 0.3 mL 28 x 1 Syringe Sig: One (1) syringe Miscellaneous four times a day as needed for insulin administration. Disp:*100 syringes* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Sepsis from urinary source Chronic urinary retention, likely neurogenic bladder Myocardial infarction S/P Stroke with residual hemiparesis Hematemesis Discharge Condition: Stable. Patient at baseline function with right sided hemiparesis and expressive aphasia. Discharge Instructions: You were hospitalized with an upper GI bleed. The cause of this bleed is unknown, possibly inflammation of the stomach lining. You were started on Protonix which should minimize the inflammation. You also had a heart attack. You underwent cardiac catheterization which showed diffuse blockages in your coronary arteries. You were started on several medications for your heart. You were diagnosed with a urinary tract infection and were treated with antibiotics. Finally, you had urinary retention while in the hospital. You had a Foley catheter placed which should remain in place until you follow up with Urology. Please continue Foley care as instructed. Please continue Physical Therapy and Speech Therapy. . Please take all of your medications as prescribed. If you experience chest pain, shortness of breath, bloody emesis, or other concerning symptoms, please go to the ER. . Please keep your Foley catheter in until you follow up with Urology. Followup Instructions: You have the following Neurology appt scheduled: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 190**] Date/Time:[**2162-7-30**] 10:30 . When you return to [**Location (un) 804**], please establish care with a primary doctor as soon as possible. We will be faxing your discharge summary to the 2 doctors [**Name5 (PTitle) **] have listed. Please discuss follow up care with Urology in approximately 4 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**] MD [**MD Number(1) 298**] Completed by:[**2162-7-26**]

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icd9cm

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Discharge summary

report

Admission Date: [**2203-9-6**] Discharge Date: [**2203-10-4**] Date of Birth: [**2122-4-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: CHF and NSTEMI Major Surgical or Invasive Procedure: Intubation x2 Hemodialysis Esophagogastroduodenoscopy History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: Mr [**Known lastname **] is a 81 yo man with h/o transitional cell CA of the bladder s/p nephrectomy in [**2198**], type I diabetes, hypertension, CRI (baseline Cr 3.5), hypertension, hyperlipidemia who began having URI symptoms with cough productive of thick sputum last friday. He underwent radiation to a skin cancer on his cheek and has thereafter had very dry mouth and thick sputum he has been unable to cough up. He denies any fevers, chills, night sweats, weight-loss, or sick contacts but does report paroxysms of shortness of breath and one episode of dark red hemoptysis this morning. Sunday evening he found himself breathing very uncomfortably with significant orthopnea. He denies nausea, diaphoresis, or chest pain. He presented to [**Hospital **] hospital at 3am on Monday where his initial vitals were T 98.7, HR 88, RR 18, SaO2 85% RA and 95% on 2L N/C, BP 151/72 with HR 85. CXR showed Rt-sided infiltrate so he was started on CTX and azithromycin to treat community-acquired pneumonia. EKG initially showed NSR with rate 85 and no ischaemic changes. His hypoxia quickly worsened to requiring 100% NRB and was noted on CXR to possible pulmonary edema with BNP of 1259. He was treated with lasix without good result. He subsuquently ruled in for MI with CK peak of 211 and CK-MB of 8.5. He later went into rapid atrial fibrillation with heart rates in the 130's-140's and was subsequently placed on a diltialzem and heparin drip. He was also noted to have acute renal failure with Cr of 3.5 up from his baseline of 2.8. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . *** Cardiac review of systems is notable for mild chest pressure earlier this morning chest pain. At baseline he has no dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: PAST MEDICAL HISTORY: type I diabetes Transitional cell carcinoma s/p right nephroureterectomy and BCG therapy CRI, baseline Cr 2.8 (Dr. [**First Name (STitle) 10083**] primary nephrologist) HTN Hypercholesterolemia h/o A.Fib/flutter s/p Cholecystecomy s/p Achilles tendon rupture . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension. No history of cardiac catheterization Social History: SOCIAL and FAMILY HISTORY: Former smoker, quit 35 years ago. Owns his own company that makes teflon that coats coronary stents. Family History: Has no FH early coronary disease. Physical Exam: PHYSICAL EXAMINATION: VS: T 98.6, BP 140/83, HR 95, RR 22, 93 O2 % on 100% NRB Gen: WDWN elderly male in moderate respiratory distress. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, JVP difficult to assess due to habitus. CV: PMI located in 5th intercostal space, midclavicular line. irregular rhythm, tachycardic, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. moderate respiratory distress, coughing. loud ronchi heard throughout with [**Hospital1 **]-basilar crackles and scattered crackles throughout rt lung. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; DP pulses not palpable but feet warm Left: Carotid 2+ without bruit; Femoral 2+ without bruit; DP pulses non-palpable, but feet warm Pertinent Results: OSH admission EKG: NSR with rate 86, normal axis, borderline LAE, possible Q in V1-2. No ST of T wave changes. . EKG on transfer demonstrated coarse atrial fibrillation with ventricular rate of 120, normal axis, no hypertrophy, normal intervals. Non-spesific diffuse ST depression and TWI. possible q wave in V1 and aVR. . . [**2203-9-6**]. Echo. The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2198-10-1**], there has been interval development of mild aortic stenosis and left ventricular hypertrophy (aortic valve velocity not evaluated on prior study). Elevated left ventricular filling pressures are now present. Estimated pulmonary artery pressures could not be assessed on the current study. The rhythm is now atrial fibrillation with a rapid ventricular response. . ETT performed at [**Hospital **] hospital (records not available) on [**2-/2199**] demonstrated: He exercised for 3 min and 39 sec on a [**Doctor First Name **] protocol achieved a maximal heart rate of 94% with no angina or ischemic EKG changes there may have been a subtle inferior wall defect thought to be artifact. EF 65%. . CXR. [**2203-9-6**]. IMPRESSION: New right upper lobe and right lower lung pneumonia possibly aspiration pneumonia with likely involvement of the left lower lung also. . EGD [**2203-9-23**].IMPRESION:The previously noted mucosal abnormality on the incisura was not noted on this exam. Otherwise normal EGD to duodenal bulb . CXR [**2203-10-3**] Comparison is made to the prior examinations dated [**2203-9-26**] and [**2203-9-27**]. The right-sided double lumen central venous catheter is stable in position. The cardiac silhouette is within normal limits. There is improvement of the vascular engorgement and asymmetric pulmonary edema noted on the prior examinations. The left retrocardiac opacity persists, likely reflects a small-to-moderate effusion and atelectasis, difficult to exclude pneumonia . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2203-10-4**] 06:38AM 12.4* 2.86* 9.2* 26.8* 94 32.0 34.1 15.9* 389 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2203-10-2**] 06:30AM 61.8 29.6 7.5 0.8 0.3 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2203-10-4**] 06:38AM 389 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2203-10-4**] 06:38AM 127* 32* 3.0* 138 4.1 100 30 12 Brief Hospital Course: Briefly, this is a 81yM with medical history including transitional cell CA s/p nephrectomy, HTN, Type I Diabetes Mellitus, CRI (baseline Cr approximately 2.8), who was initially admitted to [**Hospital1 18**] for NSTEMI in the setting of afib with RVR. He had presented to an OSH with URI-like symptoms one month ago and been treated for CAP with a course of Azithromycin. He subsequently decompensated into afib with RVR and when he presented to the [**Hospital1 18**] Tn was elevated over 2 and he had prominent airspace opacities on CXR. The patient was admitted to the CCU for hypoxia assumed to be secondary to pulmonary edema and MRSA pneumonia requiring intubation. The patient was transferred to MICU care given hemodynamics consistent with sepsis, and eventually initiated on HD for worsening volume status and renal function. The patient was eventually successfully extubated although noted to develop hypoxia previously while awaiting HD over the weekend, and has now completed 14 day course of Vanc for MRSA PNA. His course has been further complicated by GIB of an uncertain source while on ASA, with EGD showing abnormal gastric mucosa and esophagogastric erosions. ASA was initially d/c'd. Additionally, he also had very labile and poorly controlled blood glucose. . On [**2203-9-26**], while on medical floor, the patient developed hyperglycemia into the 600s, uncontrolled with NPH, and SOB for 2-3 hours, with oxygen sats dropping to 88% even on supplemental oxygen. Due to this hypoxia and hyperglycemia he was transferred to the MICU for insulin gtt, HD, and closer monitoring. Hypoxemia has responded to one session of HD [**9-28**] with 2kg of ultrafiltration. He was taken off insulin gtt on [**2203-9-28**] and placed on Lantus 40 and RISS. At this Lantus dose his BS dropped to 61 and 1 amp glucose was given; that evening Lantus was lowered to 35U [**First Name8 (NamePattern2) **] [**Last Name (un) 9718**] recs and morning labs showed BS = 41. The Insulin was then sequentially lowered to 30, then 24, the following nights [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs. . . . Cardiac-- # Rhythm. Patient was initially admitted for atrial fibrillation with RVR to 140s, which required esmolol gtt and diltiazem gtt. He converted back to NSR with few recurrent episodes of afib, and is now back in afib. He has not reached target HR but well tolerates high HRs (90-110) and drops SBP when rate control is very aggressive. Although he was initially anticoagulated with Heparin gtt this was discontinued for GI bleed on [**2203-9-6**]. - We held ASA for risk of bleed, and started ASA after his repeat EGD which showed normal gastric mucosa. - Current rhythm afib on high-dose Metoprolol and verapamil, with SBP maintained in the 110s-130s and HR ranges from 80s-90s. We changed his metoprol and verapamil to long-acting forumulations the morning of discharge. He is currently Toprol XL 200 mg po and Verapamil long acting 120 mg po. Metoprolol can be titrated up as he was previously on metoprolol 100 mg tid. -He did not come into the hospital on coumadin, but recommended that he follow up with his PCP regarding initiation of anticoagulation. He had a regular rate and rhythm on morning of discharge. . # Pump. Recent Echo with preserved EF. Volume overload was present in setting of ARF, he has had 12# taken off during the course of hospitalization. - HD on Mon/Wed/Fri schedule . # Hypoxia. Hypoxia during hospitalization was secondary to volume overload and later MRSA PNA (see below). Volume has responded well to HD. Currently not hypoxic and off of O2. Required intubation during first CCU stay and was extubated, then reintubated during following MICU stay, stabalized, and sent to the floor, extubated. - Continued HD on Mon/Wed/Fri schedule per above . # Hyperglycemia. Labile and high blood sugars required insulin gtt and MICU transfer. The [**Last Name (un) **] team was following. At discharge on Lantus 18 U with sliding scale. His blood sugars ranged 142-291 on day of discharge. . . # Pneumonia. Resolved. Patient had MRSA Pneumonia, initially treated with Levo/Flagyl, now s/p 14 days Vancomycin/Zosyn without evidence of infection. - We continued chest PT, incentive Spirometry -He had a low grade temp and a slightly elevated WBC, a repeat CXR showed showed a L retrocardiac opacity that most likely was a small effusion with atelectasis, but could not exclude pneumonia. It was unchanged from pervious week's CXR. Blood cultures are pending. . # Recent GI Bleed. Hct stable at last check. Endoscopy (EGD) during admission to CCU revealed no active bleeding, but the presence of abnormal mucosa, possible hematoma. repeat EGD showed normal esophagus to duodenum. Previously noted mucosal abnormality was not there. We stopped ASA initially but restarted after the repeat EGD. We continued his PPI. . # ARF. Patient with chronic renal failure secondary to hypertensive and diabetic nephropathy as well as s/p nephrectomy for TCC. On admission, patient was in acute on chronic renal failure and was oliguric. Impression was patient had pre-renal ARF from poor forward flow in setting of Afib - HD was inititated on Mon/Wed/Fri . # Low grade temperature [**10-3**]--?Aspitation pneumonia/pneumonitis. Increase in WBCs. He denied fever, cough, SOB, diarrhea, dysuria. Repeat CXR showed no change from previous weeks study. Slight retrocardiac opacity that could not exclude pneumonia. Urinalysis negative. Urine cultures and blood culture pending. Recommend follow up speech and swallow assessment. Medications on Admission: HOME MEDICATIONS: *** Humalog 4 Units q AM, 6 Units q PM Humalin N 26 Units q am Lopressor 100 mg [**Hospital1 **] Norvasc 5 mg [**Hospital1 **] Lasix 40 mg qAM, 20 mg qPM Allopurinol 100 mg [**Hospital1 **] Colchicine 0.6 mg q day Aspirin 81 mg q day Colace 100 mg q day Catapress 11 patch q week Primrose Oil 1000 mg [**Hospital1 **] 1 Preservision [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 2. Allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Artificial Saliva 0.15-0.15 % Solution [**Hospital1 **]: 1-2 MLs Mucous membrane Q4-6H (every 4 to 6 hours) as needed. Disp:*50 ML(s)* Refills:*0* 6. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Hospital1 **]: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*30 ML(s)* Refills:*0* 7. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:*120 ML(s)* Refills:*0* 8. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed. Disp:*1 * Refills:*0* 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 11. Insulin Glargine Subcutaneous 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 13. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 14. Epoetin Alfa 4,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection MWF (Monday-Wednesday-Friday). 15. Verapamil 120 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 16. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Atrial fibrillation Hypertension Diabetes Mellitus Type I Upper gastrointestinal bleed Acute Renal Failure - initiation of hemodialysis. Secondary: Chronic renal insufficiency History of Methicillin Resistant Staph Aureus pneumonia History of transitional cell carcinoma status post nephrectomy peripheral arterial disease of rt leg, B carotids Hypercholesterolemia status post Cholecystecomy status post Achilles tendon rupture paget's disease of the bone s/p rt hip surgery Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with difficulty breathing. You have had an extended hospital stay with multiple problems including a high heart rate, an upper gastrointestinal bleed, pneumonia, and high blood sugars. . We have made many changes to your medications, so it is important that you dispose the old medications and continue current meds as prescribe done on discharge. . If you have shortness of breath, chest pain, fevers, nausea, vomiting, fluctuations in your blood sugars please contact your PCP or return to the emergency room. Followup Instructions: You should also have a follow-up appointment with your PCP [**2-15**] weeks after discharge. Please call Dr. [**Last Name (STitle) 1438**] at [**Telephone/Fax (1) 39397**]. Completed by:[**2203-10-6**]

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Discharge summary

report

Admission Date: [**2183-3-11**] Discharge Date: [**2183-3-19**] Date of Birth: [**2131-7-19**] Sex: M Service: MEDICINE Allergies: Bactrim / Percocet / Morphine / Lipitor / Fioricet Attending:[**First Name3 (LF) 562**] Chief Complaint: Rigors and difficulty breathing Major Surgical or Invasive Procedure: Placement of Right Internal Jugular Vein line Removal of Right Internal Jugular Vein line Transesophageal echocardiogram (TEE) Placement of Left PICC line History of Present Illness: Mr. [**Known lastname 9700**] reports that 1 day prior to admission, he was feeling well and at baseline. He went to bed on Monday evening, slept well, was woken up by his dogs at 1:15 am and took them out for a walk without any problems. However, at 4:45am his alarm went off for work and he noted he had rigors and difficulty breathing. He states that he felt he couldnt get a full breath in and began to have anxiety and feel panicked as well. He took his temperature and was 101.9. At that point in time he decided to call the ambulance. . In ED, he had a temp of 105.7 and his blood pressure began to fall. Cultures were sent and he was resuscitated with 7L and transferred to the MICU. He was started on pressors and given Vanc/Cefepime/Azithro and Tamiflu empirically. He was given more fluids and became volume overloaded, developing SOB and an oxygen requirement. After decreasing fluid rate and giving supplemental oxygen, he stabilized. He was never intubated. His blood culture was found to have strep pneumococcal and his antibiotics were tailored to ceftriaxone. . ROS: He reports having some mild R flank pain similar to past kidney stone pain on Monday night that is now resolved. He reports that he has had ezcematous rashes for months [**3-3**] allergic reaction from his Anti-Retroviral therapy. He states he had been scratching the skin and had mild bleeding from his R arm. He denied any chest pain, urinary symptoms, change in bowel movements, recent dental procedures, instrumentation, sick contacts, or dog bites. . Past Medical History: -HIV (last CD4 on [**3-10**] 500, last viral load on [**10-6**] 305 copies/ml, currently off HAART) -Emergency splenectomy after assault in [**2168**] (has been vaccinated with Pneumovax) -Migraines -Nephrolithiasis -Shingles -Left ankle arthroscopy in [**2182**] -Arthroscopic ACL repair -Tonsillectomy -Vasovagal syncope -Right inguinal hernia repair in [**2173**] -Obstructive sleep apnea (uses CPAP) -Hyperlipidemia -BPH Social History: He has two daughters and 4 grandchildren. He is divorced. He works in nuclear cardiology at [**Hospital1 2025**]. He lives alone with his dogs and performs all of his ADLs. He has never smoked, he drinks rarely, no IVDU, only smoked marijuana three times. Not currently sexually active but is bisexual. He had multiple male sexual partners in the past and had unprotected intercourse. He believes he contracted HIV from having unprotected sex with a partner who has since passed away of AIDS. Family History: Paternal grandfather and maternal grandmother - DM2 Maternal grandfather died from MI at age 58 Sister died from ovarian cancer at age 50 Physical Exam: PHYSICAL EXAM: Vitals - T: 98 BP: 106/50 HR: 68 RR: 18 02 sat: 95% on RA GENERAL: in NAD, comfortable, lying in bed, appears stated age, occasional nonproductive cough HEENT: normocephalic, atraumatic, shotty cervical lymphadenopathy CARDIAC: RRR, nl S1/S2, no murmurs, rubs or gallops appreciated, no carotid bruits LUNG: CTAB, no crackles or wheezing ABDOMEN: +BS, nontender to palpation, nondistended EXT: warm to palpation, pedal pulses palpable bilaterally, mild ankle edema BACK: No CVA tenderness NEURO: alert and oriented x 3; good fund of knowledge DERM: Scaly eczematous rash on right calf and left forearm Pertinent Results: MICRO: -[**3-11**] blood Cx x 2: Strep pneumo, sensitive to ceftriaxone -[**3-11**] Urine Cx: no growth -[**3-11**] viral antigen test for Adenovirus, Influenza A & B, Parainfluenza 1/2/3 and Respiratory Syncytial Virus: negative -[**3-12**] blood Cx: no growth -[**3-13**] blood cx: no growth -[**3-13**] sputum: oral flora, no legionella, acid fast negative, no fungus . STUDIES: -[**3-11**] CXR: No evidence of acute intrathoracic process. -[**3-11**] CT Abdomen/pelvis: No acute intra-abdominal or pelvic process identified. Multiple retroperitoneal, periportal, and bilateral external iliac lymph nodes either reactive in nature and/or attributed to HIV. -[**3-11**] repeat CXR: Mild prominence of the central pulmonary vasculature without overt CHF. Bibasilar atelectasis. L lower lobe retrocardiac opacity atelectasis vs pneumonia. -[**3-12**] TTE: LVEF >55%, no vegetations seen on aortic valve or mitral valve. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. No endocarditis or abscess seen. -[**3-15**] CXR: low lung volumes, bilateral pleural effusions, bibasilar atelectasis, no focal consolidation is seen. -[**3-16**] CXR: L PICC in place -[**3-19**] TEE: no vegetations . [**2183-3-11**] 11:00PM LACTATE-2.5* [**2183-3-11**] 10:47PM GLUCOSE-128* UREA N-20 CREAT-1.3* SODIUM-142 POTASSIUM-3.6 CHLORIDE-112* TOTAL CO2-21* ANION GAP-13 [**2183-3-11**] 10:47PM CALCIUM-7.5* PHOSPHATE-1.4* MAGNESIUM-1.2* [**2183-3-11**] 09:45PM LACTATE-2.5* [**2183-3-11**] 01:15PM LACTATE-2.1* [**2183-3-11**] 12:06PM LACTATE-2.0 [**2183-3-11**] 11:09AM LACTATE-2.3* [**2183-3-11**] 10:14AM LACTATE-2.0 [**2183-3-11**] 08:56AM LACTATE-1.7 [**2183-3-11**] 08:56AM PT-14.3* PTT-27.7 INR(PT)-1.2* [**2183-3-11**] 07:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2183-3-11**] 07:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2183-3-11**] 07:50AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2183-3-11**] 06:06AM LACTATE-2.8* [**2183-3-11**] 06:05AM GLUCOSE-81 UREA N-20 CREAT-1.2 SODIUM-139 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14 [**2183-3-11**] 06:05AM estGFR-Using this [**2183-3-11**] 06:05AM ALT(SGPT)-30 AST(SGOT)-40 LD(LDH)-234 CK(CPK)-440* ALK PHOS-62 AMYLASE-184* TOT BILI-0.7 [**2183-3-11**] 06:05AM LIPASE-48 [**2183-3-11**] 06:05AM CK-MB-4 cTropnT-<0.01 [**2183-3-11**] 06:05AM ALBUMIN-4.3 CALCIUM-9.5 PHOSPHATE-2.2*# MAGNESIUM-1.7 [**2183-3-11**] 06:05AM CORTISOL-38.3* [**2183-3-11**] 06:05AM CRP-2.6 [**2183-3-11**] 06:05AM WBC-9.1 RBC-4.82 HGB-14.6 HCT-41.1 MCV-85 MCH-30.3 MCHC-35.4* RDW-14.2 [**2183-3-11**] 06:05AM NEUTS-70.6* LYMPHS-24.9 MONOS-0.5* EOS-3.6 BASOS-0.3 [**2183-3-11**] 06:05AM PLT COUNT-274 [**2183-3-11**] 06:05AM WBC-9.1 LYMPH-25 ABS LYMPH-2275 CD3-61 ABS CD3-1382 CD4-22 ABS CD4-500 CD8-39 ABS CD8-881* CD4/CD8-0.6* Brief Hospital Course: 51 M with history of splenectomy, HIV, presented with sudden onset fevers, chills followed by hypotension [**3-3**] pneumococcal sepsis. . #Streptococcal pneumoniae bacteremia: Possible sources of pneumococcal bacteremia included pneumonia, infective endocarditis, and peritonitis. CXR was negative x 3 for pneumonia. CT abdomen did not show any evidence of pathology or fluid collections. The TTE did not show any vegetations. A TEE did not show any vegetations. Mr. [**Known lastname 9700**] began tailored treatment with ceftriaxone after sensitivities from his blood culture returned. His WBC began to trend down and he became afebrile; surveillance blood cultures were negative x 2. A PICC was put in place for his 2 week course of ceftriaxone. . #Thrombocytopenia: Mr. [**Known lastname 9700**] developed thrombocytopenia likely secondary to his sepsis and bacteremia. He was found to be negative for Heparin PF4 Antibody Test. His platelet count trended up throughout his hospitalization to normal ranges with treatment for his bacteremia. . #Allergic reactions (rash and lip swelling): Upon admission, Mr. [**Known lastname 9700**] had blanching erythematous macular rash that was initially full body. Possible etiologies include type I hypersensitivity reaction to one of several antibiotics he received or vancomycin red man syndrome. He no longer has any evidence of rash. He also developed lip swelling that was not clearly related to any particular medication. No thorat swelling, hives or other sx. The only potential [**Doctor Last Name 360**] was Fiorecet that he took for a headache although he has tolerated this in the past, and there was significant delay between the medication and effects. Fiorecet was listed as an allergy in OMR. Given mild reactions to minor agents, he was referred to allergy for consideration of further testing. . #Transaminitis: AST and ALT were elevated likely secondary to septic shock and end-organ damange from hypoperfusion. They improved throughout hospitalization with resuscitation. - Would recheck post hospitalization to assure normalization. . #HIV: Mr. [**Known lastname 9700**] [**Last Name (Titles) 8910**] his HAART after an allergic reaction more than one year ago. His absolute CD4 count is 500/mm3 and last viral load 305 copies/ml therefore there is currently no need for prophylaxis or treatment. Mr. [**Known lastname 9700**] should follow-up with his PCP regarding potential future need to restart medication. . #Anemia: Mr. [**Known lastname 9700**] had a decreased Hct likely secondary to increased consumption from sepsis as well as dilution effect from massive resuscitation. His hematocrit began to trend upwards after IVF was [**Known lastname 8910**] and he was treated with antibiotics. . #OSA: Stable throughout hospitalization. He utilized CPAP machine nightly. . #Migraines: He had increased frequency of migraines throughout hospitalization, which were controlled with tylenol. He took one dose of fioricet on [**3-15**] after which he developed isolated lip swelling. There was no associated rash or anaphylactic reaction. The swelling resolved with benadryl. This was documented as a new allergy. . #FEN/GI: Regular diet was tolerated. Phosphate and potassium repleted after MICU stay. . #Prophylaxis: During hospitalization, he was on Heparin for DVT prevention; also encouraged ambulation multiple times per day. On ranitidine for ulcer prevention. On senna for bowel regimen. Medications on Admission: Cholestoff dietary supplement Discharge Medications: 1. Ceftriaxone 2 gram Recon Soln Sig: Two (2) gram Intravenous once a day for 7 days: Last dose 2/25. Disp:*7 doses* Refills:*0* 2. Sodium Chloride 0.9 % 0.9 % Solution Sig: [**6-8**] ml Injection SASH and PRN. 3. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: 3-5 MLs Intravenous SASH and PRN as needed for line flush. 4. Cholest Off 450 mg Tablet Sig: One (1) Tablet PO once a day. 5. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: Sepsis secondary to pneumococcal bacteremia Asplenia Secondary: HIV OSA Migraines Hypercholesterolemia Discharge Condition: Normotensive, oxygen saturation >95% on RA, able to ambulate, tolerating food Discharge Instructions: It was a pleasure taking care of you at the [**Hospital1 18**]. You were brought to the ED with rigors, shortness of breath, high fevers, and decreased blood pressure. You were brought to the MICU and resuscitated with fluids. Your blood cultures were growing streptococcal pneumoniae and you were treated with appropriate antibiotics. A work-up for the cause of your bacteremia was begun. You had multiple chest x-rays, which did not show any signs of pneumonia. We performed a CT scan of your abdomen and pelvis which showed a few enlarged lymph nodes, but no fluid collection or other pathology. You underwent a transthoracic echocardiogram, which did not show any evidence of vegetations on your valves suggesting endocarditis. You also underwent a transesophageal echocardiogram, which did not show any vegetations. A PICC line was put in place for your 2 week course of antibiotics. Please return to the hospital if you experience fevers, chills, night sweats, nausea, vomiting, light-headedness or other concerning symptoms. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 9625**] on Tuesday, [**3-25**] at 1pm. Phone # [**Telephone/Fax (1) 9701**]. Please follow-up at [**Hospital 9039**] Clinic, One [**Location (un) **] Place, [**Apartment Address(1) 9702**] [**Location (un) **], MA. Phone #[**Telephone/Fax (1) 9316**]. [**2183-5-29**] at 4pm. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9703**], [**Name12 (NameIs) 280**] You have an appointment with your sleep doctor. Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2183-7-3**] 3:30 Completed by:[**2183-3-20**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10944, 10996

6843, 10312

342, 499

11153, 11233

3836, 6820

12317, 12960

3043, 3183

10393, 10921

11017, 11132

10338, 10370

11257, 12294

3213, 3817

271, 304

527, 2068

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2532, 3027

30,730

148,481

2724

Discharge summary

report

Admission Date: [**2115-8-29**] Discharge Date: [**2115-10-5**] Date of Birth: [**2069-3-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: GI bleeding. Major Surgical or Invasive Procedure: TIPS IR guided Hepatic artery embolization Exploratory Laparotomy History of Present Illness: 46 yo F w/ EtOH cirrohsis, h/o admissions for alcohol withdrawals, celiac disease, hypothyroidism and chronic anemia p/w dizziness x 7-8 days. Patient had large amounts of melena on sunday and monday. She them progressively felt dizzy over the week and she presented today to the ED. Also, she had a mechanical fall on [**2115-8-22**] on her face for which she presented to an OSH. No imaging was performed then. . In the ED, her VS were T 97.8, HR 72, BP 90/50, RR 18 and O2 sat 100% on RA. Her Hct came back at 10.4 (baseline around 25) . 2 PIV were placed, she was given 2L IVF, started on octreotide drip and admitted to MICU for emergency EGD. . Pt was recently hospitalized at [**Hospital1 **] ([**Date range (3) 13481**]) for fatigue and was worked up extensively for liver failure (admission ALT 22, AST 179, Alk phos 162, total bili 5.8), inc. liver biopsy which showed high likelihood of ETOH hepatitis. Pt was treated with lasix/aldactone, nadolol, vitamin supplements, and a course of pentoxifylline. She is being followed by liver clinic. Pt was also extensively worked up for anemia (admission hct 17.8). Heme was consulted on the pt and felt it was multifactorial, inc. ETOH suppression, hypothyroidism, celiac/nutritional deficiency. Pt was treated with PRBCs and B12/folate/iron supplementation. EGD/colonoscopy during the admission showed grade I non-bleeding esophageal varices and rectal varices, and pt was placed on nadolol. She did have 1 episode of BRBPR. She had another admission for BRBPR from [**Date range (1) 13482**] with stable hct. She was seen by Liver and was felt to be stable compared to previous admission in [**2115-1-31**]. A RUQ ultrasound showed no portal HTN. She received her outpatient doses of Lasix and spironolactone. Ammonia levels were followed and were as high as 128; however, pt remained oriented (though lethargic on day of admission from lorazepam for ETOH withdrawal) without asterixis. Pt was started on lactulose. Past Medical History: Alcoholism with numerous hospitalizations for detoxification Alcoholic cirrhosis Rectal variceal bleeding GERD Celiac disease on gluten-free diet since [**2112**] Anemia, multifactorial Hashimoto's thyroiditis Social History: Patient lives by herself and is currently on disability. Sister, husband, and children live in the area. Denied tobacco use. Last etoh reported to be in [**2115-1-31**]. Denied IVDA. Family History: Mom: Healthy [**Name (NI) **]: deceased from Lung CA Sister: [**Name (NI) 13483**] thyroiditis Physical Exam: VS 97.0, 68, 93/53, 18, 100RA Gen: NAD, c/o chills HEENT: icteric, MMM, JV flat, L mandibular ecchymocosis Chest: CTA on anterior exam CV: RRR, 2/6 systolic murmur w/o radiation Abd: S/NT/ND/+ BS/liver enlarged Ext: edema L>R, non-pitting Neuro: AOx3, grossly intact Pertinent Results: [**2115-8-29**] 02:55PM HCT-10.6* [**2115-8-29**] 01:09PM GLUCOSE-122* UREA N-44* CREAT-3.2*# SODIUM-132* POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-21* ANION GAP-16 [**2115-8-29**] 01:09PM estGFR-Using this [**2115-8-29**] 01:09PM ALT(SGPT)-17 AST(SGOT)-67* ALK PHOS-167* AMYLASE-84 TOT BILI-3.3* [**2115-8-29**] 01:09PM LIPASE-66* [**2115-8-29**] 01:09PM WBC-5.5# RBC-0.86*# HGB-3.4*# HCT-10.4*# MCV-120*# MCH-39.1*# MCHC-32.6 RDW-19.7* [**2115-8-29**] 01:09PM NEUTS-68.9 LYMPHS-23.4 MONOS-5.4 EOS-1.9 BASOS-0.5 [**2115-8-29**] 01:09PM PLT COUNT-86* [**2115-8-29**] 01:09PM PT-17.8* PTT-40.7* INR(PT)-1.7* Liver U/S [**2115-6-25**] 1. Coarsened nodular liver consistent with chronic liver disease. 2. Thick-walled gallbladder with sludge and gallstones also consistent with chronic liver disease. 3. Normal arterial and venous waveforms of the hepatic vasculature. . CT Head [**2115-8-29**]: IMPRESSION: No acute intracranial hemorrhage or mass effect. . ECG [**2115-8-29**]: Baseline artifact. Probable sinus rhythm. Leftward axis. Low precordial voltage. Q-T interval prolonged for the rate. ST-T wave abnormalities. Since the previous tracing of [**2115-2-3**] the QRS voltage has decreased. . EGD [**2115-8-29**]: Impression: Varices at the lower third of the esophagus. Granularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy. Varices at the fundus. . Colonoscopy [**2115-8-30**]: Granularity, petechiae and congestion in the whole colon compatible with portal hypertensive colopathy. Large rectal varices. Blood in the rectum. . Abd U/S [**2115-8-30**]: 1. Patent portal veins. 2. Cholelithiasis and sludge. 3. Cirrhosis, splenomegaly, and ascites. 4. Echogenic liver, consistent with fatty infiltration. Other forms of hepatic disease including liver fibrosis and cirrhosis are in the differential. . Left LENI [**2115-8-31**]: IMPRESSION: 1. No evidence of DVT. 2. 3.3 cm left popliteal [**Hospital Ward Name 4675**] cyst. . Knee xray [**2115-9-1**] No fracture, mild degenerative changes, no effusion, mild OA. . ECHO [**2115-9-10**]: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-1**]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Liver biopsy [**2115-9-14**]: Liver, right lobe, biopsy: Cirrhosis. Severe micro- and macrosteatosis with associated intracellular hyalin and balloon cell degeneration. Mild lobular and moderate septal mixed inflammation. Mild cholestasis. Trichrome stain shows marked fibrosis. Iron stain shows mild increase in iron in hepatocytes. Note: The findings are consistent with a toxic/metabolic injury. . ABD U/S [**2115-9-18**]: IMPRESSION: 1. Patent TIPS with appropriate direction of flow and unchanged velocities. 2. Hepatic cirrhosis without masses identified. 3. Ascites. 4. Gallbladder sludge and stones. . CXR [**2115-9-20**]: IMPRESSION: Interval improvement in mild pulmonary edema. Persistent bibasilar atelectasis with small bilateral pleural effusions. Brief Hospital Course: 1) GIB: Originally presented with HCT of 10 in the setting of esophageal variceal bleed. A total of 7 units of PRBC were transfused in the MICU. EGD did not show source of bleeding with some gastritis and varices. Patient was maintained on octreotide drip and received a 3-day course of ceftriaxone for SBP prophylaxis. The day after admission patient underwent a colonoscopy that showed portal hypertensive colopathy, large recta varices and blood in rectum. In the MICU, a total of 7 units of PRBC were transfused. EGD did not show source of bleeding with some gastritis and varices. She underwent TIPS on [**2115-9-3**]. She was started on midodrine as well as diazepam per CIWA scale (did not require any during the first three days of admission). Her acute renal failure slowly improved with transfusions and IV fluid bolusus as needed. She was then transfered to hepatorenal service with a hematocrit of 24.9. On the floor, she was noted to be progressively anemic and continued to lose blood. She was found to have an pseudoaneurysmal bleed and was mangaged with transfusions of FFP and pRBCs until she became hypotensive with a Hct of 16. She was then transferred back to the MICU where she underwent R hepatic artery embolization with coiling and then glue. She then went for exploratory lap on [**2115-9-14**] where she was found to have 5 L of hematoma mixed with ascites. She had some failure to wean from the vent, but was extubated on [**2115-9-16**] after receiving multiple units of PRBC. She was again transferred back to the floor on [**2115-9-20**] for further management. She had elevated bilirubin up to 13.2 when transferred to the floor, thought to be a combination of hemolysis from blood transfusions, sheering of RBCs through the TIPS, and decompensated liver failure. Since admission to the floor, pt remained stable with no source of bleeding. HCt's were trended and pt was transfused for HCT <22. LFT's and renal function were monitored. Pt has persistent elevation of Tbili from [**12-13**], a course of ursodiol did not improve bili and it was discontinued. . 2) ETOH cirrhosis/Elevated T-biliAscites. On octreotide drip and midodrine as well as diazepam per CIWA scale (did not require any during the first three days of admission). Octreotide and midodrine were discontinued and pt did not have an hypotensive episodes. Nadolol was stopped due to bleeding history. Lasix and aldactone were used for diuresis of fluid/ascites. These values were titrated based on clinical exam and renal function. Pt will likely require social work or addiction counseling as an outpatient as she cannot be consider for transplant with active ETOH intake. T-bili as above. Pt began to drain from the site of an old paracentesis. An ostomy bag was placed to collect the fluid. Pt recieved 2 sutures on day of discharge to aid in the draining. Sutures may be removed in [**10-13**] days. . 3) Acute renal failure likely in setting of volume depletion. Slowly improved with transfusions and IV fluid bolusus as needed. Acute worsening upon second transfer to the MICU which was improved to 0.8 when she was transferred to the floor. Creatinine was trended while patient was undergoing diuresis. Daily weights were checked. Pt currently on 80mg po lasix and 200mg Po aldactone. . 4) Knee pain: unclear etiology, knee on exam not swollen, without effusions. Given history of fall, plain films of the knee were ordered to rule out patella fracture. Xray showed no fracture. Knee pain was no longer an active issue throughout the remainder of the admission. . 5) LLE edema: LENI on LLE showed no DVT. She continued to have diffuse LE anasarca and diuretics were limited by acute renal failure. Diuretics were uptitrated as renal function allowed and edema improved. . 6) UTI - Enterococcus UTI on [**2115-9-10**]. Treated originally with vancomycin and Pip-Tazo, continued for 10 day course of vancomycin. . 7) Hypothyroid: continued with synthroid, TSH high with low Free T4. Pt should follow up with her endocrinologist as an outpatient to follow up on her thyroid function. . 8) Deconditioning-Pt was seen by PT during admission. SHe was given nutritional supplements. She will be requiring rehab upon discharge to further gain strength and mobility. . Medications on Admission: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 2. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY 3. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY 6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H prn 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 PO Q12H 8. Spironolactone 25 mg Tablet Sig: Three (3) Tablet PO DAILY 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) 10. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY 11. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-1**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 10. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 12. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO once a day. 13. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary: S/P TIPS with complication of peritoneal bleed, s/p ex-lap . Secondary: Esophageal variceal bleed Alcoholism with numerous hospitalizations for detoxification Alcoholic cirrhosis Rectal variceal bleeding GERD Celiac disease on gluten-free diet since [**2112**] Anemia, multifactorial Hashimoto's thyroiditis Discharge Condition: Good, stable, afebrile Discharge Instructions: You were admitted to [**Hospital1 18**] for a upper GI bleed for which you received a TIPS procedure. You then had a bleeding complication of the TIPS which required a stay in the MICU and surgery. You were stabilized and moved out of the MICU. You were then transferred to the medical floor where your hematocrit and liver function was monitored. You began to drain from the site of an old paracentesis which was sutured. The sutures should be removed in [**10-13**] days. . The following medications were changed during this admission: -Your spironolactone was increased to 200mg daily. -Your lasix is now 80mg daily -Your nadolol was discontinued . You should return to the ED or call your doctor if you experience worsening abdominal pain, shortness of breath, dizziness, loss of consciousness, blood in your stool, dark stools, fever greater than 101.4 degrees F, or any other symptoms that concern you. Followup Instructions: Please call your hepatologist Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Telephone/Fax (1) 2422**] to schedule a follow up appointment within 1 week of discharge. . Please call you endocrinologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 13484**] to schedule a follow up appointment. . Please call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] at [**Telephone/Fax (1) 2205**] to schedule a follow up appointment. . You will need a TIPS ultrasound one month after discharge with special attention to the R.hepatic vein. Additional report should be sent to Dr. [**First Name (STitle) 3175**] at fax [**Telephone/Fax (1) 13485**].

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icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "39.79", "45.13", "54.19", "54.91", "45.23", "99.04", "50.11", "99.07", "39.1", "99.29" ]

icd9pcs

[ [ [] ] ]

12993, 13065

6861, 11138

327, 395

13427, 13452

3247, 6838

14412, 15177

2847, 2944

11882, 12970

13086, 13406

11164, 11859

13476, 14389

2959, 3228

275, 289

423, 2396

2418, 2630

2646, 2831

12,881

177,188

17949

Discharge summary

report

Admission Date: [**2180-5-5**] Discharge Date: [**2180-5-16**] Date of Birth: [**2180-5-5**] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: The patient is a 39 and 1/7 weeks gestational age infant transferred to the NICU at the request of Dr. [**Last Name (STitle) 49694**], for a consultation regarding hypotonia and dysmorphic features. MATERNAL HISTORY: A 32 year old gravida III, para I, now II, woman with past obstetrical history notable for spontaneous abortion in [**2176**], and spontaneous vaginal delivery at 41 weeks in [**2177**], a son alive and well. PAST MEDICAL HISTORY: Noncontributory. FAMILY HISTORY: Noncontributory. PRENATAL SCREENS: O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, GBS negative, triple screen charted as "normal". PREGNANCY HISTORY: Last menstrual period [**2179-8-6**], for estimated date of confinement [**2180-5-11**], estimated gestational age 39 and 1/7 weeks. Eighteen week ultrasound normal and consistent with dates. Mother complained of decreased fetal movement throughout pregnancy. A 34.6 week ultrasound showed reduced fetal movement but normal amniotic fluid volume and umbilical flow. Pregnancy otherwise uncomplicated. Repeat cesarean section under epidural anesthesia. No maternal intrapartum fever or fetal tachycardia. Rupture of membranes at delivery yielding clear amniotic fluid. NEONATAL COURSE: NICU not in attendance at delivery. Apgar eight at one minute and nine at five minutes. No resuscitative interventions by report. NICU consultation requested given antenatal findings and postnatal physical findings. PHYSICAL EXAMINATION: Saturation 92% in 21% FIO2. Blood pressure 68/38, mean 51, heart rate 145, respiratory rate 38, temperature 95.9, birth weight 3350 grams. Anterior fontanelle soft, open, flat. Epicanthal folds, redundant nuchal folds, no macroglossia, palate intact. No nasal flaring. Chest - no retractions, good breath sounds bilaterally and no crackles. Cardiovascular - well perfused, regular rate and rhythm, femoral pulses normal. S1 and S2 normal, no murmur. The abdomen is soft, nondistended, thin umbilical cord, no organomegaly, no masses, bowel sounds active, anus patent. Genitourinary normal penis, left testis undescended, right testis descended. Central nervous system - responsive to stimuli, tone decreased, generalized. Moving all limbs symmetrically. Suck/roof/gag/grasp/Moro normal. Integument normal. Musculoskeletal - bilateral single palmar creases, short digits. Spine, hips, clavicles are normal. HOSPITAL COURSE: 1. Cardiovascular - A cardiac evaluation and a cardiac consult was performed due to an initial oxygen requirement, comfortable tachypnea, and an enlarged cardiothymic silouette. Four extremity blood pressures were within normal limits, an EKG was normal for age, a hyperoxia challenge revealed a paO2 of 273. A cardiac consult was obtained and an echocardiogram was performed. The echocardiogram revealed patent foramen ovale, small patent ductus arteriosus, right ventricular hypertension, qualitatively good biventricular systolic function and very small inferior pericardial effusion. The cardiology service would like to see baby [**Name (NI) 49695**] in 1 month in the cardiology clinic. At that time a repeat echocardiogram will be done to ensure closure of the PDA and evaluate pulmonary pressures. 2. Respiratory - The patient initially required oxygen at approximately 300cc flow with approximately 30 to 60% FIO2. The oxygen requirement was due to central hypotonia, shallow respirations and bilateral lobe atelectasis. There was probably also mild increased pulmonary pressures early in his course that partly contributed to the oxygen requirment. His respirations and chest excursion steadily improved and on day of life six, he transitioned to low flow nasal cannula. On day of life nine he transitioned to room air where he currently remains. He has had no apnea and/or bradycardia episodes. 3. FEN - The patient briefly required intravenous fluids but promptly advanced to full enteral feeds which he tolerated without difficulty. He is currently po ad lib with Enfamil 20 (with Fe). Birthweight 3350 gms, L 20.25 in, HC 33.5 cm. Discharge weight 3335 gms, L 56 cm, HC 34.5 cm. 4. Hematology - The patient initial complete blood count showed a white blood cell count of 19.0 with a differential of 79 polys, 5 bands and 14 lymphocytes. His hematocrit was 63.0, and his platelet count was 234,000. He had mild physiologic hyperbilirubinemia with a bilirubin of 11.6 on day of life four which clinically improved. He never needed phototherapy. 5. Infectious disease - No issues. 6. Genetics - Given the constellation of admission physical findings, a cytogenetics evaluation was sent. The analysis revealed trisomy 21. Of the 11 lymphocytes that were studied, all had trisomy 21, therefore showing no to minimal mosaicism. To further evaluate the degree of mosaicism, we have requested that the cytogenetics lab evaluate a greater number of cells (closer to 30). Results are pending. The family was referred to the Down Syndrome clinic at [**Hospital3 1810**] and Dr. [**Last Name (STitle) **]. They have already met with Dr. [**Last Name (STitle) **]. Finally, the family has expressed interest in genetic counseling to determine risk of Trisomy 21 in future children. This should be done throught the Genetics service at [**Hospital3 1810**]. The general genetics team met with the family prior to discharge to discuss counseling and future testing. 7. Social - The parents were very attentive and involved in his care throughout his hospitalization. Our staff attempted in as much as we could to answer all their questions and concerns. We also recruited the help of the Down Syndrome Clinic at [**Hospital3 1810**] and had mother meet and speak on the telephone on several occasions with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] on [**2180-5-16**]. 8. Sensory - Audiology - Hearing screening was performed as automated auditory brain stem responses. The patient's hearing was referred and he will need further testing at a later date with Audiology at [**Hospital3 1810**]. 9. Psychosocial - [**Hospital1 69**] social work was involved with the family. The contact social worker is [**Name (NI) **] and she can be reached at [**Telephone/Fax (1) **]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home. PRIMARY CARE PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 732**], [**Hospital3 2358**] Medical Center. Telephone number [**Telephone/Fax (1) 49696**]. Fax [**Telephone/Fax (1) 49697**]. CARE AND RECOMMENDATIONS: 1. Feeds at Discharge - Enfamil 20 p.o. ad lib. 2. Medications - None. 3. Car Seat Position Screening - Passed. 4. State Newborn Screening Status - Sent per protocol with no notification of abnormal results. 5. Immunizations Received - Hepatitis B vaccination [**2180-5-16**]. 6. Follow-Up Appointments (Parents to arrange specific appointment date and times): a. Pediatrician - Dr. [**First Name (STitle) 732**], [**2180-5-19**]. b. Genetics/Down Syndrome Clinic/Dr. [**Last Name (STitle) **] - in 1 month, telephone [**Telephone/Fax (1) 49698**]. c. Cardiology - in 1 month, telephone [**Telephone/Fax (1) 46235**]. d. Audiology - [**Hospital3 1810**] ([**Last Name (un) 9795**] 11), telephone [**Telephone/Fax (1) 48318**]. e. Early Intervention Program (EIP) - Family support EIP, telephone [**Telephone/Fax (1) 44332**]. f. VNA - [**Location (un) 86**] VNA, telephone [**Telephone/Fax (1) 37525**]. Fax [**Telephone/Fax (1) 49699**]. DISCHARGE DIAGNOSES: 1. Trisomy 21. 2. Respiratory distress and oxygen requirement, resolved. 3. Patent ductus arteriosus. 4. Referred hearing screen. [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **],M.D. [**MD Number(1) 37201**] Dictated By:[**Last Name (NamePattern1) 44694**] MEDQUIST36 D: [**2180-5-12**] 14:12 T: [**2180-5-12**] 16:21 JOB#: [**Job Number 49700**]

[ "758.0", "V05.3", "778.3", "747.0", "745.5", "782.4", "752.51", "V29.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.55" ]

icd9pcs

[ [ [] ] ]

6559, 6793

658, 1680

7823, 8222

2640, 6503

6819, 7802

1703, 2623

171, 600

623, 641

6528, 6535

30,646

120,334

33056

Discharge summary

report

Admission Date: [**2108-6-13**] Discharge Date: [**2108-6-21**] Date of Birth: [**2060-4-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: transferred from OSH for nausea, vomiting, abdominal pain, fever Major Surgical or Invasive Procedure: central line insertion History of Present Illness: The patient is a 48M w/ Down's syndrome, ESRD, DM2, SVC syndrome on coumadin, and gallstones who was transferred from [**Hospital1 5979**] ED after presenting with nausea, vomiting, RUQ pain, and low grade fever. His sister states that he began vomiting after lunch today and was complaining of abdominal pain. He has had intermittent abdominal pain in the RUQ and epigastric region for the last several months, but today it seemed worse and more constant, so he presented to [**Hospital3 **]. There he was given Vanc, Gent, cefoxitin, as well as Zofran, Ativan for anxiety, morphine, and Pepcid. He was transferred to [**Hospital1 18**] for further management, as he was scheduled for ERCP on [**6-14**] anyway for stent removal and residual stone extraction from ERCP done in [**Month (only) 116**] for cholelithiasis. On arrival, he had a low-grade fever of 100.0, BP was 130/80, and HR was 102. He complained of thirst but his abdominal pain was minimal on exam. Per his sister, his mental status was at baseline and had not been different today. Other than the nausea/vomiting and abdominal discomfort, he has not had any other focal symptoms. He has baseline shortness of breath that is not any worse today. Past Medical History: 1. Down's Syndrome (trisomy 21) 2. End-stage renal disease on hemodialysis 3. Type 2 diabetes mellitus 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea 7. Chronic diastolic congestive heart failure 8. Superior vena cava syndrome on chronic anticoagulation 9. ESRD-related anemia and secondary hyperparathyroidism 10. History of gastrointestinal hemorrhage 11. History of respiratory failure from flash pulmonary edema from CHF 12. Choledocholithiasis and cholelithiasis, s/p biliary stent placement in [**2108-3-22**]. Social History: lives with his sister, who is his primary caretaker. non [**Name2 (NI) 1818**]. no alcohol. denies any illicit drugs. Family History: Diabetes in both parents and hypertension and emphysema. Physical Exam: Appearance: mildly uncomfortable Vitals: T: 100.0 BP: 130/80 HR: 102 RR: 20 O2: 99% RA Head: microcephalic, atraumatic Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no exudate ENT: Dry MM Neck: No JVD, no carotid bruits Cardiovascular: RRR, nl S1/S2, no m/r/g Respiratory: CTA bilaterally, comfortable, no wheezing, no ronchi, no rales Gastrointestinal: soft, non-tender, non-distended, no hepatosplenomegaly, normal bowel sounds Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint swelling, no edema in the bilateral extremities Neurological: Limited neurologic exam due to Down's syndrome. Awake and alert, mostly non-verbal, responds to basic verbal commands. Integument: warm, no rash, no ulcer Pertinent Results: [**Hospital3 **] labs [**2108-6-12**]: Chem 10: 138/4.5/98/24/1078.1/159/8.7/1.8/8.8 Calcium: 8.7 CBC: 12.7/41.5/323 albumin: 2.7 alk phos: 554 Total bili: 1.4 AST/ALT: 1465/824 Lipase: 27 Brief Hospital Course: A/P: 48M w/ Down's syndrome, ESRD on HD, DM2, SVC sydnrome on anticoagulation, gallstones transferred from OSH with N/V, abdominal pain, leukocytosis, and fever, concerning for SIRS and cholangitis. His code status was temporarily reversed for ERCP. He was electively intubated and had 1 ERCP with temporary improvement. However, he again deteriorated and required second ERCP. He then became bacteremic with pan-resistant Klebsiella, thought to be from dialysis line. This was changed, and the new line could not function as well as the former because of poor venous anatomy. Due to persistent bacteremia, sepsis, hypotension, and inability to attain further dailysis access, decision was made to transition patient to CMO. He subsequently expired after withdrawal of the ventilator. Medications on Admission: levothryoxine 100mcg qd lisinopril 20mg [**Hospital1 **] Nephrocaps 1 po qd Renagel 1600mg with meals Phoslo 2600mg with meals ASA 81mg qd metoprolol 75mg [**Hospital1 **] Lipitor 10mg qd coumadin 2.5mg qd trazodone 50mg qhs prn Pro-Stat 64 2oz tid (protein supplmeent) ketoconazole 2% cream to feet [**Hospital1 **] hydrocortisone 2.5% lotion [**Hospital1 **] prn Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2108-6-22**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2180-7-8**] Discharge Date: [**2180-7-14**] Date of Birth: [**2148-7-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: 2yM with history of EtOH abuse and hypertension who presented to [**Hospital3 **] on [**7-6**] with the nausea, vomiting, and epigastric pain. The pain began the day previous and was epigastric in location and described as boring. He attributed this to his usual gastritis secondary to NSAID use. However, over the following day his pain worsened as was accompanied by anorexia, nausea, and an episode of non-bloody, vomitting on the morning of [**7-7**]. Per his report, his last drink was four days prior ([**7-2**]). On arrival to OSH ED, his blood pressure was 163/111. On admission, he had elevated lipase (2866) and amylase (981), serum glucose 211, white blood cell count 18.5K, AST 104, LDH not checked. At that time, lab values also notable for elevated creatinine (1.6) and calcium 10.5, with hematocrit 54.5%. Ultrasound of abdomen showed fatty infiltration of the liver, but the pancreas was not clearly visualized. Over his ED course, his blood pressure increased to 200/135 (pulse 92). OSH course: Admitted to ICU for hemodynamic monitoring. He was made NPO and given IV fluids. He was seen by GI service, who recommended CT abdomen/pelvis, aggressive IV fluids, close vital sign monitoring, frequent LFT, amylase, and lipase checks, and pain management with IV hydromorphone. Ciprofloxacin and metronidazole were initiated, but discontinued quickly. He was also seen by cardiology service, and received IV labetalol the first night of admission. He was subsequently started on amlodipine and hydralazine for blood pressure control. Possible alcohol withdrawal was treated with Serax protocol, and multivitamin, thiamine, and folate were initiated. GU was consulted for difficult foley catheter insertion. Past Medical History: - EtOH abuse - Borderline hypertension (had been discussing with PCP initiation of medications) Social History: Engaged. Works for equipment company, also does audio work. Active alcohol user. Not daily, but drinks several beers each time when he drinks (12 beers + 3 shots whisky). Denies tobacco, illicits. Per OSH report, last drink was [**7-2**]. Family History: Mother and father with CAD. No family history of EtOH abuse or pancreatitis Physical Exam: VS BP 143/102, HR 126, O2 86% on RA-->94% on 4L Gen: anxious appearing overweight man in mild distress HEENT: oropharynx clear, moist mucous membranes Skin: + psoriatic lesions on knuckles, R knee Heart: regular, tachycardic, no murmurs Lungs: clear bilaterally with decreased breath sounds at the bases Back: no CVA tenderness Abdomen: distended, no bowel sounds heard, tympanic to percussion, tender to palpation in epigastrium, no fluid wave or shifting dullness, no rebound or guarding Pertinent Results: Admission labs: [**2180-7-8**] 05:37PM WBC-13.3* RBC-4.19* HGB-12.9* HCT-39.7* MCV-95 MCH-30.7 MCHC-32.4 RDW-14.0 [**2180-7-8**] 05:37PM NEUTS-89* BANDS-3 LYMPHS-5* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2180-7-8**] 05:37PM ALT(SGPT)-26 AST(SGOT)-51* LD(LDH)-530* ALK PHOS-50 AMYLASE-285* TOT BILI-0.7 [**2180-7-8**] 05:37PM GLUCOSE-111* UREA N-11 CREAT-1.1 SODIUM-138 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15 [**2180-7-8**] 05:37PM LIPASE-692* Discharge Labs: [**2180-7-14**] 07:00AM BLOOD WBC-14.4* RBC-3.66* Hgb-10.9* Hct-33.1* MCV-90 MCH-29.9 MCHC-33.1 RDW-14.2 Plt Ct-492*# [**2180-7-12**] 06:10AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.7 CXR: Small to moderate left pleural effusion similar in appearance to slightly increased. Brief Hospital Course: 32 year old man with a history of EtOH abuse presented with pancreatitis most likely related to chronic alcohol abuse. He was started on IVF, made NPO, and required IV dilaudid for pain. Surgery was consulted but there was no evidence of necrotizing pancreatitis. He was tabilized in ICU and transferred to floor on [**7-11**]. He was then transitioned to PO medications and diet. The amylase and lipase trended down and were 58 and 68, respectively on the day of discharge. The abdominal pain improved on discharge. He was placed on CIWA with 10 mg Valium for scores great than 10. The scale was discontinued on [**7-12**]. The abdomen was increasingly distended over the first day and he was stooling only small amounts. Repeated KUBs showed dilated right colon. This was likely due to ileus secondary to opiates and acute pancreatitis. He was given a bowel regimen and opiates were minimized. He had 2L of oxygen requirement on floor with 80-85% ambulatory SaO2. This was likely due to interstitial non cardiogenic pulmonary edema. He received two doses of lasix as he received more than 15 L of IVF fluids in the ICU. He is now 95% on RA. He had no evidence of congestive heart failure or hospital acquired pneumonia. He had WBC of 14.4 which was elevated from his admission WBC of 13.3. [**Doctor First Name **] was afebrile while on the floor and denied cough or sputum production. He needs repeat CBC at next visit as this may be due to evolving pneumonia or pancreatic pseudocyst. His exertional tachycardia was most likely sedondary to fluid sequestration from severe pancreatitis and from hypoxia due to interstitial pulmonary edema. In regards to his hypertension, this seems to have been a chronic issue for him although he was never treated as an outpatient. It was worse in the setting of pain and EtOH withdrawal. Hydralazine and labetalol were started and titrated up while he was in ICU. We discontinued them and treated him with atenolol and HCTZ on floor with improved BP control. His elevated LFTs are secondary to pancreatitis itself a component of liver disease [**3-20**] EtOH given fatty infiltration on recent US. The macrocytic Anemia is due to combination of nutritional deficiency and EtOH. Folate was supplemented on floor and he will continue it as outpatient. Medications on Admission: None Discharge Disposition: Home Discharge Diagnosis: Primary: Acute alcoholic pancreatitis Secondary: Alcohol withdrawal Hypertension Psoriatic arthritis Discharge Condition: Stable, tolerating regular died, pain well managed. Discharge Instructions: You admitted for severe acute pancreatitis secondary to alcohol use. You required observation in the ICU with aggressive treatment that included pain medication and intravenous fluids. While in the hospital you experienced symptoms of alcohol withdrawal and were treated with Valium to prevent serious complications of withdrawal. Your pain improved and your pancreatic enzymes returned to [**Location 213**] levels. You had significant swelling, otherwise known as edema, secondary the aggressive fluids resusciation you received in the ICU. We started you on a diuretic which will help you get rid of the extra fluid. You also experience some shortness of breath which can likely be attributed to the extra fluid and abdominal distention which made it difficult to take a deep breath. This has improved by discharge. New medications: Hydracholorothiazide 25mg by mouth once a day Atenolol 25mg by mouth twice a day Dilaudid 4mg by mouth every 4 hours prn abdominal pain (please limit use to only when necessary as this medication causes sedation, constipation, urinary retention, and carries a risk of addiction). Please call PCP if you have worsening shortness of breath, productive cough, or fever for evaluation of pneumonia. Also call your PCP if you develop chest pain, abdominal pain, nausea, vomiting or any other concerning symptom. Please make continued effort to abstain from alcohol use as you are at increased risk for further injury to your pancreas. Please seek out support or assistance with sobriety. It was a pleasure taking part of you care. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) 26672**] on Monday [**2180-7-17**] @ 2:30PM. Please be sure to keep this appointment or make other arrangements to be seen by weeks end. You should have blood drawn then (complete blood count) and have your oxygenation saturations checked again. Completed by:[**2180-7-16**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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45764

Discharge summary

report

Admission Date: [**2166-10-21**] Discharge Date: [**2166-10-27**] Date of Birth: [**2084-10-17**] Sex: F Service: MEDICINE Allergies: Protamine / Lovenox Attending:[**First Name3 (LF) 898**] Chief Complaint: Anemia Major Surgical or Invasive Procedure: [**10-22**]-Dialysis [**10-23**]- EGD [**10-23**]- Colonoscopy [**10-24**]- Dialysis [**10-27**]- Dialysis History of Present Illness: 82 yo F with recent hip fx, multiple prior GI bleeds, h/o of st jude valve and ESRD on HD, presents from rehab with incidental finding of anemia at HD. Pt was noted to have Hct 19.4 at dialysis, in setting of INR 4.4, for which she received 2U pRBCs. Pt's Hct only bumpted to 20 and thus pt referred to ED for evaluation. She was unaware of any change in her state of health, denying lightheadedness, dizziness, chest pain, palpitations, shortness of breath, nausea, vomiting or abdominal pain. She described her stool as dark brown but denied red or black ostomy output, hematuria, or any trauma. In the ED: initial vitals were : T98.6 HR150(inaccurate) BP120/42 RR18 O291%RA. EKG normal sinus. NG lavage was preformed and showed minimal coffee ground blood which cleared quickly. Exam was otherwise normal and ROS negative as above. Labs were significant for CBC: Hct 22.6, Cr 5.5, CEs neg x 1, INR 3.3 without any vit K. Pt given IV PPI drip, typed and crossed but not given blood prior to transfer. Access was difficult as left arm off limits due to fistula, right IJ clotted, were unable to get femoral access and ultimatelly had AC and EJ 18G PIVs placed. Renal was informed and plan for HD tomorrow after transfusion. Prior to transfer pt's vitals were T98.2, HR78, BP129/46, RR12, O2100%. Past Medical History: 1. repeated Hx of gastrointestinal bleeding (most recent [**Month (only) 116**]/09, found to have GE junction polyp, clipped, recommended repeat in 6-8wks, not done) 2. Left hemicolectomy with transverse colostomy for GIB [**11-13**], found to have severe diverticulosis, no particular source of bleeding found 3. Diastolic CHF (EF 65-75%) on 2L O2 4. Status post tracheostomy placement after prolonged intubation in ICU (at time of colectomy) - removed 5. Severe AS s/p mechanical AVR, [**Hospital3 **], goal INR [**2-11**] 6. Hypertension 7. Elevated cholesterol 8. Diabetes type 2 9. End-stage renal disease on HD MWF (via LUE AVF revised on [**11-16**]) 10. Bilateral total knee replacment 11. Multiple skin lesions removed by general and plastic surgery 12. Hypothyroidism 13. Presumptive history of atrial fibrillation; on amiodarone Social History: Lives at home with husband, and son [**Name (NI) **] who lives below her in the same house. (on [**Location (un) 453**] of 2-family home) Other children in the area and involved in her care. Pt is a retired former manager. Is a non-smoker, no alcohol use, no IVDU. Family History: She is an only child. Grandfather died of cancer but son is not sure of what type. Three sons with htn. Physical Exam: DISCHARGE VS: T 98.6 BP= 142/60 HR= 66 RR= 20 O2= 100% RA Fingersticks: 144, 135, 137, 117 PHYSICAL EXAM GENERAL: Pleasant, well-appearing elderly African American lady, sitting up in bed in NAD. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, mechanical S2. no JVD LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, Non-tender, Not distended, no palpable hepatosplenomegaly. ostomy in LLQ with greenish brown liquidy output EXTREMITIES: Trace edema, no calf pain, 1+ DP/PT pulses B/L SKIN: No rashes/lesions. Old ecchymosis on right upper arm, no hematoma. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation and stength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**10-22**] LEFT HIP SOFT TISSUE ULTRASOUND: Focused son[**Name (NI) 493**] examination performed over the soft tissues of the left hip reveals no discrete hematoma. IMPRESSIONS: No discrete hematoma seen in the soft tissues overlying the left hip. [**10-27**] HCT 29.3 [**10-26**] HCT 28.3 [**10-25**] HCT 27.2 [**10-23**] EGD- No abnormal findings to explain melena. [**Month (only) 116**] have to evaluate for AVMs in SB with capsule study and if negative, a Meckel's scan as well. Endoscope induced traumatic [**Doctor First Name 329**] [**Doctor Last Name **] tears with minimal bleeding noted in distal third of esophagus Normal stomach. Normal duodenum [**10-23**] COLONOSCOPY- A few diverticula with medium openings were seen in the transverse colon and ascending colon. Diverticulosis appeared to be of moderate severity. Diverticulosis of the transverse colon and ascending colon Otherwise normal colonoscopy to cecum No clear source of lower GI bleed noted. Recommend capsule study to rule out AVMs and also a meckel's scan Brief Hospital Course: Ms. [**Known lastname **] 82 year-old lady with coronary artery disease, mechanical aortic valve replacement, on coumadin, history of GI bleeds, end-stage renal disease due to diabetes and hypertension, on hemodialysis, who presented from rehab with findings of anemia at hemodialysis and inappropriate hematocrit response to blood transfusion. 1. GI BLEED- Ms. [**Known lastname **] was intially admitted to the ICU on [**10-21**] due to her history of multiple GI bleeds; she was transfused 2 units of blood. She was transferred to the general medical service on [**10-22**] and was hemodynamically stable. She was evaluated by gastroenterology prior to transfer, who recommended stopping coumadin and bridging her with heparin gtt in order to allow her INR to decrease to a level safe for endoscopy/colonoscopy. She underwent endoscopy/colonoscopy on [**10-23**] without complications. No active source of bleeding was identified, although colonoscopy revealed several diverticulae. She has a history of ateriovenous malformations which could be related to Aortic Stenosis (essentially, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 30060**] syndrome) or to end-stage kidney disease and hemodialysis. GI recommended outpatient capsule endoscopy to better evaluate the small bowel, which could be a potential source of bleed. She is scheduled for capsule endoscopy on [**11-3**]. 2. MECHANICAL AORTIC VALVE- Ms [**Known lastname 47133**] outpatient regimen of 3mg Coumadin daily was held until INR was 2.5 and bridged with heparin so she would be appropriate for GI procedure on [**10-23**]. After procedure, her Coumadin was re-started without a need for heparin bridging as INR was 2.1. She was discharged on her home regimen of 3mg daily and will need close INR follow-up. INR was 2.1 on day of discharge. 3. END-STAGE RENAL DISEASE- Patient is on Monday, Weds, Friday dialysis schedule and received dialysis on [**9-14**] and [**10-27**]. Nephrocaps and sevalemer were continued. She received 2 units of blood at dialysis on [**10-24**] due to a HCT of 23.1. Her HCT had been around 23-25 throughout the remainder of her hospital course, and she was asymptomatic. She has outpatient renal follow-up. Medications on Admission: 1. Docusate Sodium 100 mg twice daily 2. Nexium 40 mg PO once a day. 3. Senna 8.6 mg PO BID prn 4. Simvastatin 20 mg PO DAILY 5. Amiodarone 200 mg PO DAILY 6. Ambien 5 mg PO at bedtime prn. 7. Lactulose 10 gram/15 mL Solution Oral prn 8. Levothyroxine 88 mcg PO DAILY 9. Warfarin 3 mg Daily 10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY 11. Acetaminophen 1000 mg PO Q 8H as needed for fever/pain. 12. Sevelamer Carbonate 2400 mg PO TID W/MEALS 13. Aranesp (Polysorbate) Injection 14. Aspirin 81 mg PO once a day Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. 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:*0* 9. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Lactulose 10 gram/15 mL Solution Sig: One (1) PO once a day as needed for constipation. 12. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 14. Aranesp (Polysorbate) Injection Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: PRIMARY: GI bleed SECONDARY: coronary artery disease, mechanical aortic valve replacement, end-stage renal disease, diabetes, hypertension Discharge Condition: stable, afebrile, HCT stable Discharge Instructions: It was a pleasure being invovled in your care, Ms. [**Known lastname **]. You were admitted to the hospital with low blood counts and concern for GI bleeding. You had an EGD (scope of your esophagus and stomach) and colonoscopy which revealed no obvious source of bleeding. The GI doctors recommend that [**Name5 (PTitle) **] have an outpatient capsule endoscopy. This is essentially a big pill you swallow that has a camera in it and it can see the parts of your bowel that the EGD and Colonscope can't see. Please keep your capsule endoscopy schedule as below. Your medications have CHANGED as follows: 1. We ADDED pantoprazole 40mg by mouth TWICE per day instead of your nexium 40mg once per day 2. We STOPPED your Aspirin. Please do not take aspirin anymore as it can contribute to GI bleeding. You can continue to take your coumadin for your valve as well as the rest of your other medications as indicated. Please call your physician [**Last Name (NamePattern4) **] 911 if you experience crushing chest pain, intractable nausea or vomiting, fevers/chills, difficulty breathing, or blood in your urine vomit or stool or any other concerning medical symptom. Followup Instructions: 1. DIALYSIS,SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2166-10-24**] 12:00 2. You are scheduled to have an outpatient CAPSULE ENDOSCOPY on Monday [**11-3**] at 8am- please arrive by 730am to [**Hospital Ward Name 1950**] 4 (GI rooms on the [**Hospital Ward Name 516**] of [**Hospital1 18**], [**Location (un) **]) You will need to call [**Location (un) 13544**] at [**Telephone/Fax (1) 13545**] to go over the details of this test. (or if you need to reschedule) She will get you all the information you need prior to the study, so please contact her before your scheduled time. 3. [**Last Name (LF) **],[**First Name3 (LF) **] AV CARE AV CARE [**Location (un) **] (NHB) Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2166-12-8**] 8:00 Completed by:[**2166-10-27**]

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icd9cm

[ [ [] ] ]

[ "45.23", "39.95", "45.13" ]

icd9pcs

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1911

Discharge summary

report

Admission Date: [**2189-2-18**] Discharge Date: [**2189-2-21**] Date of Birth: [**2144-6-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5608**] Chief Complaint: hypertension & possible change in MS Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 44 year-old male with h/o metastatic renal cell carcinoma s/p nephrectomy and renal insuficiency who is admitted for BP control and concern about cognitive function. . He presented this morning to outpatient oncology clinic to get a CT torso follow up CT scan. He has been on Sutent therapy since [**Month (only) 404**]. He was admitted early for pre-hydration due his poor renal function. He received mucomist, d51/2 normal and d5/Bicarb, He also discontinued his lisinopril per renal recomendations and his metoprolol was increased to control his BP. BP elevation is common in the setting of sutent therapy. At home, his BP has been ranging 140s-170s/ 80s-90s. While in the treatment area, he reported a frontal headache with elevated BP 186/104. He was given tylenol for headache, and IV BP meds including hydralazine and lasix. Upon evaluation, he also had difficulties performing "serial 7's" which was a significant change from his baseline. . Of note, in [**7-10**]/[**2187**], he developed posterior leukoencephalopathy in the setting of gemcitabine and Sutent chemotherapy. He did required ICU care to control his BP with esmolol and NTG. Per oncology fellow report, the first sign of his rapid deterioration was inability to perform serial 7. He later on deteriorated until he was unable to recognize his wife or remember his [**Hospital1 **] names. . Given this prior episode, there was a concern for rapid deterioriation and being unable to control his BP properly. . He received a total of Hydralaxine 30 mg, lisinopril 40 po and lasix 10 mg Iv with still Bp in the 170's. Of note, he also has been gaining weight over the last 3 weeks ~ 30 pounds. with worsenign abdominal distension and lower extremity edema. . He corrently reports a /10 headache, frontal pulsatile. ROS: Denied fever, chills, SOB, cough, chest pain, abdominal pain, blood in stools Past Medical History: Renal cell carcinoma - debulking nephrectomy with regional lymph node dissection on [**2187-11-16**] - dendritic cell fusion vaccine trial- [**2-6**] -Sutent & Gemzar on ([**Date range (3) 10646**]) Protocol # 04-385; taken off study for posterior leukoencephalopathy (see DC summary [**2188-7-23**]) -torisel ([**Date range (1) 10647**]) -sutent,continuous ([**Date range (3) 10648**]) Social History: He is married with 3 children. Employed as a lawyer at a pharmaceutical company. He denies tobacco, alcohol, or IVDA. Family History: Sister with [**Name (NI) 4522**] disease. No other history of gastrointestinal diseases. Physical Exam: Vitals: T:97.7 P:76 R:18 BP:179/101 SaO2: 99 RA General: Awake, alert, NAD HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus Neck: supple, no JVD Pulmonary: Decrease breath sounds bases. no crackles. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND,, ? shifting dullness. Extremities: 2+ edema. up to the knees. upper extremity edeam hands Skin: vesicules in the knuckles with erythema. Neurologic: alert, oriented x3, CN Ii-XII normal. DTR ++/++++, strenght [**4-6**] upper and lower extremities. coordination finger to nose ok. serial 7 ok, spelling world backwards normal. Pertinent Results: LABS: [**2189-2-18**] 04:25PM BLOOD Glucose-97 UreaN-26* Creat-1.7* Na-132* K-5.4* Cl-106 HCO3-18* AnGap-13 [**2189-2-19**] 03:52AM BLOOD Glucose-96 UreaN-28* Creat-1.7* Na-131* K-7.1* Cl-108 HCO3-16* AnGap-14 [**2189-2-19**] 10:00PM BLOOD Glucose-119* UreaN-28* Creat-1.9* Na-133 K-5.3* Cl-109* HCO3-18* AnGap-11 [**2189-2-20**] 05:24AM BLOOD Glucose-99 UreaN-28* Creat-1.8* Na-133 K-5.3* Cl-109* HCO3-17* AnGap-12 [**2189-2-19**] 03:52AM BLOOD ALT-29 AST-36 LD(LDH)-268* AlkPhos-211* TotBili-0.1 [**2189-2-20**] 05:24AM BLOOD WBC-3.9* RBC-2.51* Hgb-7.4* Hct-23.3* MCV-93 MCH-29.7 MCHC-32.0 RDW-23.5* Plt Ct-244 . MRI Head [**2189-2-18**] IMPRESSION: Subtle areas of FLAIR and T2 hyperintensity in the left frontal and parietal and occipital lobes bilaterally. The findings are less prominent than on the previous study and could represent resolving posterior reversible leukoencephalopathy. Continued followup recommended. No evidence of an acute infarct. . CT Chest/Abd/Pelvis [**2189-2-18**] IMPRESSION: 1. Interval progression of disease as demonstrated by the development of innumerable new pulmonary nodules in comparison to the torso CT of [**2188-12-1**]. New and enlarging hepatic metastases as well as interval increase in size of nephrectomy bed and retroperitoneal lesions as compared to [**2189-1-21**]. 2. Increasing bilateral pleural effusions. 3. Ground-glass nodular opacities at the lung bases, which could reflect atelectasis and underlying nodules, although lymphangiectatic tumor spread is not entirely excluded. Brief Hospital Course: The patient is a 44 year-old male with h/o metastatic renal cancer s/p nephrectomy currently on sutent therapy who admitted with elevated BP and change in cognitive function. The patient was admitted to the [**Hospital Unit Name 153**] from [**Date range (1) 10649**] for further control of BP. Hospital course is as follows by problem: # Hypertension: The patient had prior episode of posterior leukoencephalopathy in the setting of hyptertensive urgency requiring strict BP control. He is on Lisinopril and a BB at home, with etiology of hypertension believed to be [**1-3**] to sutent. The patient's ACEI was held given planned contrast study and in this setting had elevated SBP up to 186 w/ question of mental status changes. Given concern for possible reoccurance of prior leukoencephalopathy, the patient was admitted to [**Hospital Unit Name 153**] for tight BP control. At time of admission, patient c/o only mild headache and denied chest pain, SOB, palpitations. EKG was unremarkable. He was initially on IV medications, including esmolol and hydralazine prn. He was transitioned to oral medications which was uptitrated as necessary to Metoprolol 50mg TID and Hydralazine 75 mg TID. Lisnopril was not restarted given hyperkalemia (see below). . # Decrease in cognitive function: Upon admission to the [**Hospital Unit Name 153**] the patient was alert and oriented x3 with normal neurological exam. No deficits were noted on mini-mental. Strict BP control was attempted as above. Neurological exam remained stable throughout admission. MRI [**2-18**] showed possible resolving posterior reversible leukoencephalopathy with no acute infarct seen on imaging. . # Onc/ renal cell carcinoma: The patient is currently on sutent therpay, as above. CT Torso [**2-18**] shows interval progression of disease. He will f/u in onc clinic on [**2-23**] for further discussion of management. . # Hyperkalemia: The patient has a history of hyperkalemia and nephritic range proteinuria with baseline K+ between [**4-7**]. On admission he had a K of 7, which trended down to 5.3 with lasix, kayexalate, and sodium bicarbonate. EKG was unremarkable, as above. Etiology was felt to possibly be secondary to RTA & non-complaince with home regimen of kayexalate & sodium bicarb. . # CKD: The patient has chronic disease with baseline creatinine 1.7 and known nephrotic range proteinuria thought to be secondary to Torisel. The patient had a urine Anion Gap +18 consistent with RTA, but urinary ph 5.5. He is followed by the renal service as outpatient. Creatinine remained stable throughout admission with no acute issues. He will f/u in nephrology clinic for further management. . # Diffuse edema: The patient had diffuse edema likely secondary to nephrotic range proteinuria. There were no signs of pulmonary edema. Per his report, gaining weight over last 3 weeks. This improved throughout admission with lasix. . # Anemia: The patient has a history of normocytic, normochronic anemia with BL HCT in mid-20s. He was transfused 1u PRBC on [**2-20**] for HCT 23 and was given IV lasix before and after transfusion to prevent fluid overload. He tolerated this well with appropriate increase in hct. . # The patient was discharged home on [**2-21**] in good condition, afebrile, VSS, with mental status at baseline and improved BP control. He will f/u in onc clinic on [**2-23**]. Medications on Admission: Lisinopril - on hold last 2 days Metoprolol 25 mg QID Lorazepam 1 mg 2 tab qhs and every 6 hr PRN insomnia Megace 10 daily Oxycontin 10 [**Hospital1 **] Percocet PRN Sunitinib until yesterday evening Ferrous sulfate Senna Vitamin B12 daily colace Ascorbic acid Calcium carbonate Discharge Disposition: Home Discharge Diagnosis: Mental status changes Hypertensive Hyperkalemia Renal Cell Carcinoma Discharge Condition: Stable Discharge Instructions: You were admitted with mental status changes likely due to hypertensive encephalopathy as you improved significantly when the blood pressure was better controlled and the MRI scans showed improvement from previous studies. You also developped high potassium in your blood that was treated with kayexalate, lasix & restarting sodium bicarbonate tabs. We have stopped your lisinopril, you should not be taking this anymore unless instructed by a physician. [**Name10 (NameIs) **] have started an additional blood pressure medication called Hydralazine 75mg every 8hrs & we have increased the Metoprolol to 50mg every 8hrs. Please check your blood pressure regularly over the weekend and call your physician if you see any measurements greater than 160/80. Followup Instructions: You have an appointment on [**2-23**] with Hem/Onc. Please be sure to call in over the weekend if you develop a single blood pressure [**Location (un) 1131**] over 160/80.

[ "197.0", "V10.52", "197.7", "276.2", "585.9", "437.2", "285.22", "588.89", "276.7" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8828, 8834

5121, 8498

352, 358

8946, 8954

3562, 5098

9759, 9934

2834, 2924

8855, 8925

8524, 8805

8978, 9736

2939, 3543

276, 314

386, 2270

2292, 2682

2698, 2818

10,814

141,014

52776

Discharge summary

report

Admission Date: [**2159-12-20**] Discharge Date: [**2159-12-26**] Date of Birth: [**2079-1-17**] Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Streptomycin / Citric Acid / Atenolol Attending:[**First Name3 (LF) 1674**] Chief Complaint: Lethargy, fall Major Surgical or Invasive Procedure: none History of Present Illness: This is an 80 year-old man/woman with the history below who presents after a fall at homoe last night: per wife, he slid off of bed onto bottom, mechanical fall, did not hit head, no LOC. Had not been feeling well the day prior, "weak", slept all day. Had a cough at night. Denies fevers, chills, nausea, vomiting, dysuria. Came to the ED, found to be hypoxic (room air sat 92%) and febrile to 102.9. CXR negative, but given cough and fever, pt. given one gram of ctx. then 500 mg levofloxacin emperically for pneumonia. Cardiac enzymes were negative for the first set, UA negative. Hemodynamically stable. Creatinine was very slightly elevated above baseline, was given IV hydration (2 litres NS) and admitted. Blood and urine cultures are pending. Past Medical History: Hx of presyncope . - Conduction system disease: right bundle branch block, left anterior fascicular block, borderline PR interval . - [**Company 1543**] Virtuoso dual chambered ICD: [**Company 1543**] 6949 Fidelis lead which is the subject of a recently released FDA recall. For this reason his numbers of detection in the VF zone were lengthened ([**2159-11-20**])and the alarms for his impedance measurements were narrowed. He remains programmed in DDD mode with a lower rate of 70, and to treat rates greater than 188 beats per minute . - severe cardiomyopathy with LVEF of 35%, LVH, moderate mitral regurgitation, status post cardiac arrest in [**Month (only) 956**], chronic atrial fibrillation, status post ICD placement, multiple cardioversions with other conduction abnormalities, one vessel coronary artery disease, bare metal stent placed . -initially diagnosed with rectal cancer T3 N0, stage IIA, in 03/[**2157**]. He received neoadjuvant 5-FU and radiation and then underwent [**Month (only) **] surgery in 09/[**2157**]. On that surgery, he was found to have no positive lymph nodes. He received 4 cycles of 5-FU and leucovorin adjuvantly . BPH Incidental R liver cyst - stable since [**4-19**] Diverticulosis Basal cell CA of the nose - removed [**2157-2-15**] CVA [**2150**] - resulting in dysesthesias R hand - imaging consistent with lacunar hypodensity c/w lacunar infarct, L cerebellar hypodensity c/w chronic infarct Cervical spondylosis Hypertension varicose veins Sleep apnea on CPAP Social History: lives in [**Location 745**] with wife [**Name (NI) **], one son, one daughter, 6 grandchildren, retired computer science professor, former heavy cigar smoker, quit in [**2150**], [**2-17**] drinks per week Family History: Father died MI in 80s, Mother died PE in 80s, twin sister died of colitis age 30s, no family h/o colon, breast, uterine, or ovarian ca Physical Exam: T Max (past 24 hours): 102.9 Temp: 98 BP:110/66 HR: 90 RR: 18 Oxygen Saturation 98 3L (on room air) General Appearance: pale, comfortable, NAD . Ophthalmologic/Eyes: : PERLLA, EOMI, mild conjuctival injection, anicteric . Otolaryngologic (ENT): no sinus tenderness, dry mucous membranes, oropharynx without exudate or lesions, no supraclavicular or cervical lymphadenopathy, no thyromegaly or thyroid nodules . Cardiovascular: Irregular rate and rhythm, fixed split S2, no murmurs, rubs, or gallops appreciated. No carotid bruits. JVD flat (less than 6 cm) . Respiratory: CTA b/l with good air movement throughout - no rales or wheezes . Gastrointestinal/abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly . Genitourinary: foley draining dark colored (amber) urine . Musculoskeletal: no cyanosis, clubbing or edema . Integumentary: skin dry, no rashes, no jaundice . Neurological: Alert. Oriented to self, time, place, situation. CN II-XII intact. Moving all four extremities. . Psychiatric:pleasant, appropriate affect. . Heme/Lymph: no cervical or supraclavicular lymphadenopathy Pertinent Results: [**2159-12-20**] 12:50AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2159-12-20**] 12:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2159-12-20**] 12:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2159-12-20**] 12:50AM PT-19.8* PTT-31.3 INR(PT)-1.9* [**2159-12-20**] 12:50AM PLT COUNT-116* [**2159-12-20**] 12:50AM NEUTS-70.3* LYMPHS-19.7 MONOS-8.7 EOS-0.4 BASOS-0.9 [**2159-12-20**] 12:50AM WBC-2.7* RBC-4.14* HGB-12.3* HCT-36.7* MCV-89 MCH-29.8 MCHC-33.6 RDW-15.3 [**2159-12-20**] 12:50AM CK-MB-3 [**2159-12-20**] 12:50AM cTropnT-0.02* [**2159-12-20**] 12:50AM CK(CPK)-288* [**2159-12-20**] 12:50AM estGFR-Using this [**2159-12-20**] 12:50AM UREA N-30* CREAT-1.8* SODIUM-132* POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-22 ANION GAP-19 [**2159-12-20**] 01:22AM LACTATE-3.1* [**2159-12-20**] 04:01AM LACTATE-1.1 [**2159-12-20**] 09:15AM PT-19.8* PTT-34.9 INR(PT)-1.8* [**2159-12-20**] 09:15AM PLT SMR-LOW PLT COUNT-99* [**2159-12-20**] 09:15AM WBC-6.0# RBC-4.15* HGB-12.2* HCT-37.9* MCV-91 MCH-29.3 MCHC-32.1 RDW-14.7 [**2159-12-20**] 09:15AM CALCIUM-8.1* PHOSPHATE-3.3 MAGNESIUM-1.9 [**2159-12-20**] 09:15AM CK-MB-7 cTropnT-0.03* [**2159-12-20**] 09:15AM ALT(SGPT)-27 AST(SGOT)-48* LD(LDH)-356* CK(CPK)-356* ALK PHOS-61 TOT BILI-2.4* [**2159-12-20**] 09:15AM GLUCOSE-157* UREA N-28* CREAT-1.6* SODIUM-135 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18 [**2159-12-20**] 04:00PM PT-23.0* PTT-32.2 INR(PT)-2.2* [**2159-12-20**] 04:00PM PLT COUNT-89* [**2159-12-20**] 04:00PM WBC-4.0 RBC-3.77* HGB-11.1* HCT-34.4* MCV-91 MCH-29.4 MCHC-32.2 RDW-14.6 [**2159-12-20**] 04:00PM CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-3.5* [**2159-12-20**] 04:00PM CK-MB-12* MB INDX-3.4 cTropnT-0.19* [**2159-12-20**] 04:00PM ALT(SGPT)-28 AST(SGOT)-52* LD(LDH)-341* CK(CPK)-357* ALK PHOS-49 TOT BILI-1.6* [**2159-12-20**] 04:00PM GLUCOSE-166* UREA N-28* CREAT-1.6* SODIUM-132* POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-13 [**2159-12-20**] 07:44PM URINE MUCOUS-MOD [**2159-12-20**] 07:44PM URINE HYALINE-[**3-19**]* [**2159-12-20**] 07:44PM URINE RBC-[**6-24**]* WBC-[**3-19**] BACTERIA-FEW YEAST-NONE EPI-0 [**2159-12-20**] 07:44PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2159-12-20**] 07:44PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 Brief Hospital Course: 80 year-old man with a history of severe cardiomyopathy with LVEF 30% with hx. cardiac arrest, DDD pacer, ICD, and stent to Cx. artery, chronic afib on anticoagulation, presenting with one day history of lethargy, cough, and s/p mechanical fall without trauma, found to be febrile and hypoxic in the emergency department, concerning for early pneumonia. . 1) Fever and hypoxia - history most consistent with a viral pneumonia. No definiative lobar, bacterial process. Continued levofloxacin emperically with improvement. . 2) Leukopenia and thrombocytopenia (relative): Resolved. . 3) Malaise, somnolence, anorexia - all likely due to infection, viral vs. bacterial pneumonia. Monitor, encourage PO intake. . 4) Chronic Systolic Heart Failure due to CAD with hx. cardiac arrest and mult conduction system abnormalities s/p pacer and ICD: Ruled out MI. Cont. ASA, Plavix. . 5) Chronic Kidney Disease, stage III: C r at baseline, slight elevation, but NOT acute renal failure (not up by 25%). . 6) Dehydration, mild. Hold lasix as above for now, gentle IVF until taking adequate PO. . 7) Atrial Fibrillation - rate controlled. Continue toprol, warfarin. . 8) Sleep apnea on CPAP - asked wife to bring machine from home - she will today. . Medications on Admission: aspirin 325 mg daily, Plavix 75 mg daily, Lasix 20 mg daily, lisinopril 5 mg daily, Toprol-XL 25 mg daily, Flomax 0.4 mg at bedtime, and warfarin 2 mg. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CHF exacerbation Atrial fibrillation viral syndrome Discharge Condition: stable Discharge Instructions: Weigh yourself every morning. If your weight ever increases by more than 2 pounds in one day, please call your doctor. Be sure to take Lasix 20 mg per day. Be sure to complete all of your antibiotics. Followup Instructions: Please be sure to follow up with nurse [**Doctor Last Name **] of cardiology -Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2160-1-23**] 11:30 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2160-1-23**] 3:00 Call the infectious disease clinic for an appointment within the next month: ([**Telephone/Fax (1) 6732**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2160-1-16**]

[ "428.23", "V45.02", "414.8", "403.90", "276.51", "276.1", "284.1", "276.3", "584.9", "410.71", "480.9", "427.1", "428.0", "V10.06", "600.00", "585.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8131, 8189

6683, 7928

349, 356

8285, 8294

4193, 6660

8546, 9163

2920, 3056

8210, 8264

7954, 8108

8318, 8523

3071, 4174

295, 311

384, 1144

1166, 2680

2696, 2904

83,182

144,426

42312

Discharge summary

report

Admission Date: [**2117-4-19**] Discharge Date: [**2117-5-12**] Date of Birth: [**2047-9-10**] Sex: M Service: SURGERY Allergies: XIBROM Attending:[**First Name3 (LF) 2836**] Chief Complaint: pancreatitis Major Surgical or Invasive Procedure: [**4-22**] - IR abscess drain placement History of Present Illness: Mr. [**Known lastname **] is a 69 year old male with complicated PMH of necrotizing hemorrhagic pancreatitis c/b abdominal compartment syndrome and cardiac arrest, s/p IR drain placement for drainage of intra-abdominal fluid collections and most recently admitted for upsizing of his drains w/ new cultures that returned w/ GPC/GNR/pseudomonas and was subsequently treated w/ vancomycin and meropenem. During the last admission he also underwent placement of IVC filter and treatment of lower GIB. He was discharged back to [**Hospital 100**] Rehab and there he has been transitioned to TPN and TF's there were stopped for persistent diarrhea.He was found to be Cdiff positive in the beginning of [**Month (only) 958**] and started on PO vanc and rifaximin. He had a CT scan on [**2117-4-13**] which showed a colopancreatic fistual and persistent fluid collections. He is admitted today for IR upsizing of his drains which have been putting out scant fluid in the past several days. He denies N/V, fevers, c/p, SOB or signifant pain. Has persistent liquidy stool as mentioned above. Past Medical History: PMH: 1. Gastroesophageal reflux disease 2. Vitamin deficiency 3. Hypertension 4. B12 deficiency anemia 5. Gastritis 6. Benign prostatic hypertrophy 7. Hyperlipidemia 8. Calculus of the kidney 9. Macular degeneration of the retina 10. Cataracts, status post cataract removal with lens prosthesis 11. necrotizing hemorrhagic pancreatitis c/b multiple abdominal fluid collections 12. pancreatico-colic fistula 13. GIB . PSH: remote: Cataract removal with lens prosthesis [**2116-10-2**]: Bedside decompressive laparotomy for abdominal compartment syndrome [**2116-10-21**]: Re-exploration, [**Last Name (un) **] gastrostomy, debridement of suprapubic subcutaneous tissue, muscle, and fascia. [**2116-12-2**] ([**Hospital1 498**]): exploratory laparotomy, drainage of infected hemorrhagic collections with placement of sump drains x3 [**12-5**] & [**12-8**] ([**Hospital1 498**]): wash out and partial closure of abdominal wound [**2116-12-10**] ([**Hospital1 498**]): closure of abdominal wound [**2116-12-24**] ([**Hospital1 498**]): Open tracheostomy [**2116-12-25**] ([**Hospital1 498**]): Tracheostomy exchange Social History: Currently resident at [**Hospital 100**] Rehab. Accompanied by son who corroborates history. Denies tobacco and alcohol use. Denies IVDY/Illicits. Family History: No family history of pancreatitis or pancreatic malignancy Physical Exam: Gen - chacectic, alert, oriented x1 CV - rrr, no murmur Resp - bilateral rhonchi Abd - multiple [**Last Name (un) **]-pancreatico-cutaneous fistulae draining grey liquid; soft, non-distended, +BS Extr - 1+ edema bilateral lower extremities, 1+ pulses Pertinent Results: [**2117-5-12**] 02:34AM BLOOD WBC-3.8* RBC-2.99* Hgb-8.8* Hct-29.0* MCV-97 MCH-29.5 MCHC-30.4* RDW-15.6* Plt Ct-188 [**2117-5-10**] 03:49AM BLOOD PT-13.9* PTT-45.4* INR(PT)-1.3* [**2117-5-12**] 02:34AM BLOOD Glucose-105* UreaN-38* Creat-0.4* Na-143 K-4.1 Cl-109* HCO3-29 AnGap-9 [**2117-5-12**] 02:34AM BLOOD ALT-77* AST-75* LD(LDH)-125 AlkPhos-442* TotBili-0.4 [**2117-5-12**] 02:34AM BLOOD Albumin-2.1* Calcium-9.3 Phos-3.9 Mg-1.9 Brief Hospital Course: 69 year old male with complicated PMH of necrotizing hemorrhagic pancreatitis c/b abdominal compartment syndrome and cardiac arrest, s/p IR drain placement for drainage of intra-abdominal fluid collections and most recently admitted for upsizing of his drains w/ new cultures that returned w/ GPC/GNR/pseudomonas and was subsequently treated w/vancomycin and meropenem. During the last admission he also underwent placement of IVC filter and treatment of lower GIB. He was discharged back to [**Hospital 100**] Rehab and there he has been transitioned to TPN and TF's there were stopped for persistent diarrhea. He was found to be Cdiff positive in the beginning of [**Month (only) 958**] and started on PO vanc and rifaximin. On the day of admission he was admitted to the floor. HE was started on TPN and C diff was checked. [**4-27**] : admitted to SICU, 750 cc fluid drained from L chest tube w/ pigtail placed, NCHCT wnl, MS [**Last Name (Titles) **]/wane, lasix x 1, Bipap w/ minimal change in resp acidosis, EEG [**4-28**]: off bipap, CO2 unchanged, lowered CO2 load in TPN and halving rate. Lopressor [**Month (only) **] to 50 QID due to [**Month (only) **] BP with afternoon dose. Off bipap, became more somnelent, reintubated around 1900 for hypercarbia, increasing hypoxia, and respiratory failure. MRI pending. Temp to 103->pan cx, IV vanc/cefepime started [**4-20**]: right presaccral drain pulled out accidentaly, Cdiff neg, plan for IR intervention. He was treated for a sacral decubital ulcer. [**Date range (1) 91669**]: Rectal tube discontinued. A new 12Fr drain was placed by IR to presacral collection. His chest was drained with bialteral 20Fr chest tubes to R and L. No further diarrhea. Vancomycin and Rifaxamin stopped, drains flushing well, no BM since flexiseal removed [**4-28**]: patient was noted to have acute MS change and respiratory acidosis. He was transferred to the ICU. A L chest pigtail was placed. Head CT neg, BiPap, 10 lasix administered. He was intubated. EEG performed with background encephalopathy (L slower than R). T102, pan Cx, added cefepime [**4-29**]: Removed left pleural pigtail. CT torso - contents in tracheo-bronchial tree. Bronch removed thick sputum from left lung. BAL sent. t/f 1U pRBC for Hct 25.6. Guiac positive right abdominal drain. Started micafungin. [**4-30**]: Decreased kcals in TPN. 250cc 5% albumin x1 for SBP 80's with improvement to 110's. Hct 25 -> 1u -> 27, hypercarbic->TPN decreased in kilocalories, vent weaned [**5-1**]: on CMV due to elevated CO2. D/c micafungin and flagyl. attempted on CPAP/PS intermittently, becomes tachypnec to 30s-40s. Started TF 10mL/hr, hypercarbic->back on CMV, stopped mica/flag per ID, TPN [**5-2**]: Fentanyl 12.5mcg x3, CPAP for most of day, CMV at night for comfort [**5-3**]: metop 50->75'''', TF adv to goal, TPN dc'd, lasix 10 (fluid overload), f/u urine cx, ID recs, vanc dc'd, cipro d c'd, started on linezolid(enterococc)/tobra/cefep (pseudomonas) [**5-4**]: less tachycardic on metop 75'''', TF to goal, TPN dc'd; ID: d/c linezolid, restart tobra if level <1, rpt UA,UCx; vent weaned to [**5-15**], RSBI 64. Increased output w/ TF's, so restart TPN. [**5-5**]: Hyperchloremic metabolic acidosis, likely [**2-11**] TPN. Decreased chloride in TPN. Passed 2-hour SBT with RSBI 86 and improved ABG. 1u PRBC for Hct 24.6, improved to 29.3. [**5-6**]: RSBI 60s on CPAP 5/5. [**5-7**]: Change KVO fluid to D5W; t/f 1U pRBC for Hct 25.8. [**5-8**]: RSBI in afternoon: 77; in PM: 66-90 [**5-9**]: Extubated in AM. Episode of desaturation to low 90's x2, improved with coughing, chest PT, and turning left side up. Increased metoprolol. Noted left lateral drain out when changing dressing overnight. [**5-10**]: family meeting to establish long term goals of care, during PM shift, made DNR per family and pt wishes (no CP/medications), however may be intubated [**5-11**]- [**5-12**]: Patient stable on tpn,still with continued feculent drain output. Dcd to rehab. Medications on Admission: Meds from [**Hospital 100**] Rehab ([**4-19**]): ANTIBIOTICS: IV ciprofloxacin [**Hospital1 **], oral vancomycin 125 mg q6 hrs via G-tube, IV vancomycin 1250 mg qd (last trough 12.8 on [**2117-4-15**]), flagyl 500''', fluconazole 400 po qd, rifaximin 400''' . OTHER MEDICATIONS: cadexomer iodine gel', cipro 0.3% opth soln 1gtt'''' OD (right), insulin lispro sliding scale, lactobacill gg/lactinex 1 tab po tid, metoprolol tartrate 100'''' via G-tube, miconazole 2% pwd', octreotide 50mcg tid, pantoprazole IV 40', , sodium bicarbonate 325''', tobramycin/dexamethasone 1gtt OD qhs, TPN with lipids Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. insulin regular human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED). 3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**1-11**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 6. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO Q6H (every 6 hours). 7. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 8. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 9. dextrose 50% in water (D50W) Syringe Sig: 12.5 gm Intravenous PRN (as needed) as needed for hypoglycemia protocol. 10. fentanyl citrate (PF) 50 mcg/mL Solution Sig: 12.5-25 mcg Injection Q4H (every 4 hours) as needed for pain. 11. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Necrotizing hemorrhagic pancreatitis requiring IV anbiotics and drain placement, upsizing Discharge Condition: Stable. Note family wishes for: DNR (however, pt may be intubated if required.) Discharge Instructions: DIET: Absolutely strict NPO. No TF until approved by the patient's surgeon. DRAIN CARE: Pre sacral- flush with 5 cc saline and aspirate until nothing comes out q6hr Left flank- flush with 5 cc saline and aspirate until nothing comes out q6hr Right flank- to intermittent wall suction, ensure that it keeps sumping Patient should not have any tube feeds or PO feeds due to fistula, and should only be maintained on TPN. All drains should be to suction and flushed with 10cc q 6hrs. Followup Instructions: Infectious disease appointment: patient will be discharged on IV cefipime, to continue until [**2117-5-20**]. Patient may follow-up with Dr. [**Last Name (STitle) **] on [**2117-5-17**] at 11:30AM or with Dr.[**Name (NI) **] at his rehab facility. Provider: [**Name10 (NameIs) 14621**] [**Last Name (NamePattern4) 14622**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2117-5-17**] 11:30 Please follow-up with Dr. [**First Name (STitle) **] in 2 weeks. Completed by:[**2117-5-12**]

[ "507.0", "272.4", "707.03", "V12.51", "577.8", "518.81", "V45.61", "V12.53", "530.81", "707.09", "569.81", "038.9", "362.50", "V43.1", "599.0", "276.4", "511.9", "V13.01", "707.22", "567.22", "577.0", "785.0", "577.1", "V49.86", "600.00", "041.7", "995.92", "293.0", "348.30", "401.9", "281.1", "268.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "34.04", "96.6", "96.72", "99.15", "96.04", "33.24", "38.91" ]

icd9pcs

[ [ [] ] ]

9377, 9443

3556, 7545

279, 320

9576, 9657

3099, 3533

10187, 10676

2752, 2813

8194, 9354

9464, 9555

7571, 8171

9681, 10164

2828, 3080

227, 241

348, 1434

1456, 2570

2586, 2736

109

125,288

14799

Discharge summary

report

Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]

[ "284.1", "V58.61", "789.00", "710.0", "285.9", "585.6", "V12.51", "403.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

10991, 10997

6599, 8992

305, 320

11192, 11216

4031, 4031

12296, 12771

3224, 3348

9423, 10968

11018, 11018

9018, 9400

11240, 12273

4916, 6576

3363, 4012

245, 267

348, 1295

11112, 11171

4047, 4900

11037, 11091

1317, 2997

3013, 3208

109

135,923

14803

Discharge summary

report

Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]

[ "327.23", "V12.51", "789.09", "V45.89", "V58.61", "285.21", "710.0", "403.01", "287.5", "300.4", "585.6", "V45.11", "799.02", "425.1", "E935.2" ]

icd9cm

[ [ [] ] ]

[ "39.95", "93.90" ]

icd9pcs

[ [ [] ] ]

10136, 10142

4922, 8582

308, 314

10250, 10323

4406, 4899

11330, 12060

3850, 3975

9057, 10113

10163, 10163

8608, 9034

10347, 11307

3990, 4387

241, 270

342, 1751

10182, 10229

1773, 3622

3638, 3834

27,184

188,377

1031

Discharge summary

report

Admission Date: [**2133-2-3**] Discharge Date: [**2133-2-13**] Service: MEDICINE Allergies: Streptokinase / Avandia / Amiodarone / Phenergan / Morphine / Percocet Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: chronic cholecystitis with cholelithiasis Major Surgical or Invasive Procedure: laparoscopic cholecystectomy History of Present Illness: This 86-year-old gentleman recently presented with a bad flareup of acute cholecystitis which put him in the hospital at [**Hospital1 3343**] for a number of days back in [**Month (only) 359**]. He admits to having a 20-year history of abdominal pain with known gallstones. He is a diabetic. He also has a cardiac history including coronary artery bypass graft with anticoagulation for atrial fibrillation. Dr. [**Last Name (STitle) **] met Mr. [**Known lastname **] and his family in my office and discussed the fact that he has recurrent problems and symptoms from known gallstones. He has not yet had an ERCP although an EUS showed that he has no evidence of stones in his bile duct. Dr. [**Last Name (STitle) **] indicated that a laparoscopic cholecystectomy would be indicated for his [**Last Name **] problem in that this has become quite symptomatic for him. I did tell him that this would be a bit risky due to his age as well as his cardiac comorbidities and the fact that he is on anticoagulation. The risks and benefits were discussed. He understood these risks and wished to proceed, and provided informed consent to that effect. Past Medical History: - Diverticulosis - s/p lower GI bleed with recent admission as noted above - Ischemic cardiomyopathy, NYHA Class III - Coronary artery disease s/p CABGx2 ([**2109**] and redo [**2118**]) - Chronic systolic congestive heart failure with severely depressed ventricular function, last LVEF 25% - Biventricular pacemaker and [**Year (4 digits) 3941**], s/p AVJ ablation [**2125**] - Diabetes Mellitus - Chronic a-fib - s/p MVA [**6-15**] injuring back, chest & hit head - Chronic renal insufficiency, stage 3 - Cholelithiasis - Pancreatic cysts - Hyperlipidemia - Gunshot wounds to left lower extremity with decreased sensation - Low back pain - Cataracts Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: Noncontributory Physical Exam: On physical exam, his abdomen is soft, nontender and nondistended with positive bowel sounds. He has no evidence of a [**Doctor Last Name 515**] sign. His CABG incision goes down into the epigastrium. There is no evidence of any hernias in either his abdomen or inguinal region. A rectal exam was deferred today. The rest of his physical exam is normal. His cardiac exam shows an irregular rhythm. Pertinent Results: EKG: Afib with ventricular pacing at 69bpm, wide QRS in RBBB pattern. . TELEMETRY: Ventricular pacing. . Gall Bladder pathology: Gallbladder: Chronic cholecystitis Cholelithiasis, cholesterol-type. . Admission labs: [**2133-2-3**] 10:31AM TYPE-ART PO2-222* PCO2-113* PH-7.02* TOTAL CO2-31* BASE XS--5 INTUBATED-NOT INTUBA COMMENTS-AMBUED [**2133-2-3**] 10:31AM O2 SAT-98 [**2133-2-3**] 10:54AM WBC-10.2# RBC-4.07* HGB-11.8* HCT-36.4* MCV-89 MCH-29.1 MCHC-32.6 RDW-14.5 [**2133-2-3**] 10:54AM PLT COUNT-172 [**2133-2-3**] 10:54AM GLUCOSE-336* UREA N-43* CREAT-1.6* SODIUM-135 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15 [**2133-2-3**] 10:54AM CALCIUM-8.0* PHOSPHATE-5.5*# MAGNESIUM-2.0 [**2133-2-3**] 10:54AM ACETONE-NEGATIVE . Discharge labs: [**2133-2-13**] 07:05AM BLOOD WBC-6.2 RBC-2.74* Hgb-8.1* Hct-24.0* MCV-88 MCH-29.8 MCHC-33.9 RDW-15.5 Plt Ct-263 [**2133-2-13**] 07:05AM BLOOD Plt Ct-263 [**2133-2-13**] 07:05AM BLOOD PT-27.2* PTT-41.4* INR(PT)-2.7* [**2133-2-13**] 07:05AM BLOOD Glucose-122* UreaN-46* Creat-1.4* Na-135 K-3.8 Cl-97 HCO3-29 AnGap-13 [**2133-2-13**] 07:05AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.2 Brief Hospital Course: Mr. [**Known lastname **] was admitted to Dr.[**Name (NI) 2829**] Pancreaticobiliary Surgery Service on [**2133-2-3**] and underwent laparoscopic cholecystectomy. He tolerated the procedure well, but his post-operative course was complicated by respiratory distress in the PACU requiring reintubation and admission to the Surgical ICU. After transfer to the ICU, he was weaned from the vent and then extubated and subsequently transferred to the floor. The rest of his post-operative course was uneventful, however, due to his age, comorbidities and the stress of the surgery, he required a number of days to recover. During that time, he was transitioned off of IV fluids and his diet was advanced. His pain was well controlled on oral medications. Due to his low ejection fraction and the fluid shifts of surgery, the patient's weight had increased from a baseline of the low 130s to the mid 140 lb range. Thus, on POD 5, in consultation with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], the patient was transferred to the Cardiology service for management of his fluid overload secondary to his congestive heart failure in the setting of a surgical intervention and the associated fluid shifts. On the cardiology service he was diuresed with 80mg IV lasix, followed by a lasix drip at 10mg/hr. He tolerated diuresis well, with no signs of hemodynamic compromise. He self-reported his dry weight to be 135 lbs. On transfer he was at 68kgs (150lbs) with pitting posterior thigh and buttock edema. His creatinine rose slightly to 1.6, but came down to 1.4 prior to discharge. His weight was approximately 64kgs (140lbs) at the time of discharge. He was returned to his previous home dose of 80mg once a day, to be titrated as needed to maintain his weight. The patient had mild abdominal pain post-surgically, that worsened [**2133-2-12**]. He was found to have low pelvic pain. He had been having small, frequent urination while being diuresed. A foley catheter was placed, draining 800ccs of urine with resolution of his pain. The foley catheter was left in place and he was started on Flomax (tamsulosin). He will follow up with urology to do an outpatient voiding trial [**2133-2-25**] after his bladder has had time to recover. In the setting of his urinary retention, a UA and urine culture were checked. The UA was equivocal (mildly elevated WBCs but no bacteria). The culture grew >100,000 colonies of enterococcus and the patient later complained of slight burning with his foley catheter. He was started on amoxicillin 875mg Q12 hours for a 14-day course. The patient has atrial fibrillation, s/p pacer placement and AV junction ablation. He restarted coumadin post-op with a lovenox bridge. Once his INR was stably over 2.0, his lovenox was stopped. Prior to discharge his INR was 2.7, and his goal INR has been 1.5-2.5 because of bleeding complications. He was discharged on a half dose of Coumadin (1.25mg daily) and will follow-up with the [**Hospital 18**] [**Hospital 197**] clinic. He will follow-up in Dr.[**Name (NI) 2829**] clinic in three weeks for a post-op check. He had staples in his scalp from a fall prior to discharge. The staples were removed and steri-strips placed. He was seen by physical therapy who felt he could walk well, even with a foley bag in place. Medications on Admission: lipitor 40', Carvedilol 6.25", digoxin 125mcg', enalapril 10", lovenox, eplerenone 25', Lasix 80', Isosorbide Monoitrate SR 30', levothyroxine 150mcg', Nitrostat 0.4mg prn Chest pain, protonix 40", Miralax [**Hospital1 **], Coumadin (has been on hold x 1 week), ambien 5', ASA 81', Vitamin B12, Fish oil, Vitamin B6, Lantus 32 qAM, Humalog SS Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous QAM. 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual Q5 minutes as needed for chest pain: Up to three doses. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO twice a day. 12. Warfarin 2.5 mg Tablet Sig: 0.5 (half) Tablet PO DAILY (Daily): Dosage to be titrated by your doctor. 13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 17. Vitamin B-6 Oral 18. Fish Oil Oral 19. Vitamin B-12 Oral 20. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous QACHS: Please resume your home insulin sliding scale. 21. Outpatient Lab Work Please have your hematocrit and INR drawn and the results faxed to the [**Hospital 18**] [**Hospital 197**] Clinic at ([**Telephone/Fax (1) 3053**]. 22. Amoxicillin 875 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: vna carenetwork Discharge Diagnosis: chronic cholecystitis with cholelithiasis congestive heart failure Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted for a cholecystectomy. The surgery went well, but afterwards you were fluid overloaded and were transferred to the cardiology service for diuresis. Your weight came down and you are now ready to go home. You will get physical therapy at home to help you regain your strength. . While you were here, you had trouble urinating, most likely because your prostate is enlarged. A foley catheter was placed. You will keep the foley catheter in until your urology appointment. You were also found to have a urinary tract infection and were started on an antibiotic, augmentin. You should take augmentin for two weeks. . You have chronic heart failure and need to monitor your fluid status very closely. Weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. Try to limit your salt intake to 2 grams daily. . Some changes were made to your medications: - We lowered your coumadin for the next few days. You should take half of a 2.5mg tablet once a day. - We started flomax (tamsulosin) to take once a day at night. - We started augmentin 875mg by mouth to be taken twice a day. Followup Instructions: Please follow up with [**Doctor First Name **], the NP in Dr.[**Name (NI) 3536**] office on [**2-25**] at 10am. You can call his office at ([**Telephone/Fax (1) 3942**] to confirm that appointment. That same morning, [**2-25**], you should follow up in the urology clinic at 8am. Their phone number is [**Telephone/Fax (1) 164**]. Please follow-up in Dr.[**Name (NI) 2829**] office in 3 weeks, Friday, [**3-6**]. You can call ([**Telephone/Fax (1) 2363**] to set up an appointment time. Completed by:[**2133-2-15**]

[ "250.00", "428.0", "428.23", "041.4", "585.3", "574.10", "V58.67", "V45.01", "V58.61", "E885.9", "V45.81", "873.0", "414.00", "427.31", "599.0", "414.8", "403.90", "788.20", "V45.02", "518.5" ]

icd9cm

[ [ [] ] ]

[ "51.23", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

9675, 9721

3980, 7322

327, 357

9831, 9831

2807, 3015

11166, 11686

2351, 2368

7715, 9652

9742, 9810

7348, 7692

10007, 11143

3581, 3957

2383, 2788

246, 289

385, 1534

3031, 3565

9845, 9983

1556, 2209

2225, 2335

47,100

102,357

53338

Discharge summary

report

Admission Date: [**2141-4-6**] Discharge Date: [**2141-4-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 86 yo Iranian (farsi speaking) male with h/o COPD (on home o2 (uses 2-3h qdaily of home o2 overall), HTN, restless leg syndrome, h/o anemia (prior studies showing thalesemia) and BPH presenting today with 2 days symptoms of SOB and AMS. Per daughter and pt - pt was in his USOH till 2 days prior - started having increasing SOB along with new cough with increasing sputum production, no f/c, no cp, no HA, ab pain, n/v, but + constipation - along with sob sx - pt with decreasing po intake - noted decreased urinary production yesterday with darker urine - today in ED with increased intake has finally increased production. Pt denies any recent changes in urination prior - BPH controlled without sx of dribbing, urgency, change of frequency till just yesterday. In terms of mentation - pt also has been having mild increased confusion - usually AA0x3 - only x2 now with process as above. In [**Name (NI) **] pt initially 91% on RA - noted pt usually uses o2 3h/day - but using more frequency past couple days without response. Also noted pt having increased fatigue and generalized weakness past couple days without ambulation - at baseline can ambulate (+/- can/walker at times). Pt noted afebrile in ED - given nebs, IV solumedrol and dose of levoquin IV and admitted for copd exacerbation. Review of systems: . Constitutional: No weight loss/gain, +fatigue, malaise, fevers, chills, rigors, night sweats, anorexia. HEENT: +chronic loss of vision, no photophobia. No dry motuh, oral ulcers, bleeding nose or [**Male First Name (un) **], tinnitus, or sinus pain. Cardiac: No chest pain, palpitations, LE edema, orthopnea, PND, but + DOE. Respiratory: +SOB, NO pleuritic pain, no hemoptysis, + cough. GI: No nausea, vomiting, abdominal pain, abdominal swelling, diarrhea, but notable for + constiatpion, no hematemesis, hematochezia, or melena. Heme: No bleeding, bruising. Lymph: No lymphadenopathy. GU: +per HPI. Skin: No rashes, pruritius. Endocrine: No change in skin or hair, no heat or cold intolerance. MS: No myalgias, arthralgias, back or nec pain. Neuro: No numbness, weakness or parasthesias. No dizziness, lightheadedness, vertigo. No confusion or headache. but positive pains in LE from restless leg - controlled with home meds Psychiatric: No active depression or anxiety. Past Medical History: COPD - uses prn home o2 Restless Leg Syndrome HTN CKD Stage III based on review of labs this admission (baseline 1.8-2.0) Depression Knee Replacement Macular Degeneration BPH Thalasemia Social History: Lives at home with wife, daughter lives on floor below. Heavy Tobacco history, 70 years smoking, quit few years ago. no etoh, no drugs Family History: NC - no CAD, but + h/o COPD in family. Physical Exam: Exam VS T current 99.2 BP 120/59 HR 105 RR 20 O2sat: 96% 4L o2nc Gen: In NAD. HEENT: PERRL, EOMI. No scleral icterus. No conjunctival injection. Mucous membranes moist. No oral ulcers. Neck: Supple, no LAD, no JVP elevation. Lungs: +prolonged exp phase with end exp wheezing - mild-mod tight airflow CV: RRR, +[**2-24**] HSM at apex, no r/g Abdomen: soft, NT, ND, NABS Extremities: warm and well perfused, no cyanosis, clubbing, +trace pedal edema Neurological: alert and oriented X 2 - baseline aa0x3 of note per daughter in room, CN [**Name (NI) 12428**] intact. Notable that pt well alert - no evidence of somnulance Psychiatric: Appropriate. GU: deferred. Pertinent Results: [**2141-4-6**] 09:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2141-4-6**] 10:00AM LACTATE-1.1 [**2141-4-6**] 09:50AM BLOOD WBC-11.6* RBC-4.79 Hgb-9.1* Hct-32.0* MCV-67* MCH-19.1* MCHC-28.6* RDW-16.5* Plt Ct-209 [**2141-4-6**] 09:50AM BLOOD Neuts-79.6* Lymphs-13.3* Monos-5.1 Eos-1.8 Baso-0.2 [**2141-4-9**] 05:00AM BLOOD WBC-8.4 RBC-4.45* Hgb-8.9* Hct-28.8* MCV-65* MCH-20.0* MCHC-30.9* RDW-17.5* Plt Ct-176 [**2141-4-7**] 02:00PM BLOOD Type-ART pO2-69* pCO2-105* pH-7.16* calTCO2-40* Base XS-4 Intubat-NOT INTUBA [**2141-4-8**] 12:15PM BLOOD Type-ART pO2-69* pCO2-70* pH-7.31* calTCO2-37* Base XS-5 Admisson CXR: PA AND LATERAL CHEST RADIOGRAPH: Lungs are clear. There is no consolidation, effusion or pneumothorax. Trace pleural thickening is seen in the major fissure on lateral film, likely right sided. A small calcified nodule in the right mid lung likely reflects a granuloma. Hilar and cardiomediastinal contours are unchanged. The aorta is tortuous. There is no evidence for volume overload. There is degenerative change in the thoracic spine, with unchanged wedge deformity of a mid thoracic vertebral body. There are no suspicious lytic or sclerotic osseous lesions. . IMPRESSION: 1. No acute cardiopulmonary process. 2. Unchanged degenerative change with wedge deformity of a mid thoracic vertebral body. . EKG: reviewed - sinus tach - no acute ST/TW changes, old LAD, poor r-wave progression, possible LAE Brief Hospital Course: 86 yo Iranian (farsi speaking) male with h/o COPD (on home o2 (uses 2-3h qdaily of home o2 overall), HTN, restless leg syndrome, BPH transferred for hypercarbic respiratory failure. # Acute on Chronic Hypercarbic repiratory failure: # Acute COPD exacerbation He presented to the ED with shortness of breath and change in mental status. He was admitted to the floor for ARF and COPD exacerbation. He then develooped AMS and and decreased respiratory rate with a gas of 7.16/105/69. This was thought to be secondary to methadone overdose due to taking 30mg [**Hospital1 **] rather than 15mg [**Hospital1 **] when he received 10mg tabs rather than 5mg tabs from his pharmacy. He required BiPAP the first day in the ICU given that his PCO2 was 105 on the floor. He was started on a narcan gtt with improvement of his respiratory status. His narcan gtt was discontinued on [**4-8**] in the AM as he was alert and speaking farsi. He was given fentanyl boluses and ativan while in the ICU to help with withdrawal and to tx his restless leg syndrome. He was started on Solumedrol 125mg IV q6hrs which was continued x2 days, then transitioned to prednisone. He was also started on azithromycin. [**4-9**] his home dose of methadone was restarted 15mg PO BID. Pt is on 2L oxygen at home but taken off oxygen this AM with goal O2 sat 88-92% as likely is chronic CO2 retainer. Patient??????s mental status is at baseline now oriented to self and yr by his calendar, confirmed with family that his mental status is good. He was given Rx for albuterol MDI and is to continue his home inhalers as well. # Acute on Chronic Renal Failure ?????? appeared pre renal in etiology, now resolved. He is to continue his home Tamsulosin and Finasteride, lasix. # Restless Leg syndrome ?????? See above patient may have accidentally overdosed on his methadone. His mental status responded to a narcan gtt. He was given prn fentanyl until [**4-9**] at which point he was restarted on his home methadone 15mg PO BID. Emphasized appropriate dosing to pt, family, and have set up VNA services to ensure he understands his medication. # Anemia, microcytic - has h/o thalessemia. HCT stable during admission. # Code status: he did not require intubation and family reports he does not have any history of COPD hospitalizations. Code status is full, but his providers did discuss with family the possibility of a comfort-focused, noninvasive approach when he was very ill in the unit. Recommend that further goals of care discussion continue with his PCP. Medications on Admission: Below medications confirmed with family with pill boxes: . lasix 40mg qdaily atrovent tid methadone 15 mg [**Hospital1 **] flomax 0.4mg qdaily finasteride 5mg qdaily ocuvite 150-30-6-150 cap qdaily vit b12 1000mcg [**Hospital1 **] cranberry-vit c -vit E 140 -100-3- cap tid Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Methadone 10 mg Tablet Sig: one and a half Tablet PO twice a day: Please look carefully at your bottle at home. Your family reports that the pharmacy recently gave you 10 mg tablets. You should take 15 mg per dose, twice a day. 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 1* Refills:*0* 5. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation three times a day: please continue to take this medication as you were at home. I have not made any deliberate changes. 6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Continue taking this medication (vitamin B12) as you were at home. 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Ocuvite 150-30-6-150 mg-unit-mg-mg Capsule Sig: One (1) Capsule PO daily (): Continue as you have been taking at home. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Hypercarbic respiratory failure Acute COPD exacerbation Restless legs syndrome Chronic kidney disease Anxiety Discharge Condition: stable Discharge Instructions: Please seek medical attention if you develop new shortness of breath, fever, coughing Review your medication list carefully and compare to your bottles at home. Your methadone should be 15 mg twice daily. If you do not already have an albuterol inhaler, you should fill out the prescription we have given you. If you already have one at home, you can continue taking it as prescribed by your primary care physician. [**Name Initial (NameIs) **] have not changed any of your other medications. Followup Instructions: Please contact your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] for a follow-up appointment [**Telephone/Fax (1) 18651**] in the next 1-2 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2141-4-11**]

[ "788.20", "600.01", "276.2", "E937.9", "585.3", "293.0", "285.21", "584.9", "491.21", "282.49", "300.00", "333.94", "790.29", "403.90", "564.09", "518.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9281, 9339

5306, 7852

281, 287

9493, 9502

3773, 5283

10048, 10357

3013, 3053

8177, 9258

9360, 9472

7878, 8154

9526, 10025

3068, 3754

1646, 2635

222, 243

315, 1627

2657, 2844

2860, 2997

60,936

169,986

38267

Discharge summary

report

Admission Date: [**2113-5-5**] Discharge Date: [**2113-5-6**] Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 5018**] Chief Complaint: Reason for consult: intracranial bleeding Major Surgical or Invasive Procedure: CT HEAD DIALYSIS [**2113-5-6**] History of Present Illness: [**Known firstname 5969**] is an 89 year-old right-handed woman with complex past medical history which includes end stage renal disease recently started on dialysis, HTN, AFib s/p pacemaker and in coumadin, hyperlipidemia amoung other conditions who presented with with left sided weakness secondary to right thalamic hemorrhage. Patient had her dialysis session yesterday and she was reportedly more tired than usual. This morning around 9am her daughter woke her up and was helping her to go to the bathroom, when she noted that [**Known firstname 5969**] was leaning to the left side. Patient was returning from the bathroom in her walker when she continuing to lean to the left and ended up falling. Her daughter picked her up and noticed a overall weakness described as "dead weight". There was no LOC, and patient was speaking through the episode. She continue at home waiting for the nurse home to evaluated her. After her evaluation around 11am, 911 was called and patient was transferred to the [**Hospital 85279**] hospital. There she was evaluated and underwent a CT which revealed right basal ganglia hemorrhage. Patient had INR of 2.67 and she received FFP and vit K, doses uncertain and transfer to [**Hospital1 18**] for further care. In the ED [**Hospital1 18**] patient has been stable, if anything she is slightly better according to her daughter report. Of Note: Patient has been in coumadin for the past 3 weeks, after one medical visit that she was noted to have abnormal cardiac rhythm. No details were given. Regarding to her renal disease, [**Known firstname 5969**] started dialysis last month. Dr [**Last Name (STitle) **] is Dr [**Last Name (STitle) **]. The dyalisis sessions happen on: Tuesday, Thursday and Saturday [**Street Address(1) 85280**]. She has a subclavian dialysis catheter. ROS: The pt denied headache, loss of vision, blurred vision, vertigo. Denied difficulties producing or comprehending speech. The pt denied recent fever or chills.Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: PMH: 1. End stage renal disease as above 2. HTN 3. pacemaker for AFib, sick sinus syndrome, presyncope with pauses in [**2108**] 4. History of palpitations 5. Hyperlipidemia 6. Hiatal hernia with GERD 7. Right knee total replacement in [**2096**] 8. Right carotid endarterectomy in [**2108-4-1**] 9. Appendicectomy 10. Uterine suspension 11. Hemorrhoidectomy 12. ex-smoker 13. Remote history of pancreatitis 14. Hearing impairment bilaterally Social History: Social Hx: Lives with her daugther and receives visit from nurse at home. Family History: Family Hx: non-contributory Physical Exam: Physical Exam: Vitals: T: afebrile P: 87bpm RR R: 16 BP: 157/75 SaO2: General: Awake, cooperative, NAD. Falling asleep easily. During the evaluation two episodes of respiratory pause were observed without desaturation. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Neurologic: -Mental Status: awake, easily falling asleep, but also easily arousable.. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was dysarthric. Able to follow both midline and appendicular commands. CN I: not tested II,III: VFF to confrontation, surgical pupils bilaterally, fundi normal III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: left facial weakness VIII: hearing impairment bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**4-5**] bilaterally XII: tongue protrudes midline, Motor: Left leg xternally rotated. Overall thin patient, mildly decreased tone in the left side. Significant asterixis L>R. Evident Left pronator drift. Delt [**Hospital1 **] Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 4 4 4 4 4 4 4 R 5 5 5 5 5 5 5 IP Quad Hamst DF [**Last Name (un) 938**] PF L2 L3 L4-S1 L4 L5 S1/S2 L 4 4 4 4 4 4 R 5 5 5 5 5 5 Reflex: [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 3 3 3 3 3 babinski R 2 2 2 2 2 Flexor -Sensory: No deficits to light touch. Left sided extinction to DSS. -Coordination: No intention tremor. -Gait: not tested. Pertinent Results: [**2113-5-5**] 05:30PM GLUCOSE-82 UREA N-12 CREAT-3.4* SODIUM-139 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-32 ANION GAP-15 [**2113-5-5**] 05:30PM estGFR-Using this [**2113-5-5**] 05:30PM CK(CPK)-40 [**2113-5-5**] 05:30PM cTropnT-0.06* [**2113-5-5**] 05:30PM CK-MB-2 [**2113-5-5**] 05:30PM WBC-7.6 RBC-4.02* HGB-11.8* HCT-36.9 MCV-92 MCH-29.2 MCHC-31.8 RDW-16.4* [**2113-5-5**] 05:30PM PLT COUNT-184 [**2113-5-5**] 05:30PM PT-18.6* PTT-31.0 INR(PT)-1.7* [**2113-5-6**] 01:52AM BLOOD WBC-7.8 RBC-3.88* Hgb-11.2* Hct-36.2 MCV-93 MCH-29.0 MCHC-31.1 RDW-16.6* Plt Ct-184 [**2113-5-6**] 01:52AM BLOOD Neuts-70.7* Lymphs-22.7 Monos-6.0 Eos-0.5 Baso-0.2 [**2113-5-6**] 01:52AM BLOOD PT-14.8* PTT-27.8 INR(PT)-1.3* [**2113-5-6**] 01:52AM BLOOD Glucose-97 UreaN-15 Creat-4.0* Na-139 K-3.8 Cl-97 HCO3-32 AnGap-14 [**2113-5-6**] 10:28AM BLOOD CK(CPK)-31 [**2113-5-6**] 10:28AM BLOOD CK(CPK)-31 [**2113-5-6**] 01:52AM BLOOD ALT-11 AST-17 LD(LDH)-205 CK(CPK)-28* AlkPhos-66 Amylase-104* TotBili-0.5 [**2113-5-6**] 01:52AM BLOOD Lipase-29 [**2113-5-6**] 10:28AM BLOOD CK-MB-3 [**2113-5-6**] 01:52AM BLOOD CK-MB-2 cTropnT-0.07* [**2113-5-5**] 05:30PM BLOOD cTropnT-0.06* [**2113-5-5**] 05:30PM BLOOD CK-MB-2 [**2113-5-6**] 10:28AM BLOOD Cholest-208* [**2113-5-6**] 01:52AM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.3 Mg-1.9 UricAcd-4.5 Cholest-192 [**2113-5-6**] 10:28AM BLOOD %HbA1c-5.2 eAG-103 [**2113-5-6**] 01:52AM BLOOD %HbA1c-5.1 eAG-100 [**2113-5-6**] 10:28AM BLOOD Triglyc-87 HDL-54 CHOL/HD-3.9 LDLcalc-137* [**2113-5-6**] 01:52AM BLOOD Triglyc-97 HDL-51 CHOL/HD-3.8 LDLcalc-122 [**2113-5-6**] 10:28AM BLOOD TSH-0.91 [**2113-5-6**] 01:52AM BLOOD TSH-1.0 [**2113-5-6**] 01:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2113-5-5**] 05:30PM BLOOD LtGrnHD-HOLD CT HEAD [**2113-5-5**] 6:46 FINDINGS: There is a 21 x 15 mm hyperdensity consistent with intraparenchymal hemorrhage, within the right basal ganglia with evidence of surrounding vasogenic edema which is relatively unchanged in size and appearance since the CT scan obtained earlier today, previously 20 x 15 mm. There is 5-mm leftward shift of normally midline structures which is relatively unchanged from the CT scan obtained earlier today. There is no evidence of acute major vascular territorial infarction. Bilateral dystrophic calcifications are noted within the cerbellar hemispheres. There is no evidence of acute fracture. The bilateral mastoid air cells appear well aerated on the left side but appear relatively less aerated on the right side with no evidence of underlying fracture or air cell opacification. IMPRESSION: No interval change since the CT scan obtained earlier today with stable size and appearance of the right basal ganglia hemorrhage and adjacent hemorrhage and stable shift of normally midline structures. CT HEAD 9:17am REASON FOR EXAM: Intracranial hemorrhage. COMPARISON: Head CT from [**2113-5-5**]. NON-CONTRAST HEAD CT: Right thalamic and basal ganglia hematoma with surrounding vasogenic edema and 8 mm of midline shift is only minimally increased in size and mass effect as compared to prior study, may be secondary to slice selection. There is small amount of intraventricular hemorrhage within the right lateral ventricle, unchanged since [**2113-5-5**]. There is no new area of intracranial hemorrhage. Cerebellar calcifications and basal ganglia calcifications are also noted. Prominence of the lateral ventricles and cerebral sulci is compatible with age-appropriate atrophy. Periventricular and subcortical white matter hypodensities are compatible with chronic small vessel ischemic disease. Osseous structures appear stable since prior exam. This exam is severely limited due to motion artifact. IMPRESSION: Limited study due to motion artifact. No change in the right basal ganglia and thalamic hemorrhage with 8 mm of midline shift as well as extension into the right lateral ventricle. Consider close follow up if no intervention is contemplated; further work up for underlying vascular/mass lesion, even though this is more likely to be related to HTN. CT HEAD WITHOUT CONTRAST. 5:55 pm COMPARISON: [**2113-5-6**] at 9:20 a.m. TECHNIQUE: MDCT axially acquired images through the brain were obtained. No IV contrast was administered. HISTORY: Altered mental status change with intracranial hemorrhage, evaluate for interval change. FINDINGS: The previously identified right thalamic and basal ganglial hemorrhage has markedly increased in size and currently measures approximately 3.9 x 4.3 cm (2A, 15). In addition, there has been intraventricular extension of hemorrhage with blood within the entire ventricular system including the fourth ventricle. There is obstructive hydrocephalus with dilation of the temporal horns. There is shift of normally midline structures towards the left by approximately 10 mm. This has increased when compared to prior exam. In addition, there is effacement of the suprasellar cistern consistent with uncal herniation. Extensive motion somewhat limits evaluation of exam. Mucosal retention cyst in the right maxillary sinus is noted. Underpneumatized right mastoid air cells are also identified. IMPRESSION: Marked interval increase in right thalamic and basal ganglial hemorrhage with new intraventricular extension, hydrocephalus. Worsening left subfalcine herniation and uncal herniation. Underlyign vascular lesion/ mass cannot be excluded. Brief Hospital Course: This is an 89 year-old right-handed woman with a complex past medical history which included end stage renal disease recently started on dialysis three times a week, HTN, AFib s/p pacemaker, and recently started on coumadin (INR 2.67 at OSH), hyperlipidemia amoung other conditions who presented with with left sided weakness secondary to right thalamic hemorrhage. Patient had been stable, but more sleepy. Patient had two episodes of respiratory pauses without desaturation during the clinical evaluation in the ED. She was admitted to the Neuro ICU with the plan to monitor INR (1.7, 1.6 as to she was reversed at the OSH) and to check CT scan in the am. On [**2113-5-6**], she was examined on rounds and was awake with left sided weakness and transfer to the Neuro step down unit was ordered. Home antihypertensives were restarted. Labs showed Na 139, Cr 3.4, troponin 0.07 from 0.06. CT head repeated at 9:15 am and showed No change in the right basal ganglia and thalamic hemorrhage with 8 mm of midline shift as well as extension into the right lateral ventricle. Dialysis was arranged that afternoon since she typically receives it on (Saturday, tuesday, thursday) and this was started but not completed since the line was clotted. She did not receive heparin or tpa products during dialysis. BP and other vitals were stable during dialysis but developed right arm tremors and nausea at that time. She was transferred to the step down unit and evaluated. SBP was in the 140s, but she was not arousing to voice, not following commands, and pupils sluggishly reactive. STAT CT head ordered and showed marked interval increase in right basal ganglia hemorrhage with new intraventricular extension, hydrocephalus, and worsening left subfalcine herniation and uncal herniation. She had respiratory arrest en route from the scanner back to the floor. She arrived on the floor bradycardic and passed away several minutes later. Family discussions with two of her daughters were ongoing during her hospital course and they were considering CMO status which is what they felt their mother would have wanted. They had declined NG tube placement for medications. She was DNR/DNI for her hospital course although the intial admission note and orders were listed as full code. This was corrected prior to her passing. Daughters understood the grave situation and after she stopped breathing requested over the phone that no aggressive measures be taken. Daughters returned to the hospital after her passing and we requested the chaplain to help with grieving. Daughters declined autopsy and case discussed with the medical examiner since she passed within 24 hours of admission and he declined the case. Medications on Admission: Medications: Amlodipine 5mg daily Hydralazine 50mg [**Hospital1 **] Metoprolol 75mg [**Hospital1 **] Warfarin 2mg daily and yesterday her daughter received a communication to hold coumadin for three days. AREDS (?) Nephrocaps Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Intracerebral hemorrhage (non traumatic) Atrial fibrillation ESRD Discharge Condition: Deceased [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2113-5-13**]

[ "342.90", "272.4", "V45.11", "427.31", "403.91", "431", "V58.61", "V45.01", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

13548, 13557

10538, 13242

285, 318

13666, 13820

5075, 8021

3145, 3175

13519, 13525

13578, 13645

13268, 13496

3205, 3731

203, 247

346, 2571

8030, 10515

3746, 5056

2593, 3038

3054, 3129

6,228

183,771

28384

Discharge summary

report

Admission Date: [**2197-12-26**] Discharge Date: [**2198-1-5**] Date of Birth: [**2118-5-3**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Right neck and mid scapula pain Major Surgical or Invasive Procedure: [**1-1**] CABG x4 (LIMA>LAD, SVG>OM, SVG>Diag, SVG>PDA) History of Present Illness: 79 yo F with known CAD now with recurrent symptoms and abnormal stress test, referred for cath which showed 3VD. Referred for CABG. Past Medical History: Hyperlipidemia, GERD, arthritis, Osteoporosis, CAD s/p IMI, Urethral stricture > tx w/ dilation q6month, Hysterectomy, Chronic yeast infection, Psoriasis Social History: Lives alone, son and his family live nearby, non-smoker, no EtOH Family History: Family history: No CAD history Physical Exam: NAD 65 18 124/41 CV RRR distant S1S2 Lungs CTAB ant/lat Abdomen benign Extrem warm, trace BLE edema Extensive BLE varicose veins Pertinent Results: [**2198-1-4**] 08:00AM BLOOD WBC-9.1 RBC-3.22* Hgb-10.1* Hct-29.3* MCV-91 MCH-31.5 MCHC-34.6 RDW-14.4 Plt Ct-106* [**2198-1-4**] 08:00AM BLOOD Plt Ct-106* [**2198-1-4**] 08:00AM BLOOD Glucose-87 UreaN-27* Creat-1.0 Na-136 K-4.4 Cl-102 HCO3-24 AnGap-14 [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 68868**] (Complete) Done [**2198-1-1**] at 10:57:40 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2118-5-3**] Age (years): 79 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Coronary artery disease. Left ventricular function. Preoperative assessment. ICD-9 Codes: 440.0 Test Information Date/Time: [**2198-1-1**] at 10:57 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW5-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 1.7 cm <= 3.0 cm Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: 1.9 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF (>55%). LV WALL MOTION: Regional left ventricular wall motion findings as shown below; remaining LV segments contract normally. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions PRE BYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. An epiaortic scan was performed. Focal calcifications in the ascending aorta are visualized but not at the canullation or cross clamp sight. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST BYPASS Biventricular systolic function remains preserved. Study is unchanged from prebypass. Brief Hospital Course: She underwent preoperaive workup and on [**1-1**] was taken to the operatin room where she underwent a CABG x 4. She was transferred to the ICU in critical but stable condition. She was extubated later that same day. She was transferred to the floor on POD #1. Her chest tubes and epicardial wires were removed, she was started on lopressor & lasix. She has remained hemodynamically stable, but slow to progress from an ambulation standpoint. For this reason, she is being transferred to rehab to progress with physical therapy, mobility and independence. Medications on Admission: Plavix 75', Lisinopril 5', Toprol XL 50', Crestor 10', ASA 325', Zantac 150', Isosorbide 30', Actonel 35 qwk, Diflucan qwk, Taclonex ointment to feet, Lotrisone vaginal cream Discharge Medications: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 3. Clotrimazole 1 % Cream Sig: One (1) Appl Topical QHS (once a day (at bedtime)). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: then re-evaluate need for continued diuresis. 8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days: while on lasix. 9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: Hellenic - [**Location (un) 2624**] Discharge Diagnosis: CAD now s/p CABG Hyperlipidemia, GERD, arthritis, Osteoporosis, CAD s/p IMI, Urethral stricture > tx w/ dilation q6month, Hysterectomy, Chronic yeast infection, Psoriasis Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 4469**] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Completed by:[**2198-1-5**]

[ "598.8", "412", "716.90", "696.1", "414.01", "733.00", "413.9", "V45.82", "530.81", "272.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6065, 6127

4411, 4970

352, 410

6342, 6350

1046, 4388

6649, 6759

863, 880

5196, 6042

6148, 6321

4997, 5173

6374, 6626

895, 1026

281, 314

438, 571

593, 748

764, 831

50,649

166,092

54986

Discharge summary

report

Admission Date: [**2117-6-29**] Discharge Date: [**2117-7-6**] Date of Birth: [**2042-3-21**] Sex: M Service: CARDIOTHORACIC Allergies: Demerol Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [**2117-6-29**] CABG x3(LIMA->LAD,SVG->RCA,freeRIMA->LCX) History of Present Illness: 75 year old male with new onset crescendo pattern angina. He reports chest heaviness on exertion such as carrying trash cans or walking 60 feet. This chest discomfort resolves with 5 minutes of rest. He had a prior stress test at the [**Hospital1 **] in [**2112**] where it was inconclusive and pharmacological imaging was recommended. A Cardiolyte stress on [**2117-6-9**] with Dr [**Last Name (STitle) **] was significantly abnormal with inferior ischemia and preserved EF. He was referred for left heart catheterization and was found to have three vessel disease and is now being referred to cardiac surgery for revascularization. Past Medical History: Hypertension Bipolar disorder Past Surgical History: Gallbladder [**2076**] Hemorrhoidectomy [**2073**] Appendectomy Hernia with mesh repair x2 Social History: Race:Caucasian Last Dental Exam:edentulous Lives with:wife Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 112283**] Occupation: Retired industrial security official Cigarettes: Smoked yes [x] Other Tobacco use:quit cigars in [**2054**]'s ETOH: Social 1-2 beers couple times per month Illicit drug use: denies Family History: Premature coronary artery disease- unknown Physical Exam: Pulse:54 Resp:18 O2 sat:100/RA B/P Right:155/67 Left:152/70 Height:5'8" Weight:204 lbs General: Essential tremor Skin: Dry [x] intact [] Macular papular rash on mid lower chest and bilateral groins HEENT: PERRLA [x] EOMI [x] Upper and lower dentures Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [] non-tender [x] bowel sounds + [x] Large umbilical hernia with well healed midline and upper quadrant scars Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:cath site Left:2+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: ECHO: Prebypass The left atrium is mildly dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. There is mild symmetric left ventricular hypertrophy. Estimated EF 55%. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are three aortic valve leaflets. A mass is present on the aortic valve, likely fibroelastoma. Mild to moderate ([**11-23**]+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2117-6-29**] at 0930. Postbypass: Preserved left ventricular function, unchanged from prebypass. Persistent 1+ mitral regurgitation and aortic regurgitation. There is no evidence of aortic dissection. Head CT [**2117-6-30**]: FINDINGS: There is no intracranial hemorrhage, edema, or mass effect. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The ventricles and sulci are unremarkable in size given the patient's age. The visualized paranasal sinuses demonstrate minimal fluid within the left sphenoid sinus, but the visualized portion of mastoid air cells is clear. IMPRESSION: No acute intracranial process; specifically no evidence of hemorrhage. Labs: [**2117-7-6**] BUN/Cr: 32/1.4 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2117-6-29**] where the patient underwent Coronary artery bypass grafting x3 with the left internal mammary artery to left anterior descending artery, and the free right internal mammary artery to the diagonal artery, and spliced saphenous vein graft to the posterior descending artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 patient extubated, and breathing comfortably. The patient was hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He did exhibit some delirium and word finding difficulty in the initial post-op period. Neurology was consulted and narcotics discontinued. Head CT was negative. Delirium cleared and the patient was oriented prior to discharge to rehab. The patient was transferred to the telemetry floor for further recovery. He did vacillate between Sinus Rhythm and AFib for several days. Beta blocker was titrated as tolerated and the patient was started on Amiodarone and Coumadin. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility and rehab was recommended. Patient requires use of a walker. By the time of discharge on POD 7 the patient was ambulating with the use of a walker. The wound was healing and pain was controlled with oral analgesics. The patient was discharged [**Hospital3 4103**] on the [**Doctor Last Name **] in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Amlodipine 5 mg PO DAILY 2. benazepril *NF* 10 mg Oral daily 3. Clopidogrel 75 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Lithium Carbonate 300 mg PO TID 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Aspirin 325 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Atorvastatin 40 mg PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Lithium Carbonate 300 mg PO TID 4. Multivitamins 1 TAB PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Amiodarone 400 mg PO DAILY 400 mg daily for 7 days, then decrease to 200mg daily ongoing per your cardiologist. RX *amiodarone 200 mg 2 tablet(s) by mouth once a day Disp #*44 Tablet Refills:*1 7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY Duration: 3 Months for patients with radial artery graft RX *Imdur 60 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 8. Metoprolol Tartrate 25 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 9. Ranitidine 150 mg PO DAILY Duration: 2 Weeks to prevent stress ulcer after surgery RX *Acid Control 150 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 10. Warfarin 5 mg PO DAILY16 11. Acetaminophen 650 mg PO Q4H:PRN pain 12. Amlodipine 5 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. Furosemide 20 mg PO DAILY continue until lower extremity edema resolves. 15. Potassium Chloride 10 mEq PO DAILY Hold for K+ > 4.5, only give while on lasix. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Past Medical History: Hypertension Bipolar disorder Post-op Afib Past Surgical History: Gallbladder [**2076**] Hemorrhoidectomy [**2073**] Appendectomy Hernia with mesh repair x2 Discharge Condition: Alert and oriented x3 nonfocal Deconditioned, ambulates with walker at this time. Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, faint drainage with bilateral abrasions and blisters some intact others opening and draining serous fluid. Ecchymosis bilaterally medial and posterior aspects of thighs. +2 Lower extremity edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2117-8-5**] at 1:00pm in the [**Hospital **] Medical office building, [**Doctor First Name **], [**Hospital Unit Name **] Cardiologist:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**Telephone/Fax (1) 7960**] [**2117-7-19**] at 11:30AM Please call to schedule appointments with your Primary Care Dr. [**First Name11 (Name Pattern1) 10984**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 25517**] in [**2-25**] 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** Completed by:[**2117-7-6**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7399, 7493

3920, 5673

290, 350

7716, 8129

2445, 3897

8970, 9763

1539, 1584

6142, 7376

7514, 7514

5699, 6119

8153, 8947

7602, 7695

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234, 252

378, 1014

7536, 7579

1198, 1523

31,024

182,863

33096

Discharge summary

report

Admission Date: [**2106-3-15**] Discharge Date: [**2106-3-18**] Date of Birth: [**2076-4-4**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1973**] Chief Complaint: Seizure, Arrythmia Major Surgical or Invasive Procedure: intubation History of Present Illness: Mr. [**Known lastname 76929**] is a 29 yo Male w/o significant PMHx who presents with episode of shaking to the ED. History is obtained from girlfriend and family as patient is intubated and sedated. Per girlfriend, patient was in usual state of health until 11 a.m. the morning of admission when he developed sudden onset jerking movements of his body, starting in his bilateral UE, and progressing to his entire body, with fall to the ground and head trauma. During this episode his eyes rolled back, he foamed at the mouth, and he was not conscious. His girlfriend denied associated tongue biting or urinary/fecal incontinence. This episode lasted for 2 minutes, followed by 10-15 minutes where he was confused and difficult to arouse, and had no recollection of the event. At this point she called EMS, and he was transported to the ED. Patient's family denies any toxins or exposures. He did not have recent travel. His girlfriend noted that he did drink 8 beers the night prior while watching the Super Bowl but that this was not unusual for him. She denied any recent head trauma, fevers, chills, sore throat, rhinorrhea, congestion, chest pain, nausea, vomiting, diarrhea. He did have a mild upset stomach after eating a chicken [**Location (un) 6002**] the night before, but did not have n/v. She denies that he engaged in any illicit substances, including specifically no IV drugs including cocaine. He had a normal affect, and per his girlfriend, did not endorse any symptoms of depression. His family noted that he did not have any febrile seizures in childhood, and had no medical problems growing up. While in the ED, patient was noted to have another event similar to the one noted above, and was given Ativan IV to break the episode. Shortly afterwards, he was also noted to have an SVT and given adenosine as well, and upon breaking the EKG was consistent with WPW with AVRT. Patient also had an LP performed which was unremarkable, as well as a head CT. He was seen by toxicology, who considered wellbutrin overdose as etiology for seizures. Past Medical History: None Social History: Patient works as a lawyer in downtown [**Name (NI) 86**]. He drinks socially. Denies drugs or tobacco. Family involved and live in [**Location (un) **]. Family History: CAD and DM2. No history of sudden death, seizure, arrhythmia Physical Exam: VS: 97.3, 126/64, 85, 24, 96% Gen: well appearing. NAD HEENT: PERRL. MMM. NCAT. COR: RRR. I/VI systolic ejection murmur at RUSB. No rubs or gallops. PULM: CTAB no RRW. ABD: Soft, NT/ND. Normoactive bowel sounds. No organomegaly. EXT: WWP. No CCE. NEURO: CAOx3, Non-Focal Pertinent Results: [**2106-3-17**] 05:18AM BLOOD WBC-7.2 RBC-4.20* Hgb-12.0* Hct-35.4* MCV-84 MCH-28.5 MCHC-33.8 RDW-12.9 Plt Ct-204 [**2106-3-16**] 04:21AM BLOOD WBC-7.5# RBC-4.60 Hgb-13.3* Hct-38.3* MCV-83 MCH-28.9 MCHC-34.7 RDW-12.5 Plt Ct-254 [**2106-3-15**] 01:30PM BLOOD WBC-15.8* RBC-5.11 Hgb-14.3 Hct-43.6 MCV-85 MCH-28.0 MCHC-32.8 RDW-12.5 Plt Ct-361 [**2106-3-15**] 01:30PM BLOOD Neuts-69.4 Lymphs-24.8 Monos-4.2 Eos-1.3 Baso-0.4 [**2106-3-15**] 01:30PM BLOOD PT-12.7 PTT-23.1 INR(PT)-1.1 [**2106-3-17**] 04:59PM BLOOD Glucose-127* UreaN-11 Creat-1.0 Na-145 K-3.8 Cl-110* HCO3-28 AnGap-11 [**2106-3-17**] 04:59PM BLOOD CK(CPK)-4931* [**2106-3-17**] 01:25PM BLOOD CK(CPK)-4453* [**2106-3-17**] 05:18AM BLOOD CK(CPK)-3582* [**2106-3-17**] 01:00AM BLOOD CK(CPK)-2521* [**2106-3-16**] 06:03PM BLOOD ALT-36 AST-54* LD(LDH)-389* CK(CPK)-1821* AlkPhos-44 Amylase-67 TotBili-1.7* [**2106-3-16**] 03:00PM BLOOD CK(CPK)-1341* [**2106-3-16**] 04:21AM BLOOD CK(CPK)-737* [**2106-3-15**] 01:30PM BLOOD CK(CPK)-138 [**2106-3-16**] 06:03PM BLOOD Lipase-25 [**2106-3-15**] 01:30PM BLOOD CK-MB-4 cTropnT-<0.01 [**2106-3-17**] 04:59PM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8 [**2106-3-15**] 09:32PM BLOOD Triglyc-136 [**2106-3-15**] 01:30PM BLOOD Osmolal-307 [**2106-3-15**] 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2106-3-15**] 11:22PM BLOOD Type-ART pO2-204* pCO2-35 pH-7.42 calTCO2-23 Base XS-0 [**2106-3-15**] 11:22PM BLOOD Lactate-1.2 [**2106-3-15**] 10:42PM BLOOD Lactate-2.0 [**2106-3-15**] 01:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015 [**2106-3-15**] 01:30PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2106-3-15**] 01:30PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2 [**2106-3-15**] 01:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2106-3-15**] 04:37PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-86 Monos-14 [**2106-3-15**] 04:37PM CEREBROSPINAL FLUID (CSF) TotProt-35 Glucose-87 Time Taken Not Noted Log-In Date/Time: [**2106-3-15**] 4:39 pm CSF;SPINAL FLUID #3. **FINAL REPORT [**2106-3-18**]** GRAM STAIN (Final [**2106-3-15**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2106-3-18**]): NO GROWTH. CT HEAD W/O CONTRAST [**2106-3-15**] 1:46 PM FINDINGS: There is no intracranial hemorrhage, mass, shift of normally midline structures, edema, hydrocephalus or major vascular territorial infarct. The [**Doctor Last Name 352**]-white differentiation is preserved throughout. The ventricles and sulci are normal in contour and configuration. No fractures are identified. IMPRESSION: No intracranial hemorrhage. CHEST (PORTABLE AP) [**2106-3-15**] 1:38 PM IMPRESSION: Appropriate positioning of ETT and NGT. No acute cardiopulmonary abnormalities. MR HEAD W & W/O CONTRAST [**2106-3-16**] 9:14 AM MR BRAIN WITHOUT AND WITH INTRAVENOUS GADOLINIUM: There is no evidence of hemorrhage, edema, masses, mass effect or infarction. The ventricles and sulci are normal in caliber and configuration. No diffusion abnormalities are detected. The hippocampi are symmetric in morphology, signal intensity, enhancement characteristics. There are no foci of abnormal enhancement post contrast. A moderately large air- fluid level is seen within the right sphenoid air cell. There is moderate mucosal thickening in bilateral ethmoid air cells. Slow flow within the right jugular bulb is incidentally noted. The remaining vascular flow patterns are within normla limits. A small Thornwaldt cyst measures 5 mm. IMPRESSION: Unremarkable MRI brain. Sinusitis. TTE [**2106-3-16**]: Conclusions The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no systolic anterior motion of the mitral valve leaflets. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with low normal systolic function. EEG Study Date of [**2106-3-17**] IMPRESSION: Abnormal portable EEG due to the occasional bursts of irregular slowing in the left temporal region and due to the single burst of sharp theta slowing. The left temporal slowing suggests a focal subcortical abnormality in the left hemisphere, but the tracing cannot specify its etiology. The burst of sharp activity reflects a deeper midline or generalized process. It included sharp features but no overtly epileptiform abnormalities. The background often reflected drowsiness. The cardiac monitor showed an intermittently irregular rhythm. Brief Hospital Course: A/P: Mr. [**Known lastname 76929**] is a 29 yo M w/o significant PMHx who presents with tonic-clonic seizure activity and AVNRT with WPW. 1. Generalized tonic-clonic seizures - Patient without a clear etiology including no history of significant alcohol use, other ingestions, CNS masses, or traumatic brain injury. Urine and serum tox screens negative, including a negative ETOH level. Osmolal gap WNL (3.5). LP performed in the ED did not show evidence of infection. - Neurology Consultation - EEG/MRI as above - Seizure precautions were used in house, but no further seizures - Keppra 1000 mg load, 500 mg [**Hospital1 **] per neurology recommendations, until [**3-20**] then to 750 until [**3-25**] with 1000mg - toxicology consultation - Rhabdomyolysis presumably from seizure - Patient informed he can not drive for 6 months from last seizure. 2. Altered mental status - intubated in ED for airway protection in setting of tonic-clonic seizures. No evidence of respiratory failure. - Propofol gtt for sedation while intubated - Weaned 3. [**Doctor Last Name 13534**]-Parkinson-White with AVNRT. - Patient with episode of AVNRT requiring adenosine while having a tonic-clonic seizure. Likely developed arrhythmia in setting of stress. - Post resolution of AVNRT noted with delta-waves and short PR interval - Monitored on telemetry, with episodes of bradycardia with WPW morphology - Repeat EKG with no changes - Planned ablation [**4-1**] with Dr. [**Last Name (STitle) **] - EP Consultation Medications on Admission: none Discharge Medications: 1. Keppra 250 mg Tablet Sig: Two (2) Tablet PO twice a day: Increase to 3 tabs [**Hospital1 **] on [**3-20**], then to 4 tabs [**Hospital1 **] [**3-25**]. Disp:*120 Tablet(s)* Refills:*2* 2. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Generalized Seizure [**Doctor Last Name 13534**]-Parkinson-White Syndrome Arrythmia Rhabdomyolysis Discharge Condition: Good Discharge Instructions: Return to the hospital with seizures, confusion, fevers/chills, palpitations, chest pain. You should not drink any alcohol, as this can start a seizure You should not engage in activities which either a seizure or arrythmia could be dangerous such as sports, standing on heights. Under state law you may not drive a car for 6 months from your last seizure. You will be returning to the medical center to have a cardiac arrythmia ablation procedure. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 3294**] Date/Time:[**2106-4-12**] 8:00 [**Hospital Ward Name 23**] 8 ([**Hospital Ward Name 516**]) Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] 2/21/08@0[**Telephone/Fax (1) 76930**] for Cardiac Ablation ([**Hospital Ward Name 517**] - You will be contact[**Name (NI) **] for details)

[ "276.2", "V15.82", "426.7", "427.89", "728.88", "276.0", "348.30", "473.9", "780.39" ]

icd9cm

[ [ [] ] ]

[ "96.71", "03.31", "96.04" ]

icd9pcs

[ [ [] ] ]

10288, 10294

8353, 9855

299, 311

10436, 10442

2985, 8330

10943, 11333

2617, 2679

9910, 10265

10315, 10415

9881, 9887

10466, 10920

2694, 2966

241, 261

339, 2403

2425, 2431

2447, 2601

30,026

119,429

9037

Discharge summary

report

Admission Date: [**2170-1-20**] Discharge Date: [**2170-3-23**] Date of Birth: [**2122-1-24**] Sex: M Service: SURGERY Allergies: Latex Attending:[**First Name3 (LF) 1384**] Chief Complaint: Abdominal pain, fever Major Surgical or Invasive Procedure: [**2170-2-10**]: Orthotopic Liver Transplant History of Present Illness: Please refer to the admission note of Dr. [**Last Name (STitle) 656**] for full details of history. Briefly, Dr. [**Known lastname 10165**] is a 47 year old man with history of hepatitis B cirrhosis, portal hypertension, with no history of encephalopathy, who presented earlier this evening with abdominal pain and low grade fever. He was in his usual state of health until he noticed crampy abdominal pain with radiation to the back. He noted fevers later in the day, along with nausea, vomiting, and diarrhea. Denies sick contacts. Of note, he was recently admitted in [**11/2169**] for pneumococcal bacteremia. . In the ED, vitals were 100.5 120/56 73 16 97%RA. UA negative, no leukocytosis. CXR without infiltrate. Patient received morphine and demerol for his abdominal pain, and 3L normal saline. . On the floor, his mental status was attributed to overmedication in the ED versus hepatic encephalopathy. He was given his normal doses of lactulose and monitored. However, over the course of the evening, he became more hypotensive with high fevers (to 103F). He continued to have abdominal pain (primarily in the left lower quadrant). Given his low blood pressures, low urine output, and mental status, he was transferred to the ICU for further monitoring. Past Medical History: - HBV cirrhosis, e antigen negative, undetectable viral load with elevated LFTs, cirrhosis, MELD of 27 - Anal fissure in [**2168-4-25**] - Diarrheal illness started in [**Country 3399**] [**3-1**] - Iron overload but negative for hemochromatosis gene mutation. - Grade 2 esophageal varices noted on EGD [**2167**] - Kidney stones [**2159**] and [**2165**] - Streptococcus pneumonia, bacteremia, septic shock - Strongyloides serology +, s/p ivermectin - Fasciola serology +, s/p triclabendazole - s/p perirectal abscess drainage Social History: Lives with wife and one daughter. [**Name (NI) **] alcohol, no tobacco, no drugs. Professor [**First Name (Titles) **] [**Last Name (Titles) 31255**]. Family History: family history is negative for liver disease. His wife has been vaccinated for hepatitis B. He has a 9-year-old daughter who is currently in school. His mother is alive at the age of 74 having recently suffered from a cerebrovascular accident. His father is 78 years old. There is no family history of liver disease or cancers. Physical Exam: VITALS: T102F, BP 85/46, HR 95, Sat 98%2L, RR 16 GENERAL: Jaundiced, lying in bed, appears very lethargic, able to answer questions appropriately HEENT: Pupils constricted and minimally reactive, OP clear NECK: Elevated JVP to level of ear at ~30 degrees CARD: RRR, systolic murmur at left upper sternal border RESP: CTA bilaterally ABD: Soft, tender to palpation in RUQ, minimal bowel sounds RECTAL: Guaiac EXT: [**12-27**]+ pitting edema in lower extremities bilaterally, 2+ DP pulses NEURO: A&O x 2, responds appropriately, moving all four extremities Pertinent Results: On Admission: [**2170-1-20**] WBC-4.0 RBC-2.86* Hgb-10.4* Hct-30.2* MCV-106* MCH-36.6* MCHC-34.6 RDW-17.4* Plt Ct-52* PT-26.5* PTT-57.5* INR(PT)-2.6* Glucose-96 UreaN-11 Creat-0.8 Na-132* K-5.1 Cl-104 HCO3-25 AnGap-8 ALT-87* AST-204* LD(LDH)-427* AlkPhos-291* TotBili-10.7* Lipase-25 Albumin-2.3* Calcium-8.3* Phos-2.9 Mg-2.0 On Discharge: WBC-6.5 RBC-3.33* Hgb-10.2* Hct-29.2* MCV-87 MCH-30.5 MCHC-34.8 RDW-19.5* Plt Ct-173 Glucose-119* UreaN-47* Creat-1.0 Na-134 K-4.8 Cl-97 HCO3-28 AnGap-14 ALT-137* AST-68* AlkPhos-162* TotBili-1.8* Brief Hospital Course: A/P: Pt is a 48 yo man w/ Hep B cirrhosis, gram negative klebsiella sepsis and respiratory failure, coagulopathy. #) Sepsis: Pt with initial pancytopenia followed by acute leukocytosis, fevers, hypotension. Infectious w/u has yielded Klebsiella bacteremia (from cx on [**1-22**]), also with blood cx on [**1-24**] with [**Female First Name (un) **] species. Has been treated w/ broad spectrum abx, initially on Zosyn for klebsiella and caspofungin for fungemia. However, pt was slow to clinically improve on appropriate meds (zosyn and caspofungin) w/ continued rising leukocytosis and low fibrinogen. Was evaluated by abd CT for possible abscess which was negative. Was empirically started on flagyl for possible c diff (given loose, green stools) with improvement of leukocytosis, DIC labs (fibrinogen now stabilized). C diff x 3 negative. Pt was maintained on zosyn, caspofungin for some time w/ clinical stability, off of pressors, but then re-spiked fever and became hypotensive again requiring pressor support. Therefore abx re-broadened, and pt now remains on Vanc, meropenem, cipro, flagyl, caspofungin to cover his known bacteremia's as well as possible VAP. Pt now off pressors again. Plan to: - Continue broad spectrum abx w/ Vanc, [**Last Name (un) 2830**], cipro, flagyl, caspo These were all discontinued by the 24th day post op liver transplant. Blood cultures last drawn on [**2-27**] which were negative. Urine culture from [**3-11**] grew Enterobacter and he received 5 days of Cipro. # Hypoxia/respiratory failure: Due to above septic state, as well as total body anasarca. Resp status currently stable on assist control ventilation - now weaned to CPAP and PS. S/p fluid removal w/ CVVH. # Intra-cranial hemorrhage: Pt had head CT done on [**2170-1-29**] for continued altered mental status (see below) that demonstrated scattered small ICH. Presumably due to hypercoaguable state. Neurosurg and neurology consulted. Rpt head CT w/ stable bleed, not enlarging. MRI/A with ?small 1-2mm aneurysms, nothing else notable. EEG unremarkable. Pt w/ another rpt head CT [**2-6**] w/ no interval change. # Coagulopathy: Pt coagulopathic with elevated INR and low plts [**1-27**] liver dysfxn, also with low fibrinogen due to septic state. # Acute renal failure: With above septic picture, pt developed acute renal failure/anuria. Also likely component of hepato-renal syndrome. Currently on CVVH for renal failure, as well as octreotide/midodrine for component of HRS, with improvement of fluid status, BP, and now making small urine. However CVVH w/ continued clotting. Creatinine normalized to about 1.0 by time of discharge. # Anemia: Pt w/ persistent anemia, responsive to transfusions, but not as much of a bump as expected. Etiologies include coagulopathy causing oozing from line sites, continued clotting of CVVH line, underlying sytemic illness w/ likely poor RBC production. # AFib/flutter: Pt has been transiently going into rapid AFib/flutter on occasion during ICU course. Resolved by time of discharge. # Liver failure: Pt w/ ESLD [**1-27**] hepatitis B. Followed actively by Dr. [**Last Name (STitle) 497**] on hepatology service. Currently in liver failure/end stage disease, with T bili > 30, synthetic dysfunction. Pt currently activated on tranplant list. He received liver transplant on [**2170-2-10**]. Surgery was performed by Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) 816**]. PLease see the operative note for surgical detail. 1) Neurologic- The patient's mental status imporved daily after his transplant. The likley etiology of his prior mental status changes was encephalopthy secondary to his liver failure. As an adjunct, all sedating medications and narcotics were minimized. The patient was noted to demonstrate minimal movement of his upper and lower extremities, despite clearing of his mental status. As no improvement was noted by POD4, a non-contrast head CT was obtained to evaluate for progression of his prior intracranial bleeding. This CT demonstrated resolution of the prior bleeding, and no new mass effect. The neurology service was consulted and recommended peripheral neurologic studies as well as an MRI/MRA. A nerve conduction study was obtained which demonstrated a motor neuropathy, consistent with a critical illness myopathy. The MRI/MRA demonstrated a 2-mm aneurysm arising from the left paraclinoid/ophthalmic segment of the internal left internal carotid artery which was not significantly changed from prior imaging, and a normal MRA of the neck. The Physical Therapy service and Occupational Therapy service were consulted and provided daily rehabilitation for the patient after extubation. 2) Respiratory- The patient required mechanical ventilatory support which was weaned gradually to pressure support ventilation. The patient self-extubated on POD 7. Although his oxygenation was adequate, his mental status was not appropriate for airway protection. He was therefor re-intubated and ventilated until he was able to follow commands appropriately ([**2170-2-18**]), at which time he was extubated. His oxygentation requirements slowly diminished until POD 11, at which time he acutely required increasing amounts of oxygen. A CXR demonstrated a large R pleural effusion, which was subsequently drained with a pig-tail catheter. The catheter initially drained over 4L of blood-tinged fluid over 24 hours, and subsequently slowed. The Thoracic Surgical Service was consulted for managment recommendations. The patient's oxygenation improved and his lung re-expanded fully one day after placement of the pigtail catheter. 3) Cardiovascular- The patient's hemodynamic status was relatively stable in his post-operative ICU recovery period, requiring no vasopressor support. He did have atrial fibrillation on POD 4 which was managed with B-blockade. Rate control was achieved with metoprolol and after consultation with the Cardiology Service, the decision was made to hold long-term anti-coagulation and to utilize B-blockers as the primary treatment [**Doctor Last Name 360**] for the new onset AF. The AF, which was felt to be secondary to fluid shifts as well as peri-operative stress (no evidence on ischemia, normal thyroid studies, normal electrolyte status) converted to normal sinus rhythm with B-blockade. 4) GI- The patient was maintained on a proton-pump inhibitor for stress ulcer prophylaxis. His stools remained guiaic negative. Loperamide and psyllium wafers were administered to decrease the volume of diarrhea (C.diff negative x 6) which was felt to be secondary to his tube feedings. His liver transplant functioned well, with his PT normalizing by POD 4, and continual improvement in his Bilirubin. 5) FEN- the patient was volume overloaded pre-operatively and in the early post-operative period. Initially, CVVHD was required, renal; function has improved to normal, Lytes maintained WNL 6) Renal- the patient was in acute renal failure during his MICU course. Postoperatively he required CVVHD which was discontinued following transplant. 7) Heme- the patient was maintained on heparin DVT prophylaxis as well as compression boots for DVT prophylaxis. He required cryoprecipitate, FFP, platelets and PRBC transfusions immediately in the post-op period to correct his peri-op coagulopathy, but stabilized by POD 2. On POD 7, the patients Hct decreased from 31 to 27. A CT scan of the abdomen and pelvis demonstrated a 6x8 cm peri-hepatic hematoma. The patient was given 3 units PRBCs and platelets, with stabilization of his Hct thereafter. The etiology of the hematoma was unclear as he had undergone no recent procedures or trauma to the area. 8) ID-Post op he completed a 25 day course of Caspofungin, a 10 day course of Flagyl, a 14 day course of Meropenem and a 13 day course of Vanco, these were completion dosing for pre-op infections. He was also treated with a 5 day course of Cipro for an E coli UTI which has been completed. 9) Endocrine- the patients blood sugars were well controlled post-operatively using an intravenous insulin drip initially, followed by conversion to a SC insulin sliding scale. His TSH was checked in the setting of his new onset atrial fibrillaiton and did not evidence hyperthyroidism 10) Immunosuppression- the patient received standard post OLT immunosuppression as well as standard anti-microbial prophylaxis. Medications on Admission: Entecavir 0.5 mg PO DAILY Famotidine 20 mg PO Q12H Lactulose 30ml ML PO BID Nadolol 20 mg PO DAILY Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four times a day. 2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-27**] Sprays Nasal QID (4 times a day) as needed. 3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) for 4 days: Then decrease to 12.5 on [**3-28**]. 10. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 12. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime: Plus follow Regular Insulin Sliding Scale q ACHS. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: End Stage Liver Disease now status post Orthotopic liver transplant Discharge Condition: Stable Discharge Instructions: Please call the transplant center at [**Telephone/Fax (1) 673**] if the patient experiences fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down medications. Monitor abdominal incision site for redness, drainage or discharge Lab tests per transplant clinic guidelines No medications down [**Last Name (un) **]-duodenal tube please Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2170-3-28**] 9:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2170-4-4**] 9:20 [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2170-4-4**] 10:00 Completed by:[**2170-3-23**]

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icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "99.15", "38.95", "00.93", "96.04", "50.11", "38.93", "50.59", "33.24", "34.91", "39.95" ]

icd9pcs

[ [ [] ] ]

13565, 13644

3852, 12276

287, 333

13756, 13765

3291, 3291

14171, 14626

2365, 2700

12426, 13542

13665, 13735

12302, 12403

13789, 14148

2715, 3272

3631, 3829

226, 249

361, 1626

3305, 3617

1648, 2179

2195, 2349

82,411

120,188

52010

Discharge summary

report

Admission Date: [**2125-7-21**] Discharge Date: [**2125-7-26**] Date of Birth: [**2040-11-24**] Sex: F Service: MEDICINE Allergies: ibuprofen / Lipitor / scallops Attending:[**First Name3 (LF) 2736**] Chief Complaint: [**Hospital 7792**] transferred from OSH Major Surgical or Invasive Procedure: Percutaneous coronary intervention History of Present Illness: Ms. [**Known lastname 6632**] is a 84 yo female with history of HTN, HLD, CKD, known LBBB who presented to [**Hospital3 **] [**7-19**] after waking up at 2am with sudden onset shortness of breath. Had 2 other similar episodes that were less intense in the last two weeks. Per daughter, patient has been less active in the last 6 months, and especially in the last week. On the night prior to presentation, she felt warm and was sweating, some chills no fevers. Previous baseline, pt reports that she is very active, exercises 30 min daily and walks 1 hr daily. . In the ED at [**Hospital1 **] ([**7-19**] 4am), pt initially required BiPAP. 199lbs (90.4kg), 97.6 Temp, WBC = 14.4, 110s-120s/50s-60s, HR 70s-80s, BNP 421, BUN 27, Cr 1.3, TnI < .06, Per their read CXR right upper and right lower lobe pna with some background edema, started on ceftrixone, azithro (day 1 [**2125-7-19**]). Admitted to their ICU for BiPAP. Cards was consulted on [**7-19**] there who rcommended second set of enzymes. 2nd set of Card enzymes at [**7-19**] 8am show TroponinI 2.95, no chest pain, EKG showed ? => started on Heparin gtt, ASA 325, Plavix 300mg, Deemed not candidate for cath due to PNA and on ABX and "even patient refuses" . [**First Name8 (NamePattern2) **] [**Hospital1 **] records "Old Echo shows EF 35-40%" On [**2125-7-20**] had rapid response at [**Hospital1 **] when patient complained of right shoulder pain and SOB. Vitals were 160/90, HR 88-120, RR 30, SpO2 98% on NRB, cold/clammy, received DuoNebs, "EKG showed changes consistent with old ekg" then started on Heparin drip and enzymes ordered, "pt refused cardiac cath". On [**2125-7-21**] AM deemed to require Cath at [**Hospital1 18**], made aware to Dr. [**Last Name (STitle) 107675**]. Kept on Heparin, ASA, Plavix, Beta blockade on transfer. . MEDS AT [**Hospital1 **] PRIOR TO TX [**2125-7-21**] 8AM: Lasix 40mg PO daily, Plavix 75mg daily, Metoprolol tartrate 25mg [**Hospital1 **], Atorva 80, ASA 325mg, Heparin gtt, Pantoprazole 40/day, naproxen 500mg/day, Azithro 500mg q 24, Ceftriaxone 1gm q 24, Ativan .5mg q4:PRN LABS AT [**Hospital1 **] [**7-21**] AM: INR 1.2, PTT 70, WBC 10.3(14.4 on admit), Hct 31.9, PLT 187, BUN 20, Cr .9, TnI 4.15 <- 1.67 ([**7-20**] PM), . On arrival to the floor, patient was 150/81, HR 96, on NRB 50% SaO2 95-100%, RR 22, using accessory muscles but comfortable, would take NRB off to speak but not in full sentences, warm, non toxic, AAOx3. Daughter [**Name (NI) **] at bedside. full code verified. Past Medical History: HTN HLD CKD LBBB Anemia Spinal fusion [**2111**], daily PT, walks with cane at baseline Diverticulosis Ligation of left Leg Vein [**2065**] Appendectomy [**2095**] Diverticulosis surgery- [**2109**] Social History: Former nurse, widowed, 6 children, 15 grandchildre, 6 great grandchildren, lives in [**Hospital1 **] village Non smoker, exposed to second hand smoke from husband for 10 [**Name2 (NI) 1686**]. No alcohol use. Family History: Parents with MI in their 60s Physical Exam: ADMISSION: VS: T= 98.8 BP= 150/81 HR= 92 RR= 22 O2 sat= 95-100% on NRB GENERAL: white caucasian female in NAD. Oriented x3. Mood, affect appropriate. answers all questions. sister [**Name (NI) **] at bedside. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of [**4-26**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS: On NRB, No chest wall deformities, scoliosis or kyphosis. Resp were labored with abdominal breathing. Decreased BS b/l, basilar crackels. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm, No edema SKIN: No stasis dermatitis, ulcers. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ DISCHARGE: GENERAL: white caucasian female in NAD. Oriented x3. Mood, affect appropriate. answers all questions. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of [**4-26**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS: CTAB, no wheezing, rales, rhonchi. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm, No edema SKIN: No stasis dermatitis, ulcers. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: LABS: [**2125-7-22**] 01:20AM BLOOD WBC-10.1 RBC-3.70* Hgb-10.7* Hct-33.1* MCV-90 MCH-29.1 MCHC-32.5 RDW-13.7 Plt Ct-210 [**2125-7-22**] 01:20AM BLOOD PT-12.7* PTT-70.7* INR(PT)-1.2* [**2125-7-22**] 01:20AM BLOOD Glucose-110* UreaN-19 Creat-1.2* Na-146* K-4.2 Cl-107 HCO3-32 AnGap-11 [**2125-7-22**] 01:20AM BLOOD CK-MB-9 cTropnT-0.94* proBNP-5701* [**2125-7-22**] 01:20AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1 . . STUDIES: [**2125-7-23**] ECHO: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. A left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size is normal. with moderate global free wall hypokinesis. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. Significant pulmonic regurgitation is seen. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with severe global hypokinesis. Moderate right ventricular hypokinesis. . [**2125-7-24**] Cardiac Catheterization: 1. Selective coronary angiography of this right dominant system demonstrated three vessel coronary artery disease. The LMCA had no angiographically-apparent flow-limiting disease. The mid LAD had a long 70% stenosis. The ramus was irregular with an 80% stenosis. The mid LCx had a 50% stenosis. There was a subtotal occlusion of the mid RCA. 2. Resting hemodynamics revealed significantly elevated right and left sided filling pressures with an RVEDP of 23 mmHg and PCWP of 36 mmHg. There was significant pulmonary artery systolic hypertension with a PASP of 61 mmHg. The cardiac output and cardiac index were depressed at 3.38 L/min and 1.85 L/min/m2 respectively. There was mildly elevated systemic arterial hypertension with a central aortic pressure of 148/66 mmHg. 3. Successful PCI of the right coronary artery with a 2.5 x 12mm INTEGRITY OTW bare metal stent. Final angiography revealed no residual in-stent stenosis, no angiographically apparent dissection, and TIMI 3 flow. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Elevated left and right sided filling pressures. 3. Elevated pulmonary artery systolic pressure. 4. Depressed cardiac output and cardiac index. 5. Successful PCI of the right coronary artery with bare metal stent placement. Brief Hospital Course: 84 y/o female admitted to [**Hospital1 **] for acutely worsening PND/DOE, stay complicated by acute onset chest pain with elevated TnI and chronic LBBB changes. Transferred to [**Hospital1 18**] for potential PCI in the morning. . # CORONARIES: acute NSTEMI/UA given rise in Troponin after admission, No prior cath history or cardiac hx, EKG with old LBBB, sinus. No arrhythmia, chest pain non-refractory, HD stable, unclear if CHF worsening. Non-emergent cath indicated. Shwe was started on atorvastatin 80, ASA 325 and Heparin gtt. She was loaded with plavix (300mg) and continued on 75mg daily. In the cath lab, she was found to have three vessel CAD with with 70% stenosis of the mid-LAD, 80% stenosis of the ramus, and 99% occlusion of the mid LCx with 50% stenosis. She had elevated right and left sided filling pressures with a RVEDP of 23 and PCWP of 36. There was significant pulmonary artery systolic hypertension with a PASP of 61 mmHg. The cardiac output and cardiac index were depressed at 3.38 L/min and 1.85 L/min/m2 respectively. She received a BMS to the RCA. She was d/c home on the aforementioned medications including Metoprolol, lisinopril, plavix, ASA, Crestor, spironolactone and Lasix. # PUMP: Old Echo EF 35-40% [**First Name8 (NamePattern2) **] [**Hospital1 **] notes, symptoms (PND, DOE) suggestive of systolic CHF decompensation. Exam positive for crackles and decreased breathsounds b/l suggestive of overload. CXR here also suggestive of overload. (At home on furosemide 40mg/day and lisinopril 40mg/day, was on Lasix 40mg po daily at [**Hospital1 **]). An Echo on [**7-23**] showed mild symmetric left ventricular hypertrophy with severe global hypokinesis (EF 20%). Moderate right ventricular hypokinesis. She was treated with diuresis and her ACEI was restarted prior to discharge. # Acute Resp Distress - requiring BiPAP at [**Hospital1 **], currently on NRB, multifactorial, decompensated sCHF with potentially PNA. No h/o COPD/asthma or smoking. WBC at [**Hospital1 **] 14.4 on admission, 10.4 on transfer, afebrile while at [**Hospital1 **], afebrile here. She had a negative swallow evaluation at OSH. On transfer she was on Azithro/Ceftriaxone for possible CAP which could not be excluded on CXR from OSH d/t severe pulmonary edema. However, repeat CXR did not show focal consolidation and abx were discontinued. She was treated with nebs PRN and diuresis with improved her respiratory status and prior to discharge she was 97-99% on RA and lungs were CTAB. # Atrial Fibrillation - she developed AF with RVR treated with Metoprolol IV. She was then started on PO metoprolol and it was titrated up. She was d/c home on Metop XL 200mg daily. Due to her CHADS2 = 3, she was bridged from Heparin gtt to coumadin and d/c on lovenox until her INR is therapeutic with a goal INR of [**12-22**]. . # SIRS (WBC > 12, RR > 20)- PNA suggested on CXR at [**Hospital1 **], on ABX which were d/c when once diuresed and there was no evidence of focal lung consolidation. In addition, she was afebrile and WBC was down trending on day of discharge. . # HTN - chronic, currently normotensive 120s-130s, HR 70s-90s, At home on lasix, verap, lisinopril. On transfer Metop 25 [**Hospital1 **] added given cardiac injury. She was discharged on metoprolol, lisinopril, spironolactone and lasix. She was scheduled to follow up with Dr. [**Last Name (STitle) 10543**] in Cardiology and with her PCP for hospital [**Name9 (PRE) 702**]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Pravastatin 20 mg PO DAILY 2. Verapamil 180 mg PO Q8H 3. Furosemide 40 mg PO DAILY hold for sbp < 100, hr < 55 4. Lisinopril 20 mg PO DAILY hold for sbp < 100, hr < 55 Discharge Medications: 1. Furosemide 40 mg PO DAILY hold for sbp < 100, hr < 55 2. Lisinopril 40 mg PO DAILY 3. Aspirin 325 mg PO DAILY RX *aspirin 325 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 4. Rosuvastatin Calcium 40 mg PO DAILY RX *rosuvastatin [Crestor] 40 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 5. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 6. Enoxaparin Sodium 80 mg SC BID RX *enoxaparin 80 mg/0.8 mL one syringe twice a day Disp #*8 Syringe Refills:*2 7. Metoprolol Succinate XL 200 mg PO DAILY RX *metoprolol succinate 200 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 8. Spironolactone 12.5 mg PO DAILY RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 9. TraMADOL (Ultram) 25 mg PO Q6H:PRN back pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*2 10. Warfarin 5 mg PO DAILY16 RX *warfarin 2 mg 2.5 tablet(s) by mouth daily Disp #*75 Tablet Refills:*2 11. Outpatient Lab Work Check Chem-7 and INR on Monday [**7-30**] with results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] Phone: [**Telephone/Fax (1) 4475**] Fax: [**Telephone/Fax (1) 29683**] ICD9: 428 Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Acute on chronic systolic congestive heart failure Non ST elevation myocardial infarction Acute on chronic kidney injury Atrial fibrillation with rapid ventricular response 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: Dear Ms. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were transferred from [**Hospital3 **] after having a heart attack and trouble breathing. You needed a stent to open one of the arteries in your heart. You will need to take aspiring and plavix every day for at least one month and probably longer. Do not stop taking aspirin and plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 10543**] says that it is OK. Your heart was found to be weaker and fluid had backed up into your lungs making it hard to breathe. You received intravenous lasix and 7 pounds of fluid was removed. Your weight at discharge is 192 pounds. You will need to weigh yourself every day in the morning and call Dr. [**Last Name (STitle) 71206**] if weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. You were started on warfarin (coumadin) to prevent a blood clot/stroke because of the atrial fibrillation. You heart is now in a regular rhythm but you are still at risk for a stroke and for the atrial fibrillation to return. Dr. [**Last Name (STitle) 10543**] will tell you how much warfarin to take every day. Minor bleeding such as bleeding gums, bleeding hemmorrhoids or nosebleeds are common on warfarin. Please call Dr. [**Last Name (STitle) 10543**] if not notice your stool is black or red, you feel weak or dizzy or you have bruising that is getting worse. Followup Instructions: Name: [**Last Name (LF) 10543**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 4474**] Phone: [**Telephone/Fax (1) 4475**] Appointment: Thursday [**2125-8-2**] 2:15pm *Please bring your insurance cards and a photo ID with you to this appointment. Name: [**Last Name (LF) **],[**First Name3 (LF) **] G. Location: [**Hospital3 **] GROUP- Primary Care Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 67474**] Appointment: Thursday [**2125-8-9**] 3:30pm

[ "428.23", "410.71", "428.0", "427.31", "584.9", "V45.89", "272.4", "285.9", "585.9", "V45.4", "V45.79", "426.3", "403.90", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.06", "37.22", "00.40", "00.45", "88.56", "00.66" ]

icd9pcs

[ [ [] ] ]

12828, 12899

7728, 11197

333, 369

13116, 13116

4874, 7414

14782, 15516

3364, 3394

11516, 12805

12920, 13095

11223, 11493

7431, 7705

13299, 14759

3409, 4855

253, 295

397, 2898

13131, 13275

2920, 3121

3137, 3348

54,564

159,140

39672

Discharge summary

report

Admission Date: [**2147-7-30**] Discharge Date: [**2147-8-9**] Date of Birth: [**2123-6-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2279**] Chief Complaint: Fever, Hypotension, Altered Mental Status Major Surgical or Invasive Procedure: Intubation right internal jugular vein cannulation PICC line insertion incision and drainage of right arm abscess History of Present Illness: 24 year old man presented to OSH with CP, SOB, headache, dizziness, fever, night sweat and chills. Per family, he had started having chest pain/rib pain and fever with cough a number of days prior. On the day of admission to [**Hospital 1474**] hospital he complained of difficulty breathing and talking, a severe headache with dizziness, hemoptysis and some swelling and erythema in his right arm. Per his family there were no recent sick contact, travel, bug bite, changes in urination/bowel patterns. He injects anabolic steroids to his thigh muscles but denied IVDU. . On route to OHS ER, he was found to be tachycardic to 130s, BP of 90/52, RR 10 sat of 94% on NC. He was give narcan 1mg x1, and fluids. . At [**Hospital1 1474**], he reportly told ED physician there that he had gotten hurt in a Bar fight or a dirt bike accident. He was confused, hypoxic, and hypotensivie. He had a rectal temp of 103, was given vancomycin, zosyn, 7 L of fluids, tylenol. He was noted to have a creatine of 3.5. Bedside echo was done without any epicardial effusion/cardiac abnormality. Levophed was started and he was intubated for airway protection prior to med-flight . He had multiple imaging studies done at [**Hospital1 1474**] - CXR: wnl; R. forearm - wnl; CT head - negative; CT chest - LLL consolidation, RL atelectasis. Ill defined nodular opacities see in the upper lungs b/l (? aspiration/pneumonia/pulmonary contusion), no rib fracture, no acute intraabdominal traumatic injury, HSM with diffused hepatic steatosis, no fracture/subluxation of spine; CT C-spine - wnl. Labs were significant for alk phose 299, [**Last Name (un) **] 3.1, Hct 38.6, WBC 6.8, plt 94, bands 15, Cr 3.5, 7.35/39/89. . At [**Hospital1 18**] ED, he was found to be in sinus tach HR 148 (sinus) BP 155/90 sat 95, temp of 103. Initially, levophed was stopped, SBP leveled off at 110's. He had a CT of RUE which was negative. CVL was placed. He was placed on versed and fentanyl but due to agitation he was switched to propafol, which cause him to become hypotensive and requiring levophed and neo. Prior to transfer to ICU, his VS: 101.8 105 95/51 16 100% PEEP 10. EKG - diffused ST-T changes correlated to ischemia. Blood cultures were sent. Bedside echo- no effusion, good movement, no obvious vegetations. FAST was negative. He was transfered to the ICU for continued care. Past Medical History: opioid abuse anxiety seizure when pt was 10 mo old right knee surgery, shoulder dislocation Social History: - Tobacco: smoke 0.5 pack regularly - Alcohol: use socially, denies use prior to admission - Illicits: Marijuana and Hallucinogens in the past but not currently. Uses anabolic steroids injections in thigh muscle. Denies IVDU. Family History: Niece has MS. [**First Name (Titles) **] [**Last Name (Titles) **] with DM. [**Last Name (Titles) **] had testicular cancer. aunt has cancer. father HTN and dyslipidemia. Physical Exam: Vitals: T: 100.1 BP:95/69 P:90 R:16 18 O2:100% Sat on Vent (550x16, 60% peep 10) General: intubated, cold to touch. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: admission labs: . [**2147-7-30**] 06:52PM BLOOD WBC-21.0*# RBC-4.36* Hgb-13.1* Hct-39.1* MCV-90 MCH-30.1 MCHC-33.6 RDW-14.3 Plt Ct-141* [**2147-7-30**] 01:00PM BLOOD UreaN-91* Creat-3.2* [**2147-7-30**] 06:52PM BLOOD Glucose-158* UreaN-79* Creat-2.4* Na-136 K-4.8 Cl-102 HCO3-24 AnGap-15 [**2147-7-30**] 06:52PM BLOOD ALT-26 AST-39 LD(LDH)-393* CK(CPK)-83 AlkPhos-203* Amylase-45 TotBili-1.3 [**2147-7-30**] 01:00PM BLOOD PT-17.4* PTT-38.2* INR(PT)-1.6* [**2147-7-30**] 06:52PM BLOOD Albumin-3.0* [**2147-7-30**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8* Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2147-7-30**] 01:10PM BLOOD pH-7.26* [**2147-7-30**] 01:10PM BLOOD Glucose-139* Lactate-2.2* [**2147-7-30**] 01:10PM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG . discharge labs: [**2147-8-9**] 06:27AM BLOOD WBC-7.5 RBC-3.92* Hgb-11.7* Hct-34.5* MCV-88 MCH-30.0 MCHC-34.0 RDW-15.3 Plt Ct-532* [**2147-8-9**] 06:27AM BLOOD Glucose-100 UreaN-20 Creat-0.7 Na-134 K-4.3 Cl-102 HCO3-24 AnGap-12 [**2147-8-8**] 12:44PM BLOOD PT-15.4* PTT-26.7 INR(PT)-1.3* [**2147-8-9**] 06:27AM BLOOD ALT-112* AST-51* AlkPhos-148* TotBili-0.7 [**2147-7-30**] 06:52PM BLOOD Albumin-3.0* Calcium-7.4* Phos-4.9* Mg-2.9* Iron-8* Cholest-75 [**2147-8-8**] 05:21AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2 . Liver functions trend: [**2147-7-30**] 06:52PM BLOOD ALT-26 AST-39 LD(LDH)-393* CK(CPK)-83 AlkPhos-203* Amylase-45 TotBili-1.3 [**2147-8-7**] 03:41AM BLOOD ALT-134* AST-106* AlkPhos-218* TotBili-0.8 [**2147-8-9**] 06:27AM BLOOD ALT-112* AST-51* AlkPhos-148* TotBili-0.7 . Serologies: [**2147-8-7**] 03:41AM BLOOD HCV Ab-NEGATIVE HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE [**2147-8-5**] 05:18PM BLOOD HIV Ab-NEGATIVE . microbiology: . [**2147-7-30**] 8:23 pm SPUTUM: BETA STREPTOCOCCUS GROUP C. SPARSE GROWTH. YEAST. SPARSE GROWTH. . . [**2147-7-30**] 9:34 pm EAR Source: Ear, external auditory canal. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. CITROBACTER FREUNDII COMPLEX. RARE GROWTH. ________________________________________________ CITROBACTER FREUNDII COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . . [**2147-8-7**] 11:15 am SWAB Source: R forearm. . GRAM STAIN (Final [**2147-8-7**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2147-8-9**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. . . Blood cultures: [**7-30**], [**7-31**], [**8-1**], [**8-2**], [**8-3**]: negative . Outside Hospital blood cultures [**2147-7-30**] ([**Hospital 24356**] hospital): Group C strep and Fusobacterium. . . . Radiology: . . ............... CXR [**2147-7-30**]: 1. Hazy diffuse opacity of the left hemithorax, could be due to aspiration or asymmetric pulmonary edema. More focal opacity in the left lung base may be atelectasis or aspiration. 2. Endotracheal and nasogastric tubes in place. . CXR [**2147-8-7**] Bilateral opacities demonstrate interval improvement. The hilar and mediastinal contours appear stable. Heart is of normal size without pericardial effusions. No pneumothorax is present. No pleural effusions are visualized. . ............... TTE [**2147-7-31**]: Atrial and ventricular size, heart wall thickness, valves, cardiac index and systolic function all normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. ............... CT chest [**2147-7-31**]: Extensive bilateral multifocal pneumonia with multiple areas of consolidation, air bronchograms as well as ground-glass like bilateral nodule-like opacities. No evidence of larger pleural fluid collections, notably no evidence of empyema. . CT chest [**2147-8-7**] 1. Small loculated left lower pleural fluid collection with slight interval increase in size since [**2147-8-1**] suggesting empyema or complex exudative effusions. 2. Marked interval improvement in bilateral lower lobe consolidations consistent with improving pneumonia. 3. Multifocal upper lobe ground-glass opacities are unchanged since previous imaging and likely due to residual foci of infection. . ............... RUQ U/S [**2147-8-7**] 1. 0.7-cm hyperechoic lesion in the right lobe of the liver, likely a hemangioma but a small non-liquefied abscess cannot be excluded. 2. Small pericardial effusion. . .............. US Right Upper EXTREMITY Antecubital fossa 2.1 cm fluid collection measuring up to 2 cm deep. Left distal lower forearm sub-cm subcutaneous nodule, could represent a small phlegmon or a small fluid collection. . .............. CT ORBIT, SELLA & IAC W/O CONTRAST [**2147-8-2**] Fluid-opacification of the mastoid air cells and middle ear cavities, bilaterally, with abundant fluid layering in the nasal choanae and nasopharynx. There is no evidence of "coalescence" or bone destruction at any site. This constellation of findings favors "passive" effusions related to prolonged supine positioning and intubation, rather than a primary infectious process. . .............. ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2147-8-1**] No acute intra-abdominal or intrapelvic process. There is a trace amount of free fluid, but no focal collections or abscesses are present. . ............... MR C,T,L-SPINE W& W/O CONTRAST [**2147-7-31**] 1. No evidence of osteomyelitis, discitis or epidural abscess. 2. The cerebellar tonsils terminate approximately 7 mm below the foramen magnum, consistent with a Chiari I malformation. No evidence of a syrinx. 3. Mildly narrow cervical spinal canal due to short pedicles. . .............. Brief Hospital Course: 24yo male with history of anxiety and anabolic steroid injections who was transferred from [**Hospital 24356**] Hospital with sepsis and septic shock and had a 7 day MICU course with subsequent management on the internal medicine floor. . by problem: . # Septic shock: Mr. [**Known lastname **] was originally air-transferred to our institution from [**Hospital 24356**] hospital where he presented with high fever, low blood pressures and AMS. He was intubated, mechanically ventilated treated with pressors and transferred to our institution. He was admitted here to the ICU, treated with IVF and wide-spectrum antibiotics as well as continuing support with mechanical ventilation and pressors. His hemodynamics and respiration improved and he was weaned off pressors and extubated on [**8-5**]. His fevers subsequently resolved and he was also able to be weaned off oxygen. He was transferred to the medicine floor on [**8-6**] and was HD stable, well saturated on room air and afebrile through-out his course on the floor. . # polymicrobial bacteremia: Blood cultures at [**Hospital 24356**] Hospital grew group C strep (Strep milleri) and Fusobacterium. Blood cultures in our institution were negative. As for possible sources/foci of infection, Mr. [**Known lastname **] had a LLL pneumonia with growth of group C strep from sputum; He had 2 small RUE abscesses with rare culture growth of coag negative staphylococci from drained content; He also had pus draining from his ear with growth of pan sensitive CITROBACTER FREUNDII COMPLEX and coagulase negative staphylococci. It is difficult to say which one of these foci if any was the original focus of infection and which resulted from hematogenous spread but a primary RUE cellulitis which later caused bacteremia, sepsis and seeding of lung and ear is not unlikely though the patient denied any history of IVDU. A TTE was obtained with clear visualization of the cardiac valves which showed no evidence of endocardial vegetations and repeated blood cultures were, as already mentioned, negative. Mr. [**Known lastname **] was initially treated with piperacilline-tazobactam + clinda. These were later modified per culture sensitivities to Unacyn. He was discharged on home treatment with IV ampicillin + PO Flagyl. . # pneumonia and left pleural fluid collection: Mr. [**Known lastname **] presented with bilateral lower lobe consolidations and diffuse bil opacities which improved on follow up imagings with a residual LLL infiltrate and resolution of previous diffuse opacities on his last pre-discharge CXR. Repeated Chest CTs also demonstrated a small loculated left lower pleural collection which was initially suspected to represent empyema or a complex exudative effusion. Interventional Pulmonology and Cardio-Thoracic Surgery consults were obtained, the collection was deemed too small for percutaneous drainage and, in-light of the patient's clinical improvement and stable condition, a conservative approach was advocated with continued Abx treatment and follow-up CT 2 weeks post discharge. Mr. [**Known lastname **] will be followed in the outpatient [**Hospital 87440**] clinic with the results of his f/u thoracic CT scan. . # Ear infection - Mr. [**Known lastname **] had drainage of Pus from his ear which resolved with systemic antibiotics. Cultures were positive for CITROBACTER FREUNDII COMPLEX and coagulase negative staphylococci. Later otoscopic exams revealed bilateral Otitis Media W/ Effusion which was attributed to his intubation and supine posture. No clinical signs of mastoiditis were observed and CT scan of the head and temporal bones was negative for mastoiditis/bone destruction. Mr. [**Known lastname **] is scheduled for post-discharge audiogram and ENT follow-up. . # RUE abscesses: 2 small abscesses in RUE were identified on clinical examination and corroborated by RUE US, one of these was incised and drained pussy content with many WBC but no bacteria per gram stain and rare growth of coag negative staphylococci in culture; The tract was left open for secondary healing which proceeded without complication. . #Transaminitis and elevated INR: Mr. [**Known lastname **] had mild elevations of AST, ALT, ALKP and INR during his hospital course. RUQ U/S was normal except for a 0.7-cm hyperechoic lesion in the right lobe of the liver which was consistent with a hemangioma. This study was revised a number of times with radiology and a differential diagnosis of liver abscess was thought very unlikely for this finding. Liver functions trended down on subsequent follow-up and the transient elevation was thought to be most likely drug induced or a reflection of mild shock liver. Serology for viral hepatitis was negative. Liver functions and INR will continue to be followed in the out patient setting until complete normalization. . #acute renal failure - Mr. [**Known lastname **] initially presented with Creatinin and BUN levels of 3.2 and 91 respectively. This picture was consistent with acute pre-renal failure secondary to septic shock and hypovolemia. He was treated with IVF with subsequent normalization of renal functions and good urine output. His total fluid balance was positive 6000-7000 ml upon graduation from the ICU. On the medicine floor he was adequately hydrated orally and had good urine output and stable normal renal function. . #anemia and thrombocytopenia - Mr. [**Known lastname **] had a hematocrit drop to a minimum of 28.7 and a drop in platelet count to a nadir of 72,000. This was most likely attributable to BM suppression in the setting of septic shock. His stool guaiacs were negative and he had no signs or symptoms of bleeding or hemolysis. His blood counts later recovered and he had a Hct of 11.7 and a mild thrombocytosis of 532 on discharge. His CBC will continue to be followed in the patient setting. . #anxiety - Mr. [**Known lastname **] has a history of generalized anxiety disorder as well as medical narcotics abuse and tobacco smoking. Prior to his hospitalization he was treated with Xanax and clonidine for his anxiety and Suboxone for narcotic dependence. He had a high sedative requirement in the ICU and upon transfer to the floor had initially complained of anxiety which he said was only mildly worse than not his base-line state of anxiety. His anxiety was attributed to his known anxiety condition with a possible additional contribution of narcotic withdrawal as his suboxone was not continued during his hospital course. On the floor he was treated with PO Valium and a nicotine patch. Valium was gradually weaned with no apparent worsening of his anxiety. He was discharged on his home dose of Xanax. Clonidine was not renewed due to his recent history of hypotension and borderline blood pressures. He will continue out patient follow up with Dr. [**Last Name (STitle) 87441**] for treatment of his anxiety and substance dependence. Medications on Admission: suboxone 8mg PO daily xanax 2mg PO daily Clonidine 0.2mg PO daily Discharge Medications: 1. Xanax 2 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) grams Intravenous every four (4) hours for 6 weeks. Disp:*84 doses* Refills:*2* 3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 6 weeks. Disp:*42 Tablet(s)* Refills:*2* 4. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: Septic shock Pneumonia Right Upper Extremity abscesses Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were airlifted to our institution in a state of "septic shock" which happens when germs enter your blood-stream causing a severe reaction including high fever and low blood pressure. As you were very sick you were admitted to the Intensive Care Unit where you were treated intravenous fluids and antibiotics to increase your blood pressure and fight the infection. A tube was placed in your airway and you were connected to a breathing machine because the infection involved your lungs and was preventing you from breathing effectively. Besides the infection in your lungs you were also found to have two pockets of infection in your right forearm, pus draining from an infection in your ear, and another pocket of infection near your left lung. With the above treatment your condition steadily improved, your blood pressure stabalized and you were able to breath on your own and be disconnected from life support. You were then transferred to the General Medicine floor where you continued to get intravenous antibiotics through a central intravenous cathter called a PICC line which was inserted into your right arm. You will go home with the PICC line through which you will continue to receive antibiotics for a a few more weeks from a nurse that will visit you daily in your home. You will also take another antibiotic in pills. You will probably require these antibiotics for another 6 weeks. The exact length of treatment will be determined by the infectious disease specialists that will be following you as an outpatient. Although you have been feeling much better and will continue to improve this prolonged treatment course is neccessary to get rid of all the pockets of infection and prevent its reccurrence. You will need to have another chest CT and be followed by our chest surgeons inorder to make sure that the pocket of infection near your left lung resolves. You should also keep the appointments for a hearing test and an ear doctor specialist that we have arranged for you. The following changes were made to your medications: 1. Intravenous Ampicillin which will be administered to you by a home visit nurse. 2. Flagyl pills which are oral antibiotics that you will take 3 times a day. 3. A multi-vitamin pill that you should continue to take once a day. 4. Your clonidin and suboxone were held. You should see Dr. [**Last Name (STitle) 87442**] about restarting these medications. Followup Instructions: Follow up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Location (un) 57552**], [**Location (un) **],[**Numeric Identifier 57553**] Phone: [**Telephone/Fax (1) 21566**] [**2148-8-13**]:30am Please call [**Telephone/Fax (1) 87443**] to make an appointment with Dr. [**Last Name (STitle) 87442**]. Please also keep the following appointments: Department: RADIOLOGY When: TUESDAY [**2147-8-22**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ***You must fast 3 hours before this scan*** Department: Thoracic Surgery When: THURSDAY [**2147-8-24**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: FRIDAY [**2147-8-25**] at 9:00 AM With: [**Name6 (MD) 1423**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Dept: Otolaryngology When: [**9-8**] at 9:30am With: [**First Name4 (NamePattern1) 10827**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2349**] (audiology appt 1st followed by appt with Dr [**First Name (STitle) **] Where: [**Apartment Address(1) 17722**], [**Location (un) 55**] MA Department: INFECTIOUS DISEASE When: TUESDAY [**2147-9-19**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**] Completed by:[**2147-8-13**]

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18793

Discharge summary

report

Admission Date: [**2176-12-1**] Discharge Date: [**2176-12-11**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2009**] Chief Complaint: Lacrimal duct infection, Bacterial UTI Major Surgical or Invasive Procedure: EGD History of Present Illness: 87 year old [**Hospital **] transfered from [**Hospital3 **], with concern for endophthalmitis and UTI. Also of note is acute renal failure. The patient was apparently found down at his house by his wife, and was down for a reported 10 minutes. He was seen at [**Hospital3 7571**]Hospital by Dr. [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) 10262**] in the ED, where he was noted hypotensive, orthostatic, with a positive UA. He was also noted with a severe right eye infection as follows in the ED transfer note: [**Location (un) **] ED: "Severe right eye infection - extropion, with chemosis, injection, cloudy cornea with 100% flourescein uptake. Visual Acuity 20/200 on left, finger count on right. Pressures: 18-22 on right, 18-20 on left. Got IV cipro, and cipro drops q 1 hour. There is no optho in house coverage to see patient if admitted here. Of note - was dx with right conjuntivitis 10 days ago which improved on cipro gtt." The patient was also noted with a UTI, and was given IV Unasyn, agressive hydration with improvement in his blood pressure. In our ED, ophthamology was called, and will be seeing the patient while in house. Vitals in the ED 100 109/49, 21, 100%3L. Patient states that he gets his care at the VA, however the patient has no records at the VA since [**2158**]. I will clarify this with his wife. Past Medical History: Lower back pain s/p 2 back surgeries Possible history of PUD denies HTN, hyperlipidemia, diabetes Social History: lives with wife; retired from computer assembly plant; no EtOH; no toboacco; enjoys golf; former runner Family History: Non-Contributory to this admission Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: + Photophobia, + Severe Visual Changes as in HPI HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 97.6, 113/72, 85, 22, 100 2L% GEN: Uncomfortable, Lethargic Pain: 0/10 HEENT: EOMI, winces to light, cloudy cornea Right eye with lack of red reflex, injected sclera, Able to resolve light/dark and fingers, Dry MM, - OP Lesions although poor dentition, 4cm keloid on occiptal area PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, CN II-XII grossly intact (other than eye as above) Pertinent Results: Admission labs: [**2176-12-1**] 06:00AM GLUCOSE-100 UREA N-53* CREAT-1.4* SODIUM-139 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14 [**2176-12-1**] 06:00AM ALT(SGPT)-12 AST(SGOT)-26 ALK PHOS-94 AMYLASE-130* TOT BILI-0.2 [**2176-12-1**] 06:00AM LIPASE-24 [**2176-12-1**] 06:00AM ALBUMIN-3.4* [**2176-12-1**] 06:00AM WBC-12.9*# RBC-3.11* HGB-9.3* HCT-28.0* MCV-90# MCH-29.9# MCHC-33.2 RDW-13.2 [**2176-12-1**] 06:00AM NEUTS-81.5* LYMPHS-15.6* MONOS-2.6 EOS-0.1 BASOS-0.3 [**2176-12-1**] 06:00AM PLT COUNT-242 .EGD Tuesday, [**2176-12-3**] Impression: Ulcers in the fundus Two clots adjacent to each other, which could not be removed despite extensive washing. No active bleeding. The clot on the right had a likely protruding visible vessel. (thermal therapy) Appeared to have had prior vagotomy and pyloroplasty. Otherwise normal EGD to second part of the duodenum . Portable TTE (Complete) Done [**2176-12-3**] at 3:43:34 PM FINAL IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Moderate pulmonary hypertension. . ECG Study Date of [**2176-12-3**] 9:16:46 AM Sinus rhythm with atrial premature beats. Earlier wide complex beats may be atrial with aberration versus ventricular. Since the previous tracing the rate is slower. Otherwise, findings are unchanged. TRACING #3 Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 77 182 76 356/385 69 23 156 Imaging: Orbit CT [**12-1**]: IMPRESSION: Mildly enlarged right lacrimal gland relative to the left, possibly inflammatory or infectious in etiology. However, rare occurrence of lacrimal gland neoplastic process cannot be excluded. Air-fluid level in right sphenoid sinus pterygoid recess suggests an acute inflamamtory process. Orbit CT [**12-9**]: IMPRESSION: 1. Unchanged mildly enlarged right lacrimal gland relative to the left. Interval decrease in periorbital and lid swelling. There is no evidence to suggest orbital cellulitis or abscess in the region of this mildly enlarged lacrimal gland. 2. Slightly decreased air-fluid level in the right sphenoid sinus suggests resolving acute inflammatory process. 3. These findings were discussed with Dr. [**Last Name (STitle) **] at 2:15 p.m. on [**2176-12-9**]. . Head CT [**12-5**]: CONCLUSION: 1. No evidence of hemorrhage, edema, masses, mass effect or infarction. 2. Prominent sulci and ventriculomegaly, likely related to age-related atrophy. 3. These findings were discussed with Dr. [**Last Name (STitle) **] at 9:45 AM on [**2176-12-5**]. . Discharge labs: [**2176-12-10**] 06:27AM BLOOD WBC-7.5 RBC-3.30* Hgb-9.7* Hct-29.0* MCV-88 MCH-29.4 MCHC-33.5 RDW-17.2* Plt Ct-232 [**2176-12-10**] 06:27AM BLOOD Glucose-109* UreaN-16 Creat-1.2 Na-138 K-4.1 Cl-104 HCO3-28 AnGap-10 Brief Hospital Course: 1. Acute Blood Loss Anemia due to Gastric Ulcer with Hemorhage, with hpylori infection. On HD # 2, he was found to have a acute anemia, with a hct of 11. He was transferred to the ICU. He was treated with large volume transfusion (9 units PRBC, 2 Units FFP). EGD performed with ulcer with visible vessel. Central access maintained until patient stabilized. GI consultation followed. Of note, the patient is a difficult crossmatch due to antibodies. He will require a repeat EGD in [**5-14**] weeks. He should remain on [**Hospital1 **] PPI until then. He should remain on carafate for a few more weeks. In addition, he should complete 2 weeks of treatment with amoxicillin/clarithromycin/prilosec for H pylori disease. . 2. Acute Eye inflammation: Threatened vision, due to patient has suffered severe decrease in visual acuity, so an emergent ophthomology consult was obtained. He was treated with Ciprofloxacin optic and erythromycin ointment. Urgent orbital CT of the right orbit did not demonstrate abscess or endophthalmitis. He failed to improve with appropriate therapy, and had worsening pain/exam on [**12-7**], at which time he was found to have a new corneal ulcer in addition to ongoing dacryadenitis. Once he completed a course of IV antibiotics (for UTI, as below) he was changed to cefpodoxime. His eye did not improve. Repeat CT showed persistent inflammation. He was transferred to the [**Hospital 13128**] for a second opinion, and Dr. [**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **] of oculoplastics diagnosed him with most likely a floppy eyelid syndrome with corneal ulcerations. He recommended aggressive eye lubrication and ointments, and follow up in 1 month with a local eye doctor, for reassessment and consideration of a wedge resection of his eyelid if his functional status improves. . 3. Acute Renal Failure: Likely due to initial infection and hypotension. Resolved with IV fluid rescusitation. . 4. Bacterial UTI: He was diagnosed with a urinary tract infection. Unasyn changed to Cefepime in discussion with ID. He has already completed a full course of IV antibiotics. . 5. Metabolic Encephalopathy, Fall: Multifactorial Likely some underlying dementia, but clearly delerious. Geriatrics consult obtained. Patient fell on [**2176-12-5**] and a CT head and arm xray were negative. Mental status markedly improved with normalization of his day night cycle and treatment of his infection. . Full Code Medications on Admission: states he takes no medications Discharge Medications: 1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 2 weeks. 2. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day). 4. erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5 inch Ophthalmic four times a day. 5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) mg PO DAILY (Daily). 7. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 8. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection [**Hospital1 **] (2 times a day). 9. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) as needed for agitation/delerium. 10. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 2 weeks. 11. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 12. Artificial Tears Drops Sig: Two (2) drops Ophthalmic q 1 hour. 13. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 11496**] - [**Location (un) **] Discharge Diagnosis: Corneal ulcer UTI, bacterial Acute blood loss anemia GI hemorrhage secondary to peptic ulcer disease H pylori disease Acute delirium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with a urinary tract infection and sepsis. Additionally, you had an ulcer in your stomach which lead to a life threatening GI bleed which required 9 units of blood transfusion. You were also found to have a severe lacrimal duct (tear duct) inflammation and an ulcer on your eye. The doctors at [**Hospital 13128**] thought this was due to floppy eyelid syndrome, which caused the inflammation. All of these conditions improved with treatment. You are now being transferred to rehab to regain your strength after this serious illness. . Medication changes: Complete 2 weeks of treatment for H. pylori with prilosec, amoxicillin, and clarithromycin. Use the eye drops every hour while you are awake. Use the eye ointments four times per day. . Follow up with the opthalmologist as below. Followup Instructions: You will need to follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 51461**] after discharge. It is important for you to follow up for a repeat EGD in [**5-14**] weeks. and a repeat eye exam in 1 month. . The eye doctor at [**Hospital 13128**] Infirmary that you saw is [**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **]. He is at [**Telephone/Fax (1) 32768**]. He thinks you may need surgery on your eye - and if you recover from your acute illness, you may want to follow up with him for surgery. You can discuss this with your PCP when you see him.

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Discharge summary

report

Admission Date: [**2178-3-6**] Discharge Date: [**2178-3-11**] Date of Birth: [**2103-11-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: inferior vena cava filter placement by interventional radiology right thoracentesis by interventional pulmonology History of Present Illness: 74M hx melanoma stg1 resected [**2136**], resected prostate CA [**2172**] who presents w/ one week of SOB and DOE. He reports he has had several days of lethargy, low grade fevers, non productive cough and DOE. Was seen by his PCP [**Last Name (NamePattern4) **] [**3-4**] with these complaints and exam was notable for bibasilar rales, R>L LE edema. CXR was done which showed a new right pleural effusion and vascular congestion. PCP was concerned for new CHF, w/ question of viral cardiomyopathy given recent episode of labryinthitis and started patient on lasix 20 mg PO daily and ordered echo. TTE was performed on [**3-6**] which showed mild concentric LVH w/ normal left and right ventricular fx (EF 65%), PA systolic pressure of 30 mmHg, a small pericardial effusion w/o evidence of tamponade. He was seen in f/u clinic when exam was notable for new tachycardia to 110s, BP 130/60, O2 sat of 92%, and [**1-12**]+ edema in R lower leg with JVP of 6 and pulsus of 5. He was sent to the ED for evaluation of possible DVT/PE. . In the ED, initial VS were: 98.2 110 137/81 20 90% on room air, 94% 2L NC. Exam was notable for mildly tachypnea and a mildly swollen RLE with a positive [**Last Name (un) 5813**] sign. Patient underwent CTA of the chest which showed bilateral pulmonary emboli involving the right upper, middle, and lower segmental vessels and the left lower lobe segmental branches. There was no CT evidence of R heart strain. CT was also notable for a R pleural effusion, pulmonary nodules, and hilar/mediastinal LAD. Patient was guaiac negative and started on a heparin gtt w/ bolus and admitted to the MICU for further management. VS on transfer were: 148/73 100 20 92% on 2L. . In the MICU he was placed on a heparin drip and observed overnight. His oxygen requirement increased to 4L and he was saturating 92% on 4L at the time of transfer to the floor. He was comfortable, not in respiratory distress, without chest pain or palpitations. Past Medical History: Diabetes mellitus (last A1c 6.6 in [**1-22**]; diet controlled) BPPV Melanoma (Stage I, dx and excised in [**2136**]) Prostate cancer s/p radical prostatectomy and negative LN dissection ([**12/2172**]) Cataracts Pulmonary nodules (first noted in [**2171**], s/p biopsy; followed by Dr. [**Last Name (STitle) 108420**] at [**Hospital1 112**]) Neuropathy Tremor Diverticulosis Colonic polyps (adenomatous in [**2174**]) Celiac artery aneurysm (followed by Dr. [**Last Name (STitle) 17974**] at [**Hospital1 112**]) s/p CCY s/p inguinal hernia repair Social History: Retired. Was a former physicist/electrical engineer. Lives in [**Location (un) **], MA with his wife. - Tobacco: Smoked [**1-12**] cigarettes daily for 2 years in his twenties. - Alcohol: Rare. - Illicits: Denies. Family History: No family history of clots of bleeding disorders. No h/o CAD, DM, colon or prostate cancer. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 6 cm at 30 degrees, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased BS in R base 1/3 up with dullness to percussion; no wheezes or rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred Skin: well healed surgical incision in left mid axillary line; Physical Exam on discharge: Vitals: Tm 100.1F, Tc 99.9. 132-149/60-62, 96-112, 18, 93% ra -> 87-91% ra -> 95% 2L nc General: elderly man in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple CV: Tachycardic, normal S1, S2, no murmurs, rubs, gallops Lungs: bibasilar spiratory crackles R > L, no wheezes or rhonchi. No dullness to percussion Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, no cyanosis, no edema Pertinent Results: [**2178-3-9**] Radiology CHEST (PORTABLE AP) FINDINGS: No previous images. No evidence of pneumothorax. Cardiac silhouette is at the upper limits of normal size. Engorgement of pulmonary vessels is consistent with elevated pulmonary venous pressure. Poor definition of the left hemidiaphragm suggests layering effusions with associated compressive atelectasis. [**2178-3-9**] Radiology [**Numeric Identifier 108421**] INS ENDOVAS VENA IMPRESSION: Successful uncomplicated placement of an Option retrievable IVC filter below the takeoff of the renal veins. [**2178-3-7**] Radiology BILAT LOWER EXT VEINS 1. Partially occlusive thrombus in the right popliteal vein with occlusive thrombus in the right posterior tibial and peroneal veins. 2. No evidence of DVT in the left lower extremity. [**2178-3-6**] CT Chest: 1. Bilateral segmental pulmonary emboli with relative sparing of the left upper lobe branches. Attenuated pulmonary arteries and mild leftward interventricular septal bowing concerning for right heart strain. 2. Conglomerate soft tissue density within the right hilus concerning for a primary lung carcinoma. Peribronchovascular opacities, as well as septal thickening are concerning for extension of tumor and lymphangitic spread. 3. Moderate-to-severe mediastinal lymphadenopathy and hilar adenopathy. Moderate nonhemorrhagic right pleural effusion and pericardial effusion, both concerning for malignant involvement. 4. Numerous basilar pulmonary nodules concerning for hematogenous metastatic spread. [**2178-3-6**] ECHO ([**Location (un) 2274**]): TTE ([**3-6**]- [**Location (un) 2274**]): 1. Resting tachycardia (HR>100bpm). 2. There is mild concentric left ventricular hypertrophy with normal systolic function 3. The right ventricle is mildly enlarged. 4. The right ventricular systolic function is at the low normal. 5. The right atrial size is normal. RA collapses in atrial systole possibly consistent with hypovolemia 6. The aortic valve is trileaflet and is mildly thickened with trace aortic insufficiency 7. Estimated PA systolic pressure, calculated from peak TR velocity, is 30 mmHg above RA pressure. 8. Small concentric pericardial effusion. There is no evidence of cardiac tamponade. Echodensity seen along RA wall in the effusion (subcostal view), which is probably the wall of the RA in motion, collapsing from low filling pressures, but cannot exclude clot. MICROBIOLOGY: URINE CULTURE (Final [**2178-3-10**]): ENTEROBACTER CLOACAE COMPLEX. 10,000-100,000 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. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Pleural fluid studies: PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Meso Macro Other [**2178-3-9**] 16:10 1075* [**2166**]* 26* 33* 2* 8* 30* 1*1 ATYPICAL CELLS AND CLUSTERS PRESENT SEE CYTOLOGY REPORT FOR ADDITIONAL INFORMATION PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Cholest [**2178-3-9**] 16:10 3.1 143 154 57 [**2178-3-9**] 16:57 pH 7.531 [**2178-3-9**] Cytology PLEURAL FLUID [**2178-3-10**] Pathology Tissue: Cell block from right [**2178-3-11**] Radiology BONE SCAN IMPRESSION: No evidence of metastatic disease in the bones. Degerative changes of the thoracic spine and shoulders. [**2178-3-11**] Radiology MR HEAD W & W/O CONTRAS IMPRESSION: 1. No evidence of metastatic disease in the brain. 2. A small focus of slightly increased signal intensity in the left parietal bone posteriorly on the FLAIR and DWI sequences -suspicious for osseous lesion- correlate with non-contrast CT Head and Bone scan. [**2178-3-11**] Radiology CT ABD & PELVIS WITH CO 1. No evidence of metastatic disease within the abdomen or pelvis. 2. Bilateral pleural effusions and bilateral pulmonary nodules as discussed on recent CT chest. 3. Comparison with prior imaging is recommended for probable hepatic cyst andindeterminate 9mm splenic lesion to evaluate for stability. Brief Hospital Course: 74 yo M w/ h/o DM and prostate ca s/p resection presenting with DOE and RLE found to have submassive PE and new lung mass and right pleural effusion. #) Pulmonary embolism: Extensive clot burden with BNP of >1000, mild signs of septal bowing on echo, no evidence of RV strain on exam. Pt was initially treated with heparin drip, Given extensive pulmonary emboli, RLE DVT, and possible malignancy with unclear plans for further workup, a retrievable IVC filter was placed by interventional radiology without issue. Pt was then transitioned to enoxaparin, which he will continue given anticipated need for biopsy soon. Pt initially required 4L nc, which showed rapid improvement. Pt's O2 sat was 91-94% on room air, but desaturated to 87-89% during sleep. Pt was not dyspneic. Pt was discharged on enoxaparin 90mcg sc bid and sent with home O2 for sleep and comfort during exertion. Pt was seen by physical therapy, who cleared Pt to return home. #) Deep vein thrombosis: Pt initially presented with RLE swelling. Bilateral lower extremity dopplers showed RLE DVT. Pt was treated with heparin drip and enoxaparin 90mcg sc bid as above for pulmonary embolism. Pt's right lower extremity swelling improved rapidly with anticoagulation and by date of discharge, his lower extremities were equal in size. Pt only reported mild tenderness to palpation of right lower extremity. #) Pulmonary nodules/hilar mass: Hilar mass is new finding and per radiology, tracking w/ bronchovascular structures makes it concerning for primary lung process. Very remote light smoking history. Rare alcohol use. No family history of malignanacy. Most recent CT scan [**2176-10-11**] without evidence of hilar mass. In setting of hilar and mediastinal LAD and unprovoked DVT, there is concern for stage 4 pulmonary malignancy (due to effusion). Does have a hx of remote melanoma and prostate CA. PSA wnl. Abnormal cells were noted on effusion (see below). Cytology was still pending upon discharge. Pt was seen by inpatient oncology, Dr. [**Last Name (STitle) **]. Pt had imaging including CT chest, abdomen, and pelvis, MR head, and bone scan with no clear metastatic disease, but extensive malignant disease in the chest w/ hilar and mediastinal lymphadenopathy and signs of lymphangitic carcinomatosis. Family wants to have oncology follow-up at [**Hospital1 18**], although Pt is [**Name (NI) 2287**]. Pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] states that Pt can follow-up with whichever oncologist he chooses. Pt's workup will depend on the results of Pt's pleural effusion cytology, which is still pending. If cytology is positive for malignant cells, malignant effusion automatically places at stage 4. If effusion analysis is negative for malignant cells, Pt may have further workup with biopsy. Per interventional pulmonology, mass is amenable to EBUS guided biopsy as an outpatient. Pt was scheduled for outpatient follow-up with Dr. [**Last Name (STitle) **] in 1 week. #) Likely malignant pleural effusion: New onset. No h/o CHF and no evidence of cardiac dysfunction on recent TTE, making this etiology less likely. Other possibilities include maligancy (particularly in setting of nodules and LAD) vs. infectious vs. autoimmune. 1.4L of serosanguinous fluid was removed. Fluid labs showed: RBCs [**2166**], WBCs 1075, 25% pmns, 33% lymphs, 2% monos, 8% mesos, 30% macros, 1% other. Protein 3.1, Glucose 143, LD 154, cholesterol 57. pH 7.53. Pt has exudative effusion by cholesterol, protein, ldh. Pt's oxygenation and respiration greatly improved after right thoracentesis. Pt had no evidence of re-accumulation by day of discharge. Pt was scheduled for outpatient follow-up with interventional pulmonology in 2 weeks. #) Cough: Dry cough with deep inspiration likely from pulmonary embolism. Low suspicion for XR since CT chest did not show infectious process. Pt was very bothered by cough. [**Year (4 digits) 108422**]-Dextromethorphan cough syrup was ineffective, as were tesselon pearles. Pt felt some relief with [**Year (4 digits) 108422**]-codeine syrup and was discharged with a prescription. #) Fever / urinary tract infection: temp to 100.4 on [**3-7**], initially suspected clot fever from thrombus/embolism resorption. Urine culture on [**3-7**] grew 10-100k Enterobacter cloacae pan-sensitive except nitrofurantoin. Pt was treated with ciprofloxacin 500mg po bid for 2 weeks for complicated UTI given Pt's foley placement. Blood cultures from [**3-7**] showed no growth to date. #) hematuria: somewhat bloody urine previously, attributed to foley, which has since been removed. Little to no hematuria now. Resolved since repeat UA only showed 8 RBCs. #) Diabetes mellitus: usually diet controlled. A1c 6.6 in [**Month (only) 404**]. Insulin sliding scale. TRANSITIONAL ISSUES: -Pleural effusion cytology still pending. Further oncological workup will depend on cytology results as described above. -Will need to follow-up oxygen requirement and assess for pleural effusion reaccumulation. -[**Month (only) 116**] need repeat imaging to assess treatment of pulmonary emboli. -Pt has a retrievable IVC filter which should be removed as soon as his staging / biopsy procedures are completed. Medications on Admission: Ambien 10 mg PO qHS Lasix 20 mg PO daily (increased to 40 mg daily on [**3-6**]) Propanolol 40 mg PO prn Niacin 500 mg MVI Discharge Medications: 1. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. niacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. propranolol 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for PRN. 5. enoxaparin 100 mg/mL Syringe Sig: One (1) mL Subcutaneous twice a day. Disp:*qs for 1 month syringes* Refills:*2* 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. Disp:*28 Tablet(s)* Refills:*0* 7. oxygen oxygen, 1-2 L/min, continuous via nasal canula as needed. Pt desaturates to 88% with ambulation on room air. 8. [**Month/Year (2) 108422**] AC 10-100 mg/5 mL Liquid Sig: Five (5) mL PO every four (4) hours as needed for cough: Do not drive or operate machinery on this medication. Disp:*qs 1 month mL* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Bilateral pulmonary emboli Lung mass Right pleural effusion Right leg deep vein thrombosis Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 108423**], You came to the hospital because you had shortness of breath and fatigue. You were found to have multiple blood clots (pulmonary emboli) in your lungs and a blood clot in your right leg. You were started on blood thinners to treat these clots in the intensive care unit and stabilized before you were transferred to the medical floor. You had a filter placed in your inferior vena cava to prevent further blood clots from migrating to your lungs. Our specialists also drained fluid that was collected around your right lung. This fluid was sent for cellular studies, which are still pending. You were also noted to have a lung mass. Depending on the results of the lung fluid studies, you may need to have a bronchoscopy and biopsy. For this reason, you will continue to take enoxaparin (Lovenox) while your lung mass workup plans are still being finalized. You were seen by our cancer specialists, who will see you in clinic as an outpatient. You had several imaging studies that were requested by your cancer doctors, and they will discuss the results with you. You will also see our lung specialists in two weeks. Although you are breathing much better now, we have arranged for oxygen to be provided for you at home in case you need it. We have made a follow-up appointment for you to see your primary care physician in three days. We have made the following changes to your medications: STOP taking furosemide (lasix) (you were on this for presumed congestive heart failure, but you do not have this diagnosis) START using oxygen via nasal canula as needed START taking ciprofloxacin 500mg tablets, one tab by mouth every 12 hours for 2 weeks START using enoxaparin (Lovenox) subcutaneous injections, 100mg, every 12 hours until instructed to stop by your doctors [**Name5 (PTitle) **] taking [**Name5 (PTitle) 108422**] AC (with codeine) 10-100 mg/5 mL Liquid Five mL by mouth every four hours as needed for cough: Do not drive or operate machinery on this medication. Please continue to take your other medications as previously prescribed. Followup Instructions: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Location (un) 2274**]-[**University/College **] [**Hospital1 **] Wellesly [**Numeric Identifier **] Phone: ([**Telephone/Fax (1) 108424**] When: Friday, [**3-13**] at 12:00pm We are working on a follow up appointment with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the Hematology/Oncology department in the next week. You will be called at home with the appointment. If you have not heard by tomorrow, please call [**0-0-**]. Department: WEST PROCEDURAL CENTER When: MONDAY [**2178-3-23**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage ***You will need a chest xray prior to this appointment. You will receive written instructions about this in the mail. Please cal above number with any questions. Department: WEST PROCEDURAL CENTER When: MONDAY [**2178-3-23**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Please call our registration department at [**Telephone/Fax (1) 10676**] to update you outpatient record prior to the above [**Hospital1 18**] appointments. Completed by:[**2178-3-12**]

[ "196.1", "333.1", "423.9", "V70.7", "511.81", "V46.2", "250.60", "799.02", "V10.46", "453.42", "V15.82", "453.41", "599.0", "V10.82", "E879.6", "415.19", "041.85", "599.71", "996.64", "357.2", "162.8" ]

icd9cm

[ [ [] ] ]

[ "88.51", "38.7", "34.91" ]

icd9pcs

[ [ [] ] ]

15646, 15652

9361, 14156

322, 438

15811, 15811

4535, 9338

18073, 19677

3250, 3343

14763, 15623

15673, 15790

14616, 14740

15962, 17360

3358, 3987

4015, 4516

14177, 14590

17390, 18050

263, 284

466, 2430

15826, 15938

2452, 3003

3019, 3234

26,935

122,350

31744

Discharge summary

report

Admission Date: [**2136-9-23**] Discharge Date: [**2136-9-28**] Date of Birth: [**2083-6-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: sternal wound infection Major Surgical or Invasive Procedure: s/p sternal debridement/VAC placement [**9-24**] sternal plating/pect. flap advancement [**2136-9-25**] PICC line placement [**2136-9-27**] History of Present Illness: 53 yo male s/p cabg [**9-6**] and sternal plating on [**9-7**] returns on [**9-23**] with fever and increasing sternal wound drainage.Admitted for further management by Dr. [**Last Name (STitle) **] and plastic surgery service. Past Medical History: CAD s/p cabg sternal wound infection Hyperlipidemia HTN Obesity Umbilical hernia New onset diabetes type 2 Past laminectomy Social History: Retired semi-pro football player. He is know a trucking company manager. He drinks 5 drinks per week. Denies tobacco use. Family History: Father with CAD at age 53. Physical Exam: 130/78 T 101 HR 84 RR 22 94% RA sat 117.2 kg 69" alert and oriented x3, no acute distress RRRsternal incision with yellowish drainage CTAB abd soft, NT, ND + BS Pertinent Results: [**2136-9-27**] 05:28AM BLOOD WBC-8.6 RBC-2.95* Hgb-8.5* Hct-26.1* MCV-88 MCH-28.8 MCHC-32.5 RDW-14.5 Plt Ct-694* [**2136-9-23**] 07:10PM BLOOD WBC-14.4* RBC-3.47* Hgb-10.2* Hct-30.3* MCV-87 MCH-29.5 MCHC-33.8 RDW-13.9 Plt Ct-773* [**2136-9-23**] 07:10PM BLOOD Neuts-86.8* Lymphs-8.3* Monos-3.7 Eos-1.1 Baso-0.1 [**2136-9-27**] 05:28AM BLOOD PT-12.8 PTT-25.2 INR(PT)-1.1 [**2136-9-27**] 05:28AM BLOOD Plt Ct-694* [**2136-9-27**] 05:28AM BLOOD Glucose-181* UreaN-14 Creat-0.8 Na-138 K-4.4 Cl-99 HCO3-29 AnGap-14 [**2136-9-26**] 03:25PM BLOOD ALT-60* AST-31 LD(LDH)-150 AlkPhos-152* TotBili-0.3 RADIOLOGY Final Report CHEST (PA & LAT) [**2136-9-28**] 9:53 AM CHEST (PA & LAT) Reason: check effusions [**Hospital 93**] MEDICAL CONDITION: 53 y/o M s/p CABG presenting with sternal wound infection. REASON FOR THIS EXAMINATION: check effusions PA & LATERAL VIEWS CHEST: REASON FOR EXAM: S/P CABG with sternal wound infection. Follow up pleural effusions. Comparison is made with prior study performed a day earlier. Small bilateral pleural effusions greater in the left side are improved. Aside from discoid atelectasis in the left lower lobe, the lungs are clear. Allowing for difference in technique and positioning of the patient, there has been interval decrease in cardiomediastinal size. There is no pneumothorax. DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: MON [**2136-10-1**] 9:51 AM Brief Hospital Course: Admitted [**9-23**] and taken to OR on [**9-24**] with Dr. [**Last Name (STitle) **] and plastic surgery for consultation. CT scan suspicious for substernal infection. Wound debrided superficially, and multiple cultures sent with VAC dressing applied. Transferred to the CSRU in stable condition. Kept intubated and returned to the OR the next day for sternal plating and pect. flap advancement with Dr. [**First Name (STitle) **].Extubated the next day. ID consult done for abx management. Transferred to the floor on [**9-26**] to begin increasing his activity level. PICC line placed for continued IV abx therapy and [**Last Name (un) **] consult also done for better glucose management.Cleared for discharge to home with services on [**9-28**]. IV nafcillin to continue until [**11-5**] with followup appts. to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] of the ID service. Medications on Admission: metoprolol 50 mg [**Hospital1 **] ASA 81 mg daily motrin 600 mg po q6hours metformin 500 mg [**Hospital1 **] atorvastatin 40 mg daily ranitidine 150 mg [**Hospital1 **] Discharge Medications: 1. PICC PICC line care per NEHT protocol. 2. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours): Through [**11-5**]. Disp:*240 doses* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(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:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. Disp:*3 units* Refills:*2* 9. Outpatient Lab Work CBC, LFTs, BUN/Cr. weekly, fax results to Dr. [**First Name (STitle) 1075**] @ [**Telephone/Fax (1) **] Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Superficial sternal wound infection. s/p CABGx4 [**9-7**] IDDM HTN elev. chol. obesity umbilical hernia Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for sternal drainage, temp.>101.5 Do not use creams, lotions, or powders on wounds. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 16412**] for 1-2 weeks. Make an appointment with Dr. [**First Name (STitle) **] for 2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2136-10-26**] 10:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2136-11-9**] 9:00 Completed by:[**2136-10-15**]

[ "998.59", "V45.81", "401.9", "278.00", "288.60", "414.00", "E878.8", "553.1", "V58.66", "250.00", "V45.4", "V58.67", "518.0", "996.49", "041.11", "272.4", "V09.0" ]

icd9cm

[ [ [] ] ]

[ "99.21", "34.79", "38.93", "77.61", "34.03" ]

icd9pcs

[ [ [] ] ]

5082, 5144

2883, 3792

345, 487

5292, 5300

1280, 1988

5763, 6249

1048, 1076

4011, 5059

2025, 2084

5165, 5271

3818, 3988

5324, 5740

1091, 1261

282, 307

2113, 2860

515, 744

766, 892

908, 1032

67,984

113,948

53113

Discharge summary

report

Admission Date: [**2100-8-24**] Discharge Date: [**2100-8-29**] Date of Birth: [**2047-10-18**] Sex: M Service: CARDIOTHORACIC Allergies: Tylenol / Simvastatin Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2100-8-24**] Coronary Artery Bypass Graft x 3 - left internal mammary artery to left anterior descending artery, saphenous vein grafts to diagonal and PDA History of Present Illness: 52yo man with known CAD s/p inferior MI([**2089**]) and stenting in [**2090**] and [**2096**]. Now with recurrent chest pain over the last 2 months. Had +ETT then referred for cardiac cath. Cath revealed multivessel disease and he was referred for surgical revascularization. Past Medical History: - Coronary artery disease s/p inferior MI([**2089**]) with BMS to distal RCA. S/p PTCA [**2090**] of distal RCA secondary to in-stent restenosis, s/p DES of PLB([**6-/2099**])& LAD([**8-/2099**]) - Diabetes Mellitus II w/peripheral neuropathy(feet) - Hypertension - Hypercholesterolemia - + tobacco use - Tremors-primary - MVA ([**2098**])w/concussion and rib fx Social History: Race:caucasian Last Dental Exam: Lives with: 2 children-Daughter 16yo, son 18yo (divorced-exwife deceased) Occupation:electrician Tobacco: ongoing- 1ppd 30Pk yrs ETOH:1 drink/wk Family History: father died of MI @57yo Physical Exam: Pulse: 52 Resp: 16 O2 sat: 94%-RA B/P 120/90 Right: Left: Height: 73" Weight: 224 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM []paresthesia/sensitivity from jaw extending behind left ear Chest: Lungs w/insp/exp wheezes Heart: RRR [x] Irregular [] Murmur-none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: mild [] Neuro: Grossly intact-essential tremors Pulses: Femoral Right: Left: DP Right: Left: PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit Right: Left Pertinent Results: Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage, the Left atrial appendage ejection velocities were aproximately 20cm/s (borderline) . A small secundum atrial septal defect is present. There is bidirectional flow. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild focal left ventricular hypokinesis (LVEF = 40 %). There is hypokinesia of the apical and mid portions of the inferior wall and inferoseptal walls. The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is mild mitral regurgitation. Dr. [**Last Name (STitle) **] was notified in person of the results. Post CPB: There is mild hypokinesis of the anteroseptal wall, otherwise all other prebypass findings are unchanged. Mild mitral regurgitation persists. The aortic contours are intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2100-8-24**] 12:24 Brief Hospital Course: Mr. [**Known lastname **] was a same day admission after undergoing a pre-operative work-up prior to admission. On [**8-24**] he was brought directly to the operating room where he underwent a coronary artery bypass grafting x3 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein grafts to the posterior descending artery and the first diagonal artery. This procedure was erformed by Dr. [**Last Name (STitle) **]. Please see the operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in critical but stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. His home propanolol was restarted. He was transferred to the surgical step down floor. His chest tubes and wires were removed. He did develop right calf pain and tenderness. Ultrasound did not reveal evidence of DVT. The physical therapy service assessed him and felt he would be safe for discharge to home. By post-operative day 5 he was ready for discharge to home. All follow-up appointments were advised. Medications on Admission: Propanolol 160 mg [**Hospital1 **] Ibuprofen 800 mg TID Soma 350mg TID prn Metformin 500 mg [**Hospital1 **] Prilosec 20mg daily MVI daily ASA 81 mg daily Glyburide 1.25 mg daily Clonazepam 1 mg daily" Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough for 2 weeks. Disp:*90 Capsule(s)* Refills:*0* 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Propranolol 40 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**] Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*1 MDI* Refills:*1* 12. Glyburide 2.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 15. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft Past medical history: - s/p inferior MI([**2089**]) with BMS to distal RCA. S/p PTCA [**2090**] of distal RCA secondary to in-stent restenosis, s/p DES of PLB([**6-/2099**])& LAD([**8-/2099**]) - Diabetes Mellitus II w/peripheral neuropathy(feet) - Hypertension - Hypercholesterolemia - + tobacco use - Tremors-primary - MVA ([**2098**])w/concussion and rib fx Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema trace bilaterally 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) **] for Dr. [**Last Name (STitle) **] Thursday [**9-16**] @ 9:15 AM @[**Hospital1 **] [**Telephone/Fax (1) 109410**] Cardiologist: Dr. [**Last Name (STitle) 31888**] [**9-27**] @ 9:30 AM @ [**Hospital1 **] Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 54160**] [**Name (STitle) **] in [**3-8**] 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** Completed by:[**2100-8-29**]

[ "745.5", "V45.82", "272.0", "511.9", "357.2", "414.01", "412", "401.9", "781.0", "250.60", "305.1", "285.9", "729.5" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6399, 6472

3476, 4606

300, 460

6934, 7173

2103, 3006

8096, 8715

1362, 1387

4858, 6376

6493, 6550

4632, 4835

7197, 8073

1402, 2084

250, 262

488, 765

6572, 6913

1167, 1346

3017, 3453

9,047

169,379

13753

Discharge summary

report

Admission Date: [**2107-4-10**] Discharge Date: [**2107-4-20**] Date of Birth: [**2060-10-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4057**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: right thoracentesis History of Present Illness: 46yo woman with a history of breast cancer metastatic to liver, lungs, [**First Name3 (LF) 500**], brain who presents with dyspnea. She has a history of malignant left pleural effusion, which has been treated with thoracentesis and pleurodesis. She also has a history of right pleural effusion, which was tapped on [**1-22**]. She now presents with increased level of dyspnea times 5 days. She denied any chest pain, pleurisy, abdominal pain, cough, fever/chills. She does endorse nausea/vomiting, decreased po intake, and weight loss. In ED, had thoracentesis with 1300cc drained. Past Medical History: 1. Metastatic breast cancer -mets to [**Last Name (LF) 500**], [**First Name3 (LF) **], liver, lungs -s/p XRT, lumpectomy -s/p 2 cylces of neoadjuvant FAC -s/p whole brain irradiation and lumbosacral radiation -s/p 5-FU -s/p Tamoxifen [**Date range (1) 41374**] -s/p tx with weekly epirubicin/taxotere -currently on Arimidex 2. left pleural effusion - s/p thoracentesis, s/p talc pleurodesis in [**2103**] 3. right pleural effusion - thoracentesis in [**1-22**] Social History: She was born on [**Last Name (un) 41375**]and St. [**Location (un) **]. She moved to the U.S. in [**2087**]. She has a teenage daughter. She denied tobacco, alcohol. She is a retired house cleaner and lives alone. Family History: Negative for breast cancer and ovarian cancer. Physical Exam: 98.8, 109, 160/100, 18, 100% 5L NC gen: sleepy, arousable, no acute distress heent: NCAT, EOMI, PERRL, anicteric, oropharynx clear cv: tachycardic, regular rhythm, no m/r/g skin: anterior chest wall ulceration, nodular breast lesions resp: decreased breath sounds in both lung bases R>L dullness to percussion to mid lung field on right abd: soft, NABS, NT/ND extr: no c/c/e neuro: no focal deficits Pertinent Results: [**2107-4-10**] 07:00AM GLUCOSE-79 UREA N-7 CREAT-0.4 SODIUM-129* POTASSIUM-4.4 CHLORIDE-89* TOTAL CO2-30* ANION GAP-14 [**2107-4-10**] 07:00AM LD(LDH)-441* [**2107-4-10**] 07:00AM TOT PROT-6.5 CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.2 [**2107-4-10**] 07:00AM OSMOLAL-265* [**2107-4-10**] 07:00AM WBC-7.0 RBC-5.20 HGB-13.1 HCT-40.7 MCV-78* MCH-25.3* MCHC-32.3 RDW-14.6 [**2107-4-10**] 07:00AM PLT COUNT-308 [**2107-4-10**] 03:15AM URINE HOURS-RANDOM UREA N-375 CREAT-43 SODIUM-28 [**2107-4-9**] 11:45PM PLEURAL TOT PROT-4.2 GLUCOSE-115 LD(LDH)-312 ALBUMIN-2.4 [**2107-4-9**] 08:30PM cTropnT-<0.01 [**2107-4-9**] 08:30PM CK-MB-3 [**2107-4-9**] 08:30PM ALBUMIN-3.9 [**2107-4-9**] 08:30PM WBC-7.2 RBC-5.13 HGB-13.5 HCT-41.2 MCV-80* MCH-26.2* MCHC-32.7 RDW-14.9 [**2107-4-9**] 08:30PM HYPOCHROM-1+ MICROCYT-1+ [**2107-4-9**] 08:30PM PLT COUNT-326 Brief Hospital Course: 46yo woman with history of metastatic breast cancer to lung, liver, bones, brain presented with dyspnea secondary to recurrent pleural effusion. 1. Recurrent right pleural effusion She has a history of malignant left pleural effusion, which has been tapped and is s/p pleurodesis. She presented in [**1-22**] with right pleural effusion. She now presented with dyspnea and recurrent right pleural effusion. This was drained by thoracentesis, and then pleurodesed by Interventional Pulmonary service. The chest tube was removed after three days of chest tube output of less than 150cc. 2. Hospital acquired pneumonia She developed new onset of multifocal infiltrates during her hospital course, and had a transient leukocytosis. She was started on empiric broad spectrum abx, including ceftazidime, azithromycin, and vancomycin. Sputum cultures only revealed oropharyngeal flora. Other infectious workup included negative UA/urine cultures, and blood cultures (pending). 3. Sinus tachycardia She has had extensive workup for this - no clear evidence of fever, pain, anxiety, pulmonary embolism (negative CTA during this admission) to explain this. She was given NS for volume repletion, as she became progressively alkalotic and had a FeNa of < 1% (all consistent with volume contraction). 4. Anemia Hypochromic, microcytic anemia with iron studies consistent with anemia of chronic inflammation. _ _ ________________________________________________________________ *update: she was sent to the MICU for increased respiratory distress. During the course of her MICU stay, discussion was held with her family, and she was made Comfort Measures Only. . She thereafter returned to the OMED service and passed away. Medications on Admission: Arimidex Discharge Disposition: Expired Facility: deceased Discharge Diagnosis: 1. metastatic breast cancer 2. recurrent malignant effusion 3. hospital acquired pneumonia 4. tachycardia 5. anemia of chronic inflammation Discharge Condition: deceased Discharge Instructions: - Followup Instructions: -

[ "276.1", "276.4", "518.84", "V66.7", "174.8", "280.9", "198.5", "197.2", "427.89", "197.0", "197.7", "198.3" ]

icd9cm

[ [ [] ] ]

[ "34.91", "34.04", "97.41", "34.92" ]

icd9pcs

[ [ [] ] ]

4862, 4891

3074, 4803

324, 345

5074, 5084

2183, 3051

5134, 5138

1692, 1740

4912, 5053

4829, 4839

5108, 5111

1755, 2164

277, 286

373, 959

981, 1444

1460, 1676

63,219

194,579

52645

Discharge summary

report

Admission Date: [**2130-11-15**] Discharge Date: [**2130-11-19**] Date of Birth: [**2073-12-12**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Known firstname 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2130-11-15**] - Coronary artery bypass graft x1 (left internal mammary artery to left anterior descending artery) History of Present Illness: Mr. [**Known lastname **] is an active 56 year old who was jogging when he started to experience dyspnea this summer about 5-6 minutes into his usual run. He mentioned this to his primary care physician and was referred for a stress test, which he failed. On cardiac catheterization found that he had a high grade ostial LAD lesion extending to the left main so he was referred for surgical evaluation Past Medical History: depression migraine headaches Social History: Lives with:wife in [**Name2 (NI) **] Occupation:estate planning attorney Cigarettes: Smoked no [x] ETOH: < 1 drink/week [] [**3-13**] drinks/week [] >8 drinks/week [x] Denies ellicit drug use Family History: father had CABG at age 70. 4 siblings with no CAD. Physical Exam: Pulse: 60 Resp: 18 O2 sat: 98%RA B/P Left: 135/96 Height: 5 feet 11 inches Weight:169 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 [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] No Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right:- Left:- Pertinent Results: [**2130-11-15**] ECHO PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results before incision. POST-BYPASS: Preserved biventricular systolic function. LVEF 55%. Trivial MR> Intact thoracic aorta. [**2130-11-19**] 05:20AM BLOOD WBC-4.7 RBC-3.38* Hgb-10.0* Hct-30.6* MCV-91 MCH-29.6 MCHC-32.7 RDW-12.9 Plt Ct-203 [**2130-11-15**] 01:38PM BLOOD WBC-8.4# RBC-3.65* Hgb-11.0* Hct-32.7* MCV-90 MCH-30.2 MCHC-33.7 RDW-12.6 Plt Ct-163 [**2130-11-15**] 01:38PM BLOOD PT-13.1 PTT-38.2* INR(PT)-1.1 [**2130-11-19**] 05:20AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-138 K-4.2 Cl-101 HCO3-33* AnGap-8 [**2130-11-15**] 01:38PM BLOOD UreaN-15 Creat-0.7 Na-139 K-4.4 Cl-108 HCO3-28 AnGap-7* Sinus rhythm. Non-specific inferior ST-T wave changes. Non-specific ST-T wave changes in leads V5-V6. Compared to the previous tracing of [**2130-11-10**] there is no change. Intervals Axes Rate PR QRS QT/QTc P QRS T 67 142 80 [**Telephone/Fax (2) 108655**] 17 Brief Hospital Course: He was admitted on [**2130-11-15**] for surgical management of his cornary artery disease. He was taken to the operating room for coronary artery bypass grafting to one vessel. Please see operative note for details. Postoperatively he was taken to the intesnive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. On postoperative day one, he was transferred to the step down unit for further recovery. He did have issues with nausea and medications were adjusted. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for asistance with his postoperative strength and mobility. His nausea resolved and he was tolerating his diet on post operative day three. He continued to progress and was ready for discharge home with services on post operative day four. Medications on Admission: DESVENLAFAXINE [PRISTIQ] - (Prescribed by Other Provider) - 50 mg Tablet Extended Release 24 hr - 1.5 Tablet(s) by mouth daily NAPROXEN - 500 mg Tablet - one Tablet(s) by mouth q 12 hours as needed for migraine ZOLMITRIPTAN [ZOMIG ZMT] - 5 mg Tablet, Rapid Dissolve - one Tablet(s) by mouth prn migraine as needed take with naproxen as directed Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. desvenlafaxine 50 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. 5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for breakthrough pain . Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery diseases/p cabg depression migraine headaches Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Edema - none 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 [**2130-12-21**] at 1:00 Cardiologist: Dr. [**Last Name (STitle) 911**] [**Telephone/Fax (1) 62**] on [**2130-12-21**] at 2:40 Wound check [**Telephone/Fax (1) 170**] on [**2130-11-28**] at 10:30 (cardiac surgery office) Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**5-9**] 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** Completed by:[**2130-11-19**]

[ "787.02", "311", "414.01", "346.90" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

5800, 5858

3540, 4451

323, 442

5964, 6134

1883, 3517

7023, 7667

1154, 1208

4848, 5777

5879, 5943

4477, 4825

6158, 7000

1223, 1864

273, 285

470, 873

895, 927

943, 1138

4,909

106,627

9702

Discharge summary

report

Admission Date: [**2200-10-7**] Discharge Date: [**2200-11-7**] Date of Birth: [**2152-10-23**] Sex: M Service: CARD [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This is a 47 year old male patient with a known history of coronary artery disease who had been medically managed for the past few years. He recently had a positive exercise tolerance test in [**Month (only) 359**] of this year due to increasing dyspnea on exertion. He was then admitted to the [**Hospital6 3872**] on [**2200-10-3**], due to shortness of breath and palpitations accompanied by lightheadedness. He was ruled out for myocardial infarction and underwent cardiac catheterization on [**2200-10-6**], which revealed significant three vessel coronary artery disease with a left ventricular ejection fraction of 50%. He was transferred to the [**Hospital1 188**] for a possible coronary artery bypass graft. The patient has a known right femoral arteriovenous fistula which was found at the [**Hospital6 3872**]. PAST MEDICAL HISTORY: 1. Known coronary artery disease. 2. Poorly controlled type 2 diabetes mellitus. 3. Gastroesophageal reflux disease. 4. Hypertension. 5. Hypercholesterolemia. 6. Asthma. 7. Diabetic retinopathy; diabetic neuropathy. 8. Obesity. 9. Former smoker. SOCIAL HISTORY: The patient denies alcohol use. He is married and lives with his wife. PAST SURGICAL HISTORY: He is status post right vitrectomy and laser surgery both eyes. ALLERGIES: The patient states and allergy to Hydrochlorothiazide. MEDICATIONS: 1. Lantus insulin 20 units q. a.m.; 120 units q. h.s. 2. Humalog sliding scale insulin six times per day. 3. Glucophage SR 1500 mg q. p.m. 4. Norvasc 10 mg q. day. 5. Atenolol 50 mg q. h.s. 6. Lipitor 10 mg q. day. 7. Tricor 160 mg q. day. 8. Covera 240 mg q. h.s. 9. Pepcid 20 mg twice a day. 10. Singulair. 11. Prednisolone eye drops to the right eye six times a day. LABORATORY: Upon admission, white blood cell count 4,600, hematocrit 32.9, platelet count 201. Sodium 134, potassium 4.5, chloride 101, CO2 27, BUN 10, creatinine 1.7, glucose 339 and hemoglobin A1C of 10.2%. PHYSICAL EXAMINATION: On admission, neurologically he was grossly intact. His lungs were clear to auscultation bilaterally. Coronary examination was regular rate and rhythm. Abdomen was soft, obese, nontender. Extremities were warm and well perfused. HOSPITAL COURSE: The patient had a Vascular Surgical Consultation the following day due to the arteriovenous fistula in the patient's right groin and since the patient was not symptomatic with that and his examination was not remarkable, it was their recommendation to evaluate him once he had recovered from his cardiac surgery and to be followed in the Vascular Surgery Clinic. The patient was taken to the Operating Room on [**2200-10-10**], by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], where he underwent coronary artery bypass graft times four with a left internal mammary artery to the left anterior descending, saphenous vein graft to the PDA, saphenous vein graft to the obtuse marginal; saphenous vein graft to the ramus. Postoperatively, the patient was on Propofol, insulin and Neo-synephrine intravenous drips and he required a temporary epicardial pacing at that time. He was transported from the Operating Room to the Cardiac Surgery Recovery Unit in good condition. On the morning of postoperative day one, it was noted that the patient had spontaneously dislodged his endotracheal tube and was ultimately reintubated by the Anesthesia Service. Over the next two to three days in the Intensive Care Unit, the patient was maintained on Neo-Synephrine, insulin and propofol drips. He remains intubated, on a ventilator. He had some significant problems with restlessness and agitation, requiring continued sedation at that time. The patient was noted to have elevated temperatures in the 101.0 to 102.0 F. range, and Infectious Disease consult was obtained on [**10-13**] and the patient was pan cultured as well at that time. It was their recommendation to empirically treat him with board spectrum antibiotics and he was placed on Vancomycin and Zosyn at that time. He was also fully cultured. The patient had multiple attempts at weaning from mechanical ventilation through the course of the next few days. He self extubated a few times as well and failed, requiring urgent reintubation and he has ultimately undergone tracheostomy performed by Dr. [**Last Name (STitle) 952**] on [**2200-10-23**]. Initial cultures from the fever spikes postoperatively were negative. He did, however, wind up having Methicillin resistant Staphylococcus aureus in his sputum, although when that was ultimately found he did not have a fever or white count at the time. He was placed on intravenous Vancomycin for an approximately two week period when that was initially discovered. The patient had been started on tube feeds which he had been tolerating quite well and was increased to goal. The [**Hospital **] Clinic Service was following him for diabetes mellitus management throughout his Intensive Care Unit stay. The patient was begun on beta blockers increased and has been tolerating those well. On [**10-31**], the Skin Care Nursing Service was consulted because the patient had a progressively increasing coccygeal decubitus ulcer. He started with some redness prior to going to the Operating Room but this progressed throughout his postoperative course. It was their recommendation to cleanse the wound and to place an Aquagel dressing over the open area and to cover that with a Tegaderm over that. The patient has progressed with ventilator weaning. He tolerated CPAP with minimal levels of pressure support for prolonged periods. He also tolerates tracheostomy collar for varying lengths of time without getting tired, anywhere from two to six hours at a time. The patient has also progressed well from a Physical Therapy standpoint. He does ambulate. With some assistance, he ambulated approximately 100 feet. The patient underwent a bedside Swallow evaluation approximately a week ago which he passed very well and his tube feeds have been discontinued. He underwent a calorie count and he is taking in an adequate amount of calories orally without the need for tube feed. He is, however, receiving supplements of Boost Plus three times a day to meet his caloric needs. The patient has remained afebrile. He has remained hemodynamically stable and he is ready to be transferred to a rehabilitation facility to progress with his Physical Therapy and Ventilator weaning needs. His physical examination today, [**11-7**], is as follows: His weight today is 108.2 kilograms; his preoperative weight was 112. His vital signs include a temperature of 97.2 F.; pulse of 82 in normal sinus rhythm; blood pressure 110/47; respiratory rate 24; oxygen saturation 99%. Most recent laboratory values include a white blood cell count of 9,200, hematocrit of 32.7 and a platelet count of 371. Sodium 138, potassium 4.6, chloride 99, CO2 31, BUN 24, creatinine 0.9, glucose 121. The patient is neurologically alert and oriented. He moves all extremities well and he follows commands appropriately. On his respiratory examination, his lungs are clear to auscultation bilaterally. Coronary examination is regular rate and rhythm. His sternum is stable. His incision is healing well. His abdomen is obese, soft, nontender, with positive bowel sounds. Extremities are warm and well perfused. The right leg saphenous vein harvest site is also healing well and he has no peripheral edema. The patient has a #8 Shiley tracheostomy in place and he is varying between the ventilator CPAP with pressure support mode and a tracheostomy collar. DISCHARGE MEDICATIONS: 1. Prednisolone acetate 1% eye drops to the right eye four times a day. 2. Hydralazine 20 mg p.o. four times a day. 3. Clonazepam 1 mg three times a day. 4. Colace 100 mg twice a day. 5. Zantac 150 mg twice a day. 6. Aspirin 325 mg q. day. 7. Heparin 5000 units subcutaneously q. eight hours. 8. Metoprolol 100 mg q. eight hours. 9. Lasix 80 mg q. day. 10. Zinc 220 mg q. day. 11. Vitamin C 500 mg twice a day. 12. Multivitamin one p.o. q. day. 13. Lantus insulin 100 units subcutaneously at bed time q. h.s. 14. Sliding scale Humalog coverage as follows: For coverage for breakfast and lunch are as follows: Glucose 100 to 150, 4 units; 151 to 200 8 units; 201 to 250, 14 units; 251 to 300, 18 units; 301 to 400, 20 units; greater than 400, 24 units. Coverage before dinner is: Glucose 150 to 200, 4 units; 201 to 250, 6 units; 251 to 300, 8 units; 301 to 400, 10 units; greater than 400, 12 units. Coverage at bed time is: Glucose of 150 to 200, 2 units; 200 to 250, 3 units; 250 to 300, 4 units; 300 to 400, 5 units and greater than 400, 6 units. 15. Atrovent and Albuterol Metered-Dose Inhalers on a p.r.n. basis. CONDITION AT DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass graft. 2. Respiratory failure status post tracheostomy placement. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2200-11-7**] 14:41 T: [**2200-11-7**] 16:43 JOB#: [**Job Number 32777**]

[ "250.50", "780.6", "411.1", "518.5", "250.40", "997.1", "414.01", "707.0", "998.89" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "39.61", "31.1", "33.23", "36.13", "36.15", "93.90", "96.6" ]

icd9pcs

[ [ [] ] ]

9011, 9391

7823, 8967

2424, 7800

1410, 2149

2172, 2406

8983, 8990

189, 1018

1040, 1296

1313, 1386

59,049

104,501

24776

Discharge summary

report

Admission Date: [**2174-5-26**] Discharge Date: [**2174-5-28**] Date of Birth: [**2115-8-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: AICD firing Major Surgical or Invasive Procedure: None History of Present Illness: 58 yo man with CAD s/p IMI and subsequent systolic dysfuntion (EF 25-30%), HTN, hyperchol, OSA, VT s/p ICD implantation presents with AICD shocks. On Sunday, he had VT that was not terminated by AVP and his ICD shocked him. He sent tele to Dr.[**Last Name (STitle) **] which showed 12 VT episodes. No intervention was planned at that time. Of note, he recently stopped his carvedilol himself about 3 weeks ago because he thought is was making him tired though he's been on this medication for a long time. He was recently admitted in [**Month (only) 547**] for elective VT ablation. He states that prior to [**Month (only) 547**] he his AVP sucessfully terminted his VT and he had not had a shock in over a year. More recently in the past 3 weeks, he's had a total of 4 shocks (one Sunday, one at work today and 2 here in the ED). He's unclear if this correlates with stopping his carvedilol. Today, at work, he again went into VT and AVP was unsucessful at converting and it shocked him. He had no CP or SOB at the time. He called EMS and was brought here. In ER, VS 98.0 86 156/95 18 100%RA. EKG with old RBBB otherwise unremarkable for ischemia. He had another episode of VTach, which the ICD attempted twice to ATP and then fired. EP was consulted and witnessed a second failed ATP and AICD firing. He was admitted to the CCU for further monitoring. Currently, he feels well and has no complaints. He states that when he goes into VT he does not have chest pain or shortness of breath - states that it feels like his heart is being 'tickled'. Denies blurred vision or lightheadedness during these episodes. Past Medical History: CAD s/p inferoposterior MI with PTCA [**2159**], [**2173**] Dyslipidemia Hypertension Chronic Systolic Heart Failure, EF 25-30%. Nonsustained ventricular tachycardia with ICD [**8-/2170**] S/p VT ablation [**4-/2174**] Hypertension Hyperlipidemia Obstructive sleep apnea H/o vitamin B12 deficiency Nephrolithiasis Peripheral neuropathy Remote history of peptic ulcer disease GERD Status post tonsillectomy and adenoidectomy. Social History: Social history is significant for the presence of current tobacco use (40 pack year history). There is no history of alcohol abuse.Pt lives at home with his wife and daughter. [**Name (NI) **] is on disability but still works part time in management for the [**Location (un) 86**] retirement board. Family History: There is no family history of premature coronary artery disease or sudden death. Father had atrial fibrillation. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: On Admission: VS: T:98.3 HR:78 BP:126/74 RR:17 SpO2:94% General Appearance: Well nourished, No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL, Pupils dilated Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur: Systolic), distant heart sounds thoughout Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : , Bronchial: throughout, Wheezes : scant, Diminished: bilaterally) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: No(t) Muscle wasting Skin: Warm Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to): person, place, time and purpose, Movement: Purposeful, Tone: Normal Pertinent Results: ADMISSION LABS: - WBC-8.1 RBC-4.61 HGB-14.0 HCT-41.1 MCV-89 MCH-30.3 MCHC-34.0 RDW-15.7* - PLT COUNT-245 - NEUTS-63.2 LYMPHS-30.2 MONOS-4.5 EOS-1.4 BASOS-0.7 - CALCIUM-9.9 PHOSPHATE-3.9 MAGNESIUM-2.2 - CK-MB-5 - cTropnT-<0.01 - CK(CPK)-147 - GLUCOSE-97 UREA N-13 CREAT-1.4* SODIUM-140 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-30 ANION GAP-17 - CALCIUM-9.7 MAGNESIUM-2.1 Brief Hospital Course: 58 yo man with CAD s/p IMI and subsequent systolic dysfuntion (EF 25-30%), HTN, hyperchol, OSA, VT s/p ICD implantation presents with recurrant VT after self discontinuation of carvedilol. # RHYTHM, VT: Patient has VT s/p multiple ablations. Patient recently stopped his Carvediolol, which likely contributed to new failure of ICD to terminate VT. Carvedilol restarted and patient had no further episodes of VT. Was observed for 24 hours and discharge home with EP follow up on home medications of mexilitine and quinidine. # CAD: Not an active issue. Patient is s/p IMI with PCI in 08/[**2173**]. ETT on [**2174-4-28**] showing stable severe fixed defects involving the inferior and lateral walls, and the apex, with associated akinesis. Cardiac enzymes were negative in ED, has had no chest pain. Did not ROMI given low clinical suspicion. Continued atorvastatin, aspirin, and restarted BB as above. Also restarted Diovan which was stopped during last admission [**2-7**] renal failure and never restarted as out patient. # CHRONIC SYSTOLIC HEART FAILURE: Stable, not actively managed whie in patient. EF 20-25% on last echo in [**8-13**]. Continued home po lasix 60mg [**Hospital1 **] and restarted BB as above. [**Last Name (un) **] restarted as above. # HYPERLIPIDEMIA: Continued atorvastatin and niacin. # CHRONIC RENAL INSUFFICIENCY: On admission, Cr 1.4. Baseline Cr 0.9 to 1.3 but recently ranging up to 2.2. [**Last Name (un) **] restarted as above. # PERIPHERAL NEUROPATHY: Unknown cause, not a diabetic per prior notes. Continued home gabapentin and oxycodone for pain. # OSA: Known complex OSA per out patient sleep note. Used home CPAP # Code: FULL Medications on Admission: 1. Allopurinol 150 mg qd 2. Atorvastatin 80 mg qd 3. Carvedilol 12.5 mg PO BID --- prescribed but not taking at home 4. Duloxetine 60 mg qd 5. Gabapentin 600 mg tid 6. Gabapentin 900 Q9 P.M. 7. Aspirin 325 mg qd 8. Omega-3 Fatty Acids Capsule qd 9. Mexiletine 150 mg Q8H 10. Niacin 500 mg qhs 11. Quinidine Gluconate 648 q8h 12. Acetaminophen-Codeine 300/30 [**1-7**] Tab q4h prn 13. Pramipexole 0.125 mg qhs 14. Furosemide 60 mg [**Hospital1 **] 15. Vitamin B Complex 1 tab qd 16. Melatonin 3 mg qhs 17. Nicotine 14 mg/24 hr Patch 18. Oxycodone 5-10 mg qhs prn pain 19. Lorazepam 0.5 mg q6h prn anxiety 20. Magnesium 250 mg qd Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q9PM (). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 10. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q8H (every 8 hours). 11. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs (). 13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 14. B-Complex with Vitamin C Tablet Sig: One (1) Cap PO DAILY (Daily). 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 16. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO HS (at bedtime). 17. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Ventricular tachycardia Secondary: CAD, Dyslipidemia, HTN, OSA, GERD Discharge Condition: stable, pain free, afebrile Discharge Instructions: You were admitted to the hospital for AICD firing. It was felt that you had a heart arrhythmia secondary to stopping our carvedilol. This medication was restarted and you heartrate was much improved. Please continue this medication in the future. In addition, your diovan was restarted at discharge at one half your prior dose. Please seek immediate medical attention if you experience chest pain, shortnss of breath, palpitations, dizziness, fevers, chills or any change from your baseline health status. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please call Dr.[**Name (NI) 62432**] office on Tuesday to make a follow up appointment in [**7-15**] days [**Telephone/Fax (1) 62**].

[ "403.90", "272.0", "428.22", "585.9", "356.9", "428.0", "427.1", "V45.82", "996.04", "412", "327.23", "414.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8189, 8195

4373, 6061

326, 332

8317, 8347

3983, 3983

9022, 9160

2768, 2997

6740, 8166

8216, 8296

6087, 6717

8371, 8999

3012, 3012

275, 288

360, 1986

3999, 4350

3027, 3964

2008, 2435

2451, 2752

27,398

183,286

34556

Discharge summary

report

Admission Date: [**2130-12-3**] Discharge Date: [**2130-12-4**] Date of Birth: [**2078-7-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: 52 yo M w hx of Type I DM, PAD, HLD, who presents with 3 days of nausea and vomiting. The patient was in his usual state of health until the day prior to admission, when he developed onset of nausea and vomiting. He admits to drinking up to 18 beers over the 2 days prior ([**Holiday **] Eve and [**Holiday **] day), though has given different histories to different physicians today. Had one dark, possibly black stool. No diarrhea. No fever or chills. He noted a cough that was non-productive and would only occur if he turned onto his side while lying in bed. Also noted decreased skin turgor. On the morning of admission, he developed heavy labored breathing and that is what led to him presenting to the ED. . Of note, he was recently admitted to the [**Holiday 1106**] service from [**11-28**] to [**11-29**] for left lower extremity angio with iliac stent placement. He was feeling fine after discharge until the onset of his current symptoms. Reports compliance with his medications. No urinary symptoms. . In the emergency department, his initial vitals were T 96.5, HR 104, BP 113/71, RR 30, O2 sat 100% on NRB. He was in mild resp distress with dry mucous membranes. Exam was otherwise unremarkable. He was quickly weaned to nasal cannula. Initial VBG was 6.87/29. Initial AG was 47+. Despite these lab data, he was mentating fine throughout. Also had WBC of 16.3 with left shift. CXR was clear. EKG with sinus tach and dynamic EKG changes suggestive of inferolateral ischemia. He was given a bolus of 10 units insulin IV followed by insulin drip. Received 7.5L NS and aspirin 325mg. Admitted to the [**Hospital Unit Name 153**] for further management. . REVIEW OF SYSTEMS: (+)ve: as above (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest pain, palpitations, rhinorrhea, nasal congestion, sputum production, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias . Past Medical History: Diabetes Mellitus, Type 1: diagnosed in [**2126-2-5**]. Hypertension Hypercholesterolemia PAD s/p fem-[**Doctor Last Name **] on [**2129-12-13**] Social History: Firefighter with construction work on the side. Lives with wife. Denies IVDU. Smoked 1 ppd x 30 years, now down to 3-8 cig/day. Drinks 6 beers/week Family History: Mom - cancer history on mom's side + HX of SCD: Dad - deceased from MI at age 42 Physical Exam: VITAL SIGNS: T=98.1 BP=108/60 HR=99 RR=19 O2= 98% on RA . . PHYSICAL EXAM GENERAL: Pleasant, well appearing middle-aged man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/[**Date Range 3899**]. Mildly dry MM. OP clear. Poor dentition. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP just above the clavicle with HOB at 30 degrees. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: CXR [**12-3**]: The lungs are clear with no evidence of pneumonia or congestive heart failure. No pleural effusions or pneumothorax. Cardiomediastinal silhouette is normal. Brief Hospital Course: 52 year old man with Type I DM presented with DKA. He had severe DKA with initial VBG pH of 6.87, AG>40, 150 urine ketones. There was unclear precipitant for DKA, but with history of nausea and vomiting, but we suspected viral gastroenteritis or gastritis from possible EtOH binge ( more likely). The patient denied missing doses of insulin, and did not have any clear localizing symptoms for infection. Initial U/A looked possibly infected, but repeat was reassuring. Patient initially had a lactate and large anion gap, which closed with IV fluids and insulin drip. He was transitioned from insulin drip to his home regimen of SQ insulin and tolerated PO diet without complaints. Urine and blood cultures are pending but no suspicion of infection. Upon transfer to floor, patient requested discharge as he was completely asymptomatic and received his regular Insulin home dose with euglycemia. He no longer have nausea or vomiting. He was advised to avoid excessive alcohol use as this may lead to dehydration from vomiting and DKA. . # Acute renal failure: On admission, creatinine was elevated to 2.2 from baseline of 0.7. This is most likely pre-renal failure in setting of severe volume depletion secondary to DKA. ARF resolved with IVF rehydration. . # HCT drop: HCT decreased to 32.8 from baseline 40. This is most likely dilutional given large volume fluid resuscitation. However, started on PO PPI given concern for possible gastritis with a plan to guaiac stools when he has bowel movement in the out patient. No evidence of blood loss clinically. . # EKG changes: Patient had dynamic EKG changes in the inferolateral distribution in setting of tachycardia and hypovolemia in ED. This was felt to be likely demand-related ischemia. He was ruled out with 2 sets of negative cardiac enzymes. The patient is high risk for CAD given DM, HTN, and family history, and should be encouraged to undergo risk stratification with TTE or stress as outpatient. This was communicated to him and he verbalized his understanding to follow up with his PCP for [**Name Initial (PRE) **] stress test. . # Nausea/Vomiting: Possibly EtOH gastritis vs viral gastroenteritis but resolved with IV fluids. No episodes of nausea or vomiting while inpatient. . # Hypertension: Initially held anti-hypertensive. . # Peripheral arterial disease: Continued on [**Name Initial (PRE) **], Statin and Cilostazol, with BB and ACEI held initially. . # Hyperlipidemia: Continued statin. . Total discharge time 56 minutes. He was discharged based on his request as he was completely asymptomatic with normal glucose. Medications on Admission: Lantus 22u qHS Novolog sliding scale [**Name Initial (PRE) **] 81mg PO daily Plavix 75mg PO daily Lisinopril 10mg PO daily Metoprolol 25mg PO BID Rosuvastatin 30mg PO daily Iron 325mg PO daily Cilostazol 100mg PO BID Ambien 10mg PO qHS Multivitamin PO daily Percocet 1-2 tabs q4 prn Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Rosuvastatin 20 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous at bedtime. 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Vomiting from gastritis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had severe uncontrolled diabetes (DKA) from drinking alcohol and vomiting. Please avoid excessive alcohol drinking and take insulin as scheduled/monitor your suger. You had severe dehydration and received IV fluids. Please maintain high oral fluid intake (>2 Liters of water/day). We restarted your blood pressure medications. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] [**Doctor First Name 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2131-1-3**] 11:00 Provider: [**Name10 (NameIs) 14633**],EQUIPMENT Date/Time:[**2131-1-3**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2131-1-3**] 1:00

[ "794.31", "276.51", "272.0", "272.4", "584.9", "443.9", "V58.67", "401.9", "V45.89", "535.50", "276.7", "250.13" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7900, 7906

3964, 6564

335, 341

7995, 7995

3765, 3941

8494, 8944

2762, 2845

6898, 7877

7927, 7974

6590, 6875

8139, 8471

2860, 3746

2054, 2410

276, 297

369, 2035

8009, 8115

2432, 2580

2596, 2746

10,299

105,814

52526

Discharge summary

report

Admission Date: [**2115-8-7**] Discharge Date: [**2115-9-6**] Date of Birth: [**2037-6-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1850**] Chief Complaint: resiratory failure Major Surgical or Invasive Procedure: --VATS --chest tube placement History of Present Illness: Source: Family, olds notes (pt non-verbal). . CC: Dyspnea . HPI: Ms. [**Known lastname 108496**] 78 yo F w/ end stage Parkinsons-like syndrome presenting to the [**Hospital1 18**] ED with SOB/tachypnea. Her daughter reports that the patient was in her usual state of health until the day of presentation when according to her regular VNA she was found in her wheelchair with sob/tachypnea. Her daughter was called and came and gave her Lasix 20mg with little improvement. Over the next 2 hours, the daughter describes the patient as becoming increasingly anxious, which is reportedly similar to her behaviour when experiencing pain. Pt has limited mobility at baseline, with Parkinsonian cogwheel rigidity, and is in a wheelchair. Per her daughter, she is able to respond to verbal commands/questions, and can focus on the speaker, though in the ED she was agitated and noncommunicative. Her daughter reports that she has had a cough x 1day, though nonproductive. She has a suction machine at home that the family uses occasional, as she is s/p removal of her bottom teeth in [**12-22**]. . In the ED, the patient was started on Ceftriaxone and Azithromycin for pneumonia, and was diuresed with Lasix for possible CHF. She was also sent for CT head given h/o recent fall and inability to communicate. While waiting for admission her BP dropped to 70s/30s and temp rose to 103.5F. She was given 4 liters of normal saline with recovery of her blood pressure to the high 90's / 40's. The sepsis protocol was initiated but the family refused placement of a central line. . ROS: + for limited mobility, with fall from wheelchair 6 days ago, hitting head, no residual symptoms per family. She has also had a right foot ulcer on heel x 3months, increased lethargy in afternoon post Parkinson meds (by family report, pt sleeps for up to 6 hours after receiving meds, they were concerned for overmedication and held her afternoon doses today, she received them in the ED). . Past Medical History: PMH: 1) Cortico-basal degeneration (treated as Parkinson's) - [**2107**] 2) PE - bilateral, [**2113-6-16**], w/ NSTEMI 3) L hip replacement - [**2112**] 4) HTN - well-controlled on lisinopril 5) Kaposi's sarcome - patient has received 3 rounds of Doxil chemotx in [**2111**], [**2113**], and [**2114**] (last [**4-21**]) 6) Hyperthyroidism 7) h/o Afib - during last hospital admission, currently not rate-controlled, no other episodes per family Social History: Greek. Denies EtOH or tobacco. Patient is non-verbal at baseline and lives with her son. She has a VNA at home. Family History: NC Physical Exam: PE: 100.2 105 78/32 20 98%NC Gen: lying in bed, rigid with arms flexed and legs extended, anxious, diaphoretic HEENT: MMM, PERRL Neck: No LAD Chest: pt unable to cooperate, anterior exam w/ good air mvmt, no crackles CV: RRR, nl S1 S2, III/VI HSM at apex. Abd: Soft, NT, ND +BS. Skin: red macular and nodular lesions on hands, feet, forearms. Ulcer on R heel, without purulent drainage or fluctuance. Dressing moist Pertinent Results: [**2115-8-6**] 04:00PM PT-17.3* PTT-24.4 INR(PT)-2.1 [**2115-8-6**] 04:00PM PLT COUNT-235 [**2115-8-6**] 04:00PM NEUTS-91.7* LYMPHS-5.1* MONOS-2.9 EOS-0.3 BASOS-0 [**2115-8-6**] 04:00PM WBC-16.0* RBC-4.11* HGB-12.3 HCT-36.3 MCV-88 MCH-29.9 MCHC-33.8 RDW-13.3 [**2115-8-6**] 04:00PM CK-MB-2 cTropnT-0.10* [**2115-8-6**] 04:00PM CK(CPK)-257* [**2115-8-6**] 04:27PM LACTATE-2.5* [**2115-8-6**] 07:05PM GLUCOSE-156* UREA N-33* CREAT-1.3* SODIUM-137 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16 [**2115-8-6**] 09:00PM URINE RBC-[**4-26**]* WBC-[**4-26**]* BACTERIA-FEW YEAST-NONE EPI-[**4-26**] [**2115-8-6**] 09:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2115-8-6**] 11:00PM CK-MB-2 cTropnT-0.10* [**2115-8-6**] 11:00PM CK(CPK)-169* [**2115-8-6**] 11:21PM LACTATE-3.1* XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CT HEAD [**8-6**]: No evidence of intracranial hemorrhage. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CXR [**8-6**]: No change since [**2115-1-13**]. Elevated left hemidiaphragm with associated minimal left basilar atelectasis and a small right pleural effusion/thickening. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX LE U/S [**8-8**]: No evidence of right lower extremity DVT. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX UE U/S [**8-11**]: Patent internal jugular and subclavian veins bilaterally. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX TTE [**8-13**]: The left atrium is mildly dilated. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is moderate/severe mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CT [**8-24**]: 1. Moderate-sized left pleural effusion, containing heterogeneous increased signal throughout. Findings suspicious for hemothorax. This could be related to the chest tube, as there is increased density fluid surrounding the chest tube tip. No evidence of abdominal or retroperitoneal hematoma. 2. Probable left renal cyst XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX RENAL U/S [**8-31**]: Atrophic right kidney. Simple left renal cyst. No evidence of hydronephrosis XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CXR [**9-5**]: Moderate sized bilateral pleural effusion with mild pulmonary edema. More intense opacification in the lower lungs could be a combination of edema and atelectasis as well as a fissural and costodiaphragmatic pleural effusion, but pneumonia cannot be excluded. No central venous line is seen. Tracheostomy tube is in standard placement. There is no appreciable pneumothorax, but a small pleural air collection might not be appreciated, particularly since the patient is supine. Brief Hospital Course: MICU Course: Patient [**Hospital 32805**] transferred to MICU for hypoxia secondary to aspiration PNA which was treated but still difficult to wean patient off ventilator. Patient then developed a presumed VAP and was treated with a 14 day course of Zosyn/vancomycin. After treatment of PNA patient initially improved on ventilator and felt that respiratory distress was secondary to pulmonary congestion. Patient was started on lasix gtt to remove fluid. Patient was extubated however after extubation patient did not look good from respiratory standpoint. Chest xray showed left pleural effusion which was felt could be contributing to patient'd respiratory distress. Patient underwent thoracentesis under U/S which drew back 20cc of blood and was aborted. After thoracentesis patient became very tachypneic and decision made to re-intubate after only 2 days s/p extubation. Later that day after thoracentesis patient became hypotensive and was found to have 10 point Hct drop and increased left lung opacity on CXR. Thoracic surgery called and chest tube placed which produced about 1L of serosanginous fluid. Patient required total 9 units of PRBC and Hct stabalized after 3 days. CT scan showed that blood was still present in pleural space even with chest tube in place so patient underwent trial of TPA through chest tube to break up any clots in pleural space. After 3 rounds of TPA and repeat CT scan decision made for patient to undergo VATS to remove any hematomas found in pleural space. During VATS patient was almost 3 weeks with ventilator support and family agreed to have tracheostomy and PEG tube placed as it was felt that patient would most likely need long term rehab to have any possible change to come off vent. After first chest tube placed patient started to spike temps and cx data positive for VRE from pleural fluid and [**11-24**] bld cx bottles. Patient was started on course of Linezolid. Chest tubes were removed after no further drainage was present, Hct stable 26-28 and CXR improvement. Respiratory failure thought to also have a possible CHF component, thus more aggressive diuresis was initiated. Pt has been maintained on pressure support setting with attempts to slowly wean her PS down (25 at discharge), PEEP 5, Vts 350-450, FiO2 40%. Her coumadin was reinitiated at time of discharge. Linezolid was day 11 of 14 at time of discharge. She has a persistent right pleural effusion. She has an elevated left hemidiaphragm. She has persistent papular lesions on her arms and legs. Medications on Admission: Lasix 60mg qAM Methimazol 5mg qd Mirapex 0.5mg [**Hospital1 **] Sinemet 25/100 1.5 tab PO tid Lisinopril 5mg PO qd Warfarin 1mg x 2 days/wk (Wed and Sat), 2mg x 5days/wk Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): sliding scale. 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO BID (2 times a day). 10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 11. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 12. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO bid (). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): x 4 days. 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS ([**Doctor First Name **],MO,TU,TH,FR). 17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS (WE,SA). 18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Furosemide 10 mg/mL Solution Sig: [**12-21**] ml Injection [**Hospital1 **] (2 times a day): base dose on volume status and urine output, goal is euvolemic. 20. Lorazepam 2 mg/mL Syringe Sig: 0.5-2 ml Injection Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: Shaunessey-[**Hospital1 656**] Discharge Diagnosis: PRIMARY: --Respiratory failure --hemothorax --elevated left hemidiaphragm --persistent right pleural effusion --mrsa and VRE pleural infection SECONDARY: --Cortico-basal degeneration --HTN --Kaposi's sarcoma Doxil chemotx in [**2111**], [**2113**], and [**2114**] (last [**4-21**]) --Hypothyroidism --AFIB Discharge Condition: intubated Discharge Instructions: see page 1 Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 1144**] call for an appointment when extubated and rehabilitated [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**] Completed by:[**2115-9-6**]

[ "584.9", "038.9", "998.11", "518.81", "458.29", "276.2", "682.2", "294.10", "482.41", "996.69", "285.9", "331.82", "428.30", "995.91", "V09.0", "511.8", "428.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.72", "31.1", "96.04", "99.07", "99.04", "96.6", "86.22", "34.04", "34.91", "38.93", "43.11", "00.14", "33.24", "38.91", "45.13", "99.10" ]

icd9pcs

[ [ [] ] ]

11303, 11360

6739, 9277

332, 363

11710, 11722

3431, 6716

11781, 12062

2975, 2979

9498, 11280

11381, 11689

9303, 9475

11746, 11758

2994, 3412

274, 294

391, 2359

2381, 2829

2845, 2959

19,947

132,431

4743+55603

Discharge summary

report+addendum

Admission Date: [**2183-2-18**] Discharge Date: [**2183-3-1**] Date of Birth: [**2126-3-30**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 56-year-old female with a history of many gastroesophageal surgeries for achalasia and esophageal spasms and stricture. The patient returned to Dr. [**Last Name (STitle) **] for a revision of a previous [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy. PREVIOUS MEDICAL HISTORY: Achalasia. Fibromyalgia. Migraines. Spastic colon. Esophageal spasms. Osteopenia. Asthma. Numerous esophageal dilations. Transthoracic esophageal myotomy. Cholecystectomy. G-tube placement in [**2177**] and [**2176**]. Status post [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy and J-tube placement in [**8-6**]. ADMISSION MEDICATIONS: 1. Seroquel. 2. Paxil. 3. Valium. 4. Protonix. 5. Advair. 6. Percocet. 7. MS Contin. ALLERGIES: PENICILLIN, TEGRETOL, LEVAQUIN, NONSTEROIDAL ANTI- INFLAMMATORIES, CARBAMAZEPINE, BIAXIN, ERYTHROMYCIN, VANCOMYCIN, SULFA, AND AMOXICILLIN. BRIEF DESCRIPTION AND HOSPITAL COURSE: The patient was admitted on [**2183-2-18**], and she underwent a retrosternal colon interposition with colojejunostomy and colocolostomy, feeding jejunostomy, and draining duodenostomy. The procedure was performed by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **], and he was assisted by Dr. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) 18078**] [**Last Name (NamePattern1) 14968**]. The procedure was done without any complications. The patient tolerated the procedure without any difficulty. The patient was sent to the Postanesthesia Care Unit still intubated, but in satisfactory condition. The patient remained intubated for the first 24 hours due to a history of COPD. The patient was transferred up to the Surgical Intensive Care Unit where she was extubated after successfully passing spontaneous breathing trial. While in the Surgical Intensive Care Unit, the patient did quite well, with her only complaint being large amount of pain in her abdomen. The patient was also tachycardic, but was known to be so at baseline prior to her surgery. The patient's duodenal tubes and cervical tubes were draining serosanguinous fluid. The patient was noted to have postoperative anemia and was transfused with 1 unit of packed red blood cells. The patient was seen and evaluated by Acute Pain Service, and she was taken off her epidural and placed on a Dilaudid PCA, which helped control the pain significantly. The patient was also seen and evaluated by Inpatient Clinical Nutrition, which recommended goal tube feeds, full strength, with fiber at 75 cc an hour for 24 hours. Tube feeds were not started at this time. By postoperative day 2, the patient was still complaining of a lot of pain. Cardiopulmonary function was good. Her oxygen was weaned commissurately. Her J-tube was putting out minimal drainage. Her G-tube was putting out bilious drainage, and she was placed on Protonix for prophylaxis. Due to the patient's extensive psychiatric history, the patient was seen and evaluated by Psychiatry staff, which recommended continuation of lorazepam 1 mg IV t.i.d. to prevent any withdrawal of previous benzodiazapine use. They also recommended holding her Paxil, Seroquel, Klonopin, and Valium, and to restart the Paxil and Seroquel once the patient was in a more familiar setting without any mental confusion that may have been presently resolved. The patient continued to do well in the SICU and was transferred to the floor by postoperative day 3. Her only complaints were still fair amount of abdominal pain, and she had not passed any flatus nor been out of bed at that time. The patient was also noticed to be slightly hypertensive, and her Lopressor was increased to 50 mg q.6h., and a PT/OT consult was obtained. Her mental status was waxing and [**Doctor Last Name 688**] with episodes of delirium during this time. It was determined to be most likely due to opiate analgesia. The patient was continued to be monitored for any benzodiazepine withdrawal or opioid overdose. The patient's tube feeds were started on postoperative day 3, which she tolerated without any difficulty. By postoperative day 4, the patient had been up and out of bed and appeared to be doing well, with her pain controlled adequately on the morphine PCA. The patient was scheduled to have a swallowing study done in the next couple of days. By postoperative day 5, the patient's tube feeds were at goal. She was tolerating this without any difficulty. On postoperative day 6, the patient had an acute mental status change where she was unresponsive to verbal or sternal rub. The patient was seen and evaluated by the health officers where she was found to be responsive to loud voices and withdrew to painful stimuli. This change in mental status quickly passed, and she was alert and oriented, but her speech was still sluggish. The results of this patient were transferred to the Trauma SICU for further monitoring. At this time, the patient's vital signs were stable. Temperature was 96.8, blood pressure 148/110, heart rate 120, respiratory rate 30 breaths per minute at 97 percent on 2 liters. The patient had chest CT done at this time, which showed left lower lobe opacity, which was most likely atelectasis, but infectious process could not be ruled out at this time. A repeat chest CT the following day showed a decrease in size of the left lower lobe opacity and was continued to be followed through x-rays and physical exam. In the Trauma SICU, the patient did very well and did not need to be intubated at this time. The patient underwent a bedtime swallowing study on the 24th, which indicated that the patient was not demonstrating any overt signs of aspiration. Their recommendations were to advance the patient to a regular-consistency diet and thin liquids. On [**2183-2-25**], the patient's NG tube was removed by Dr. [**Last Name (STitle) **] after the patient underwent a [**Known lastname **] bowel follow through. The [**Known lastname **] bowel follow through indicated no evidence of anastomotic leaks and a slight decrease in transit time through the distal anastomosis. The patient was restarted on Impact with fiber at three-quarter strength at 20 cc an hour, which she tolerated with a slight amount of cramping, but no abdominal distension. The patient continued to do very well in the Trauma ICU and was transferred to the floor on [**2183-2-27**], which was postoperative day 9. On this day, the patient's Foley was removed and her JP drains were removed as well. [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**] Dictated By:[**Last Name (NamePattern1) 19938**] MEDQUIST36 D: [**2183-5-13**] 11:48:33 T: [**2183-5-13**] 23:18:44 Job#: [**Job Number 19939**] Name: [**Known lastname 3317**], [**Known firstname 153**] Unit No: [**Numeric Identifier 3318**] Admission Date: [**2183-2-18**] Discharge Date: [**2183-3-1**] Date of Birth: [**2126-3-30**] Sex: F Service: ADDENDUM: This is a continuation of previous dictation. On postoperative day 10 ([**2183-2-28**]), the patient stated that she was feeling great. She was tolerating her clear liquids and tube feeds without difficulty. She was passing flatus and bowel movements and has been ambulating with assistance. Discharge planning was done at this time, and with consultation with Physical Therapy it was decided that the patient would be safe to be discharged to home when medically cleared. By postoperative day 11, the patient was medically cleared to go home with her pain controlled on oral medications and tolerating a regular diet without difficulty. DISCHARGE DISPOSITION: The patient was discharged to home with services. Services were provided by [**Hospital 3145**] Healthcare. DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient was instructed to monitor for the following: fevers, chills, nausea, vomiting, abdominal pain or distention. The patient was advised that she may resume a regular diet and that she may shower but not to bathe or swim until cleared by a physician. [**Name10 (NameIs) **] patient was advised to please follow up with Dr. [**Last Name (STitle) **] in one week and call his office for an appointment. The patient was also asked to follow up with her outpatient psychiatrist within that same timeframe. CONDITION ON DISCHARGE: The patient was discharged in good condition; afebrile, tolerating a regular diet without difficulty, on tube feeds at full strength, ambulating with assistance, and pain controlled on oral medications. DISCHARGE DIAGNOSES: Status post colonic transposition. Status post [**First Name9 (NamePattern2) 3319**] [**Doctor Last Name **] esophagectomy. Achalasia. Lap myotomy. Aspiration pneumonia. Feeding jejunostomy. Gastroesophageal reflux disease. Fibromyalgia. Depression. Chronic obstructive pulmonary disease. Difficult extubation. MEDICATIONS ON DISCHARGE: 1. Clonazepam 1 mg by mouth twice per day. 2. Metoprolol 50 mg by mouth twice per day. 3. Morphine sulfate sustained release 15 mg one tablet by mouth q.12h. 4. Morphine sulfate solution 5 mL to 10 mL by mouth q.4-6h. as needed (for pain). 5. Impact with fiber as directed. 6. Quetiapine 25 mg one tablet by mouth q.8h. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], INT Dictated By:[**Last Name (NamePattern1) 3320**] MEDQUIST36 D: [**2183-5-13**] 11:53:09 T: [**2183-5-13**] 16:29:19 Job#: [**Job Number 3321**] cc:[**Last Name (NamePattern4) 3322**]

[ "276.3", "311", "496", "530.81", "293.0", "729.1" ]

icd9cm

[ [ [] ] ]

[ "46.39", "45.94", "45.93", "42.55" ]

icd9pcs

[ [ [] ] ]

7955, 8611

8862, 9184

9210, 9821

1137, 7931

857, 1119

159, 834

8636, 8840

8,533

162,951

7736

Discharge summary

report

Admission Date: [**2138-8-26**] Discharge Date: [**2138-9-3**] Service: MEDICINE Allergies: Codeine / Bactrim Ds / Clindamycin / Cephalosporins / Vancomycin / Aspirin Attending:[**First Name3 (LF) 425**] Chief Complaint: Presyncope Major Surgical or Invasive Procedure: Dual chamber pacemaker implantation History of Present Illness: Ms. [**Known lastname **] is an 87 year-old woman with a history of diastolic CHF who was initially admitted with dizziness and shortness of breath. Patient states that she was in her normal state of health until early yesterday morning when she woke up to use the bathroom. She felt like she was "teetering on water" when sitting on the side of her bed and putting her socks on. She tried to walk to the bathroom but needed to sit down in a chair so she would not fall. She called her lifeline and they responded and transported her to the ED. The patient was + for nausea. She denied CP and SOB. . She does admit to orthopnea (sleeps on two pillows) but not PND. +LE edema. . In the ED, initial vitals were T: 98.4, BP 158/63, P 56, R 18, O2 97% on 4 L (89% on RA), and she was nauseated. Her ECG showed STE in V1 and ST depressions in V4-V6. She was given ASA and Zofran and was started on a nitro gtt and heparin gtt. She had a CXR which demonstrated instersitial edema and had a BNP of 1000. She was then admitted to [**Hospital Ward Name 121**] 3, where she was felt to be fluid overloaded and she was with furosemide 20mg PO x 1 and had 2725ml of urine output. . ROS: The patient denies any fevers, chills, vomiting, diarrhea, palpitations, chest pain, shortness of breath, urinary frequency, urgency, dysuria, focal weakness, vision changes, headache, rash or skin changes. Patient endorses constipation, which is unchanged from prior. Past Medical History: -Head injury s/p fall ([**2121**]), was in coma, cerebral hemorrhage and temporary shunt/R frontal craniotomy at that time, seizure disorder since - usual seizures are "few minutes of L face tightening" with immediate return to baseline; occur 1-2x/yr -CLBP related to lumbar stenosis and degenerative disease, associated polyradiculopathy by MRI [**4-17**] -"Possible cervical stenosis" per Dr. [**Last Name (STitle) 12528**]/neurology [**9-17**] -Polyneuropathy, per notes and per family, unknown etiology -h/o falls [**3-15**] gait disturbance (post-cerebral hemorrhage) -HTN -CHF (EF 45-50% in [**2129**]) -Hx diverticulitis in past -Arthoscopic knee surgery -Depression -Constipation -h/o RLE cellulitis on bactrim and keflex - chronic leg edema/ rt leg ulcer Social History: The patient lives home in the same house with her son, but lives on a separate floor. Son and his family assist patient with ADL's. Ambulates with assistance of [**Year (4 digits) **]. Not able to navigate stairs. Not a current smoker, but used to smoke many years back; quit over 25 years ago. Family History: Non-contributory Physical Exam: Physical Exam: Vitals: T: 96.3, BP 130/72, P 48, R 18, 95% on 2L. GEN: Well-appearing, well-nourished, no acute distress HEENT: PERRL, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline, no appreciable JVD COR: RRR, +systolic murmur, fixed split S2, radial pulses +2 PULM: crackles diffusely ABD: Soft, NT, ND, +BS, no HSM, no masses GROIN: EXT: 1+ edema to calves bilaterally, L>R 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: [**2138-8-28**] 05:44AM BLOOD WBC-5.4 RBC-4.10* Hgb-12.2 Hct-37.9 MCV-93 MCH-29.9 MCHC-32.3 RDW-13.4 Plt Ct-174 [**2138-9-3**] 08:00AM BLOOD WBC-11.2* RBC-3.81* Hgb-11.5* Hct-34.9* MCV-91 MCH-30.2 MCHC-33.0 RDW-14.2 Plt Ct-117* . [**2138-8-26**] 04:00AM BLOOD Glucose-141* UreaN-29* Creat-1.0 Na-131* K-5.8* Cl-100 HCO3-19* AnGap-18 [**2138-8-28**] 05:44AM BLOOD Glucose-101 UreaN-29* Creat-1.0 Na-139 K-4.5 Cl-100 HCO3-31 AnGap-13 [**2138-9-3**] 08:00AM BLOOD Glucose-90 UreaN-46* Creat-1.0 Na-141 K-4.5 Cl-108 HCO3-23 AnGap-15 [**2138-9-3**] 08:00AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.1 . [**2138-8-28**] 05:44AM BLOOD ALT-22 AST-22 AlkPhos-83 TotBili-0.4 [**2138-9-1**] 07:14AM BLOOD PT-12.7 PTT-23.6 INR(PT)-1.1 . [**2138-8-26**] 04:00AM BLOOD CK(CPK)-115 [**2138-8-29**] 03:28PM BLOOD CK(CPK)-102 [**2138-8-29**] 09:15PM BLOOD CK(CPK)-178* [**2138-8-30**] 06:55AM BLOOD CK(CPK)-186* [**2138-8-30**] 05:05PM BLOOD CK(CPK)-809* [**2138-8-30**] 10:40PM BLOOD CK(CPK)-720* [**2138-8-31**] 07:34AM BLOOD CK(CPK)-730* [**2138-9-3**] 08:00AM BLOOD CK(CPK)-55 . [**2138-8-26**] 04:00AM BLOOD CK-MB-4 cTropnT-0.02* proBNP-1041* [**2138-8-26**] 01:00PM BLOOD CK-MB-7 cTropnT-0.20* [**2138-8-26**] 06:58PM BLOOD CK-MB-6 cTropnT-0.12* [**2138-8-30**] 06:55AM BLOOD CK-MB-8 cTropnT-0.03* [**2138-8-30**] 05:05PM BLOOD CK-MB-24* MB Indx-3.0 cTropnT-0.04* [**2138-8-30**] 10:40PM BLOOD CK-MB-21* MB Indx-2.9 cTropnT-0.06* [**2138-8-31**] 07:34AM BLOOD CK-MB-21* MB Indx-2.9 cTropnT-0.03* [**2138-9-3**] 08:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 . Echo from [**2138-8-26**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF ~35-40 %) with inferolateral hypokinesis; views are technically suboptimal for assessment of regional wall motion. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. 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. Physiologic mitral regurgitation is seen (within normal limits). The left ventricular inflow pattern suggests impaired relaxation. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Echo repeated post pacemaker from [**2138-8-29**]: showed no pericardial effusion . CXR [**2138-8-26**]: IMPRESSION: Unchanged mild interstitial prominence, most consistent with fluid overload. . CXR [**2138-8-29**]: IMPRESSION: Left-sided dual lead pacer with leads in satisfactory position. Severe scoliosis with leftward deviation of the mediastinum. No pneumothorax. . ECG on [**8-26**]: Sinus bradycardia with Left bundle branch block . ECG on [**8-28**]: Sinus bradycardia with sinus arrest and pauses of approximately 1.5 to 2.0 seconds. Left bundle-branch block and diffuse T wave inversions and repolarization abnormalities persist. Compared with prior tracing of [**2138-8-27**] multiple abnormalities persist. However, sinus pauses are new. . ECG on [**8-30**]: Sinus rhythm. Intraventricular conduction delay of the left bundle-branch block type. Since the previous tracing of [**2138-8-29**] the rhythm is now sinus and ST-T wave abnormalities are more marked. Brief Hospital Course: 87 year-old female with h/o CHF who initially presented with presyncope and was found to be volume overloaded. Transferred to the CCU for bradycardia with multiple asymptomatic long pauses on telemetry while sleeping, now s/p pacemaker placement, now s/p severe drug reaction. . # Bradycardia: The pt was transferred to the CCU for sinus bradycardia of 30s-40s with junctional escape beats. Pt has had multiple episodes of bradycardia associated with decreased blood pressure. Her HR decreased to 20s with SBP of 80s while sleeping but would icrease to HR 50s and BP 120s when awakened. She did not experience any symptoms during her episodes, though it is possible that her bradycardia contributed to the presyncopal episode for which she originally presented. On the night prior to pacemaker placement the patient had several prolonged pauses of 9 seconds associated with transiently diminished blood pressure. The patient was sleeping comfortably during these pauses. The patient was monitored on telemetry and did not experience any complications during the placement of the dual chamber pacemaker. Post pacemaker she had a normal echo and PA/lateral CXR showing appropriate placement of pacer. . # CAD: The pt was found to have either acute or subacute coronary disease based on new echo findings of mild LVH, EF of 35-40% (previously 70%), inferiolateral hypokinesis, 2+ mitral regurgitation, and diastolic dysfunction. She did have a troponin bump from 0.12 -> 0.20 -> 0.02. After discussion with the patient and the son it was decided to treated her medically rather than to have her go to the cath lab. She was started on an ASA and a statin which was later discontinued in the context of her drug allergy reaction (see below). As per allergy the patient should never be started back on ASA. Later in her admission she had + CPKs and + troponins which were thought to be due to the steroids as her MB index was never > 3. The patient was on lisinopril at home which can be restarted as an outpatient. Please restart all medications one at a time due to her drug reaction while in the hospital. . # Acute on chronic diastolic and systolic Congestive Heart Failure: The patient was given lasix and diursed 2-3 Liters. The patient has chronic swelling of lower extremities (generally in ankles) with L > R which improved with her diuresis. She did have some ankle swelling on the day of discharge. The patient's lungs are now clear to auscultation and she does not require oxygen. Please continue to weigh patient daily, fluid restrict her to 1500cc, and give her a low sodium diet. . Hypotension/drug allergy: On [**8-29**], the day after her pacemaker was placed she developed hypotension (72/32), nausea, and eventually diffuse erythema across her abdomen. An ECG was done showing she was A paced at 60 with her baseline LBBB, a stat TTE showed no pericardial effusion, and her PA/lateral CXR showed normal placement of pacer. She was started on diphenhydramine and methyprednisolone, and her keflex was discontinued as it was thought she had a drug reaction. Clindamycin was started as an alternative antibiotic prophylaxis s/p pacemaker. The next day, the pt became hypotensive again (78/40s) with nausea, epigastric burning, itching, diffuse body erythema, and a blister on her chest. She and was bolused NS, given IV solumedrol, IV benedryl, IV pepcid. Her SBPs improved to the 90s and she was transferred back to the unit for closer monitoring. All possible offending agents were discontinued including ASA, simvastatin, BB, colace, senna, zofran, and all heparin products. The following day, the patient was noted to have oral and labial lesions on exam with oral pain and was seen by allergy who felt ASA, cefazolin, vancomycin, or clindamycin could have been the cause. The patient had prior rash with clindamycin so the reaction could have been partly due to clindamycin in conjunction with one of the other medications. Allergy placed the patient on Solumedrol 60mg IV bid, dyphenhydramine, and famotidine. The patient was monitored closely with concern for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Syndrome. At the time of discharge she was less erythematous. She was discharged on famotidine 20 PO BID, zyrtec 10mg PO qHS, and Solumedrol 60mg PO daily until the [**9-7**] with the following taper: [**9-7**] 50mg PO daily, [**9-8**] 40mg PO daily, [**9-9**] 30mg PO daily, [**9-10**] 20mg PO daily, [**9-11**] 15mg PO daily, [**9-12**] 10mg PO daily, [**9-13**] 7.5mg PO daily, [**9-14**] 5 mg PO daily, [**9-15**] 2.5mg PO daily, and [**9-16**] done. Please do not begin taper unless lesions in mouth and around lips have resolved. If the patient develops any worsening rash, you have any questions about the above taper, or any allergy concerns please call Dr.[**Name (NI) 28073**] office at [**Telephone/Fax (1) 9316**]. . # Presyncope: Likely multifactorial in setting of bradycardia with hypotension. Pt now has pacemaker in place. . # Seizure disorder: The pt has been on carbamazepine for years but it was discontinued here in the setting of her allergic reaction. She should be put back on this medication by her primary care physician after being restarted on her lisinopril. Please space out when restarting any medications on her so that she can be observed for a drug reaction. . # FEN: Continue calcium, vitamin D, and multivitamins . # Thrombocytopenia: The pt received heparin products while in the hospital but all products were discontinued after her drug reaction. Her platelets were 208 on admission and were 117 on the day of discharge. She should avoid all heparin products in case her allergic rxn could have been HIT. . # Code: Full Medications on Admission: Carbamazepine 200mg daily Lisinopril 10mg daily Caltrate-600 Plus Vitamin D3 [**Hospital1 **] Centrum Silver daily Tums 500mg qHS Discharge Medications: 1. Multivitamin PO DAILY 2. Acetaminophen 325 mg PO Q6H as needed. 3. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous before meals: Sliding scale: If Blood sugars: 0-80: 4 oz of juice 80-150: no insulin 151-200: 2 units 201-250: 4 units 251-300: 6 units 301-350: 8 units > 350: 10 units and call provider. . 4. Prednisone 20 mg Tablet Three (3) Tablet PO DAILY. 5. Famotidine 20 mg PO twice a day. 6. Zyrtec 10 mg PO at bedtime. 7. Sarna Sensitive 1 % Topical three times a day: For rash to treat itch. 8. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) **] Discharge Diagnosis: Primary: Sinus node dysfunction Coronary artery disease Chronic Diastolic Heart Failure Allergic Drug reaction Secondary: Spinal stenosis Discharge Condition: Good. Ambulating without assist. Tolerating oral medication and nutrition. Discharge Instructions: You were admitted to [**Hospital1 18**] with nausea and dizziness. You had some fluid overload and a slow heart rate. You received a pacemaker for the slow heart rate and likely had a reaction to one of the antibiotics that were started because of the pacemaker. This allergic reaction caused a severe rash that was treated with IV prednisone, famotidine and benedryl. You will be weaned off the prednisone slowly over the next 10 days. You should avoid taking clindamycin, vancomycin, cephlosporins or aspirin as one of these medications caused the rash. . Your heart is weaker now than it was in the past. You have been retaining fluid because of this and should watch for swelling or trouble breathing. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs or if you notice swelling in your legs or trouble breathing. Adhere to 2 gm sodium diet Fluid restriction: 1500cc or about 7 cups of fluid per day. Followup Instructions: Primary Care Physician: [**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2138-9-18**] 10:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2138-11-3**] 4:40 . Cardiology: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2138-9-15**] 10:00 . Device Clinic:Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2138-9-5**] 11:00 . Neurosurgery: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2138-12-16**] 9:00 Completed by:[**2138-9-3**]

[ "345.90", "428.43", "311", "428.0", "564.00", "E947.8", "414.01", "458.29", "401.9", "E849.7", "287.5", "427.81" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

13688, 13762

7137, 12866

291, 328

13945, 14022

3720, 7114

14997, 15855

2924, 2942

13046, 13665

13783, 13924

12892, 13023

14046, 14974

2972, 3701

241, 253

356, 1808

1830, 2596

2612, 2908

47,907

114,877

35345

Discharge summary

report

Admission Date: [**2194-1-1**] Discharge Date: [**2194-1-21**] Date of Birth: [**2116-5-12**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Bactrim / Cozaar / Captopril Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: 1. right-sided thoracentesis [**2194-1-3**] 2. left-sided thoracentesis [**2194-1-4**] 3. right chest tube placement [**2194-1-6**] 4. right subclavian CVL [**2194-1-6**], replaced [**2194-1-12**] 5. trach/PEG [**2194-1-10**] History of Present Illness: 77F s/p fall from standing; initially seen at OSH; she reportedly became agitated when a c-collar was placed, and required sedation, and was subsequently intubated for respiratory distress. She was transferred to [**Hospital1 18**] for further care. Her injuries noted were a C7 fracture, and chronic-appearing bilateral pleural effusions. Past Medical History: 1. CHF 2. AF 3. HTN 4. NHL 5. ?radiation treatment to thyroid Pertinent Results: [**2194-1-1**] CT cspine: 1. Acute fracture involving the superior endplate of C7 vertebral body with approximately 2 mm of retropulsion of the posterior cortex without significant canal stenosis. 2. Degenerative disease with facet changes as described above. Widening at C3-4 on the right is likely chronic. 3. Bilateral pleural effusions and atelectatic changes are better assessed on corresponding CT torso performed concurrently." [**2194-1-2**] ECHO: "Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild calcific aortic stenosis. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate pulmonary hypertension." [**2194-1-2**]: "1. C7 compression fracture and T2 horizontal vertebral body fracture without evidence of ligamentous injury or cord injury." [**2194-1-4**] BAL: MSSA 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: Neuro: Identified C7 fracture on imaging; she was placed in a [**Location (un) 2848**]-J collar. A spine consult was obtained and recommended that she remain in the collar until they would be able to examine her clinically (off sedation). An MR was also obtained. She was switched to a softer collar that allowed for slightly more flexion. She is to remain in the collar until follow up with Dr. [**Last Name (STitle) 363**] on roughly [**2194-1-20**] for reevaluation. She was sedated with propofol, but alert and oriented. A geriatrics consult was obtained -- her nighttime agitation was subsequently managed with Seroquel 25mg QHS. CV: An ECHO on [**1-2**] did not demonstrate significant cardiac abnormalities. Mild aortic stenosis was noted. She was maintained on her home beta blocker dose. She did require neosynephrine while on propofol, which was given while intubated and post-intubation for agitation. Geriatrics was consulted and suggested giving seroquel 12 mg qhs for agitation instead. Resp: In contact with her PCP who noted that her pleural effusions were chronic. We attempted extubation on Hd #2, but she developed tachypnea and respiratory distress and was reintubated. It was thought that her pleural effusions may have contributed to her respiratory compromise, and she had a right and left-sided thoracentesis on Hd #3 and 4 (respectively). Extubation was attempted a 2nd time, but again, she quickly failed after an hour, and was once again reintubated. A CVL was also placed at this time -- on imaging, she was noted to have persistent right pleural effusion and a small apical pneumothorax. Given concern that she had respiratory distress upon extubation, and was now currently on positive pressure ventilation, a 20Fr chest tube was placed in her right side. Pleural fluid analyses demonstrated a transudative fluid, which was not infected. Follwoing the chest tube placement, a 3rd extubation was attempted, but she again required reintubation. At this point, there was concern that there may be an anatomic component to her respiratory failure -- Interventional Pulmonary was asked to evaluate the patient's airways. Her son had given a vague history of a possible prior tracheostomy, and radiation to her neck -- perhaps causing some tracheal stenosis. On bronchoscopy, close evaluation demonstrated upper airway edema, with no leak when the cuff was down. She was placed on steroids, but given these findings, the decision was made to proceed with a trach/peg, expecting a longer than expected vent-dependence. She had her trach/PEG on [**2194-1-10**]. On [**1-11**] she had a episode of desaturation to the 80s for which she underwent another bronchoscopy that revealed thick brown sputum. She was placed on Vancomycin and Zosyn empirically until sputum cultures and BAL returned negative. At the time of discharge, she was tolerating increase intervals on trach mask and off the vent. GI: She received tube feeds through a dobhoff tube, then through her PEG tube. On [**1-11**] she had several loose stools and the tube feedings were held. Stool cultures x 2 were sent and found to be negative. Tube feedings were restarted on [**1-13**]. Heme: She is on Coumadin at home for her history of atrial fibrillation; she was maintained on a heparin drip while in the unit until she became therapeutic. GU: She maintained a stable creatinine and adequate urine output. ID: A [**1-4**] BAL demonstrated only 10^4 organisms of MSSA -- she was, however, on steroids, and the ICU team placed her on Levofloxacin. On [**1-11**] she had an episode of desaturation and a bronch revealed thick brown mucous. She was placed on empiric Vancomycin, Zosyn for three days until cultures returned negative. On [**1-11**] she also had an episode of hypotension concerning for septic physiology. Labs drawn at the time showed WBC = 29. Blood cultures were still negative at 4 days out. Endocr: She received a 48 hour course of dexamethasone for her supraglottic swelling, in hopes that this would improve her chances of extubation. These were discontinued following her tracheostomy. [**1-3**]: s/p R thoracentesis [**1-4**]: s/p L thoracentesis, bronch with bal [**1-5**]: cxr shows increased R apical PTX; failed extubation, will likely need trach so not starting coumadin for now, on hep gtt [**1-6**]: LMA bronch, R 20F CT, failed extubation (x3) [**1-7**]: Repositioned CT [**1-8**]: CT to WS, added levofloxacin for MSSA on BAL in setting of steroids [**1-9**]: bronch ([**Last Name (un) **], ETT) - narrowed, edematous nasopharynx, no air leak even with cuff down; pulm -> resp alkylosis (likely overbreathing [**12-30**] agitation, baseline CO2 likely 48, consider decrease MV by decreasing PS (no change in peep) to allow increased CO2 prior to extubation (maximizing respiratory drive) [**1-10**]: Trach and Peg. #8 Portex. [**1-11**]: TM for 4 hrs, then mucus plug requiring return to vent, hypotensive, pan-cx, CT pulled, vanc/zosyn started [**1-12**] CVL L removed (tip cxr sent), R subclavian placed, flagyl started for ?cdiff (diarrhea, mild abd pain, 1st set cdiff neg); bronch -> unremarkable, BAL sent, small but stable R apical PTX [**1-13**]: new small left apical ptx; hep gtt stopped [**1-14**]: ? new small pneumomediastinum, abx stopped; ger c/s - low dose Seroquel 12.5 po QHS for agitation [**1-15**]: [**Female First Name (un) **] c/s -> switch to PPI (less agitation), seroquel 25 qhs and qam PRN agitation [**1-16**]: PMV during day, agitated pm; [**Female First Name (un) **] recs - lopressor 12.5 [**Hospital1 **] (avoid atenolol), seroquel 25mg ghs and gam, NO olanzapine, DC famotidine [**1-18**]: doing well, required some pressors over night [**1-19**]: off neo, doing well on CPAP/trach mask Medications on Admission: Coumadin Atenolol Lasix ASA Calcium Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Year (2) **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal DAILY (Daily) as needed. 5. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) Injection ASDIR (AS DIRECTED). 6. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) as needed. 7. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 11. Midodrine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 12. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QHS (once a day (at bedtime)). 13. Levothyroxine 200 mcg Recon Soln [**Last Name (STitle) **]: 200mcg Recon Solns Injection DAILY (Daily). 14. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: 2.5-3.0 mg qday. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: - C7 fx - bilateral pleural effusions s/p thoracentesis - right pneumothorax s/p right chest tube placement - mild AS/AR - atrial fibrillation - hypertension - ?CHF Discharge Condition: Stable Discharge Instructions: If you have fevers/chills, persistent nausea/vomiting, severe abdominal pain, difficulty breathing, please [**Name8 (MD) 138**] MD. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**11-29**] weeks. Call for an appointment. Please follow up with Dr. [**Last Name (STitle) **] in trauma clinic in [**1-1**] weeks, call for an appointment at [**Telephone/Fax (1) 6429**] Please follow up with Dr. [**Last Name (STitle) 363**] (Orthopedics/Spine) in [**11-29**] weeks. Call [**Telephone/Fax (1) 3573**] Completed by:[**2194-1-21**]

[ "518.81", "263.9", "512.8", "401.9", "805.6", "V15.3", "530.81", "511.89", "V46.11", "428.0", "805.07", "293.0", "244.0", "E885.9", "424.1", "V10.79", "428.30", "V10.87", "427.31", "785.0", "496" ]

icd9cm

[ [ [] ] ]

[ "43.11", "31.1", "96.04", "96.72", "38.91", "34.04", "38.93", "33.22", "34.91", "33.24" ]

icd9pcs

[ [ [] ] ]

9352, 9422

1950, 7720

330, 557

9631, 9640

1032, 1927

9820, 10238

7806, 9329

9443, 9610

7746, 7783

9664, 9797

282, 292

585, 928

950, 1013

31,978

129,141

29097

Discharge summary

report

Admission Date: [**2157-2-3**] Discharge Date: [**2157-2-4**] Date of Birth: [**2098-11-15**] Sex: M Service: MEDICINE Allergies: Motrin Attending:[**First Name3 (LF) 458**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 58 yo male with h/o CAD s/p BMS x2 to bifurcation in [**9-20**], ETOH abuse, HTN, hyperlipidemia presenting with CP and SOB. Pain started at 5 pm while he was at the T stop drinking 40 oz of beer. He was on his second 40 oz beer and developed N/V and the substernal CP radiating down his left arm and back. He called his friend, who reportedly called EMS. In the ED, he continued to have CP and was found to have questionable ST elevations in I and avL and V4-V5 and ST depressions in II and avF, but flat CKs and troponins. In the ED he receieved metoprolol 5 mg x1, nitro SL, morphine 2mg x1, plavix 75, heparin gtt, zofran and was sent to the cath lab. Cardiac catheterization revealed 60-70% mid LAD lesion distal to his stent, mild LCX disease and 60-70% mid RCA. There was no intervention and the case was uncomplicated. He was transferred to the CCU for further monitoring. . On arrival to the CCU, his CP had resolved. He denied CP, nausea, dizziness, palpitations. He reports that he has not had CP since his MI in [**9-20**]. He is able to walk long distances and up stairs without any chest pain or shortness of breath. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: CAD s/p BMS x2 to LAD in [**9-21**] HTN Hyperlipidemia GSW x3 in [**Country **] s/p surgery Social History: Patient says he lives alone with a cat, but in calling his "brother" Mark (actually he works at [**Company 9904**] emergency shelter) he lives in shelter. Social history is significant smoking 1ppd for 40 years and now down to 1 pack per week. Drinks 2-3 times per week per him. Cannot quantify amount, but drink 40 oz beers. Had 2 40 oz beers just prior to presentation. Family History: No family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 96.0, BP 111/57 , HR 73, RR 14, O2 98% on 2L Gen: Middle aged male in NAD, resp or otherwise. Oriented x3 but inappropriate at times and forgets what he is going to say. Smells like alcohol. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, poor dentition Neck: no JVD CV: RR, normal S1, S2. No S4, no S3. no murmurs Chest: Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi anteriorly. Abd: Obese, soft, mildly distended, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits, groin site c/d/i with dressing with minimal ooze on dressing. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. spider angiomos on chest Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: EKG demonstrated < [**Street Address(2) 4793**] depression in II, avf with TWI with early repolarization in the anterior leads (per cardiology fellow read as not in chart). Seems generally unchanged from previous on [**1-27**]. . CARDIAC CATH: 60-70% mid LAD distal to stent and 60-70% mid RCA, no intervention . [**2157-2-3**] 06:00PM WBC-7.5 RBC-4.22* HGB-11.4* HCT-35.0* MCV-83 MCH-27.1 MCHC-32.7 RDW-16.3* [**2157-2-3**] 06:00PM ASA-4 ETHANOL-305* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2157-2-3**] 06:00PM calTIBC-511* VIT B12-519 FOLATE-GREATER TH FERRITIN-33 TRF-393* [**2157-2-3**] 06:00PM ALBUMIN-4.6 CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.1 IRON-70 [**2157-2-3**] 06:00PM CK-MB-3 [**2157-2-3**] 06:00PM cTropnT-<0.01 [**2157-2-3**] 06:00PM ALT(SGPT)-24 AST(SGOT)-31 CK(CPK)-122 ALK PHOS-62 TOT BILI-0.4 [**2157-2-3**] 06:00PM GLUCOSE-87 UREA N-9 CREAT-0.9 SODIUM-136 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17 [**2157-2-3**] 06:55PM TYPE-ART PO2-175* PCO2-44 PH-7.34* TOTAL CO2-25 BASE XS--2 INTUBATED-NOT INTUBA [**2157-2-3**] 09:12PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2157-2-3**] 10:08PM HCT-32.3* Brief Hospital Course: Mr. [**Known lastname **] was admitted with chest pain and alcohol intoxication. Due to a question of EKG changes (possible lateral ST elevations) the patient underwent cardiac catheterization which revealed 60-70% LAD and RCA lesions. No intervention was undertaken. The patient had negative cardiac enzymes and was symptom free overnight. He was scheduled for stress testing on hospital day #2 however the patient signed out AMA. He was scheduled for outpatient cardiology follow-up with his primary cardiologist Dr. [**Last Name (STitle) **] prior to leaving. No change in his home medications were made. Medications on Admission: Plavix 75 mg po qday Metoprolol 100 mg PO qday Simvastatin 80 mg PO qday Isosorbide mononitrate 90 mg qday Lisinopril 20 mg po qday Discharge Medications: Plavix 75 mg po qday Metoprolol 100 mg PO qday Simvastatin 80 mg PO qday Isosorbide mononitrate 90 mg qday Lisinopril 20 mg po qday Discharge Disposition: Home Discharge Diagnosis: Chest pain Discharge Condition: Stable Discharge Instructions: Follow-up with your cardiologist. Patient left AMA. Followup Instructions: Dr. [**Last Name (STitle) **], cardiologist at [**Hospital 4415**] ([**Hospital1 3278**]), Monday [**2157-2-7**] 12:30 PM in the South Building on the [**Location (un) 895**].

[ "V45.82", "414.01", "401.9", "272.4", "413.9", "305.00" ]

icd9cm

[ [ [] ] ]

[ "88.55", "37.22", "88.52" ]

icd9pcs

[ [ [] ] ]

5652, 5658

4705, 5314

300, 325

5712, 5720

3470, 4682

5820, 5999

2531, 2604

5496, 5629

5679, 5691

5340, 5473

5744, 5797

2619, 3451

226, 262

353, 2011

2033, 2126

2142, 2515

20,778

113,683

45686

Discharge summary

report

Admission Date: [**2180-12-2**] Discharge Date: [**2180-12-11**] Date of Birth: [**2105-9-2**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 689**] Chief Complaint: L ankle pain Major Surgical or Invasive Procedure: ORIF for left distal fib/tib fx History of Present Illness: 75 year old female with history of COPD on home O2 (2L)who presents with left ankle pain. Patient had fallen asleep on the sofa. When she awoke, she tried to get up to go to the kitchen. When she stood on her feet and turned to walk, she felt a sharp pain in her left ankle. She felt as if her foot were "caught on something." She felt as if her ankle "popped" and then she fell to the ground. She denies LOC, trauma to head, syncope. Past Medical History: -COPD on home O2 (pulmonologist at [**Hospital1 112**]- Fanta) -h/o Syncope 3 years ago (negative w/u) --Echo [**3-4**]: EF 60%, mild pulm HTN (28), E/A 0.78, no WMA, no LVH, trace MR [**Name13 (STitle) **] Knee Cyst -Anxiety -osteoporosis Social History: Widowed x 5 years. Has 2 children. Lives alone in a studio apartment in [**Location (un) **]. Has person to help clean 2x week. Son lives one block away. Formerly worked in newspaper advertising. ~120 pack year smoking history (quit [**2145**]), per patient 2 glasses of EtOH with evening meal. Per son, mother drinks quite a bit more. Family History: Mother c anxiety d/o, fa was alcoholic. Sister and 2 children all in psychiatric tx (details unknown). Physical Exam: VS: Tc & max: 98.3, HR: 105 (80-105), BP: 125/71 (124-155/53-78) HEENT: EOMI, anticteric, dry MM, neck supple, JVP not elevated Lungs: Decreased breath sounds, no audible wheezes or rhonchi Heart: Soft heart sounds, tachycardic, s1, s2, no m/g/r auscultated abd: Soft NT, ND, +BS ext: -edema, left ankle in bandage, good distal cap refill neuro: alert and oriented to hospital, but not to floor. Year=[**2179**] Pertinent Results: [**2180-12-2**] 02:30PM GLUCOSE-90 UREA N-31* CREAT-0.7 SODIUM-142 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-27 ANION GAP-13 [**2180-12-2**] 02:30PM WBC-11.5*# RBC-3.76* HGB-11.4* HCT-33.0* MCV-88 MCH-30.5 MCHC-34.7 RDW-14.0 [**2180-12-2**] 02:30PM NEUTS-84.6* BANDS-0 LYMPHS-9.7* MONOS-3.4 EOS-2.2 BASOS-0.2 [**2180-12-2**] 02:30PM PLT COUNT-321 [**2180-12-2**] 02:30PM PT-12.2 PTT-23.7 INR(PT)-1.0 [**2180-12-2**] EKG: Baseline artifact. Sinus rhythm. Modest non-specific ST-T wave changes. Poor R wave progression - cannot rule out old anteroseptal myocardial infarction. Compared to the previous tracing of [**2180-7-20**] no significant diagnostic change. [**2180-12-2**] Ankle/tib/fib films: horizontally oriented fracture through medial malleolus. Associated obliquely oriented fracture through the anterior corner of the tibia. Obliquely oriented fracture through the distal fibula with slight posterior angulation of the distal fracture fragment. Disruption of the ankle mortise with slight lateral subluxation of the distal tibia. [**2180-12-5**] CTA chest: Multiple small, nonocclusive pulmary emboli in the subsegmental branches of the left lung. Emphysematous changes. Several small, ill-defined nodular pulmonary opacities, nonspecific in appearance; followup in several months could be obtained to ensure resolution. Brief Hospital Course: 75 year old female with history of COPD presents with left tib/fib fracture and COPD exacerbation, subsequently found to have multiple pulmonary embolisms. 1) Left Ankle Tib/Fib Fracture: When patient came to the ED, her x-ray noted fractures through tibula, fibula and medial malleolus. She was admitted to the ortho service and medically cleared for surgical repair. However, overnight she had MS changes (discussed below)and adamantly refused surgery recommended the next morning. Several days later, the patient consented to surgery, and underwent an ORIF without complications. She was fitted for a bivalve cast and cleared for rehab. She will follow-up with orthopedics in 2 weeks following discharge . 2) Mental Status Changes: After the patient's admission to the ortho service, she was noted to be agitated and tremulous, and, according to the staff, appeared to be having auditory hallucinations. The patient refused surgery the AM after admission. Psychiatry service was called to assess capacity. She was found to be in a confusional state and to lack capacity to make a decision. They recommended waiting until the delirium cleared to proceed with the therapy. Because of the patient's reported EtOH abuse and elevated CIWA scores, she was placed on a CIWA protocol. Prn benzos (other than CIWA protocol) and morphine were d/c'd. The patient was given a 1:1 sitter for safety. Patient was ordered for Haldol prn. Imipramine was briefly discontinued, to be replaced by nortriptyline (due to its lack of anti-cholinergic side effects), however, the patient became upset about the change and was returned to her original medication. Over the next days, the patient's mental status improved. She consented to the surgery, and was treated with tramadol and morphine for pain relief. After the operation, her mental status was mostly at baseline, except for a few reports of increased agitation and nervousness, usually correlated to larger doses of morphine. . 3) Pulmonary: Patient has a long standing history of COPD is on constant home 02 2L n/c and is treated with nebs. Upon admission, she was noted to be 87% on RA and up to 98% on 2L. Lung exam revealed rhonchi and expiratory wheezes. The patient did not have a fever or observed cough. While on the ortho service, the patient had episodes of dropping O2 sat to 76 and 80 on RA when nasal cannula was partially or fully removed by patient while delirius. When nasal cannula was repositioned, SpO2 recovered. Later, the patient became progressively tachypneic and had worsening hypoxia with ABG 7.42/45/56 on 2L of room air. Chest XR was negative for infiltrate or pleural effusions. Chest CT revealed bilateral non-obstructive thrombi of unclear age. The patient was begun on heparin gtt for PE, which was later switched to coumadin and lovenox after her surgery. She is currently on coumadin with a lovenox bridge; she will need to continue lovenox until she is therapeutic on coumadin (INR [**1-5**]) for 48 hrs. Next INR check is due [**2180-12-12**]. She was also felt to have a COPD exacerbation and was started on solumedrol, subsequently transitioned to a prednisone taper. Discussion with her PCP suggested that she had not been taking prednisone daily prior to admission, as originally thought. Albuterol/atrovent nebulizer treatments and advair were continued throughout her hospital stay. At time of discharge, her oxygen saturation was stable 94% on 2L nasal cannula. . 4) Hypertension: Over the course of her hospital stay, the patient's home dose of Lisinopril was increased and a B1 selective BB was added. Good control was achieved (120-130's systolic)on this regimen. Patient was also placed on a low salt diet. . 5) Anemia: Over the first several days of her admission, the patient's hematocrit dropped significantly from baseline. She was transfused with 2 units of blood and her hematocrit stabilized in the low 30s. . 6) Hyperglycemia. Patient has no known history of DM. Her high sugars throughout her hospital stay were most likely secondary to steriod use. Patient was placed on a SSI. Medications on Admission: Albuterol, Advair, Atrovent, Excedrin 325 mg Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) newb Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Enoxaparin 60 mg/0.6mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H (every 12 hours): continue until patient has been therapeutic on coumadin (INR [**1-5**]) for 48 hours. 6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Haloperidol 1 mg Tablet Sig: 1-2 mg PO TID (3 times a day) as needed for severe agitation or confusion. 9. Imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 11. Lisinopril 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. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Please hold if sedated. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Prednisone 20 mg Tablet Sig: Forty (40) Tablet PO DAILY (Daily): for 2 days, then 30 mg PO daily for 2 days, then 20 mg PO daily for 2 days, then 10 mg PO daily for 2 days, then 10 mg PO every other day for 3 days. 16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: chronic obstructive pulmonary disease exacerbation Secondary: left tibial/fibular fracture, pulmonary embolism, ansiety, osteoporosis, delirium, steroid-induced hyperglycemia Discharge Condition: Stable. Discharge Instructions: Please follow-up with chest pain, shortness of breath, or other symptoms that concern you. Followup Instructions: 1) Orthopedics - please call [**Telephone/Fax (1) 1228**] to schedule an appointment to see Dr. [**Last Name (STitle) 1005**] within 10-14 days following discharge 2) Primary care - please call to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1313**] ([**Telephone/Fax (1) 355**]) within 1-2 weeks following discharge from rehab Completed by:[**2180-12-11**]

[ "518.81", "293.0", "799.02", "285.9", "401.9", "E927", "300.00", "250.00", "824.4", "E849.0", "733.00", "491.21", "415.19" ]

icd9cm

[ [ [] ] ]

[ "79.36", "99.04" ]

icd9pcs

[ [ [] ] ]

9390, 9469

3335, 7414

284, 317

9697, 9707

1969, 3312

9846, 10256

1417, 1521

7509, 9367

9490, 9676

7440, 7486

9731, 9823

1536, 1950

232, 246

345, 781

803, 1045

1061, 1401

60,798

170,820

39246

Discharge summary

report

Admission Date: [**2188-4-11**] Discharge Date: [**2188-4-30**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: Shortness of breath, LE edema Major Surgical or Invasive Procedure: [**2188-4-17**] OPERATION: 1. Ultrasound-guided puncture of the left common femoral artery. 2. Contralateral second-order catheterization of the right external iliac artery. 3. Serial arteriogram of the right lower extremity. 4. Abdominal aortogram. [**2188-4-24**] Right iliofemoral and profunda femoral artery endarterectomy with saphenous vein patch angioplasty. History of Present Illness: [**Age over 90 **] M with A fib, CHF, HTN, HL, s/p recent L colectomy for [**Female First Name (un) 899**] bleed complicated by NSTEMI and ARF presents with SOB an dincreasing LE edema. Patient is a poor historian. Reports that he was having SOB for many months now and that more recently it has been getting slightly worse. Has noticed that his legs have been more swollen since his surgery in [**Month (only) 547**]. Minimal exertion will cause him ot become fairly winded, something that is not completely new to him, but is worse than it used to be. Patient otherwise thinks that he has been admitted because of his right heel ulcer. . In the ED, initial VS: 97.0, 68, 121/53, 24, 97%RA. He was found to have a BNP of [**Numeric Identifier **]. Because of symptoms of volume overload and diffuse crackles on lung exame and bilateral LE edema, he was given 40 mg IV lasix. A V/Q scan was also performed which showed low probability of PE. . Currently patient feels well, breathing feels better, comfortable. Wants to know what will be done about his foot, whether he will get an angiogram or amputation. Past Medical History: -recent admission for [**Female First Name (un) 899**] bleed requiring colectomy and 21 units of pRBCs. Admission also complicated by NSTEMI and ARF. -Hypertension -Hyperlipidemia -benign bladder tumors -atrial fibrillation -distant h/o gout in right LE -BPH Social History: Patient lives with his wife in [**Hospital3 4298**]. Wife has [**Name2 (NI) 11964**]. He is retired broadcast manager. Drinks 1 glass wine daily. Prior tobacco use, smoked 1PPD x 40 years and quit at age 60. No illicit drug use. Family History: Brother died at age 57 from MI. No family history of colon cancer, UC/Crohns Physical Exam: VS: 96.5, 108/60, 70, 20, 99%2L I/O: 240/250 GENERAL: AAOx3, labored breathing HEENT: PERRL, EOMI, dry MM. OP clear with fair dentition but missing teeth. NECK: JVP to his ear, supple, no LAD, no thyromegaly CARDIAC: S1S2, irregularly irregular, no m/r/g LUNG: bibasilar crackles, rales diffusely. No w/r/r ABDOMEN: soft, ND, NT, +BS, no HSM EXT: 2+ pedal pulses, quarter-sized ulcer over right heel, c/d/i. 2+ pitting edema to knees bilaterally NEURO: CNs II-XII grossly intact SKIN: wound on right heel Pertinent Results: LUNG SCAN Study Date of [**2188-4-11**] INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate a large defect in the posterior right lower lobe and a defect along the minor fissure. Perfusion images in the same 8 views show a smaller defect in the posterior right lower lobe. Chest x-ray shows cardiomegaly with pulmonary vascular congestion and bilateral pleural effusions, right greater than left. The above findings are consistent with a low-probability scan, with matched defects that are worse on ventilation than perfusion images. IMPRESSION: Low probability for PE. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] was notified on [**2188-4-11**] at 5 PM. [**2188-4-23**] CXR: Final Report PROCEDURE: Chest preop PA and lateral. REASON FOR EXAM: Preoperative FINDINGS: In comparison to the previous chest radiograph, bilateral layering pleural effusions are minimally changed allowing for differences in patient positioning. The appearance of the right pleural effusion is slightly unusual with a lucency in the upper margins of the fluid suggesting loculation. A lucent line along the lateral right costal margin is probably due to overlying soft tissue structures. Pulmonary vascular congestion is mild and unchanged. IMPRESSION: Large right and small left layering pleural effusions with mild vascular congestion. The findings were discussed with the referring team The study and the report were reviewed by the staff radiologist. Echo : [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86859**]Portable TTE (Complete) Done [**2188-4-12**] at 2:57:55 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (LF) **], [**First Name3 (LF) **] V. [**Hospital 18**] Hospital Medicine Program [**Location (un) 830**], PBS-2 [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2096-1-7**] Age (years): [**Age over 90 **] M Hgt (in): 71 BP (mm Hg): 72/35 Wgt (lb): 188 HR (bpm): 82 BSA (m2): 2.06 m2 Indication: Congestive heart failure. Left ventricular function. Right ventricular function. ICD-9 Codes: 428.0, 427.31, 414.8, 424.1, 424.0, 424.3, 424.2 Test Information Date/Time: [**2188-4-12**] at 14:57 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**] [**Last Name (un) 16813**], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Suboptimal Tape #: 2010W009-0:20 Machine: Vivid [**6-11**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% to 35% >= 55% Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *20 < 15 Aorta - Sinus Level: *4.3 cm <= 3.6 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 1.5 cm Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - E Wave deceleration time: 200 ms 140-250 ms TR Gradient (+ RA = PASP): *32 to 40 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2188-3-18**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Dilated RV cavity. Focal apical hypokinesis of RV free wall. Prominent moderator band/trabeculations are noted in the RV apex. AORTA: Moderately dilated aortic sinus. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Moderate (2+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Moderate to severe [3+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - body habitus. Ascites. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with focal severe hypokinesis of the distal left ventricle and dyskinesis of the apex. There is also hypokinesis of the entire inferior wall and inferior septum . Overall left ventricular systolic function is moderately depressed (LVEF= 30-35 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is dilated with focal hypokinesis of the apical free wall. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Extensive regional left ventricular dysfunction c/w multivessel CAD. Moderate to severe tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2188-3-18**] (which was a focused study), the severity of tricuspid regurgitation has increased. Estimated pulmonary artery pressures are now able to be assessed and are elevated. Moderate mitral regurgitation is now appreciated. Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2188-4-29**] 05:35 29.7* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2188-4-11**] 13:00 78.1* 9.1* 6.0 6.3* 0.4 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2188-4-28**] 09:35 15.5* 29.8 1.4* [**2188-4-28**] 06:40 255 LAB USE ONLY [**2188-4-28**] 06:40 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2188-4-29**] 05:35 941 44* 2.3* 137 3.6 97 32 12 IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES ESTIMATED GFR (MDRD CALCULATION) estGFR [**2188-4-27**] 05:20 Using this1 Using this patient's age, gender, and serum creatinine value of 2.6, Estimated GFR = 23 if non African-American (mL/min/1.73 m2) Estimated GFR = 28 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2188-4-27**] 05:20 20*1 NEW REFERENCE INTERVAL AS OF [**2187-12-10**];UPPER LIMIT (97.5TH %ILE) VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201 BLACKS 801/414 ASIANS 641/313 CPK ISOENZYMES CK-MB cTropnT proBNP [**2188-4-27**] 05:20 NotDone1 0.20*2 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2188-4-29**] 05:35 8.4 3.1 1.8 HEMATOLOGIC calTIBC Ferritn TRF [**2188-4-11**] 13:00 241* 545* 185* ANTIBIOTICS Vanco [**2188-4-23**] 07:20 16.9 VANCO @ TROUGH 6-8AM CARDIAC/PULMONARY Digoxin [**2188-4-23**] 07:20 1.4 VANCO @ TROUGH 6-8AM LAB USE ONLY LtGrnHD GreenHd Prblm HoldBLu [**2188-4-12**] 13:50 PROBLEM SO1 RECEIVED [**Year (4 digits) 86860**] FOR MRSA TEST, NO PATIENT NAME ON [**Name2 (NI) 86860**]. PROBLEM SOLVED PER WEST LAB 9:32AM RR Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS Intubat [**2188-4-24**] 18:09 ART 60 142* 40 7.48* 31* 6 INTUBATED [**2188-4-24**] 16:38 ART 56 112* 35 7.53* 30 7 INTUBATED WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl [**2188-4-24**] 18:09 93 1.3 137 3.5 99* [**2188-4-24**] 16:38 100 1.0 136 3.5 97* HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT [**2188-4-24**] 18:09 9.2* 28 [**2188-4-24**] 16:38 8.6* 26 CALCIUM freeCa [**2188-4-24**] 18:09 1.12 [**2188-4-24**] 16:38 1.14 Brief Hospital Course: [**Age over 90 **] yo M with history of A fib, CHF (EF 30-35%), HTN, HL, s/p recent admission for an [**Female First Name (un) 899**] bleed requiring 21 units of pRBCs and colectomy, complicated by NSTEMI and ARF, presenting with symptoms of volume overload in CHF exacerbation . #. CHF/Hypoxia - patient has history of CHF, TTE from [**2188-3-18**] shows an LVEF of 30-35%. Patient presented clinically overloaded, with crackles and rales diffusely and bilateral pedal edema. Patient was discharged from the surgery service on last admission without a diuretic. Following administration of IV lasix 40 mg x1 in the ED, patient had some symptomatic improvement and lung fields sounded clearer and was transferred to medicine for further management of CHF exacerbation. On the floor, patient initially saturated well on 2 L overnight, but this morning decompensated with O2 requirement fluctuating between 2-6 L of O2. ABG obtained while on 4L of O2 showed 7.48/30/63. Patient would benefit from more aggressive diuresis, however because of hypotension, will need more close monitoring than what medicine floor can offer. Patient is being transferred to ICU for closer monitoring. While in the ICU, the patient was satting comfortably in the mid 90s on 2L NC then weaned to room air. No desaturations with OOB to chair and breakfast. BP was supported as below. [**Hospital 86861**] transfered to Vascular surgery for heel ulcer. . #. Hypotension - patient has a history of hypertension for which he takes nifedipine and nadolol at home. On this admission, his SBP was initially 120s, but the morning following his admission, he was found to have a BP of 60/d while seated. IV fluids were not given because of CHF exacerbation. In the ICU, the patient received 1U PRBCs and 80 mg iv lasix initially. BPs were tenuous in the low 80s initially but improved rapidly to high 90s to low 100s over several hours and were stable since that time. Our plan was to bolus IVF if SBPs dipped into the 80s again however this wasn't necessary. On DC BP normalized. . #. GI bleed - s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 899**] bleed requiring 21 units of pRBC and colectomy with resulting colostomy. He was noted to have dark tarry melanotic stools in his colostomy bag, confirmed to be guaiac positive. Patient has a G-J tube from which we tried to perform a lavage, however we were unable to pull anything out, despite being able to flush it. GI saw the patient and reported that ostomy output was guaiac negative and the G tube was lavaged and negative. Hcts were stable while in the ICU. Ostomy output was trace guaiac positive on the morning of transfer from the ICU. Bleeding resolved. J tube removed. Xeroform applied. . # Right heel ulcer - pt had angiogram, then a Right iliofemoral and profunda femoral artery endarterectomy with saphenous vein patch angioplasty. No sequele noted. . #. Chronic renal insufficiency - baseline creatinine of ~2.5. With diuresis creatinine bumped slightly to 2.7. Patient's BUN is also elevated from baseline, uncertain what the etiology of this is. Our suspicion is that it's caused by continued GI bleeding. amd hypotension. After resusitation creatinine is back to baseline. . # CAD/biventricular dysfunction: Cardiology consult, digoxin to 0.125 qod, lasix 40 po'', coreg 6.25'', Stable on DC . #. Recent colostomy for [**Female First Name (un) 899**] bleed - gold team surgery has evaluated patient and signed off, as there is nothing for them to add to managment at this time. J tube removed by team. Xeroform to wound. . #. Hypertension - held antihypertensives as patient's SBP's ranged 70-80s . #. Hyperlipidemia - patient continued on simvastatin . #. Atrial fibrillation - not on anticoagulation due to GI bleeding. Currently in an irregularly irregular rhythm. Cardiology recs - digoxin to 0.125 qod, lasix 40 po'', coreg 6.25'' . #. distant h/o gout in right LE - patient continued on colchicine . #. BPH - patient continued on tamsulosin Medications on Admission: nadolol 40 mg daily nifedipine SR 60 mg daily aspirin 325 mg daily bacitracin zinc 500unit/g 1 application QID benzocaine 20% paste QID prn pain colchicine 0.6 mg every other day simvastatin 10 mg daily tamsulosin 0.4 mg qhs oxycodone 5-10 mg q4h prn pain trazodone 25 mg qhs prn insomnia heparin 5000 units TID Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MONDAY, WEDNESDAY, FRIDAY) (): renal dose. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Oxycodone 5 mg Tablet Sig: 0.5 - 1 Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 **] [**Hospital1 1501**] Discharge Diagnosis: CHF exacerbation R foot ulcer Peripheral Vascular disease PMH: Hypertension Hyperlipidemia Benign bladder tumors A-fib (hematuria when on coumadin) Gout BPH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**1-9**] 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 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? 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: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over 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 over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions . Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2188-5-9**] 11:00 You should follow up with a Urologist closer to your home on [**Hospital3 4298**]. Completed by:[**2188-4-30**]

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icd9cm

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[ "88.48", "00.42", "38.18", "88.42" ]

icd9pcs

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40708

Discharge summary

report

Admission Date: [**2170-8-28**] Discharge Date: [**2170-9-17**] Date of Birth: [**2122-10-4**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2836**] Chief Complaint: Pancreatic cancer Major Surgical or Invasive Procedure: [**2170-8-28**]: Whipple resection, modified classic and saphenous vein interposition graft from splenic artery to common hepatic artery. [**2170-9-6**]: CT-guided aspiration of the liver fluid collection. History of Present Illness: The patient is a 47-years-old female recently diagnosed by pancreatic adenocarcinoma by EUS FNA. The patient underwent staging laparoscopy with biopsy and intraoperative ultrasound on [**2170-8-10**] and was found to have resectable disease. The patient was scheduled for (modified classical) Whipple resection on [**2170-8-28**] with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. Past Medical History: hypothyroidism Social History: Married. 1ppd smoker. Family History: Aunt with pancreatic CA Physical Exam: On Discharge: T98.9, P 82, BP 116/82, R20, O2Sat 99RA HEENT: NCAT, PERL, EOMI CV: RRR, S1 and S2. Pulm: CTA b/l Abd: Soft, non-tender. JP drain site clean, dry, intact - no erythema; small amount of serous fluid in drain. Staples retained in middle of Whipple incision. 6-7cm open surgical incision site on RUQ and 2-3cm open incision on LUQ - incisions are clean margins, no eryethema, packed with dry gauze, no active output, fascia intact. Tissue is well perufused. Surrounding skin is well healing and intact. Ext: MAE, left leg incisional site for saphenous graft well heeling, c/d/i. Pertinent Results: Pathology Examination SPECIMEN SUBMITTED: Peripancreatic Lymph Node, Gallbladder, COMMON HEPATIC ARTERY LYMPH NODE, Proximal Jejunum, Whipple, Pylorus. Procedure date Tissue received Report Date Diagnosed by [**2170-8-28**] [**2170-8-28**] [**2170-8-31**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl Previous biopsies: [**-1/2819**] Peritoneal Implant. DIAGNOSIS: I. Lymph node, peripancreatic (A-B): One lymph node with no carcinoma seen (0/1). II. Pancreatic head, duodenum, and bile duct, Whipple resection (C-X): A. Invasive adenocarcinoma of the pancreas, moderately differentiated, with invasion of the ampulla and duodenal wall (pT3); lymphovascular invasion identified; see synoptic report. B. Metastatic adenocarcinoma involving four of eleven peripancreatic lymph nodes ([**5-14**]) - pN1. C. Resection margins free of carcinoma (tumor present 2 mm from the uncinate process). [**Month/Year (2) 1105**]. Proximal jejunum (Y-AB): Segment of unremarkable small intestine. IV. Pylorus (AC-AE): Segment of unremarkable gastric antrum/pylorus and contiguous duodenal bulb. V. Lymph nodes, common hepatic artery (AF-AG): One lymph node with no carcinoma seen (0/1). VI. Gallbladder (AH-AI): A. Chronic cholecystitis. B. Cholelithiasis, cholesterol type. Pancreas (Exocrine): Resection Synopsis Staging according to American Joint Committee on Cancer Staging Manual -- 7th Edition, [**2168**] MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy. Tumor Site: Pancreatic head. Tumor Size Greatest dimension: 3.3 cm. Additional dimensions: 2.5 cm x 2.3 cm. Other organs/Tissues Received: Gallbladder, proximal jejunum, pylorus. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G2: Moderately differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. Regional Lymph Nodes: pN1: Regional lymph node metastasis. Lymph Nodes Number examined: 13. Number involved: 4. Distant metastasis: pMX: Cannot be assessed. Margins: Margins uninvolved by invasive carcinoma: Distance from closest margin: 2 mm. Specified margin: Uncinate process. Venous/Lymphatic vessel invasion: Present. Perineural invasion: Absent. Additional Pathologic Findings: Pancreatic intraepithelial neoplasia: low grade; chronic pancreatitis. Clinical: Pancreatic cancer. MICRO: [**2170-9-2**] 1:50 pm URINE Source: Catheter. **FINAL REPORT [**2170-9-5**]** URINE CULTURE (Final [**2170-9-5**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S [**2170-9-10**] 3:37 pm SWAB Site: ABDOMEN Source: Abdominal Incision. Fluid should not be sent in swab transport media. Submit fluids in a capped syringe (no needle), red top tube, or sterile cup. GRAM STAIN (Final [**2170-9-10**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2170-9-13**]): ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R PENICILLIN G---------- =>64 R VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [**2170-9-14**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2170-8-29**]: LIVER US: IMPRESSION: 1. Limited exam due to overlying bandages and patient pain. However, arterial flow is visualized within the common hepatic artery and the right hepatic artery. The left hepatic artery and the venous interposition graft were not fully visualized. 2. Mild central intrahepatic biliary ductal dilatation with nondilated common hepatic duct to choledochojejunostomy. 3. Small amount of post-surgical free fluid. [**2170-9-4**] CT ABD: IMPRESSION: 1. 6.5 x 9.9 cm hypodense area within segments [**Last Name (LF) 1105**], [**First Name3 (LF) 690**] and IVb of the liver, suspicious for infarcation in light of 2) below. Imaging cannot exclude superimposed infection. 2. Filling defect consistent with thrombus within the hepatic artery at the porta hepatis with no demonstrable flow within the intra-hepatic arteries. The left portal vein is attenuated in appearance. 3. S/P Whipple procedure with postoperative changes at the porta hepatis and in the region of the pancreas. No leak identified. Scattered foci of free air likely post-operative. 4. Small left pleural effusion. Bibasilar dependent atelectasis, left great than right. [**2170-9-4**] LIVER DOPPLER: IMPRESSION: 1. Patent hepatic arteries and saphenous vein interposition graft. High velocities at the graft-hepatic arterial anastomosis may reflect anastomotic site turbulence. Though a nonocclusive thrombus at this location cannot be excluded by ultrasound, this is not directly visualized. 2. Patent main and right portal veins. No detectable flow in left portal vein. This may be due to slow or undetectable flow, or possibly left portal vein thrombosis. 3. Heterogeneous left hepatic lobe, corresponding to region of parenchymal ischemia or necrosis better demonstrated on preceding CT. [**2170-9-5**] CTA/CTV ABD: IMPRESSION: 1. Increase in size of large area of hypoattenuation within segment [**Doctor First Name 690**] and IVb which has a thicker rim than previously. The differential includes abscess and/or evolving infarction. 2. The intrahepatic vessels are patent including the portal vein, hepatic veins and hepatic artery. Focal high-grade (>70%) narrowing of the left hepatic artery at bifurcation with proper hepatic artery, which was not present previously. The distal right hepatic artery is attenuated for several centimeters beyond the bifurcation but patent. [**2170-9-7**] CT GUIDED NEEDLE PLACTMENT IMPRESSION: Successful CT-guided aspiration of 12cc from the left hepatic collection. A sample was sent for Gram stain and culture. [**2170-9-10**] CXR IMPRESSION: Left approach PICC tip terminating within the right atrium. [**2170-9-12**] CT ABD & PELVIS WITH CONTRAST IMPRESSION: 1. Continued organization of previously visualized hypoattenuation within segments [**Doctor First Name 690**] and IVb with the differential containing abscess and/or evolving infarction. There is a probable communication of this collection through a defect in the anterior abdominal wall (2:25, 602B:35). 2. Two skin defects are visualized consistent with interval removal of staples. [**2170-9-16**] 07:20AM BLOOD WBC-12.5* RBC-3.71* Hgb-11.0* Hct-32.6* MCV-88 MCH-29.8 MCHC-33.9 RDW-13.2 Plt Ct-949* [**2170-9-6**] 04:50AM BLOOD WBC-30.9* RBC-3.26* Hgb-9.7* Hct-28.5* MCV-87 MCH-29.8 MCHC-34.1 RDW-13.2 Plt Ct-604* [**2170-8-29**] 01:13AM BLOOD WBC-15.4* RBC-3.58* Hgb-11.3* Hct-31.8* MCV-89 MCH-31.5 MCHC-35.4* RDW-12.9 Plt Ct-334 [**2170-9-16**] 07:20AM BLOOD Glucose-99 Creat-0.6 Na-130* K-4.4 Cl-97 HCO3-25 AnGap-12 [**2170-8-29**] 01:13AM BLOOD Glucose-143* UreaN-12 Creat-0.6 Na-138 K-3.7 Cl-105 HCO3-23 AnGap-14 [**2170-9-16**] 07:20AM BLOOD ALT-30 AST-32 AlkPhos-170* TotBili-0.3 [**2170-8-29**] 09:37AM BLOOD ALT-3066* AST-2321* AlkPhos-244* Amylase-323* TotBili-0.9 [**2170-9-14**] 05:01AM BLOOD Lipase-42 [**2170-8-29**] 09:37AM BLOOD Lipase-718* [**2170-9-14**] 05:01AM BLOOD Albumin-3.2* Calcium-8.9 Phos-4.0 Mg-2.1 [**2170-9-14**] 05:01AM BLOOD Vanco-18.6 [**2170-8-28**] 09:43AM BLOOD Type-ART pO2-310* pCO2-39 pH-7.44 calTCO2-27 Base XS-2 Intubat-INTUBATED Vent-CONTROLLED [**2170-8-28**] 08:56PM BLOOD Type-ART FiO2-46 pO2-219* pCO2-32* pH-7.45 calTCO2-23 Base XS-0 -ASSIST/CON Intubat-INTUBATED Comment-ETT Brief Hospital Course: The patient with pancreatic adenocarcinoma was admitted to the HPB Surgical Service for elective resection. On [**2170-8-28**], the patient underwent Whipple resection, modified classic, and saphenous vein interposition graft from splenic artery to common hepatic artery, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the ICU, the patient arrived on the floor NPO/NGT, on IV fluids, with a foley catheter, and epidural catheter for pain control. The patient was hemodynamically stable. Neuro: The patient received Hydromorphone/Bupivacaine via epidural, APS service adjusted the rate to achieve an adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. JP amylase was checked on POD # 5, and was low. JP # 1 was removed on POD # 6. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Patient will continue JP #2 at home. HEPATOLOGY: Immediately post op, the patient's LFTs were elevated. LFTs were followed daily and started to downward on POD # 1. The patient spikes fever on POD # 6 and WBC spikes to 32.7. The patient was started on Unasyn empirically. Abdominal CT revealed 6.5 x 9.9 cm hypodense area within segments [**Date Range 1105**], [**Doctor First Name 690**] and IVb of the liver. The patient's LFTs continue to improve. On POD # 8, repeat CT scan demonstrated increase in size of large area of hypo attenuation within segment [**Doctor First Name 690**] and IVb which has a thicker rim than previously. The Hepatology Service was consulted and recommended percutaneous drainage. The patient underwent CT-guided aspiration of the liver fluid collection on POD # 10. Fluid was send for evaluation and grew enterococcus sensitive to Vancomycin. On POD#15 repeat CT showed likely communication of liver collection through abd wall. VASCULAR: On POD # 1, Doppler demonstrated arterial flow within the common hepatic artery and the right hepatic artery. The patient was started on Aspirin PR on POD # 1. On POD # 6, repeat Doppler revealed patent hepatic arteries and saphenous vein interposition graft and high velocities at the graft-hepatic arterial anastomosis. The patient was started on Heparin gtt to prevent possible thrombosis. The patient underwent abdominal CTA/CTV on POD # 7, which demonstrated patent intrahepatic vessels including the portal vein, hepatic veins and hepatic artery, focal high-grade (>70%) narrowing of the left hepatic artery at bifurcation with proper hepatic artery, which was not present previously and distal right hepatic artery is attenuated for several centimeters beyond the bifurcation but patent. Vascular surgery service recommended to discontinue Heparin gtt and continue the patient only on oral Aspirin. GU: The patient has a history of urinary retention. Her Foley was removed on POD # 4. On POD # 5, Foley was placed back s/t 700 cc of residual urine on bladder scan. Despite several attempts to remove patient's Foley, she failed voiding trials. The Foley was replaced on POD # 8 and removed on POD# 12. Pt. has been voiding well since that time with no incontinence. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Liver aspirate grew enterococcus senstive to Vancomycin. On POD#13 drainage was noted from incision site and 6 surgical staples were removed and incision site was allowed to drain. POD#14 5 staples removed from left side of wound and allowed to drain - both samples grew Vanc senstivie enterococcus. Wounds were packed with gauzed and changed [**Hospital1 **]. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1) levothyroxine [Levoxyl] 200 mcg Tablet 1 Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2170-7-23**] 2) omeprazole 40 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by mouth twice a day (Prescribed by Other Provider) [**2170-7-23**] 3) nr glucosamine sulfate [Glucosamine] Dosage uncertain Discharge Medications: 1. 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* 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) for 2 weeks. Disp:*56 Tablet(s)* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Levothroid 200 mcg Tablet Sig: One (1) Tablet PO once a day. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: Thirty (30) ML PO QHS (once a day (at bedtime)). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns Intravenous Q 12H (Every 12 Hours) for 2 weeks: Total dose 1250mg to be given twice a day. . Disp:*28 Recon Soln(s)* Refills:*0* 11. Outpatient Lab Work Vancomycin trough level q 4 days. BUN and Creatinine checked weekly. Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] and call if any questions or concerns. Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: 1. Pancreatic mass with involvement of replaced common hepatic artery. 2. Liver fluid collection 3. Urinary retention 4. Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-12**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Return immediately in ED if will develop urine retention post Foley catheter removal. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-10-2**] 11:00 [**Location (un) 861**] of [**Hospital Ward Name 23**] Building. Do not eat or drink for 3 hours before scan. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2170-10-5**] 10:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20205**], MD Phone:[**Telephone/Fax (1) 20206**] Date/Time:[**2170-10-5**] 11:30 Please follow up with Dr. [**Last Name (STitle) 25195**] (PCP).

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icd9cm

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[ "50.91", "39.26", "52.7", "51.22" ]

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16575, 16644

9902, 14801

321, 530

16833, 16833

1729, 5580

18789, 19381

1051, 1076

15162, 16552

16665, 16812

14827, 15139

16984, 17649

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5616, 9879

1105, 1686

264, 283

558, 957

16848, 16960

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1011, 1035

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109,348

30187

Discharge summary

report

Admission Date: [**2139-1-1**] Discharge Date: [**2139-1-6**] Date of Birth: [**2067-7-29**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1711**] Chief Complaint: Ventricular fibrillation and tachycardia Major Surgical or Invasive Procedure: Internal cardiac defibrillator placement History of Present Illness: 71yo M with ischemic CM, last EF 20-25%, CKD, DM, PAD with recurrent nonhealing ulcers and s/p multiple bypass/grafts. ECG shows signs of old inferior MI. EF dropped to 20% in [**2-/2138**] so patient underwent cardiac catheterization via radial access in 5/[**2138**]. Found to have 70% prox RCA (no intervention) and 80% prox Lcx (unable to stent but POBA'd). Pt has not had any chest pain. Repeat echo in [**9-/2138**] unchanged. Saw Dr. [**First Name (STitle) 437**] who suggested ICD and continued lisinopril 2.5mg daily and Toprol XL 50mg daily); uptitration limited by BP. Over past 3 weeks, he reports intermittent episodes of lightheadedness after walking, sometimes associated with nausea, that gradually subsides. He saw [**Doctor Last Name **] on [**12-24**] and was orthostatic so metolazone was stopped but he was kept on Lasix 60mg [**Hospital1 **]. . The patient sat down today at dinner table and felt dizzy and nauseated. He didn't realize he had syncopized but witnessed by family who called EMS, no head trauma. EMS noted a pale appearance and found him to be in monomorphic VT on telemetry. His blood pressures remained stable (documented BP 107/68), and he broke spontaneously into sinus rhythm. . On ED arrival, VS: P 70, BP 106/74, RR 18, O2sat 100%. He again went into VT on arrival and became unresponsive although with a pulse. As pads were being placed, he woke up and went into sinus rhythm. As amiodarone was ordered, he again went into VT and became unresponsive, this time thought to be pulseless. He was emergently shocked with 200J with restoration of sinus rhythm. He was bolused amiodarone and started on gtt. He was also given calcium gluconate due to concern for hyperkalemia in setting of chronic renal failure; hemolyzed K 6.4 on arrival; repeat K 1/2 hour later was 4.6. He received a total of 1L IVF in the ED. CXR unremarkable. On transfer, Afebrile P 86, BP 96/63 (80s-90s baseline), RR 16, O2sat 96% RA. . On review of systems, he endorses chronic LBP, h/o pulmonary emboli. S/He denies any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Denies dysuria, urgency, frequency. . Cardiac review of systems is notable for presence of syncope and for the absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. . Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: CAD s/p silent IMI -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: [**5-/2138**] cath with diffusely calcified LAD, 80% prox LCx s/p PTCA and calcified proximal and mid 70% stenoses. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Hypertension - Type 2 diabetes mellitus with neuropathy - Cardiomyopathy with LVEF of 20% - Severe PAD with multiple leg procedures followed by Dr. [**Last Name (STitle) **]. - Protein S deficiency - Anti-phospholipid antibody syndrome (positive lupus anticoagulant) - Pulmonary emboli in [**2128**] and [**2129**] s/p IVC filter placement in [**2-/2138**], off Coumadin due to UGIB - Erosive gastritis complicated by UGIB - Gout, exacerbated by HCTZ - s/p panniculectomy in [**2128**] - s/p debridement of right foot [**2135-4-9**] - chronic low back pain - Hypothyroidism Social History: -Tobacco history: Never smoker. -ETOH: former heavy, sober x many years, decided to have 2 beers with a friend today. -Illicit drugs: denies. Patient lives in [**Hospital1 392**] with his wife and daughter. [**Name (NI) **] is a retired maintenance technician. Family History: Father died at 54 of Alzheimer's disease. Mother with diabetes mellitus. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Arrival VS: T=96.9 BP=106/79 HR=83 RR=16 O2 sat=96% 3L NC GENERAL: WDWN Caucasian 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. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Skin graft over R foot intact. PULSES: Right: Carotid 2+ Femoral 1+ DP dopp PT dopp Left: Carotid 2+ Femoral 1+ DP 1+ PT 1+ Pertinent Results: Admission [**2139-1-1**] 08:15PM BLOOD WBC-7.3 RBC-4.14* Hgb-13.7* Hct-39.4* MCV-95 MCH-33.2* MCHC-34.9 RDW-18.4* Plt Ct-188 [**2139-1-1**] 08:15PM BLOOD PT-22.3* PTT-32.8 INR(PT)-2.1* [**2139-1-1**] 08:15PM BLOOD Glucose-260* UreaN-66* Creat-2.4* Na-136 K-6.9* Cl-105 HCO3-18* AnGap-20 [**2139-1-1**] 08:15PM BLOOD ALT-16 AST-59* CK(CPK)-104 AlkPhos-106 TotBili-0.2 [**2139-1-1**] 08:15PM BLOOD cTropnT-0.10* [**2139-1-1**] 08:15PM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.4 Mg-1.8 [**2139-1-1**] 08:24PM BLOOD Glucose-256* Lactate-5.8* Na-138 K-7.1* Cl-105 calHCO3-18* . =======================IMAGES============================== CXR Please note the extreme right costophrenic angle is excluded from view. Lung volumes are diminished. No consolidation or edema is evident. Calcified pleural plaques are again evident consistent with prior asbestos exposure. The mediastinum is grossly unremarkable. The cardiac silhouette is exaggerated by low lung volumes but likely grossly top normal for size. No large effusion or pneumothorax is noted within limitations. Degenerative changes are seen throughout the thoracic spine. . IMPRESSION: Relatively stable chest x-ray examination within limits. No focal consolidation noted. There are underlying calcified plaques from prior asbestos exposure. . . CXR post placement: The patient is slightly rotated to the left. A left pectoral ICD leads terminate in the expected locations of the right atrium and right ventricle. Pleural plaques are likely due to prior asbestos exposure. The cardiac and mediastinal silhouettes and hilar contours are normal. There is no pleural effusion or pneumothorax. IMPRESSION: ICD leads terminate in right atrium and right ventricle. ==========================DC Labs ================================ [**2139-1-6**] 06:00AM BLOOD WBC-7.7 RBC-3.89* Hgb-12.6* Hct-36.8* MCV-95 MCH-32.4* MCHC-34.2 RDW-18.4* Plt Ct-181 [**2139-1-6**] 06:00AM BLOOD Glucose-210* UreaN-52* Creat-2.2* Na-139 K-4.5 Cl-100 HCO3-29 AnGap-15 [**2139-1-6**] 06:00AM BLOOD Mg-2.1 [**2139-1-3**] 06:40AM BLOOD TSH-1.4 Brief Hospital Course: ASSESSMENT AND PLAN: 71yo M with CAD s/p silent inferior MI and subsequent ischemic cardiomyopathy with last EF 20%, CKD, HTN, DM, HLD who presents after monomorphic VT arrest at home with ROSC and now s/p pulseless VT/VF arrest in the [**Hospital1 18**] ED, now HD stable. . # RHYTHM: now s/p VT/VF arrest and now in sinus again on amiodarone gtt. [**Month (only) 116**] be related to old scar from known prior ischemia. EP initially wanted cath, but interventional did not feel it was necessary, CT [**Doctor First Name **] ddid't feel that revascularization was warranted, so ultimately the patient was monitored clinically and an ICD was placed. We also started him on amiodarone first IV, then transitioned to PO prior to discharge, with instructions to half the dose a week later and take 1 pill indefinitely. We also decreased his warfarin, given interaction with amiodarone and gave him a script for INR check on [**1-8**], with follow-up with Dr. [**Last Name (STitle) 54043**]. . # CORONARIES: known CAD and inferior MI, no s/s of ACS now, though new arrhythmia concerning for old scar. We continued him on ASA 81, simvastatin 10, metoprolol tartarate was given and uptitrated as bp and heart rate tolerated. He was sent home on metoprolol succinate 50 mg Tablet Sustained Release daily. . # PUMP: Last EF 20% on [**9-/2138**] TTE. CXR without signs of edema, does not appear overloaded on exam. . # UTI: Pt. reports starting treatment on [**1-1**] for UTI found incidentally on UA at PCP's office with nitrofurantoin. Asymptomatic throughout. Afebrile. UA was negative, and no treatment was given while inpatient. . # CKD: baseline Cr 1.7 in [**7-/2138**], now elevated. Most likely [**2-18**] pre-renal azotemia, less likely ATN given minimal down time. We initially held home furosemide and renally dosed his meds. He was sent home on furosemide 20 mg Tablet daily. . # Gout: we decreased his allopurinol to 100,to renally dose it given CKD . # DM: we held his home meds and covered with ISS. . # Hypothyroidism: We cntinued home levothyroxine. . CODE: Confirmed full (though patient states "I've been saying since I was 18 that I don't care if I die tomorrow." . Medications on Admission: 1. Allopurinol 300 mg daily. 2. Amitriptyline 150 mg at bedtime. 3. Diazepam 10 mg p.r.n. 4. Lasix 60 mg b.i.d. 5. Metolazone 2.5 mg three times a week (recently stopped) 6. Glipizide 10 mg b.i.d. 7. Levothyroxine 50 mcg daily. 8. Lisinopril 2.5 mg a day. 9. Metformin 1000 mg in the morning and p.r.n. in the night. 10. Metoprolol succinate 50 mg daily. 11. Omeprazole 20 mg b.i.d. 12. Simvastatin 10 mg a day. 13. Warfarin 7.5mg 3x/week (MWF), 5mg 4x/week 14. Aspirin 81 mg a day. 15. Docusate 100mg [**Hospital1 **] 16. Percocet 5/325 Q6h prn pain Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. amitriptyline 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. diazepam 5 mg Tablet Sig: 1-2 Tablets PO at bedtime. 4. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 10. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 11. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 15. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day: Take for one week total until [**1-13**], then decrease to 200 mg daily. Disp:*120 Tablet(s)* Refills:*0* 17. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Start on [**1-13**]. Disp:*30 Tablet(s)* Refills:*2* 18. Outpatient Lab Work Please check Chem-7 and INR on Thursday [**2139-1-8**] and call results to Dr.[**Last Name (STitle) 36023**],[**Last Name (STitle) **] [**Telephone/Fax (1) 36024**] 19. cephalexin 500 mg Capsule Sig: One (1) Capsule PO three times a day for 2 days. Disp:*6 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Ventricular Tachycardia Chronic Systolic Heart Failure Ischemic Cardiomyopathy Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had a dangerous heart rhythm called ventricular tachycardia that made you pass out. We started you on a new medicine called amiodarone that has prevented this heart rhythm in the hospital. An internal cardiac defibrillator was placed that will shock your heart out of this rhythm when you are home if needed. This will feel very strong and you should call Dr. [**Last Name (STitle) **] or [**First Name8 (NamePattern2) 16901**] [**Last Name (NamePattern1) **] NP[**MD Number(3) 71935**] device fires or if you pass out. You will need to take antibiotics for 2 days to prevent an infection at your pacer site. Please talk to Dr. [**Last Name (STitle) **] about exercising with this defibrillator in place. Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. We made the following changes in your medications:\ 1. Decrease the Allopurinol to 100 mg daily because of your kidney function 2. STart Amiodarone to keep your heart in a normal safe rhythm. Please take 2 pills twice daily for 1 week, then decrease to 1 pill per day. 3. We decreased your warfarin to 5 mg daily because the amiodarone interacts with the warfarin and makes your PT/INR higher. Please get your INR checked on [**2139-1-8**] with results to Dr. [**Last Name (STitle) **] who will then tell you how much warfarin to take at home. 4. Please try to avoid the use of Valium unless you take it at bedtime. This may make you more prone to falls. Followup Instructions: Electrophysiology: Department: CARDIAC SERVICES When: MONDAY [**2139-1-12**] at 11:00 AM With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Primary Care: Name: [**Hospital Ward Name 36023**],[**Hospital Ward Name **] Location: [**Location (un) 2274**]-[**Location (un) **] Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 36024**] Appt: [**1-13**] at 11:50am . Department: CARDIAC SERVICES When: WEDNESDAY [**2139-4-15**] at 10:00 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: WEDNESDAY [**2139-2-18**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Cardiology: Department: CARDIAC SERVICES When: WEDNESDAY [**2139-6-24**] at 11:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2139-1-7**]

[ "274.9", "428.22", "357.2", "427.1", "250.60", "412", "428.0", "427.5", "403.90", "V12.51", "276.7", "272.4", "427.41", "244.9", "414.01", "414.8", "289.81", "795.79", "425.4", "585.9", "443.9" ]

icd9cm

[ [ [] ] ]

[ "37.94" ]

icd9pcs

[ [ [] ] ]

11879, 11936

7294, 9472

331, 374

12083, 12083

5207, 7271

13861, 15453

4156, 4345

10073, 11856

11957, 12062

9498, 10050

12266, 13838

4360, 5188

3052, 3253

251, 293

402, 2941

12098, 12242

3284, 3862

2963, 3031

3878, 4140

31,735

155,124

32677

Discharge summary

report

Admission Date: [**2118-12-3**] Discharge Date: [**2118-12-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Spitting up blood Major Surgical or Invasive Procedure: None History of Present Illness: 84 y/o female with recent diagnosis in [**2118-8-29**] of diffuse large B cell lymphoma of the distal esophagus and proximal stomach, S/P one cycle of CHOP on [**2118-11-1**] and a second cycle of CHOP-Rituxan on [**2118-11-24**], on neulasta, who presents with hematemesis. She reports sudden onset of spiting up 2-3 tablespoons of bright red blood after severazl bites of [**Country 1073**] and cantolope. She describes a substernal burning feeling after eating, followed by spitting up blood. This happpened again when she reached the ED, spitting up 3-4 tablespoons more of bright red blood. She reports decreased po intake over the last several months due to poor appetite, with weight loss, early satiety, and occassional substernal and epigastric burning after eating. She denies fever, chills, chest pain, dyspnea, vomiting, abdominal pain, or dysuria. She did recently have some constipation, for which she took senna and colace and then had loose stools. She denies black or bloody stools. She reports rare alcohol use and has no history of liver disease. . In the ED, T 98.9 HR 88 BP 150/84 RR 18 SAT 100%RA. NG lavage for one liter cleared to pink with specks of blood. Treated with 40 mg IV protonix and 4 mg IV Zofran. Guaiac negative. Past Medical History: 1. Diffuse Large B Cell Lymphoma of the GE junction- diagnosed by biopsy during an EGD on [**2118-9-27**]. Pathology showed diffuse large B-cell lymphoma staining positive for LCA, CD20, BCL6, and MUN1. Subsequent PET-CT showed disease localized to the distal esophagus/proximal stomach. She received cycle one CHOP on [**2118-11-1**]. The Adriamycin dose was initially reduced and Rituxan held. She tolerated the first cycle of chemotherapy well. She began cycle 2 CHOP-Rituxan at full dose on [**2118-11-24**]. She is scheduled to have a repeat PET-CT on [**2118-12-13**]. They plan to repeat her bone marrow biopsy when her counts recover. 2. Peptic ulcer disease s/p partial gastrectomy & tumor excision [**2092**] 3. Mild Diastolic Dysfuction by Echo [**2118-11-1**] 4. S/P appendectomy. 5. Nephrolithiasis Social History: She lives at home with her daughter in [**Name (NI) 2624**], [**State 350**]. She is retired, but previously worked in retail. Widowed. Three daughters and a son. [**Name (NI) **] than two alcohol drinks per week. Tobacco: Smoked for 30 years, quit 40 years ago. Alcohol: Rare use on social occasions, drinking two glasses per night. No drug use. Is Catholic. Family History: Her father died of a neck cancer at 64 years. Her mother died of a malignancy that involved her eye at 38 years. One sister has [**Name (NI) 4522**] disease. Her other sister and brother have cardiovascular disease. Physical Exam: VITAL SIGNS: T 99 HR 85 BP 134/82 RR 14 SAT 100%RA GEN: Pleasant, cachectic, elderly female in no distress, occassionaly spitting up pink tinged mucous HEENT: Sunken eyes, moist mucous membranes. NECK: No LAD, no bruits HEART: Regular with 2/6 systolic flow murmur. CHEST: Lungs Clear. ABDOMEN: Good bowel sounds, soft, NT, ND, no palpable masses. EXTREMITIES: No edema, good pulses. SKIN: Warm, dry NEURO: A&Ox3, cranial nerves II-XII intact, strength 5/5 throughout Pertinent Results: [**2118-12-3**] 06:15PM WBC-9.0# RBC-3.97* HGB-12.4 HCT-35.3* MCV-89 MCH-31.4 MCHC-35.2* RDW-13.5 PLT COUNT-179 [**2118-12-3**] 06:15PM NEUTS-73* BANDS-8* LYMPHS-3* MONOS-9 EOS-0 BASOS-0 ATYPS-3* METAS-2* MYELOS-2* . [**2118-12-3**] 11:05PM HCT-31.8* . [**2118-12-3**] 06:15PM PT-13.3 PTT-22.1 INR(PT)-1.1 . [**2118-12-3**] 06:15PM GLUCOSE-119* UREA N-16 CREAT-0.7 SODIUM-143 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-29 ANION GAP-16 [**2118-12-3**] 06:15PM ALT(SGPT)-15 AST(SGOT)-19 ALK PHOS-92 AMYLASE-65 TOT BILI-0.4 [**2118-12-3**] 06:15PM LIPASE-15 . [**2118-12-3**] 06:15PM IRON-66 [**2118-12-3**] 06:15PM calTIBC-303 VIT B12-1304* FOLATE-16.0 FERRITIN-811* TRF-233 . Brief Hospital Course: Assessment: 84 y/o female with diffuse large B cell lymphoma at the GE junction and new hematemesis, s/p EGD on [**2118-12-5**] which confirs mass at GE junction with 2 cm bleeding ulcer. DDx included erosion of Lymphoma, [**Doctor First Name **]-[**Doctor Last Name **] Tear, and HSV Esophagitis . 1. Hematemesis: Likely due to bleeding from erosion of lymphoma at GE junction vs HSV esophagitis. Hct stable during hospital stay. Because of possibility of HSV esophagitis, she was switched from prophylactic dose to treatment dose Acyclovir. Pt is to continue PPI Daily, and stay on a liquid diet x 2 weeks pending repeat EGD (in 2 weeks). At that time biopsy results will need to be followed up, and well as H. Pylori results. . 2. Lymphoma: Unclear if this is progression of disease. Last treament in late [**Month (only) **]. BMT will see pt in clinic for further management of diffuse large B cell lymphoma. Of note, she is on levofloxacin for ppx after chemo, but her ANC is no longer depressed. Whether or not to continue levofloxacin can be evaluated in clinic. . 3. Bandemia with rising WBC count: Likely due to recent chemo with neulasta treatment. Afebrile with no symptoms or signs of infection. Can be followed in [**Hospital 3242**] clinic. . 4. Anemia: Likely 2/2 blood loss from hematemesis. However, hct stable for the length of stay. . 5. Diet: Pt is to continue a liquid diet for 2 weeks until f/u EGD . 6. CODE: Full, but does not wnat to be on long term life support. . 7. CONTACT: [**Name (NI) **], and daughter [**Name (NI) 16883**] [**Telephone/Fax (1) 76139**] . Medications on Admission: Acyclovir 400 mg t.i.d. prophylaxis Levofloxacin 500 mg daily prophylaxis since getting chemo Aciphex 20 mg daily taking on and off. Valium 5 mg daily. Xalatan eyedrops. Meclizine p.r.n. Senna one to two tablets b.i.d. Colace 100 mg b.i.d. . Discharge Medications: 1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY PRN (). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for vertigo. 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO 5X/D (). Disp:*150 Tablet(s)* Refills:*2* 8. 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* Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI Bleed from ulcer near Lymphoma at GE junction Secondary: 1. Diffuse Large B Cell Lymphoma of the GE junction- 2. Peptic ulcer disease s/p partial gastrectomy & tumor excision [**2092**] 3. Mild Diastolic Dysfuction by Echo [**2118-11-1**] 4. S/P appendectomy. 5. Nephrolithiasis Discharge Condition: VSS stable, afebrile, Hct stable Discharge Instructions: You were admitted to the hospital due to vommitting of blood. A test called an EGD was performed to evaluate the cause of the bleeding. During the EGD a small ulcer was found, and biopsies were taken. The results of this biopsy are not available right now, but you will be able to discuss the results with your health care provider in the clinic. By the recommendation of the GI team that saw you, you are to limit your diet to liquids for 2 weeks until another EGD is performed. You are to start taking a new medication called protonix, and stop taking Aciphex. You are also to start taking acyclovir at a higher dose. . If you have any more symptoms of spitting up blood, chest pain, nausea, or vommiting you are to go to the hospital immediately. . Please go to all of you follow up appointments as scheduled. . Please take allo of your medications as perscribed. Followup Instructions: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] for EGD: The office will call you with appointment time, It should be in 2 weeks. If they do not call you by [**2118-12-7**] please call them at [**Telephone/Fax (1) 463**] Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2118-12-8**] 10:00 AM Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2118-12-15**] 10:00 Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2118-12-15**] 10:00 Provider [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2118-12-15**] 11:00 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "530.3", "V12.71", "530.21", "054.79", "280.0", "V45.3", "799.4", "V13.01", "202.83" ]

icd9cm

[ [ [] ] ]

[ "42.92", "45.16" ]

icd9pcs

[ [ [] ] ]

6859, 6865

4228, 5826

280, 286

7206, 7241

3517, 4205

8163, 9204

2796, 3013

6119, 6836

6886, 7185

5852, 6096

7265, 8140

3028, 3498

223, 242

314, 1566

1588, 2402

2418, 2780

1,816

173,580

8470

Discharge summary

report

Admission Date: [**2196-10-7**] Discharge Date: [**2196-10-11**] Date of Birth: [**2134-2-11**] Sex: M Service: This is a 62-year-old male who presented with a history of chest pain who came for cardiac catheterization. Catheterization showed multi vessel disease and the patient was taken to the Operating Room on [**2196-10-7**] where a coronary artery bypass graft x2 was performed. The patient did well postoperatively and was transferred to the CSRU. He was fully weaned from his ventilator and was extubated. He required transfusions for a low hematocrit and for hemodynamic stability. The patient had an intra-aortic balloon pump placed during cardiac catheterization which postoperatively was removed on day 1 with no issues. PT was consulted for ambulation and he was slowly weaned from his ventilator and extubated. The patient had his chest tube removed and his diet was slowly advanced. Physical therapy evaluated him throughout his IC course as well as on the floor. He did well. His chest tube was removed and he was transferred to the floor. His Foley was also removed at that time. He did well and continued to ambulate on a regular diet. His pain was controlled. On postoperative day #4, his JP drain was removed. His wires were removed and the patient was evaluated per PT. He was discharged home in stable condition with neurologic services. The patient was instructed to follow up with is primary care physician who is also a cardiologist in one to two weeks and instructed to return to cardiothoracic surgery in two weeks for follow up for staple removal. The patient is discharged home in stable condition. The patient is discharged home on Percocet 1 to 2 tablets po q4h, Colace 100 mg po bid, Synthroid 50 mcg po qd, inhalers 2 puffs q6h, albuterol, ipratropium, enteric coated aspirin 325 po qd, Lopressor 25 po bid, Lasix 20 mg po bid and Protonix 40 mg po qd. The patient is discharged home in stable condition. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern4) 7148**] MEDQUIST36 D: [**2196-10-11**] 11:14 T: [**2196-10-11**] 13:28 JOB#: [**Job Number 29838**]

[ "425.4", "V10.79", "411.1", "285.9", "250.00", "496", "424.0", "272.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.56", "88.53", "37.61", "36.12", "37.23", "36.15", "39.61", "37.64" ]

icd9pcs

[ [ [] ] ]

26,094

124,157

18123+56913

Discharge summary

report+addendum

Admission Date: [**2146-11-20**] Discharge Date: [**2146-11-25**] Service: MICU HISTORY OF PRESENT ILLNESS: The patient is an 80 year old male with a past medical history of motor vehicle crash, cerebrovascular accident, status post tracheostomy and percutaneous endoscopic gastrostomy who presents from a rehabilitation facility with fever and increased respiratory rate. The patient was in his usual state of health until the day of admission when he had some question of confusion, temperature noted to be 104.8 and a pulse of 104. The patient also was experiencing some tachypnea which developed over the previous hours and was transferred to the [**Hospital6 1760**]. The patient had a recent admission to [**Hospital6 256**] after an motor vehicle crash, was admitted to the Trauma Service from [**2146-9-22**] to [**2146-10-12**] after he was missing for three days and found under his car. The hospitalization was notable for likely left lower lobe pneumonia, discovery of an old cerebrovascular accident, right distal clavicular fracture managed nonoperatively. The patient was unable to be delivered from the vent at that time and he received tracheostomy and percutaneous endoscopic gastrostomy on [**2146-10-11**]. The patient was also placed on an Aspen collar to be finished on [**2146-12-12**] as he was unable to clear his neck despite multiple imaging modalities being negative, the patient was unable to report clinical examination of the neck. PAST MEDICAL HISTORY: 1. Prostate cancer; 2. Motor vehicle crash, [**2146-9-22**]; 3. Cerebrovascular accident, small left frontal; 4. Right distal clavicular fracture; 5. History of Methicillin-sensitive resistant Staphylococcus aureus; 6. Right renal stone; 7. Failure to wean from ventilator, status post tracheostomy and percutaneous endoscopic gastrostomy; 8. Left lower lobe pneumonia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Bacitracin b.i.d. prn; Lactulose prn; Artificial tears; Albuterol; Atrovent nebulizers prn; Bisacodyl; Ranitidine 150 q.h.s.; Heparin subcutaneously 5000 b.i.d.; milk of magnesia; Seroquel 25 q. day; Ativan prn; Multivitamin; Colace 100 b.i.d.; Lopressor 25 and a regular insulin sliding scale. SOCIAL HISTORY: The patient currently is living at [**Hospital **] Rehabilitation Facility. Denies tobacco, alcohol or drug use in history. Contacts were the patient's wife, phone [**0-0-**], [**Name2 (NI) **]aughter [**Telephone/Fax (1) 50134**]. PHYSICAL EXAMINATION: Vital signs on admission: Temperature 101.4, pulse 85, blood pressure 110/50, respirations 20, sating 100% on 100% oxygen, pressure support ventilation. General: Elderly male appearing somewhat uncomfortable with mild injection of the sclera bilaterally, cervical spine collar in place. Pupils were 2 mm equal and reactive bilaterally. The patient was tachycardiac, normal S1 and S2, somewhat distant heartsounds. The patient's lung examination was clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended with good bowel sounds. Extremities revealed no edema. Neurological examination, the patient was disoriented, unable to follow commands, did react to painful stimuli, had 3+ reflexes bilaterally. LABORATORY DATA: An electrocardiogram revealed sinus tachycardia at 130, normal axis and intervals, slight ST depressions in lateral leads. White count 15.2, hematocrit 33.3. Laboratory data was significant for a sodium of 151. Arterial blood gases on admission 7.43/46/437. Computerized tomography scan of the head revealed no hemorrhage, mass or shift. Bilateral thalamic hyperdensities in old frontal infarct and age-related atrophy. Urinalysis was 3 to 5 red blood cells, 0-2 white blood cells, few bacteria, negative for nitrates, trace leukocytes. The patient also had a spinal tap which revealed no evidence of infection in the cerebrospinal fluid. HOSPITAL COURSE: 1. Fever - The patient with evidence of pneumonia on chest x-ray. The patient's sputum revealed coagulase positive Staphylococcus which was resistant to Oxacillin as well as two morphologies of gram negative rods. The patient was kept on his empiric antibiotics, Levofloxacin and Ceftazidime for the gram negative rods, double coverage and Vancomycin for the Oxacillin-resistant coagulase positive Staphylococcus. Plan for antibiotic course of 14 days to end on [**12-6**]. A PICC line was placed on [**11-25**] for antibiotic management as an outpatient. The patient's fever subsided during his hospital course and the patient was afebrile at the time of discharge. Further blood cultures remained negative at the time of discharge. Cerebrospinal fluid culture was negative. 2. Change in mental status - The patient's mental status changes were likely due to the pneumonia. A head computerized tomography scan was negative for bleed. Cerebrospinal fluid was negative for signs of infection in the cerebrospinal fluid. The patient's electrolyte abnormalities were corrected during his hospital course. There was no further evidence for an etiology of changes in mental status. However, the patient remained in a state of occasionally following commands although not consistently. He was not verbally responsive at any time. 3. Pulmonary - The patient with excellent oxygenation on ventilator as well as on tracheostomy mask. The patient was weaned from the ventilator and was able to tolerate approximately 12 hours a day on tracheostomy mask or with minimal assist CPAP with 5 of pressure support, however, the patient did occasionally fatigue and required assist controlled ventilation for resting. The patient remained with his tracheostomy tube at the time of discharge. 4. Fluids, electrolytes and nutrition - On admission the patient appeared volume depleted and was hypernatremic. The patient's free water deficit was calculated and corrected over time. The patient was continued on tube feeds during his hospital course and tolerated these well. The patient's hypernatremia resolved to sodiums in the normal range. He was maintained on free water boluses 250 t.i.d. for adequate hydration. 5. Cardiovascular - Repeat electrocardiogram on admission showed resolution of the ST depressions in the lateral leads. This was likely due to weight-related changes. The patient was continued on his aspirin, however, his beta blocker was held due to the fact that the patient's blood pressure did not require beta blocker. Early in his hospital course the patient's blood pressure would occasionally drop, however, this responded readily to fluids and was likely due to dehydrations. 6. Gastrointestinal - The patient was continued on his H2 blocker as well as his tube feeds. He had a percutaneous endoscopic gastrostomy tube which was well functioning during his hospital course. DISPOSITION: Return to [**Hospital **] rehabilitation for further care. CONDITION ON DISCHARGE: Stable on antibiotics, still requiring occasional resting on ventilator support. DISCHARGE STATUS: To [**Hospital **] Rehabilitation. DISCHARGE DIAGNOSIS: 1. Pneumonia 2. Methicillin-sensitive resistant Staphylococcus aureus 3. Hypernatremia 4. Requirement of mechanical ventilation 5. Hypotention DISCHARGE MEDICATIONS: 1. Lactulose prn 2. Artificial tears 3. Albuterol?atrovent nebulizers 4. Bisacodyl prn 5. Ranitidine 150 q.h.s. 6. Heparin 5000 units b.i.d. 7. Milk of magnesia prn 8. Seroquel 25 q. day 9. Multivitamin 10. Colace 100 b.i.d. 11. Regular insulin sliding scale 12. Haldol 1 t.i.d. and .5 prn 13. Levofloxacin 14. Ceftazidime 15. Vancomycin 16. Aspirin [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2146-11-24**] 17:51 T: [**2146-11-24**] 19:11 JOB#: [**Job Number 50135**] Name: [**Known lastname 3784**], [**Known firstname 2381**] J. Unit No: [**Numeric Identifier 9258**] Admission Date: [**2146-11-20**] Discharge Date: [**2146-11-29**] Date of Birth: [**2065-11-17**] Sex: M Service: Medical Intensive Care Unit ADDENDUM: This is an Addendum from admission of [**2146-11-20**]. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED): 1. FEVER ISSUES: The patient remained afebrile for the remainder of his hospitalization. Sputum culture grew out methicillin-resistant Staphylococcus aureus and Stenotrophomonas. Therefore, the patient's antibiotic regimen was changed to vancomycin and Bactrim for a 14-day course. 2. PULMONARY ISSUES: The patient did well on a tracheal collar; occasionally resting on continuous positive airway pressure or assist control. The patient was stable to discharge to rehabilitation. 3. CARDIOVASCULAR ISSUES: The patient remained tachycardic throughout the remainder of his hospital course. Studies were normal. His tachycardia was felt to be secondary to agitation. 4. ANEMIA ISSUES: The patient's iron studies were consistent with anemia of chronic disease. The patient responded well to transfusions. 5. MENTAL STATUS ISSUES: The patient's delirium was much improved. His mental status was probably at his baseline. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: To [**Hospital **] Rehabilitation. MEDICATIONS ON DISCHARGE: 1. Polyvinyl alcohol 1.4% ophthalmic drops as needed. 2. Bisacodyl 10 mg by mouth once per day as needed. 3. Multivitamin one tablet by mouth once per day. 4. Lactulose. 5. Docusate. 6. Tylenol. 7. Ranitidine. 8. Heparin 5000 units subcutaneously q.12h. 9. Aspirin 325 mg by mouth once per day. 10. Haloperidol 0.5 mg to 1 mg by mouth three times per day as needed. 11. Vancomycin 1 g intravenously q.12h. (times one dose). 12. Albuterol/ipratropium inhaler 1 to 2 puffs inhaled q.6h. as needed. DISCHARGE DIAGNOSES: 1. Acute respiratory failure. 2. Hyponatremia. 3. Staphylococcus aureus and Stenotrophomonas pneumonia. 4. Hypotension. 5. Anemia of chronic disease. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with his physicians at [**Hospital **] Rehabilitation as well as with his primary care physician. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**] Dictated By:[**Name8 (MD) 5343**] MEDQUIST36 D: [**2146-12-31**] 18:10 T: [**2147-1-5**] 02:46 JOB#: [**Job Number 9259**]

[ "V44.0", "518.84", "V10.46", "482.41", "V44.1", "276.0", "285.29" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9912, 10068

7273, 9243

7101, 7250

9374, 9891

1949, 2245

3933, 6918

10102, 10498

2520, 2532

9258, 9347

121, 1483

2547, 3915

1506, 1922

2262, 2497

6943, 7080

54,592

154,299

17329

Discharge summary

report

Admission Date: [**2153-7-22**] Discharge Date: [**2153-7-23**] Date of Birth: [**2103-4-24**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: narcotic overdose Major Surgical or Invasive Procedure: none History of Present Illness: 50 year old woman with a history of HIV, Hep C, and opiate abuse who presents with opiate overdose. The patient was found walking by the police, and was noted to be altered. She admitted to taking klonopin, and had ambien in her purse. While with the police, she was noted to have shallow breathing and was increasingly somnolent. EMS was called, and the patient was noted to be hypotensive. She was brought to the ED. . In the [**Hospital1 18**] ED, initial vs: 88 82/48 8 98% 4L. The patient underwent tox screen positive for opiates and methadone. She became increasingly obtunded with RR 4-6. She also was found to have acute kidney injury with a creatinine of 5.5. She received 4L IVF. She received 0.4 mg Narcan x 2 with small improvement in mental status. She then received 1mg IV narcan with large improvement in mental status. However, she quickly returned to somnolence with shallow breaths. She was started on a naloxone drip at 1.2 mg/hr. Her mental status cleared. She underwent CXR that showed possible multi-focal pneumonia, and received 1 dose of zosyn and levofloxacin. Prior to transfer to the floor, the patient underwent CT head and C-spine without acute findings. VS prior to transfer: 98.8 88 95/54 22 100% RA. . On arrival to the MICU, the patient is alert and oriented x 3. She complains of mild abdominal pain. She states that she last snorted heroin yesterday. She denies the use of methadone or benzos. . Possession search showed pill bottle containing 5mg methadone tablets and 1mg clonazepam tablets. Past Medical History: Hepatitis C - genotype 1B HIV Hypertension Opiate abuse Social History: Patient lives independently. She smokes 1PPD while using a nicotine patch. She abuses heroin - used to inject, now snorts. Denies other illicit drugs. Denies alcohol abuse. Patient has a community case worker and social worker. Family History: nc Physical Exam: Admission Physical Exam: Vitals: T: 97.3 BP: 113/84 P: 85 R: 18 O2: 95%RA General: Alert, oriented, no acute distress; appears somewhat fatigued; laying comfortably in bed HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, mildly tender to palpation in lower quadrants bilaterally; bowel sounds present, no organomegaly GU: foley in place draining dilute urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: multiple old track marks coursing all major visible veins, including tops of feet; healing debrided abscess on left buttocks . Discharge Physical Exam: Pertinent Results: Admission Labs: [**2153-7-22**] 04:20PM BLOOD WBC-6.6 RBC-3.49* Hgb-10.5* Hct-32.8* MCV-94# MCH-30.0# MCHC-31.9 RDW-16.2* Plt Ct-254 [**2153-7-22**] 04:20PM BLOOD Neuts-65.9 Lymphs-27.5 Monos-4.2 Eos-2.0 Baso-0.3 [**2153-7-22**] 04:20PM BLOOD Glucose-95 UreaN-73* Creat-5.5*# Na-135 K-4.3 Cl-105 HCO3-16* AnGap-18 [**2153-7-22**] 04:20PM BLOOD ALT-26 AST-45* AlkPhos-296* TotBili-0.1 [**2153-7-22**] 04:20PM BLOOD Calcium-7.3* Phos-7.7*# Mg-2.2 [**2153-7-22**] 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2153-7-22**] 04:48PM BLOOD Lactate-0.6 Brief Hospital Course: 50 year old woman with a history of HIV, Hepatitis C, and opiate abuse admitted with narcotic overdose. She left against medical advice on hospital day X 2. #) Narcotic overdose: The patient was admitted with obtundation and RR<4 in the setting of positive tox screen for both opiates and methadone. She admitted to using heroin the day prior to admission, and was found to have 5mg methadone tablets in her bag. On admission, she was started on a narcan drip at 1.2 mg/hr. Mental status cleared and respiratory drive improved. The morning following admission, narcan drip was discontinued without complication. The patient was started on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scale. Social work was consulted regarding narcotic abuse. The patient was then called out to the medical floor. Prior to being transferred to the medical floor she decided to leave against medical advice. She was able to repeat back all the risks of leaving up to and including death. She was deemed competent to make this decision. #) [**Last Name (un) **] on CKD: Patient with baseline creatinine in our system of 1.7 in [**2150**], admitted with creatinine of 5.5. Home lisinopril was held on admission. Patient possibly had a component of dehydration leading to acute kidney injury, as blood pressure and urine output improved with IV fluids. However, urine on admission was dilute with urine sodium 48 - showing likely intrinsic renal picture. Intrinsic renal disease may represent nephropathy from chronic hepatitis C, HIV, or tenofovir. Patient refused repeat lab draws and then left against medical advice. #) Hypotension: Patient with transient hypotension in the ED. Likely related to combination of dehydration and narcotic overdose. She became normotensive following 4L IVF and narcan drip. BP remained stable for the rest of admission. #) HIV: Chronic. The patient was continued on home atripla. Medications on Admission: Atripla Lisinopril Discharge Medications: left AMA Discharge Disposition: Home Discharge Diagnosis: left AMA Discharge Condition: left AMA Discharge Instructions: left AMA Followup Instructions: left AMA

[ "786.09", "780.09", "304.01", "584.8", "V08", "969.4", "070.70", "E980.3", "403.90", "458.8", "585.9", "276.51" ]

icd9cm

[ [ [] ] ]

[ "94.65" ]

icd9pcs

[ [ [] ] ]

5731, 5737

3697, 5629

322, 328

5789, 5799

3088, 3088

5856, 5867

2254, 2258

5698, 5708

5758, 5768

5655, 5675

5823, 5833

2298, 3043

265, 284

356, 1908

3104, 3674

1930, 1988

2004, 2238

3069, 3069

80,805

185,522

36187

Discharge summary

report

Admission Date: [**2188-12-20**] Discharge Date: [**2189-1-14**] Date of Birth: [**2121-4-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1493**] Chief Complaint: transferred for treatment of hepatorenal syndrome and transplant evaluation Major Surgical or Invasive Procedure: upper endoscopy, transjugular liver biopsy Left carotid endarterectomy History of Present Illness: 67 y.o. male with cryptogenic cirrhosis who was admitted to [**Hospital6 16029**] on [**12-16**] for worsening ascites. Patient is followed by an outpatient gastroenterologist who prior to his admission to [**Hospital6 16029**], had increased his diuretics from Spironolactone to 50 to 150 mg and Lasix from 40 to 60 mg. This increase was followed by a 6 liter paracentesis. Subsequent labs showed renal failure with a BUN of 79 and creatinine of 4.1 (up from a baseline of 18/0.9 in [**Month (only) 216**]). He was then admitted to the hospital for acute renal failure and what was felt to be ascites, refractory to diuretics. On the day after his admission, an additional 6 L paracentesis was performed (negative for SBP). His BP consequently fell and given the continued renal failure which was thought to be likely due to hepatorenal syndrome, he was started on albumin, midodrine and octreotide. Patient was followed by the renal team and not felt to urgently need HD. He was also noted to have a left pleural effusion and an elevated WBC and was started on Vancomycin/Zosyn for presumed nosocomial PNA (pt. had reportedly been in the hospital shortly before this hospitalization). Patient is now being transferred to [**Hospital1 18**] for further management and possible liver transplant evaluation. . Upon arrival, patient reported non-bloody emesis and complained of abdominal distention and pain from his foley. Otherwise, he had no complaints and had stable vital signs. Past Medical History: - Cryptogenic Cirrhosis: This was initially discovered [**8-12**] when imaging for nephrolithiasis incidentally noted a cirrhotic liver. Per notes from [**Hospital1 11485**], he is "heterozygous for HCC, negative for Hep B, Hep C, alpha antitrypsin and G6PD." Per the patient he had a recent normal endoscopy and colonoscopy [**10-13**]. No prior liver biopsy. - HTN - Nephrolithiasis s/p surgical stone extraction Social History: Patient denies current alcohol, tobacco or illicit drug use. He reports prior, social alcohol use and infrequent tobacco use. He has no tattoos or piercings and also denies a history of blood transfusions. He is self-employed, working in sales. Family History: Nephew with hemachromatosis, otherwise no family history of liver disease. Father died from prostate CA and mother died from CAD. Two sisters died from CAD. Two brothers alive with cardiac problems. 3 daughters alive and well. Physical Exam: Vitals: T - 97.6, BP 110/72, HR 92, RR 20, O2 Sat 96% on RA General: seated, NAD HEENT: oropharynx clear, moist MM Neck: Supple, no LAD, no JVD Cor: regular rate and rhythm, no murmurs Lungs: Decreased BS at bases, L>R Abd: distended, nontender, + shifting dullness, no rebound or guarding Ext: 3+ pitting edema to thighs bilaterally Neuro: Grossly intact; No asterixis Skin: No jaundice Pertinent Results: From [**Hospital6 16029**] on AM of [**12-20**]: WBC - 11.6 (N - 70%, L - 12.6%, M - 12.0, E - 5.1%, B - 0.5%) Hgb - 13.5 Hct - 40 Plt - 170 Na - 137 K - 3.9 Cl - 107 CO2 - 18 BUN - 75 Creatinine - 3.7 . . Admission labs: . [**2188-12-21**] 05:40AM BLOOD WBC-13.9* RBC-3.83* Hgb-13.7* Hct-40.6 MCV-106* MCH-35.8* MCHC-33.8 RDW-15.0 Plt Ct-189 [**2188-12-22**] 06:05AM BLOOD Neuts-79.3* Lymphs-10.9* Monos-7.5 Eos-1.9 Baso-0.4 [**2188-12-21**] 05:40AM BLOOD Glucose-101 UreaN-75* Creat-3.7* Na-138 K-3.9 Cl-108 HCO3-14* AnGap-20 LFT: [**2188-12-21**] 05:40AM BLOOD ALT-25 AST-34 LD(LDH)-331* AlkPhos-233* TotBili-1.6* [**2188-12-21**] 05:40AM BLOOD PT-16.8* PTT-36.0* INR(PT)-1.5* Iron studies: [**2188-12-21**] 05:40AM BLOOD calTIBC-100* Ferritn-[**2141**]* TRF-77 . Cirrhotic Work-up: [**2188-12-23**] 06:55AM BLOOD HBsAg-NEGATIVE [**2188-12-22**] 06:05AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE [**2188-12-22**] 06:05AM BLOOD AMA-NEGATIVE Smooth-POSITIVE [**2188-12-22**] 06:05AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**Last Name (un) **] [**2188-12-28**] 05:40AM BLOOD HIV Ab-NEGATIVE [**2188-12-22**] 06:05AM BLOOD HCV Ab-NEGATIVE . Discharge Labs: . [**2189-1-14**] 03:46AM BLOOD WBC-14.0* RBC-2.72* Hgb-9.7* Hct-28.7* MCV-106* MCH-35.7* MCHC-33.8 RDW-19.8* Plt Ct-201 [**2189-1-5**] 03:27AM BLOOD Neuts-78.5* Lymphs-10.9* Monos-7.1 Eos-3.1 Baso-0.3 [**2189-1-14**] 03:46AM BLOOD PT-19.2* PTT-37.1* INR(PT)-1.8* [**2189-1-14**] 03:46AM BLOOD Glucose-87 UreaN-60* Creat-3.8* Na-141 K-3.9 Cl-109* HCO3-19* AnGap-17 [**2189-1-14**] 03:46AM BLOOD ALT-18 AST-42* AlkPhos-235* TotBili-2.3* [**2189-1-14**] 03:46AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.9 Mg-2.0 . PET CT: 1. There is no definite evidence of FDG-avid disease to suggest lymphoma. 2. 18 mm hypodense lesion of the mid pole of the left kidney is FDG avid. The FDG uptake could be due to the lesion itself or to surrounding delayed FDG excretion. US can be used for further 3.Multiple foci of ground glass density. The one in the lingula is mildly FDG avid, suggesting infectious etiology. Continued anatomic followup can be used for these lesions. 4. Moderate ascites and splenomegaly and shrunken liver are compatible with cirrhosis. 5. Bilateral fluid containg inguinal hernias . . Abdominal US: 1. Very heterogeneous nodular liver which is difficult to assess for lesions with ultrasound. A contrast-enhanced CT or MRI is recommended for better characterization. 2. 2.1-cm suspicious solid-appearing left renal mass. 3. Ascites. *CXR ([**12-16**] - from [**Hospital6 16029**] compared to [**2188-11-30**]) Internal increase in left pleural effusion, as described. Left lower lobe consolidation cannot be excluded. Clinical correlation suggested. . Renal US ([**12-17**] - from [**Hospital6 16029**]) No significant interval change in comparison to the prior study. Unremarkable kidneys. This study is somewhat limited and the upper midpole left renal cyst previously identified is not clearly visualized on the current study. . Abdominal US ([**12-17**] - from [**Hospital6 16029**]) Significant amount of ascites . [**1-4**] US abd: 1. Patent hepatic vasculature. 2. Cirrhosis. 3. Large amount of ascites. A location in the right lower quadrant was marked for paracentesis to be performed by clinical staff. . [**1-4**]: Para: Protein 1.9, glucose 101, ldh 74, WBC 1000 25% polys, RBC 26,250 . Stress Test: No anginal type symptoms or significant ST segment changes suggestive of myocardial ischemia. . ECHO: 1. Mild reversible defect of the inferoseptal wall. 2. Normal wall motion and cavity size with LVEF 75%. 3. Probable abdominal ascites. . Liver, needle core biopsy: 1. Established cirrhosis with extensive sinusoidal fibrosis (confirmed by trichrome stain). 2. Iron stain shows marked iron deposition within hepatocytes and rare biliary epithelial cells. 3. Mild steatosis. 4. Mild septal mononuclear cell inflammation with a rare apoptotic hepatocyte. . Carotid Dopplers: 1. 80-99% stenosis in the left internal carotid artery. 2. 60-69% stenosis in the right internal carotid artery. 3. Elevated peak systolic velocity in the right common carotid artery which suggests presents of at least a mild stenosis. . Renal Ultrasound: Simple cyst located at the junction of the upper and mid pole of the left kidney . There are no suspicious features of this lesion. There are no other renal lesions. Brief Hospital Course: 67 y.o. male with cryptogenic cirrhosis, here with renal failure and leukocytosis. . # Cirrhosis: MELD was 25 on admission. He had no asterixis or other evidence of hepatic encephalopathy. Regarding the cause of his cirrhosis, there was high suspicion for hemochromotosis given the family history. Iron studies showed a transferrin saturation >100%. The patient's gastroenterologist was contact[**Name (NI) **] and confirmed that he was heterozygous wild type for the HFE gene mutation, making hemochromotosis an unlikely cause. Regarding other potential etiologies, the patient denied ever heavy alcohol use. Hepatitis panel was negative. Autoimmune markers and alpha 1 antitrypsin levels did not reveal a clear cause. Biopsy was undertaken via the transjugular route and demonstrated cirrhosis. NASH as former underlying cause is possible. . Transplant work-up was undertaken. Outside hospital records indicated recent colonoscopy [**10-13**] with internal hemorrhoids, small AV malformations, and 3 small polyps removed from hepatic flexure. There had also been an endoscopy with banding. Echocardiogram was essentially normal. PFTs showed a reduced DLCO but was otherwise normal. Stress test demonstrated mild reversible defect of the inferoseptal wall, cards consulted, felt to be insignificant. Renal ultrasound this admission confirmed renal cyst (NOT mass). . Carotid doppler demonstrated 80-99% blockage left internal carotid - patient underwent left carotid endarterectomy [**2189-1-13**] without complications. . Patient was placed on liver transplant list by time of discharge. Discharged on Cipro for SBP ppx, Lactulose, Omeprazole, Sucralfate, Midodrine, Sodium Bicarb. Patient was not discharged on Lasix or Aldactone due to renal function. . #Altered mental status / SBP: At baseline Patient alert, oriented, walking around [**Hospital Ward Name 121**] 10 at baseline. [**1-4**] found to be agitated and perseverating and transfered to the MICU. He did have a [**2189**] but two sequential head CTs now negative for any hemorrhage. Abdominal pain apparently new, and SBP was consideration given his ascites. Diagnostic para done 11/31 showing SBP with 1000 WBC, 25% polys. Pt treated with ceftriaxone and lactulose for SBP. Following SBP tx and lactulose enema mental status significantly improved and patient was transferred back to the floor. . # Renal Failure: Admission creatinine was 3.7 and subsequently rose as high as 4.0. Although he was quite edematous, he was breathing comfortably and had no acute indication for dialysis. Started therapy for hepato-renal syndrome - midodrine, octreotide, and albumin and titrated to maximal doses. Creatinine fell slightly with full dose treatment. It was felt that acute renal failure also had a large component of pre-renal. Octreotide and albumin were discontinued for d/c planning. Creatinine improved on midodrine only. Creatinine at time of discharge was 3.8. Patient discharged with close follow-up. Patient was not discharged on Lasix or Aldactone due to renal function. UO was adequate. . # Leukocytosis: The patient had an elevated WBC to ~14, with neutrophilia, on transfer. He had been on Vancomycin/Zosyn from the outside hospital for presumed hospital-acquired pneumonia. After the pleural effusion was drained, repeat chest xray showed no evidence of pneumonia. Ascitic fluid was tapped on admission and was negative for SBP. Blood and urine cultures were persistently negative, and he was afebrile. All antibiotics were held given the absence of a clear source. Ciprofloxacin was given briefly for a questionaly positive UA but was subsequently stopped when cultures were negative. Repeat diagnostic paracentesis was negative. WBC continued to increase, and hematology was consulted. They thought that this was most likely a leukaemoid reaction. However, para [**2189-1-4**] done in MICU demonstrated SBP and white count began trending down with cipro treatment. . # Pleural effusion: On admission, the patient had a left pleural effusion without any shortness of breath or hypoxia. The effusion was initially tapped for diagnosis, yielding a milky fluid concerning for empyema. Thus, the procedure was aborted and converted to placement of a catheter and pleural tube for drainage. Fluid analysis showed no empyema but rather a transudative exudate with elevated triglycerides, consistent with chylothorax. In the absence of recent surgical trauma to the thoracic duct, malignancy was high on the differential. There were no malignant cells in the pleural fluid. He underwent PET CT which did not show any evidence of lymphoma or other malignancy. The most likely cause of the chylothorax was thought to be his cirrhosis. The catheter was removed, but the fluid re-accumulated several days later. Repeat thoracentesis again revealed a transudative chylothorax. Still with left-sided effusion on CXR though hemidiaphragm cut off on most recent films. Medications on Admission: Lasix 60 mg daily Aldactone 150 mg daily lactulose Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): Hold dose when greater than 4 BM a day. Disp:*qs qs* Refills:*2* 2. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Outpatient Lab Work Please check labs Monday [**2189-1-19**]. Lab work: CBC, Chem-10, AST, ALT, Alk Phos, LD, INR, Bilirubin (total), Albumin. VNA services will do this and fax the results to Dr. [**Name (NI) 82064**] office at the liver center [**Telephone/Fax (1) 4400**]. His phone number is [**Telephone/Fax (1) 673**]. A script has been printed out for you. 7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary: cryptogenic cirrhosis hepatorenal syndrome ascites severe carotid stenosis s/p endarectomy pleural effusion Spontaneous Bacterial Peritonitis secondary: HTN Discharge Condition: Good, vitals stable, ambulating Discharge Instructions: You were transferred to [**Hospital1 18**] to begin a transplant evaluation for your liver disease. You had fluid around your lung that was drained. You were found to have a clogged carotid artery and consequently had a surgery called an endarectomy which removed the blockage. Tests were done to plan for a liver transplant and it is important you follow up with the Liver Center. Review your discharge medication list closely, you have been started on a number of new medications. You should no longer take lasix (furosemide) or aldatone (spironolactone) as these may worsen your kidney function. Please note that your dose of lactulose has been increased from what you were on at home. DO NOT DRIVE until you are instructed to do so by your doctors. Eat a low salt diet. Attend all your follow-up appointments. Return to the ER and call the liver center [**Telephone/Fax (1) 673**] if you experience confusion, fevers, nausea, vomiting, diarrhea, bleeding or any other concerning symptoms. Followup Instructions: You need to have labs checked on Monday [**1-19**]. VNA services will do this and fax the results to Dr.[**Name (NI) 8653**] office at the liver center [**Telephone/Fax (1) 4400**]. His phone number is [**Telephone/Fax (1) 673**]. A script has been printed out for you. 1) Vascular Surgery: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2189-1-22**] 3:50pm. They will remove your staples at this appointment. 2) Liver Clinic: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-1-23**] 1:40pm 3) Kidney Doctor: Dr. [**First Name (STitle) 805**], [**2189-1-27**] 13:00, [**Telephone/Fax (1) 3637**], [**Hospital **] Clinic [**Location (un) **] 4) It is important that you follow up with Urology on discharge. Please call [**Telephone/Fax (1) 164**] for an appointment. Completed by:[**2189-1-21**]

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icd9cm

[ [ [] ] ]

[ "00.44", "38.12", "45.16", "54.91", "50.13", "00.42", "34.09" ]

icd9pcs

[ [ [] ] ]

13940, 14015

7758, 12712

392, 465

14226, 14260

3346, 3553

15308, 16288

2695, 2923

12813, 13917

14036, 14205

12738, 12790

14284, 15285

4513, 7735

2938, 3327

277, 354

494, 1977

3569, 4497

1999, 2417

2433, 2679

3,543

176,334

52396

Discharge summary

report

Admission Date: [**2191-6-3**] Discharge Date: [**2191-6-7**] Date of Birth: [**2129-8-12**] Sex: M Service: MEDICINE Allergies: Tegretol / Dilantin / Penicillins / Sulfonamides / Bactrim Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Seizure, CP Major Surgical or Invasive Procedure: Catheterization CT scan of head History of Present Illness: Pt is a 61 y/o male with IDDM, s/p CABG a few months ago; sz d/o on lamictal presented to ED after tonic-clonic sz at home; per wife has h/o hypoglycemic sz that result in post-sz hyperglycemia (EMS FS was 320, pt seemed post-ictal). Pt did not have BM or urinate during seizure, and did not have a "feeling of this seizure" happening, no strange smells/color changes. Pt was afebrile, missed single dose of lamictal last night. He related no CP/SOB assoc with sz, but developed CP while in ED; initial ECG on arrival was like prior but repeat ECG with T changes in lateral, I, aVF (lead placement not changed), no ST elevations. Pt explains CP as a non-radiating right sub-sternal pain, [**2-21**], that felt like an ice-cube resting on his chest. He had no SOB/diaphoresis/dizziness but did remember nausea. Pt received SL nitro, lopressor, ASA which relieved his symptoms in the ED. Pt was started on Hep, bolused with 600mg Plavix and admitted to the [**Hospital1 1516**] service. Past Medical History: -DM-1: for 47 years. Retinopathy but no neuropathy, nephropathy -CAD: 4 stents [**2180**], RCA stent [**11/2189**], 3v-cabg [**9-/2190**] -Seizures: Pt states related to low blood sugar, none in years -HTN Social History: 2 cigars per week (equivalent to a 25 py hx) but has stopped within the past year. EtOH 1 drink with dinner. Retired H.S. English teacher. Lives with wife. [**Name (NI) **] 6x/week-about half mile at a time. Family History: Father: MI @40 Sister: MI @50 Physical Exam: vitals: 96.9, 122/56, 64, 18, 98%RA Gen- NAD, alert/conversational HEENT- No LAD, MMM, EOMI, no JVD, thyromegaly Cv- RRR, s1s2, 2/6 systolic murmur (AS?), no r/g Pul- CTA b/l Abd- NT/ND, no bruits L extrm- no edema, palpable pedal pulses neuro- AAO x3, CN 2-12 intact groin site: stable, no hematoma, no ozzing, no bruits Pertinent Results: EKG: changes wit ST depression in anterior leads, T wave inversions in inferior leads, T wave flattenings . Significant labs Trop (most recent first): .32, .40, .44, .74, .55, .12 . CATH [**6-6**]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent OM and LIMA grafts. Occluded RCA graft. COMMENTS: 1. Selective coronary angiography revealed a right dominant system with LMCA that had 70% lesion distally. The LAD was occluded after a large D1. The D1 had patent stents. The distal LAD filled from the LIMA but was a small diffusely diseased vessel. LCX had an 80% lesion in the proxinal vessel and there was an occluded OM that was grafted. Native RCA had a 60% lesion distal to the patent stents. Graft angiography showed occluded SVG to RCA. SVG to OM was patent but had 40% lesions at the valves. LIMA to LAD was patent. 2. Left ventriculography was deferred. 3. Hemodynamic assessment showed normal systemic pressures. . EEG [**6-4**]: IMPRESSION: This is a normal study in the awake and drowsy states. Thepresence of beta activity can be seen with the intercurrent use of benzodiazepines or barbiturates. . CXR [**6-3**]: The patient is status post midline sternotomy and CABG. The heart size is difficult to assess on an AP radiograph. There is plate-like atelectasis at the lung bases. There are linear opacities in the left paramediastinal region which may represent atelectatic changes or scarring. The lungs appear otherwise clear. No pulmonary edema is seen. IMPRESSION: No evidence of pneumonia or CHF. Plate-like atelectasis at both lung bases. Brief Hospital Course: CC: CP, hypoglycemic seizure Pt is a 61 y/o male with IDDM, s/p CABG a few months ago; sz d/o on lamictal presented to ED after tonic-clonic sz at home; per wife has h/o hypoglycemic sz that result in post-sz hyperglycemia (EMS FS was 320, pt seemed post-ictal. Pt received SL nitro, lopressor, ASA which relieved his symptoms in the ED. Pt was started on Hep, bolused with 600mg Plavix and admitted to the [**Hospital1 1516**] service. . Pt had trigger event around noon on [**6-3**] for pt becoming altered and for high BG-396, pt received 8 units of humalog. Pt had no CP, no SOB. Pt appeared pale, confused, and responded slowly to verbal commands. His vitals signs remained stable, but his BP did briefly drop to 106/48 but HR(72) and O2 sat(100%2L) were stable. Following this episode the pt did vomit, non-bloody x1. Antiemitic was given and pt was sent for CT of head to r/o intracranial bleeding, wet read no bleed. . Had additional trigger event at 17:18 found to be unresponsive to sternal rub. Pt had noticable foaming from the mouth, without tonic-clonic movement, VSS were stable. BG was 234. Pt has not received lamictal today, problem getting to floor, received Ativan. No changes with EKG, no CP/SOB. Pt remained hemodynamically stable throughout the event. An ABG was drawn and sent to the lab. Pt placed on seizure precautions. . Due to the questionable seizure and ABG lactate of 7.8 (later that night was 1.0), he was moved to the CCU for closer evaluation. His temp spiked to around 102 and a LP was done. He was started on vanco and Meropenem. The meropenem was later stopped due to possibility for causing convulsions. Pt was loaded with phenobarbitol 10mg/kg and lamicatl. After a night stay in the unit, pt was back on floor and much more awake and responsive. AFter 72 hours of no growth on the CSF, the vancomyocin was stopped. Pt recieved his cath on [**6-6**], showed three vessel disease with patent OM and LIMA grafts. He does have an occluded RCA graft. No stents or angioplasty was done. The plan was to d/c the pt and have him get a stress test(possibly MIBI) in [**12-18**] weeks to determine if further intervention is needed. Pt never experienced another bout of CP since the presentation in the ED. The pt is to follow up with Dr. [**Last Name (STitle) **] where I will ask him to draw the trough labs of lamictal and have them sent/faxed to Dr. [**Last Name (STitle) 851**] at [**Telephone/Fax (1) 891**] who will also contact Dr. [**Last Name (STitle) **]. Emails of this summary will be sent to Drs. [**First Name (STitle) **], [**Name5 (PTitle) **], and [**Doctor Last Name **]. . CAD: continue with ASA, plavix, statin, B-Blocker, ACE-i stress test(MIBI)in [**12-18**] weeks . Neuro: pt taking lamictal 150mg [**Hospital1 **] and phenobarbital 60mg [**Hospital1 **] pt will f/u as outpatient, get troughs of both meds, when Lamictal is at 8-10ug/ml, can stop phenobarbital. . DM: The patient's last Hgb A1C 7.6 on [**2191-2-21**]. He was continued on glargine with a humalog sliding scale per his home regimen. Recommend following up at [**Last Name (un) **] within the next few months . HTN: well controlled as inpatient Medications on Admission: Lantus 27 units AM Humalog SS Atorvastatin 20 mg PO DAILY Lamotrigine 150 mg PO BID Moexipril HCl 7.5 mg PO BID Metoprolol 12.5 mg PO BID Aspirin 325 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 4. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*qs Capsule, Sust. Release 24HR(s)* Refills:*2* 6. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 7. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: CAD, seizures, DM1, HTN Discharge Condition: Stable Po tolerant ambulating Discharge Instructions: Please take all your medications as directed. Please do not lift more than 10 lbs for at least one week, also do not participate in strenous activity for at least one week. Please call your primary care physician or return to the ER for: 1. shortness of breath 2. chest pain 3. fever to 101 4. palpatations 5. increased swelling in your feet 6. Bleeding or oozing from your groin site. Followup Instructions: Dr. [**Last Name (STitle) **] on [**2191-6-16**] at 11:40 Dr.[**Name (NI) 10444**] office will be contacting you for an appt. Please call Dr. [**First Name (STitle) **]([**Telephone/Fax (1) 108285**] to be seen in [**12-18**] weeks Please call and make an appt with Dr. [**Last Name (STitle) 978**] Completed by:[**2191-6-9**]

[ "414.02", "250.81", "780.39", "362.01", "V09.0", "250.51", "518.0", "287.31", "414.01", "410.71", "V45.82", "V02.59" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

8200, 8206

3855, 7033

337, 372

8274, 8306

2254, 2452

8742, 9071

1865, 1896

7246, 8177

8227, 8253

7059, 7223

2469, 3832

8330, 8719

1911, 2235

286, 299

400, 1388

1410, 1619

1635, 1849

57,092

188,383

769

Discharge summary

report

Admission Date: [**2147-4-18**] Discharge Date: [**2147-4-25**] Date of Birth: [**2071-4-24**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pressure with exertion Major Surgical or Invasive Procedure: [**2147-4-21**] Coronary artery bypass grafting x3 with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and diagonal branch. History of Present Illness: 75 year old male with history of diabetes and hyperlipidemia referred by PCP for exercise stress test for symptoms of chest discomfort with exertion. He reports that he is quite active but recently has noticed that his walking is limited by left sided chest pressure that resolves with rest. ETT demonstrated 2-4 mm horizontal ST segment depressions inferiorly and in leads V4-V6. In addition, ST segment elevation was noted in lead aVR. He was also symptomatically hypotensive with lightheadedness. He now underwent cardiac catheterization that revealed significant coronary artery disease. Past Medical History: coronary artery disease, s/p CABG hypertension hyperlipidemia type 2 DM pericarditis [**2089**] recent shingles peripheral neuropathy s/p R 4th trigger finger release s/p banding internal hemorrhoids Social History: Lives with wife. Worked at Sears and the Museum of Fine Arts - now retired. Denies hx of smoking. Drinks 2-3 glasses of wine each week. Denies illict drug use. Family History: Mother: stroke, CABG (80s) Sister: Diabetes Physical Exam: VS: 125/67 60 18 97%RA GENERAL: Thin elderly male, NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mild erythema of posterior oropharynx NECK: Supple, no JVD, no carotid bruits CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Left radial site for cath clean/dry/intact, good radial pulses, no hematoma SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: Echocardiography Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Findings LEFT ATRIUM: Elongated LA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Mildly depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Simple atheroma in descending aorta. No thoracic aortic dissection. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: TVP. Mild to moderate [[**12-25**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Mild PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-CPB: The left atrium is elongated. 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 is unusually small. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). The right ventricular cavity is mildly dilated with borderline normal free wall function. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral central regurgitation is seen. Tricuspid valve prolapse is present. POST-CPB: LV systolic function remains unchanged, estimated EF=45%. There is no evidence of dissection. [**2147-4-24**] 06:15AM BLOOD WBC-9.4 RBC-3.32* Hgb-10.1* Hct-29.6* MCV-89 MCH-30.4 MCHC-34.1 RDW-13.2 Plt Ct-153 [**2147-4-23**] 06:20AM BLOOD WBC-10.7 RBC-3.44* Hgb-10.2* Hct-29.9* MCV-87 MCH-29.7 MCHC-34.2 RDW-12.9 Plt Ct-119* [**2147-4-25**] 04:30AM BLOOD UreaN-15 Creat-0.9 Na-137 K-4.2 Cl-100 [**2147-4-24**] 06:15AM BLOOD Glucose-145* UreaN-17 Creat-0.9 Na-138 K-4.4 Cl-100 HCO3-31 AnGap-11 Brief Hospital Course: The patient was brought to the operating room on [**2147-4-21**] where the patient underwent CABG x 3 as detailed in Dr.[**Name (NI) 5572**] operative note. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. Medications on Admission: Atorvastatin 40mg daily Glipizide 2.5mg daily Metformin 1000mg [**Hospital1 **] Aspirin 162mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 5 days. Disp:*5 Packet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary artery disease s/p CABG Hypertension Hyperlipidemia Diabetes mellitus type 2 Pericarditis Shingles Peripheral neuropathy Discharge Condition: Alert and oriented x3 nonfocal Deconditioned Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**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 [**5-18**] at 1:15pm Cardiologist: Dr [**Last Name (STitle) **] on [**5-26**] at 8:00am (cardiologist that did cardiac cath and referral from PCP) Primary Care: Dr [**Last Name (STitle) 131**] [**Telephone/Fax (1) 133**] on [**6-1**] at 10:15am **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2147-4-25**]

[ "401.9", "414.01", "357.2", "455.0", "413.9", "250.60", "272.4" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.12", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

7432, 7483

5319, 6409

340, 535

7657, 7857

2386, 5296

8698, 9255

1573, 1619

6560, 7409

7504, 7636

6435, 6537

7881, 8675

1634, 2367

271, 302

563, 1156

1178, 1380

1396, 1557

27,369

113,171

33292

Discharge summary

report

Admission Date: [**2152-1-13**] Discharge Date: [**2152-1-24**] Date of Birth: [**2073-5-12**] Sex: F Service: CARDIOTHORACIC Allergies: Tetracycline Attending:[**First Name3 (LF) 165**] Chief Complaint: syncope Major Surgical or Invasive Procedure: [**2152-1-17**] dental extractions [**2152-1-18**] MV Repair/cabg x3 (26 mm CE [**Doctor Last Name 405**] ring/LIMA to LAD, SVG to OM, SVG to PDA) History of Present Illness: 78 yo female with known CAD with medical management. She had a syncope 1 week priot to admission. She ruled out for an MI at that time. St elevations with ischemia was noted, and the pt. refused initial rx and left AMA. She represented for further workup. Past Medical History: NIDDM HTN elev. chol. MI CAD Social History: retired no tobacco use no ETOH use lives alone Family History: not known Physical Exam: 98.8 RR 16 130/80 97% RA sat. 5'6" 170# NAD PERRL,anicteric,noninjected,normal oropharynx neck supple, no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] bruit appreciated CTAB RRR, no m/r/g soft, NT, ND, +BS warm, well-perfused, no peripheral edema,mild varicosities below the knee nonfocal exam, alert and oriented x3 2+ bil. fems.radials 1+ bil. DP/PTs 1+ carotids Pertinent Results: [**2152-1-23**] 02:58PM BLOOD WBC-7.7 RBC-3.43* Hgb-10.1* Hct-30.4* MCV-89 MCH-29.4 MCHC-33.2 RDW-14.6 Plt Ct-202# [**2152-1-23**] 02:58PM BLOOD Plt Ct-202# [**2152-1-23**] 02:58PM BLOOD Glucose-277* UreaN-17 Creat-1.0 Na-137 K-3.9 Cl-103 HCO3-24 AnGap-14 [**2152-1-13**] 11:55PM BLOOD %HbA1c-7.3* Conclusions PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with hypokinesis of the inferoseptal, anteroseptal, anterior and anterolateral walls. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including Milrinone and Norepinephrine, Epinephrine and is being AV paced. 1. A mitral valve annuloplasty ring is well seated. No [**Male First Name (un) **] is seen. Trace MR is seen. Mean gradient across the valve is 8mm of Hg with a CO of 5.5. 2. LV function is slightly improved. RV function is preserved. 3. Aorta is intact post decannulation. 4. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2152-1-18**] 15:56 RADIOLOGY Final Report CHEST (PA & LAT) [**2152-1-23**] 3:01 PM CHEST (PA & LAT) Reason: evaluation of effusion [**Hospital 93**] MEDICAL CONDITION: 78 year old woman with s/p mvr, cabg REASON FOR THIS EXAMINATION: evaluation of effusion CLINICAL INDICATION: Evaluate for effusion. FINDINGS: Two views of the chest were obtained and compared to the prior examination dated [**2152-1-20**]. There are persistent bilateral pleural effusions that have slightly decreased since the prior examination. There is a persistent left retrocardiac opacity likely secondary to underlying atelectasis, although a superimposed pneumonia cannot be entirely excluded. The patient is status post mitral valve replacement, CABG and median sternotomy. The cardiac silhouette is slightly less prominent as noted on the prior examination. IMPRESSION: Minimal interval decrease in size of bilateral moderate-sized pleural effusions. Otherwise, no significant interval change. DR. [**First Name (STitle) 2353**] [**Doctor Last Name **] Approved: SUN [**2152-1-23**] 5:25 PM ?????? [**2146**] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted [**1-13**] and cardiac workup completed over the next few days. Three day course of bactrim started for a UTI.Dental consult also done and chest CT done. Continued on IV heparin, then stopped for teeth extractions. IV NTG also started. Dental extractions done [**1-17**]. MVrepair /cabg x3 done [**1-18**] with Dr. [**First Name (STitle) **]. Transferred to the CVICU in fair condition on epinephrine, milrinone, levophed, and insulin drips. Extubated early in the AM POD #1. Chest tubes removed on POD #2 and trasnferred to the floor to begin increasing her activity level. Pacing wires removed on POD #3. Beta blockade titrated and she was gently diuresed toward her preop weight. Cleared for discharge to rehab, but pt. refused discharge over the weekend. Bed available and discharged to rehab on POD #6. Pt. is being covered with SSI and is to make all rehab appts. as per discharge instructions. Medications on Admission: glyburide 6 mg daily lovastatin 80 mg daily enalapril 10 mg daily toprol XL 50 mg daily ECASA 81 mg daily protonix 40 mg daily regular insulin SS ( added at OSH: xanax 0.5 mg HS/prn) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Humalog insulin per sliding scale flowsheet Discharge Disposition: Extended Care Facility: Bayberry Commons Discharge Diagnosis: CAD/MR s/p MVrepair/cabg x3 NIDDM HTN MI elev. chol. Discharge Condition: stable Discharge Instructions: no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, or drainage SHOWER daily and pat incisions dry Followup Instructions: see Dr. [**First Name (STitle) **] in [**11-24**] weeks see Dr. [**Last Name (STitle) 64868**] in [**12-26**] weeks see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2152-1-24**]

[ "424.0", "599.0", "250.00", "272.0", "401.9", "412", "428.0", "521.00", "414.01", "E878.2", "998.0", "428.23" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.12", "23.01", "36.15", "35.33", "99.04" ]

icd9pcs

[ [ [] ] ]

6509, 6552

4386, 5297

286, 437

6650, 6659

1284, 3362

6917, 7230

854, 865

5530, 6486

3399, 3436

6573, 6629

5323, 5507

6683, 6894

880, 1265

239, 248

3465, 4363

465, 722

744, 774

790, 838

21,953

109,116

6530

Discharge summary

report

Admission Date: [**2108-11-12**] Discharge Date: [**2108-11-17**] Date of Birth: [**2075-1-22**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Patient is a 33-year-old female with history of left breast cancer. Had chemotherapy. PAST MEDICAL HISTORY: Has a past medical history of depression and she also presented with a need of prophylactic mastectomy due to high risk on her right side. She had previous surgery on her left breast with biopsy. She has wisdom teeth removed and a molar removed, and she has had a history of laparoscopic surgery. ALLERGIES: Erythromycin. MEDICATIONS: The medication that she takes on a daily basis was Celexa. PHYSICAL EXAMINATION: She was otherwise in good health. She was supple, no nodes were noted on HEENT examination. Her chest was clear, S1, S2. There was a noted nipple inversion and a large mass was noted on the left. IMPRESSION: Left breast cancer. PLAN: Bilateral mastectomies with left axillary dissection. HOSPITAL COURSE: After the patient was identified, was taken to the operating room, and a combined procedure with Dr. [**Last Name (STitle) 364**], please see operative dictation. However, [**Location (un) **] and [**Doctor Last Name 13797**] left [**Last Name (un) 5884**] free flap was performed in which the vascular anastomosis was hooked into the LIMA and a right pedicle TRAM flap was performed. The patient tolerated the procedure well. Five hundred cc estimated blood loss, IV fluids 5400, urine output during the case was 690 cc. Patient was stable. Discharged to the Surgical ICU, where she stayed for 48 hours with frequent flap checks. Her postoperative hematocrit on day #1 was 28. However, after continued the Doppler checks on the left flap and the capillary refill on the right skin panel were extremely adequate throughout the duration of her stay in the ICU. However, the patient remained with persistent tachycardia. She was bolused and she was given 1 unit of packed red blood cells. She continued to do well in the postoperative course and was transferred after 48 hours to the floor. Some pain control issues were present once the patient was switched over from IV pain medications and switched to oral. However, after a minimal amount of time, the patient's pain regimen was stratified and patient continued to do well with oral pain medications. Her diet was advanced as tolerated, and patient was HEP locked as far as her IV goes. Her Foley was removed and she was ambulating frequently on the floor. However, throughout the course of this, her flap continued to remain viable being her pedicle TRAM and her free flap remained with good Doppler signal. Good skin color was noted on the skin paddles. Patient continued to ambulate under the service of Dr. [**Last Name (STitle) 364**], general surgeon attending, Medicine consult was called for persistent tachycardia. At that juncture, the consultant recommended that an EKG be performed to rule out a supraventricular tachycardia. EKG was performed and it was determined that the patient was in sinus tachycardia, and it was deemed that this patient was improving clinically as her hematocrit did come up to 25. After 1 unit, she had come up from a hematocrit of 23. Patient continued to improve over the next several days, and it was decided that the patient had met criteria for discharge. Patient was given all instructions and all questions were answered prior to discharge. DISCHARGE MEDICATIONS: 1. Aspirin. 2. Keflex. 3. Oral pain control. DISCHARGE INSTRUCTIONS: Patient was given strict instructions to followup. She was given a visiting nursing services in which to follow her drain, and patient will be seen in the office next week by Dr. [**First Name (STitle) **] in order to have drains removed and to have her wounds assessed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 740**] MEDQUIST36 D: [**2108-11-16**] 19:28 T: [**2108-11-17**] 10:14 JOB#: [**Job Number 25048**]

[ "V45.71", "174.8", "997.1", "427.89", "E878.6", "196.3" ]

icd9cm

[ [ [] ] ]

[ "85.43", "85.7" ]

icd9pcs

[ [ [] ] ]

3488, 3534

1007, 3465

3559, 4110

693, 989

158, 246

269, 670

24,120

165,964

8244

Discharge summary

report

Admission Date: [**2107-10-1**] Discharge Date: [**2107-10-6**] Date of Birth: [**2034-3-1**] Sex: M Service: GU [**Hospital **] MEDICAL COMPLAINT: Fever, status post prostate biopsy. MAJOR SURGICAL INVASIVE PROCEDURES: None. HISTORY OF PRESENT ILLNESS: This 73 year-old male with irritative symptoms and abnormal digital rectal examination who underwent a prostate biopsy in [**2107-9-28**] with [**Doctor Last Name **]. Patient's PSA was .7 which was obtained on [**2107-5-28**]. Prostate size was noted to be 20 cc at the time and a 20 core biopsy was obtained without complication. On [**9-28**] the patient felt unwell but had improvement from post procedure. On [**9-30**] the patient was noted to have rigors, fevers and malaise and presented to the emergency room. PAST MEDICAL HISTORY: Notable for nephrolithiasis and hyperlipidemia, anxiety, gastroesophageal reflux disease, hypertension, chronic renal insufficiency. PAST SURGICAL HISTORY: Significant for a transurethral resection of the prostate in [**2095**]. ALLERGIES: Aspirin which caused ulcers and sulfa with an unknown allergic reaction. MEDICATIONS: Zocor, Verapamil, Nexium, Avapro, terazosin, clonazepam. SOCIAL HISTORY: Patient is married, is retired. Does not smoke or drink. PHYSICAL EXAMINATION: Patient upon discharge had a temperature of 98.9, is currently 97.5. heart rate was 72, blood pressure 123/72, respiration rate was 16 and 97% on room air, intake 350 cc by mouth and had bathroom privileges. He is in no acute distress. He is awake, alert and oriented x3. His lungs are clear. He does have a III/VI systolic murmur most notable over the second intercostal space on the left. His abdomen is soft, nontender, nondistended. Patient's rectal examination was nontender, smooth contour with a right nodule on the right of the prostate. He shows no clubbing, cyanosis or edema on the extremities bilaterally. PERTINENT RESULTS: Patient had a white count of 9.0 on presentation to the emergency department with hematocrit of 37.9 and a platelet count of 133. His differential upon presentation shows neutrophil level of 86.7%, lymphocytes 10.1%, monocytes 2.3, eosinophils .6 and basophils .2. The urinalysis was obtained in the emergency department which was notable for large blood, positive nitrites, RBC level greater than 50, white blood cell count 21 to 50 with moderate bacteria, no yeast and epithelial cells of 0 to 2. The basic metabolic panel was obtained in the emergency department which showed a sodium of 139, a potassium of 3.7, chloride of 105, bicarb of 24, BUN of 18 and creatinine of 1.5. Glucose of 98. The patient's creatinine decreased over time and upon discharge his creatinine today is 1.2. Upon discharge his last CBC shows a white count of 5.5, hematocrit of 34.9 and platelet count of 211. He has 49% neutrophils, 41.7% lymphocytes, 4.8% monocytes, 3.9 eosinophils and .5% basophils. Patient's liver function tests were obtained on [**2107-10-6**] which showed an ALT of 160 and AST of 166., an alkaline phosphatase of 44, total bilirubin of .8. Lipase was obtained on [**10-5**] showing 38. Patient also had cardiac enzymes obtained on [**10-1**] which showed a CK MB of 2 and a troponin less than .01. Patient had an albumin of 3.8 which was obtained on [**10-5**]. Patient also had a urine culture which was sent on [**10-1**] which was grown out to be E coli 10,000 to 100,000 organs per cc. The urine was resistant to ampicillin, Cipro, gentamicin, levofloxacin. However, it was sensitive to ceftriaxone which the patient will be sent home on today. A blood culture was also obtained on [**10-1**] which was also again positive for E coli. These cultures were sensitive to ceftriaxone as well and resistant to ciprofloxacin and gentamicin. BRIEF HOSPITAL COURSE: The patient presented to the emergency room and was admitted to the urology service under Dr. [**Last Name (STitle) **] on [**2107-10-1**]. Patient was transferred from the [**Hospital Ward Name **] of the [**Hospital1 69**] to 12 Rizon. On hospital day #1 the patient did experience some rigors, had a temperature of 105, had a heart rate which was in the 130s which was normal sinus by EKG. He had a blood pressure of 100/60, was maintained on 200 cc of IV fluids of normal saline. The patient was started on ceftriaxone in the emergency room. However, because of his septic picture was transferred to the surgical Intensive Care Unit and the [**Hospital Ward Name **] of the [**Hospital1 69**] on [**10-1**] where he remained for 2 days. The patient did well in the Intensive Care Unit. He only had a temperature spike of 101.1 on hospital day #2, however, did not experience any rigors or hypotension or tachycardia at that time. An infectious disease was consult was obtained in the Intensive Care Unit and patient was switched from ceftriaxone to meropenem which he remained on throughout his hospital course. The patient did not have any more episodes of rigors or temperature spikes throughout the whole hospital course. He remained afebrile and doing well without any complaint. On hospital day #4 a CT pelvis was obtained to rule out for prostatic abscess. The final report shows no definite abscess. The patient did have a TURP defect from his TURP which he received in [**2095**]. A PICC line was also placed on the same day with a chest x-ray which showed it properly placed in the tip of the distal superior vena cava. The patient is being discharged today on IV antibiotics to continue for 2 weeks of ceftriaxone and to be switched to double strength Bactrim to be taken 1 tablet twice a day for an additional 2 weeks. MEDICATIONS ON ADMISSION: Patient was on Zocor, Verapamil, Nexium, Avapro, terazosin and clonazepam. DISCHARGE MEDICATIONS: Will include ceftriaxone. Patient is to take 1 gram q 24 and he is also to receive Pyridium to be taken for his bladder pain as well as Flomax. DISCHARGE DIAGNOSIS: Septicemia following prostate biopsy. DISCHARGE CONDITION: Good. Patient is ambulating, afebrile, tolerating p.o. and passing gas. DISCHARGE INSTRUCTIONS: The patient was told that he had a PICC line placed in his arm and that he was to receive a total of 2 weeks of antibiotics and the then start Bactrim for 2 weeks. The patient was also told that he must go to an outside laboratory in 1 week to get his liver function tests measures and to have this information faxed to the infectious disease clinic here at the [**Hospital1 188**]. Patient was also told that he is to return to routine daily living without any restrictions. He is to return or call the clinic or call the emergency room for the following conditions: For fever of greater than 101.5, any pelvic pain that he may experience, any bladder fullness, any inability to void, any nausea or vomiting or any nausea or vomiting or any other symptoms that are concerning to him. Follow up instructions: The patient is to follow up in infectious disease clinic in approximately 2 weeks. He is also to follow up with Dr. [**Last Name (STitle) **] in 2 to 3 weeks to discuss his prostate biopsy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 559**] Dictated By:[**Last Name (NamePattern1) 29268**] MEDQUIST36 D: [**2107-10-6**] 10:30:15 T: [**2107-10-6**] 11:47:16 Job#: [**Job Number 29269**]

[ "403.90", "530.81", "599.0", "998.59", "272.4", "E878.8", "585.9", "038.42" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

3820, 5655

6010, 6083

1950, 3796

5782, 5927

5949, 5988

5682, 5758

6108, 7375

981, 1213

1311, 1930

280, 800

823, 957

1230, 1288

7,949

150,110

22916+22917

Discharge summary

report+report

Admission Date: [**2123-10-7**] Discharge Date: [**2123-11-1**] Date of Birth: [**2073-8-23**] Sex: Service: CHIEF COMPLAINT: Liver transplant admission. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female here for liver transplant for hepatitis C cirrhosis with hepatocellular carcinoma. Most recent imaging demonstrated a 2-cm focus in the dome of her liver. Recent CT chest was negative for cancer. She also had portal hypertension, portal systemic encephalopathy, esophageal varices, and radiofrequency ablation for her hepatocellular carcinoma. Her MELD score was 32 most recently. A bone scan on [**2123-8-12**] demonstrated no evidence of metastatic disease and hypertrophic osteoarthropathy in the femurs and tibias, left greater than right. Most recent CT of the abdomen on [**2123-8-5**] demonstrated no residual tumor after radiofrequency ablation site in superomedial segment 8, a 1-cm lesion concerning for early hepatocellular carcinoma, a 5-mm calculus over the lower pole of the right kidney. PAST MEDICAL HISTORY: Significant for depression, anxiety. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is married with 3 children. She grew up in [**Male First Name (un) 1056**]. FAMILY HISTORY: Significant for mom with CVA x3 who is alive. Father with Alzheimer's. MEDICATIONS AT HOME: 1. Lexapro 2. Lactulose REVIEW OF SYSTEMS: She denied any recent illness. She does complain of positive headaches left frontal area. History of tension headaches. No rhinorrhea, no sore throat, no nausea or vomiting, diarrhea, no dysuria. PHYSICAL EXAMINATION: Vital signs 98.4, 73, 137/86, respiratory rate 20 and 100% on room air. General: No acute distress. Lungs were clear. Regular rate and rhythm, no murmurs. Extremities: No clubbing, cyanosis or edema, no calf tenderness. Neurologically, she was alert and oriented x3. No focal deficits. Vascular: Feet were warm with 2+ pulses bilaterally. The patient was preop'd and taken to the OR on [**2123-10-8**] for cadaver liver transplant. Surgeons were Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by resident, Dr. [**First Name8 (NamePattern2) 32712**] [**Name (STitle) **]. Please see operative note for further details. Anesthesia was general. EBL was 1400. IV fluid, she received 4300 cc of crystalloid with 2 units of FFP, 1 of cryoglobulin and 1 bag of platelets. Urine output was 1100 cc. No complications. Of note, on the operative report the donor artery was extremely small and looked like it had been stretched a little bit. It was then cut to size and an interrupted 7-0 Prolene anastomosis was accomplished. Subsequent to this, the pulse in the artery was poor. After the papaverine infusion, the pulse became excellent and there was an excellent diastolic thrill. The patient was intubated and brought to the SICU for postop care. She did well. She was followed by hepatology throughout this hospital course. She had 2 JPs, an NG tube, a Foley. She was initially intubated and weaned off propofol and extubated. Urine output was excellent. LFTs increased postoperative day 1 with an AST of 1616, ALT of 768, alkaline phosphatase 83 and total bilirubin of 1.6 from an AST of 46, ALT of 26, alkaline phosphatase of 120 and total bilirubin 1.5. A CT of the abdomen was done. A duplex ultrasound was done. This demonstrated patent hepatic vasculature including the hepatic arteries and veins and portal veins. Evaluation of the left hepatic vein, hepatic artery and portal vein were limited by the presence of overlying support structures and the color flow was demonstrated but the wave forms were poorly assessed. Two oval heterogeneously hypoechoic structures were noted adjacent to the IVC measuring 4 cm and 3.6 cm in greatest dimensions, respectively, and this was felt to represent small retrohepatic fluid collections. The pathology report from the explant demonstrated hepatocellular carcinoma and gallbladder with mild, chronic cholecystitis and no malignancy identified. A chest x-ray demonstrated right internal jugular line tip resting in the proximal SVC level. The patient continued to do well postoperatively. She received packed red blood cells and fresh frozen plasma for a hematocrit of 28.8 with an INR of 1.5. She received induction of immunosuppression of a gram of CellCept and 500 mg of Solu- Medrol. Solu-Medrol was tapered per protocol. She continued on CellCept 1 gm b.i.d. Her JPs put out approximately 135 and 445 cc for the medial and lateral drains. Urine output was excellent. Vital signs were stable. Creatinine was stable throughout this hospital course, ranging between 1.0 and 1.4. She was started on Prograf on hospital day 2. She received Diamox and Lasix to diurese excess fluid. Her weight had increased from preop. The NG tube was discontinued and her diet was advanced to sips, then clears. She tolerated this without any problems. She was maintained on heparin, low dose, for a small hepatic artery. Heparin was stopped on postop day 3. Her LFTs continued to improve. She was transferred to the medical/surgical transplant unit. She continued to do well. The pain was managed with initially morphine and later changed to Percocet. Physical therapy worked with her to gradually progress her activity and increase her strength. The Foley was discontinued on postop day 5. [**Last Name (un) **] was consulted to help manage hyperglycemia. Blood sugars ranged from 155 to 149. She received sliding scale insulin. The central line was discontinued. The medial JP was discontinued on postop day 7. On postop day 7, her LFTs were AST of 73, ALT of 142, alkaline phosphatase 121, total bilirubin 1.2. She did complain of some loose stool. Stool was sent for C. difficile and subsequently negative. She had a low-grade temperature. Blood cultures were done and subsequently negative. Given concern for slight increase in alkaline phosphatase on postop day 7, alkaline phosphatase was 102, in the catheterization lab by cardiology, an angiogram was performed to assess the hepatic artery. Selective celiac and SMA angiography as well as nonselective abdominal aortography was performed via access from bilateral common femoral arteries. Findings demonstrated no flow- limiting disease in the transplant hepatic artery. Arterial- to-arterial connection from the SMA to the celiac artery was intact. There was no significant disease in the celiac artery, SMA and bilateral renal arteries proximally. On [**10-19**], a transjugular liver biopsy was done with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 44263**] needle. At this time a right hepatic venogram demonstrated an angiographically high-grade stenosis at the right hepatic-IVC anastomosis. A 3-mm pressure gradient was observed from the right hepatic vein to the IVC/RA. Biopsy results included marked bile duct proliferation with acute cholangitis. Biliary obstruction or ischemia could not be excluded. There were no features of acute cellular rejection. On [**10-19**], postop day 11, AST was 34, ALT 96, alkaline phosphatase 209 with a total bilirubin of 1.0. Urine output was excellent. Vital signs were stable. Hematocrit was stable at 33.8. She continued on her immunosuppression. Prograf levels were adjusted daily based on levels. At this point, her Prograf level was 12.3. On [**10-20**], she underwent an abdominal CT that demonstrated a normal transplant liver on CT, with normal parenchymal enhancement, patent hepatic veins and inferior vena cava, portal veins and hepatic artery. There was a moderate amount of stenosis noted at the anastomotic site between the hepatic veins and recipient IVC, and moderate stenosis at the portal vein anastomosis site. There were normal caliber hepatic veins. These areas of narrowing were of uncertain clinical/hemodynamic significance. Clinical correlation and internal followup with Doppler was advised. A small amount of intraabdominal ascites was noted. There was no collection. Minor right basilar atelectasis was noted. On [**10-22**], she underwent an ERCP. Findings included normal major papilla. Cannulation of the biliary and pancreatic ducts were successful and deep with sphincterotome, using a free-hand technique was done. Contrast medium was injected and resulted in complete opacification. The procedure was mildly difficult. The biliary tree was narrowed at the level of the anastomosis but there was no stricture. Just proximal to the anastomosis, a small amount of contrast extravasation was noted. The pancreatic duct was filled with contrast and well visualized throughout. The course and caliber of the duct was normal with no evidence of spilling defects, masses, chronic pancreatitis or other abnormalities. An 11 x 10 French Cotton- [**Doctor Last Name **] biliary stent was placed successfully in the common bile duct above the level of the extravasation. She was started on Unasyn pre-ERCP and she continued on this for a total of 10 days. Blood cultures were negative. Urine culture was negative. All stool cultures that were sent on 5 different days were repeatedly negative. Her white blood cell count was stable in the 6.1 to 7.8 range. She remained afebrile post-ERCP and amylase postprocedure was 53 and 23. On postop day 18, on [**10-25**], a CT of the abdomen was done to evaluate the portal and hepatic vessels. Of note, an acute pulmonary embolus affecting at least the left lower lobe segmental branches was noted. This was communicated to the M.D. on service. Interval occlusion of the accessory right hepatic vein with associated perfusion abnormality was noted in segment 6 of the liver. An apparent narrowing at the presumed portal vein anastomotic site and apparent narrowing of the hepatic veins as they entered the recipient's IVC were also seen on the previous study. A CTA of the chest was done to evaluate for PE confirmation, and to rule out a saddle embolus. Impression included acute pulmonary embolus affecting the left lower lobe segmental branches and partial thrombus in the suprahepatic IVC. The patient was started on IV heparin, maintaining PTTs in the range of 60 to 80. Coumadin was initiated at 3 mg. INR increased to 2.5 after 4 days. Of note, the patient had complained of some left-sided shortness of breath 2 days prior to the chest CTA. The O2 saturations had been stable. Her oxygenation was within normal limits. She was out of bed with assistance from nursing and physical therapy. Lungs were slightly diminished in the bases. Abdomen was soft, positive bowel sounds, positive flatus. She did complain of some loose stool. Given the negative stool cultures, the CellCept was adjusted to 500 mg 4 times a day. The prednisone was decreased to 7.5 mg on postop day 21. On postop day 21, her AST was 16, ALT 22, alkaline phosphatase 148, total bilirubin 0.5. A HIDA scan was done that demonstrated no evidence of bile leak. Bilateral lower extremity noninvasive studies were done. The right and left lower limb veins were patent and compressible along their length. There was normal phasic venous flow and increased venous return with calf compressions on color Doppler. Conclusion was that there was no right or left lower limb deep venous thrombosis demonstrated. On the duplex ultrasound of the liver, it demonstrated no abnormal intrahepatic biliary dilatation. There were patent hepatic portal veins and there patent hepatic arteries. There was a small peri-transplant collection noted posteriorly. Vital signs continued to be stable. The patient was ambulating with physical therapy and it was felt that the patient could go home with continued PT visits from home VNA. Nutrition followed along and Boost supplements were provided. Appetite had increased and she was tolerating a regular diet with fair intake. She was voiding independently. She was alert and oriented. White blood cell count was 3, hematocrit 26.9, AST 66, ALT 137, alkaline phosphatase 170, total bilirubin 1.4. [**Last Name (un) **] followed along closely during this hospital course. She was started on Lantus insulin with a sliding scale. Blood sugars ranged between 83 and 107, and as high as 161. She was discharged home on [**11-1**], alert and oriented, comfortable, with Percocet, on Coumadin with therapeutic INR of 2.2. Abdomen was soft, nontender. Drain sites had been sutured. Her clips were removed and Steri-Striped. She ambulated independently. The Unasyn was stopped. She received discharge teaching from the coordinators as well as the nurses regarding her medications and insulin. Her central line was removed. She was discharged home in stable condition. DISCHARGE DIAGNOSES: 1. Hepatitis C cirrhosis, hepatocellular carcinoma. 2. Anxiety and depression. 3. Diabetes type 2. 4. Hepatic vein stenosis and recipient inferior vena cava and portal vein anastomosis. MAJOR SURGICAL PROCEDURES: Liver transplant on [**2123-10-7**]. FOLLOW UP: Followup was scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] on [**2123-11-11**]. Follow up with Dr. [**Last Name (STitle) 3273**] from the [**Last Name (un) **] was scheduled for [**2123-11-15**] at 8:30. DISCHARGE MEDICATIONS: She was discharged home on the following medications: 1. Fluconazole 200 mg 2 tablets p.o. once a day. 2. Prevacid 30 mg p.o. once a day. 3. Bactrim single strength 1 p.o. once a day. 4. Lexapro 20 mg p.o. once a day. 5. Percocet 1 tablet p.o. p.r.n. q.4-6h. 6. Lasix 20 mg 1 tablet p.o. b.i.d. 7. Valcyte 900 mg p.o. once a day. 8. Magnesium 400 mg 1 p.o. b.i.d. 9. Amaryl 2 mg p.o. every morning as needed for hyperglycemia. 10. CellCept [**Pager number **] mg p.o. q.i.d. 11. Prednisone 17.5 mg p.o. once a day. 12. Prograf 1 mg p.o. b.i.d. 13. Coumadin 2 mg p.o. once a day. 14. Insulin, regular Humulin insulin, but per sliding scale. The patient was given prescriptions for the insulin, for syringes, lancets and One Touch Ultra test strips. LABORATORY DATA: Labs upon discharge: White blood cell count 3.8, hematocrit 31.4, platelet count 107, PT 17.7, PTT 32.7, INR 2.2, sodium 139, potassium 4.9, chloride 102, bicarbonate 28, BUN 16, creatinine 1.1, glucose within normal range. AST 17, ALT 29, alkaline phosphatase 154, total bilirubin 0.4, Prograf 9.9. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2123-11-8**] 14:56:57 T: [**2123-11-9**] 10:53:55 Job#: [**Job Number 59205**] Admission Date: [**2123-10-7**] Discharge Date: [**2123-11-1**] Date of Birth: [**2073-8-23**] Sex: F Service: LIVER TRANSPLANT SURGERY SERVICE HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female with end-stage liver disease secondary to hepatitis C and hepatoma who has a history of RF ablation, and tubal ligation who is admitted for a potential liver transplant. The patient has a history of decompensates in the form of ascites diagnosed in [**2122-12-29**]. The patient had a liver biopsy demonstrating hepatocellular carcinoma, 3.5 x 3.0 cm. She has had an area of radiofrequency ablation. She denies any fevers, chills, jaundice, shortness of breath, chest pain, abdominal pain. PAST MEDICAL HISTORY: Hepatitis C, cirrhosis decompensated with encephalopathy, hepatocellular carcinoma, status post radiofrequency ablation in [**2122**]. There is also a history of major depression. MEDICATIONS ON ADMISSION: Trazodone 50 mg q.h.s., Caltrate 600 mg b.i.d., Lexapro 20 mg daily, Mycelex 3 mg daily, Lactulose 2 tablespoons daily. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: The patient is married. She feels that she contracted hepatitis C through her husband who also has hepatitis C cirrhosis currently being treated at [**Hospital6 8866**]. She denies any history of smoking, drinking, alcohol or IV drug abuse. She denies history of tattoos, but transfusions. REVIEW OF SYMPTOMS: Unremarkable. PHYSICAL EXAMINATION: Vital signs: Temperature 97.2, blood pressure 128/72, pulse 76, respirations 16, weight 178. General: Awake, alert and oriented times three, in no acute distress. HEENT: Pupils equal, round and reactive to light. No jaundice. Extraocular movements full. Neck: Supple. No lymphadenopathy. No thyromegaly. No carotid bruits. Lungs: Clear to auscultation bilaterally. No wheezes or crackles. Cardiovascular: Regular rate and rhythm. Normal S1 and S2 without murmurs. Abdomen: Obese. Positive bowel sounds. No bruits. Nontender. Extremities: No clubbing, cyanosis or edema. No rashes to the skin. Neurologic: Cranial nerves II- XII intact. Upper and lower extremities 5 out of 5 bilaterally. HOSPITAL COURSE: On [**2123-10-7**], the patient came to FAR10 for admission for possible liver transplant which was performed by Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) **] for end-stage liver disease with hepatitis C and hepatoma surgery thought she had was from a DCD liver. Please details of operative note for more information. The patient went to the ICU postoperatively. The patient was intubated and sedated. On postoperative day 1, the patient did get a duplex ultrasound of the liver demonstrating patent hepatic vasculature including hepatic arteries and veins and pleural veins. Evaluation of the left hepatic vein, hepatic artery and portal vein was limited by the presence of over length, poor structures, although __________ demonstrated wave forms are poorly assessed. There were also 2 oval heterogeneously hypoechoic structures adjacent to the IVC measuring 4 and 3.6 cm in greatest dimension. This may represent small retrohepatic fluid collection. In addition, there was turbulent flow in the main portal vein. On postoperative day 1, ALT was 68, AST 1616, alkaline phosphatase 83, total bilirubin 1.6, direct bilirubin 0.7. The patient had 2 [**Location (un) 1661**]-[**Location (un) 1662**] drains in and a T-tube placed. DICTATION ENDED [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2123-11-16**] 14:49:34 T: [**2123-11-16**] 16:01:42 Job#: [**Job Number 59206**]

[ "155.2", "070.54", "570", "251.8", "415.11", "996.82", "E932.0", "576.1", "300.00", "459.2" ]

icd9cm

[ [ [] ] ]

[ "88.47", "51.87", "50.59", "88.64", "50.11", "00.93" ]

icd9pcs

[ [ [] ] ]

1289, 1361

12751, 13012

13295, 14081

15591, 15758

16832, 18380

1382, 1409

1129, 1174

13024, 13271

16125, 16814

1429, 1626

146, 175

14097, 14802

14831, 15360

15383, 15564

15775, 16102

7,955

185,245

18062

Discharge summary

report

Admission Date: [**2121-4-24**] Discharge Date: [**2121-5-1**] Date of Birth: [**2053-8-22**] Sex: F Service: Surgery CHIEF COMPLAINT: Status post pelvic mass resection. HISTORY OF PRESENT ILLNESS: This is a 67-year-old female with a history of metastatic rectal cancer who was admitted to the Surgical Service postoperatively after pelvic resection. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Mitral valve prolapse. 4. Right kidney hydronephrosis. 5. Colon cancer; status post chemotherapy and radiation treatment. 6. Hypothyroidism. 7. Ovarian cancer. PAST SURGICAL HISTORY: 1. Anterior/posterior resection in [**2107**]. 2. Supracervical hysterectomy and bilateral salpingo-oophorectomy. 3. Multiple ventral hernia repairs. MEDICATIONS ON ADMISSION: 1. Synthroid 125 mcg p.o. once per day. 2. Atenolol 25 mg p.o. once per day. 3. Simvastatin 20 mg p.o. once per day. 4. Detrol 4 mg p.o. once per day. 5. Levaquin 250 mg p.o. once per day. 6. Pepcid 20 mg p.o. once per day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient use to smoke tobacco, but she quit many years ago. Occlusion alcohol. No intravenous drug use. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. SURGICAL PROCEDURE: On hospital day one, the patient underwent an exploratory laparotomy, lysis of adhesions, cystoscopy, bilateral ureteral stent placement, left urethral catheter placement, resection of pelvic mass, left ureteroureterostomy, resection of presacral mass, and partial vaginectomy, and partial urethrectomy. This surgery was complicated by an estimated blood loss of approximately 9000 cc. Intraoperatively, the patient received 10 liters of crystalloid fluids, 6 units of fresh frozen plasma, 13 units of packed red blood cells, and 2 units of platelets, and 2 units of cryoprecipitate. The patient had a large pelvic mass which was resected, a JJ stent placed, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain placed, and a central line placed. Immediately postoperatively, the patient was transferred to the Surgical Intensive Care Unit, at which time she was still intubated. The patient was kept on a ventilator and continued to do well and was extubated on postoperative day one. She remained hemodynamically stable. The rest of this dictation will be done by system. 2. CARDIOVASCULAR SYSTEM: Immediately postoperatively, after receiving a total of 10 liters of fluid, 6 units of fresh frozen plasma, 13 units of packed red blood cells, 2 units of units, and 2 units of cryoprecipitate the patient was hemodynamically stable. During the evening on postoperative day zero, the patient was found to have some blood pressures. Her blood pressures were in the 60s to 80s systolic over 30 to 40 diastolic. Her hematocrit was checked, at which time it was 26.3%. Her coagulations were as follows; prothrombin time was 15.5, partial thromboplastin time was 47.5, INR was 1.6, and fibrinogen was 174. The patient's hypotension responded with a bolus of one liter of fluid. Otherwise, she remained hemodynamically stable throughout her hospital course. After this point, her blood pressures remained stable; ranging between 130 to 160 systolic over 70 to 90 diastolic. 3. HEMATOLOGIC ISSUES: As stated above, the patient received multiple blood products. Her hematocrit initially postoperatively was 26.3%. She received another 2 units of packed red blood cells as well as 1 unit of fresh frozen plasma on postoperative day one. Her hematocrit remained stable at 26% to 29%. Her coagulations after receiving an additional unit of fresh frozen plasma remained stable. On [**2121-4-28**] her INR was 1, and prothrombin time was 12, and partial thromboplastin time and 30. 4. RESPIRATORY ISSUES: Initially postoperatively, the patient was transferred to the Medical Intensive Care Unit intubated on synchronized intermittent mandatory ventilation. She was on pressure support, and her FIO2 was 50%. The patient was extubated on postoperative day one and was kept on 10-liter facial mask. Her oxygen saturations were all above 95%. The patient was taken off the facial mask on postoperative day three and transferred to the regular hospital [**Hospital1 **] floor. After this point, there were no other respiratory issues. The patient remained on room air with oxygen saturations between 97% to 100%. 5. FLUIDS/ELECTROLYTES/NUTRITION/GASTROINTESTINAL ISSUES: Immediately postoperatively, the patient was kept nothing by mouth. A Pepcid intravenous drip 20 mg twice per day was given. The patient was able to tolerate a liquid diet by postoperative day two. She was further advanced, and by postoperative day three she was tolerating a regular diet. Her ostomy site remained clean, dry, and intact. There was good coloring in this area. It was producing stool and gas as well. There were no complications with the ostomy site. 6. NEUROLOGIC ISSUES: The patient was initially intubated and was given bupivacaine sedation. The patient remained awake and alert throughout her hospital stay. She suffered no neurologic damage. She was mentating and answering questions appropriately immediately postoperatively. 7. INFECTIOUS DISEASE ISSUES: The patient received three doses of prophylactic antibiotics with cefazolin 1 g q.8h. as well as Flagyl 500 mg intravenously q.8h. She remained afebrile throughout her hospital course. However, on postoperative day six, she developed some urinary incontinence. At this time, Urology recommended starting the patient on Levaquin 250 mg times three days. The patient does have a history of chronic urinary tract infections. 8. URINARY ISSUES: Initially postoperatively, the patient had a Foley catheter placed. The Foley catheter was draining clear/yellow urine without any complications. On postoperative day three, the Foley catheter was removed. The patient was able to urinate well. The patient did complain of some urinary incontinence on postoperative day five. A urinalysis was obtained which was negative. The culture was still pending to date. Given the fact that the patient has a history of chronic urinary tract infections, a Urology consultation was obtained. A postvoid residual was checked and was found to be 100 cc. It was thought that her urinary incontinence was secondary to bladder spasms. She was placed on Detrol-LA 4 mg p.o. once per day as well as a prophylactic dose of Levaquin 250 mg once per day times a total of three days. For her urinary stent, this was to remain in place until either the patient undergoes radiation treatment, or in four to six weeks the stent will be removed. MEDICATIONS ON DISCHARGE: 1. Synthroid 125 mcg p.o. once per day. 2. Atenolol 25 mg p.o. once per day. 3. Simvastatin 20 mg p.o. once per day. 4. Detrol-LA 4 mg p.o. once per day. 5. Levaquin 250 mg p.o. once per day (times a total of three days). 6. Pepcid 20 mg p.o. once per day or twice per day as needed. 7. Percocet (a total of 60 tablets were dispensed). DISCHARGE DIAGNOSES: 1. Status post cystoscopy, left ureteral stent placement, resection of presacral mass, left ureteroureterostomy, partial urethrotomy, and partial vaginectomy. 2. Hypertension. 3. Hypercholesterolemia. 4. Mitral valve prolapse. 5. Right kidney hydronephrosis. 6. History of colon cancer; status post chemotherapy and radiation treatment. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] in one to two weeks for a follow-up appointment. 2. The patient was to follow up with chemotherapy/radiation oncologist should she need further treatment. 3. The patient was to follow up with Urology in one to two weeks for stent evaluation as well as incontinence problems. 4. The patient was to follow up with her primary care physician for any further medical needs. [**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**] Dictated By:[**Last Name (NamePattern1) 1892**] MEDQUIST36 D: [**2121-5-1**] 08:41 T: [**2121-5-5**] 08:08 JOB#: [**Job Number 49981**]

[ "424.0", "272.0", "401.9", "V10.43", "591", "285.1", "244.9", "198.89", "V10.06" ]

icd9cm

[ [ [] ] ]

[ "59.8", "54.4", "56.41", "87.74", "54.3", "70.4", "57.32" ]

icd9pcs

[ [ [] ] ]

7109, 7453

6744, 7088

810, 1079

7486, 8213

630, 784

1240, 6718

153, 189

218, 372

394, 607

1096, 1206

30,109

149,452

34221+57908

Discharge summary

report+addendum

Admission Date: [**2121-4-4**] Discharge Date: [**2121-4-15**] Date of Birth: [**2044-4-29**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: CHF Major Surgical or Invasive Procedure: CABG x2(LIMA>LAD, SVG>PDA), AVR(#21 StJude epic porcine)[**4-9**] History of Present Illness: This 76-year-old patient who presented recently with an episode of congestive cardiac failure, was investigated and was found to have severe left main stem lesion with a blocked right coronary artery with mitral regurgitation and aortic stenosis with very poor left ventricular ejection fraction in the region of [**9-3**]%. Cardiac enzymes were elevated during this admission. Based on these findings, she was kept in-house for urgent coronary artery bypass grafting and aortic valve and possible mitral valve surgery. Past Medical History: PMH: none Social History: non smoker Family History: n/c Physical Exam: VS: T 98.4, BP 124/80, HR 80, RR 20, O2 sat 98% RA Gen: WF elderly afemale in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 6cm; no carotid bruits CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal did not check DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal did not check DP 2+ PT 2+ Pertinent Results: [**2121-4-12**] 07:00AM BLOOD WBC-12.4* RBC-3.29* Hgb-9.4* Hct-28.1* MCV-86 MCH-28.6 MCHC-33.4 RDW-14.2 Plt Ct-195 [**2121-4-11**] 01:01AM BLOOD PT-13.6* PTT-31.3 INR(PT)-1.2* [**2121-4-12**] 07:00AM BLOOD Glucose-101 UreaN-25* Creat-1.2* Na-136 K-4.1 Cl-101 HCO3-25 AnGap-14 [**2121-4-13**] 7:42 AM CHEST (PA & LAT) Minimal left apical pneumothorax has decreased in size since the prior study. There is no right pneumothorax. Small bilateral pleural effusions are demonstrated as well as bibasal left more than right atelectasis with no significant change since the prior study. The upper lungs are unremarkable. The cardiomediastinal silhouette is unchanged including the post-sternotomy wires [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 16810**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78815**] (Complete) Done Results Measurements Normal Range Left Atrium - Peak Pulm Vein S: 0.7 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 20% >= 55% Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *21 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 15 mm Hg Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Severe regional LV systolic dysfunction. Severely depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate-severe AS (area 0.8-1.0cm2). Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Moderate (2+) MR. TRICUSPID VALVE: Mild [1+] TR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). 1.No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with EF 20%. Overall left ventricular systolic function is severely depressed (LVEF= 20%). 3. Right ventricular chamber size and free wall motion are normal. 4.There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets are moderately thickened. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). The gradients are low across the aortic valve due to depressed myocardium and low cardiac output state. Moderate (2+) aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The mitral annulus is 3.4 cm. 7.There is a trivial/physiologic pericardial effusion. 8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2121-4-9**] at 1000am. Post bypass: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine, epinephrine and milrinone. Pt was in an intrinsic sinus rhythm. 1. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (peak gradient = 20 mmHg) with a cardiac output of 3.6L/min. No aortic regurgitation is seen. 2. There is global left ventricular systolic dysfunction with an estimated LVEF of 25 %. 3.Right ventricular systolic function is normal. 4. Mitral regurgitation remains as 2+ moderate and other valves are as described pre-bypass. 5. Aortic contours are intact post-decannulation. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2121-4-4**] for surgical management of his coronary artery disease and valve desease. she was taken directly to the operating room where he underwent: OPERATION: 1. Off-pump coronary artery bypass graft x2; left internal mammary artery to left anterior descending artery and saphenous vein graft to posterior descending artery. 2. Aortic valve replacement with a size 21 St. [**Male First Name (un) 923**] tissue Epic valve. 3. Endoscopic harvesting of the long saphenous vein from the leg Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. Within 24 hours, he had awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. S SHe was then transferred to the step down unit for further recovery. She was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Pt did go into afib. She was given amio she did convert to NSR. No anticoagulation started. Pt also had ARf from cardiac cath / resolved on DC Medications on Admission: none Discharge Medications: 1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 5 days. Disp:*10 Packet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 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:*2* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take for seven days, then 200 mg daily there after. Disp:*60 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: CAD mitral regurgitation and aortic stenosis Afib converted to NSR Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Call PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 72189**], schedule an appointment immediatly upon discharge. Call [**Doctor First Name **].[**Name8 (MD) **] MD, CARDIOTHORACIC SURGERY [**Telephone/Fax (1) 170**], schedule an appontment for four weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2121-4-13**] Name: [**Known lastname 12703**],[**Known firstname 3344**] Unit No: [**Numeric Identifier 12704**] Admission Date: [**2121-4-4**] Discharge Date: [**2121-4-15**] Date of Birth: [**2044-4-29**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: prior to discharge patients weight was at baseline, creatinine was 1.3. She was therefore not discharged home on lasix. Discharge Disposition: Home With Service Facility: [**Hospital 2057**] Hospice and VNA [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2121-4-14**]

[ "414.01", "427.89", "396.2", "E878.1", "427.31", "433.30", "458.29", "398.91", "V12.71", "E849.7", "998.0", "521.00", "512.1" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "23.09", "36.11", "99.04", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

11273, 11459

6559, 7737

323, 391

9526, 9535

1938, 6536

10298, 11250

1018, 1023

7792, 9330

9436, 9505

7763, 7769

9559, 10275

1038, 1919

280, 285

419, 940

962, 974

990, 1002

28,835

143,837

29895

Discharge summary

report

Admission Date: [**2125-10-1**] Discharge Date: [**2125-10-10**] Date of Birth: [**2078-4-18**] Sex: M Service: SURGERY Allergies: Ivp Dye, Iodine Containing / Lasix Attending:[**First Name3 (LF) 695**] Chief Complaint: Colon adenocarcinoma with hepatic metastases Major Surgical or Invasive Procedure: [**2125-10-1**] Right hepatic lobectomy, cholecystectomy, Segment 4B resection, Segment 3 mass wedge resection, Intraoperative ultrasound [**2125-10-9**] ERCP with stent placement History of Present Illness: Mr. [**Known lastname **] is a 47-year-old gentleman diagnosed with colon adenocarcinoma following work-up of fatigue and anemia. A CT scan on [**2125-3-2**] at [**Hospital1 18**] confirmed a cecal mass and lymphadenopathy, as well as multiple hepatic lesions in both lobes of the liver. There were six lesions in the left lobe, all but one in the medial segment, the largest measuring 3cm within Segment IV-A. There were 10 lesions in the right lobe, the largest measuring 6.3x4.8 cm. He was then treated with a course of FOLFOX and Avastin chemotherapy, to which he responded quite well. Serial CT scans demonstrated that there was a decrease in the size of multiple liver lesions with no new hepatic lesions and a decrease in the prominence of the cecal mass. Embolization of the right portal vein was performed on [**2125-8-10**] and serial CT scans were also followed to calculate liver volumes. The most recent study, performed on [**9-7**], demonstrated that the total liver volume was not significantly changed form prior studies at 1735 cc. The right lobe volume actually decreased to 750 cc and the left lobe volume increased to 980. Segments II and III actually decreased to 520 and segment IV increased to 350. The segment I volume increased from 56 to 109 cc. Therefore, Segments I, II, and III are now 629 cc, which was predicted to provide adequate liver volume for right hepatic trisegmentectomy. The procedure was then planned for [**10-1**], [**2125**]. Past Medical History: PMHx: OSA, Hypercholesterolemia, BPH, depression, and an asymptomatic heart murmur (no prophylaxis for procedures) PSH: varicocele repair, vasectomy, perianal abscess drainage Social History: Regular diet. 10-pack/year history of smoking, quit in [**2124**]. No IV drug or marijuana use. Blood transfusion early in [**2125**] for low hematocrit. No history of tattoos, hepatitis, or piercing. Married with two daughters ages 11 and 12 and one son age 19. [**Name2 (NI) 1403**] as a supervisor for a painting company. Family History: Sister - alive with cervical CA. Physical Exam: Upon morning of discharge: Vitals: Tm 99.9 Tc 99.8 P 93 BP 98/75-111/77 RR 20 SpO2 98%RA General: AAOx3. CV: RRR. Pulm: CTAB. GI: Soft. Mildly distended. NT. Medial JP with serobilious output. Lateral JP with serosanguinous output. Wound c/d/i with staples remaining in wound. Ext: +3 pitting edema. Warm and well perfused. Pertinent Results: Upon admission: [**2125-10-1**] WBC-4.7 Hgb-12.0 Hct-33.6 Plt Ct-86 PT-17.5 PTT-59.7 INR-1.6 Fibrino-138 Glucose-129 UreaN-8 Creat-0.9 Na-137 K-5.1 Cl-108 HCO3-23 ALT-504 AST-470 LDH-646 AlkPhos-36 TotBili-1.5 DirBili-0.6 IndBili-0.9 Lipase-17 Albumin-2.0 Calcium-9.7 Phos-4.5 Mg-2.2 Lactate-1.6 Upon discharge: [**2125-10-10**] WBC-6.9 Hgb-10.5 Hct-30.8 Plt Ct-85 Glucose-91 UreaN-9 Creat-0.9 Na-137 K-3.7 Cl-107 HCO3-23 ALT-95 AST-46 AlkPhos-250 Amylase-1278 TotBili-1.2 Lipase-1870 Albumin-2.7* Calcium-7.9 Phos-3.3 Mg-2.3 Brief Hospital Course: The patient was admitted on [**2125-10-1**] for the planned resection of the hepatic metastatic lesions. The patient tolerated the porocedure well and was transferred to the ICU postoperatively, intubated and sedated. Pressors were weaned off the evening of postoperative day #0 and he was aggressively volume resuscitated. The patient continued to do well and was extubtaed on postoperatively day #1. The following day the epidural was removed. 2 units of pRBC's and 1 unit of platelets were also transfused on postoperative day #2. The patient was transferred to the floor on postoperative day 3. By postoperative day #5, the patient was tolerating a regular diet, ambulating independently, voiding without difficulty, and had had a bowel movement. However, his RUQ lateral and medial drains continued to have significant out, around the 200-300 range for both during postoperative days [**3-16**]. The lateral drain was also noted to be bilious on postoperative day #6, confirmed with lab analysis of the drain output showing a bilirubin of 28.6. The medial drain continued to be serosanguinous and had a bilirubin of 0.7. An ERCP was performed on postoperative day #8, which showed contrast extravasation from left intrahepatic biliary duct branches at the site of resection. A 7cm 10Fr biliary catheter was then placed. The patient tolerated the procedure well and was monitored overnight for signs of pancreatitis. The his amylase and lipase were markedly elevated postprocedure, the patient was completely asymptomatic. The patient's admit weight was noted to be 104kg and he was noted to be 113.7kg on the morning of postoperative day #9. He was therefore sent home with a weeks worth of acetazolamide, 250mg orally twice daily, while monitoring his weight at home. He is to continue this until reached his admit weight or was seen in follow up a week later. Also of note, the patient's pathology was returned, which showed that an omental biopsy was positive for adenocarcinoma, a poor prognostic sign. The patient was informed of these results by Dr. [**Last Name (STitle) **] the day of his discharge, on postoperative day #9. Medications on Admission: Ambien 5mg once daily Ativan 1mg tid Vicodin 1-2 tabs q6h PRN Terazosin 2mg qhs Vytorin 1mg tab once daily Wellbutrin 200mg once daily Zantac 1mg tab once daily Compazine 10mg po tid prn nausea Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 3. Bupropion 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: 1) WEIGHT YOURSELF EVERY MORNING, WHEN YOU HIT YOUR PRE-OPERATIVE WEIGHT, CALL OFFICE AND STOP THIS MEDICATION 2) IF YOU BEGIN TO FEEL DIZZY OR EXTREMELY THIRSTY, OR IF YOUR EDEMA HAS COMPLETELY RESOLVED, CALL OFFICE AND STOP THIS MEDICATION. Disp:*14 Tablet(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 7 days: do not exceed more than 10 pills in 24 hours. Disp:*25 Tablet(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 2 weeks. Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Metastatic adenocarcinoma of the colon to the liver, s/p segment IVb hepatic resection, segment III wedge resection, cholecystectomy, and intraoperative ultrasound. Carcinomatosis confirmed by omental biopsy positive for adenocarcinoma. Discharge Condition: Stable Discharge Instructions: Go to the ER if you experience pain, bleeding, or have sudden change in drain output. Call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have any concerns or questions. Record drain outputs and care for drains as instructed. Followup Instructions: Call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] to make an appointment in 1 week. Call (Oncologist) to make an appointment Labarotory test monday [**2125-10-14**]: Chemistry [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

[ "197.6", "153.4", "285.9", "575.11", "197.7" ]

icd9cm

[ [ [] ] ]

[ "50.11", "54.23", "50.22", "50.3", "51.22", "51.87" ]

icd9pcs

[ [ [] ] ]

7099, 7105

3544, 5684

339, 521

7386, 7395

2992, 2994

7690, 8010

2590, 2625

5928, 7076

7126, 7365

5710, 5905

7419, 7667

2640, 2973

255, 301

3305, 3521

549, 2024

3008, 3289

2046, 2225

2241, 2574

22,105

155,216

44286

Discharge summary

report

Admission Date: [**2101-2-21**] Discharge Date: [**2101-2-25**] Date of Birth: [**2042-12-8**] Sex: M Service: HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 58-year-old white male has a history of mitral regurgitation, has been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with several echocardiograms over the past three years. He reports a history of shortness of breath, which he attributes to his bronchial asthma. He was referred to Dr. [**Last Name (Prefixes) **] for surgical evaluation. He denies chest pain or pressure. He had an echocardiogram done in [**7-22**], which revealed severe 4+ MR and a normal EF of 60%. He had a cardiac catheterization on [**2101-2-14**], which revealed an EF of 61%, 40% proximal RCA lesion, and normal left system. There was severe 4+ mitral regurgitation, and he is now admitted for elective MV repair. PAST MEDICAL HISTORY: 1. Significant for mitral regurgitation. 2. History of bronchial asthma for 30 years. 3. History of hypertension. 4. Status post removal of skin cancer on his face and right arm. MEDICATIONS ON ADMISSION: 1. Moduretic 5/50 mg half a tablet p.o. q.d. 2. K tabs q.d. 3. Univasc 7.5 mg p.o. q.d. 4. Multivitamin one p.o. q.d. 5. Accolate 20 mg p.o. b.i.d. 6. Vitamin C 250 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Flovent two puffs p.o. b.i.d. 9. Proventil prn. 10. Prednisone 5 mg prn during emergency asthma attacks only. ALLERGIES: He has no known allergies. His last dental exam was six months ago and he was cleared for surgery. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: He is a bus driver. He lives with his wife in [**Name (NI) 189**]. Quit smoking 34 years ago. Smoked a pack a day for 15 years prior to that. Drinks 1-2 drinks a week. REVIEW OF SYSTEMS: Is as above. PHYSICAL EXAM: On physical exam, he is a well-developed and well-nourished white male in no apparent distress. Vital signs are stable, afebrile. HEENT exam: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is benign. Neck is supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids are 2+ and equal bilaterally without bruits. Lungs had poor air exchange bilaterally without wheezes, rhonchi, or rales. Cardiovascular: Regular rate and rhythm with a [**1-22**] murmur heard best at the apex radiating to the left axilla. Abdomen was soft, nontender, and mildly obese with normoactive bowel sounds, no masses or hepatosplenomegaly. Extremities were without clubbing, cyanosis, or edema. Neurologic examination was nonfocal. Pulses were 2+ and equal bilaterally throughout. He was admitted on [**2101-2-21**] and underwent a minimally invasive mitral valve repair with a 30 mm [**Doctor Last Name 405**] annuloplasty band. The cross-clamp time was 110 minutes. Total bypass time 132 minutes. He was transferred to the CSRU in stable condition and was transiently on Neo-Synephrine. He was extubated, and had a stable postoperative night. On postoperative day one, he had his chest tube D/C'd. He did have a temperature of 101 and then was transferred to the floor in stable condition. He continued to have a stable postoperative course with the exception of temperature elevations to 101. His chest x-ray was clear. His urine culture was negative, and his white count was normal. He would usually have one or two spikes per day, but otherwise his temperature was around 99. On postoperative day #4, he was discharged home in stable condition. LABORATORIES ON DISCHARGE: Hematocrit 30.6, white count 9.2, platelets 207,000. Sodium 140, potassium 4.2, chloride 102, CO2 33, BUN 16, creatinine 0.8, blood sugar 116. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. for seven days. 2. Potassium 20 mEq p.o. b.i.d. for seven days. 3. Aspirin 325 mg p.o. q.d. 4. Percocet 1-2 tablets p.o. q.4-6h. prn pain. 5. Accolate one p.o. b.i.d. 6. Flovent two puffs b.i.d. 7. Lopressor 75 mg p.o. b.i.d. DISCHARGE DIAGNOSES: 1. Mitral regurgitation. 2. Hypertension. 3. Asthma. FO[**Last Name (STitle) **]P INSTRUCTIONS: He will follow up with Dr. [**Last Name (STitle) 43109**] in [**11-19**] weeks, Dr. [**First Name (STitle) **] in [**12-21**] weeks, and Dr. [**Last Name (Prefixes) **] in four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 6516**] MEDQUIST36 D: [**2101-2-25**] 10:56 T: [**2101-2-25**] 11:15 JOB#: [**Job Number 94973**]

[ "401.9", "493.90", "396.3", "780.6", "V10.83" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12", "99.04" ]

icd9pcs

[ [ [] ] ]

1599, 1614

4017, 4563

3744, 3996

1149, 1582

1854, 3558

3573, 3718

1824, 1838

943, 1123

1631, 1804

17,617

191,441

28341

Discharge summary

report

Admission Date: [**2195-6-12**] Discharge Date: [**2195-6-16**] Date of Birth: [**2116-1-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 79 YOM with severe cardiomyopathy and heart failure who presents with dyspnea. His recent medical course details a progressive decline in his functional status. He was recently admitted wo the [**Hospital Ward Name **] with SOB and acute on chronic renal failure. Brought by family to ED today for cough, dyspnea, and increased lower ext edema. Also noted by PCP to again have acute on chronic renal failure, lasix dose recently doubled to try to help control symptoms. Currently resting comfortably. [**Hospital Ward Name 4273**] chest pain. Complains of chronic cough productive of white sputum. In the [**Hospital1 18**] was noted to be bradycardic down to 20 while asleep and 40s when awake with systolic BPs greater than 90. He was given levofloxacin 500mg IV for presumed pneumonia prior to CXR given history of dyspnea and cough. He was also given 1L NS. Of note has recently been evaluated by both heart failure and EP services. Given poor prognosis was felt not to be a candidate for ICD. His cardiac regimen has going under several changes including transiently on amiodarone, doubling of Dig to 0.125 mcg. Past Medical History: 1. Congestive heart failure, LVEF equals 20% to 25%. 2. Severe tricuspid regurgitation. 3. Moderate to severe mitral regurgitation. 4. Status post mechanical aortic valve replacement done in [**2182**] in [**Hospital1 46**]. 5. Chronic atrial fibrillation on Coumadin. 6. Chronic renal insufficiency (baseline creatinine 2.2-2.6) 7. Cirrhosis (right heart failure). 8. Ascites. 9. GI bleed (small bowel AVM) 10. MRSA bacteremia Social History: From [**Last Name (un) 26580**], Arabic speaking only. Former farmer. Quit smoking 30 years ago (1ppd x 24 years). [**Last Name (un) 4273**] any ETOH or other drug use hx. Family History: -M: Stomach CA -F:? -No known liver disease in the family Physical Exam: Blood pressure was 94/60 mm Hg while seated. Pulse was 49 beats/min and regular, respiratory rate was 12 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVD to angle of the jaw sighting at ~60 degrees. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lung sounds were decreased at the base bilaterally with dullness to percussion. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were soft systolic murmur heard best at LUSB. . The abdominal aorta was able to be palpated. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and distended.Marked ascities present. The extremities had edema bilaterally rising above the knee. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP D PT D Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP D PT D Pertinent Results: EKG demonstrated a fib with ventricular escape. Rate 41. LAD. narrow qrs. No ST changes. TWI in V4. Low voltage in limb leads. Similar to [**2195-5-25**]. . TELEMETRY demonstrated:bradycardia . CXR: Comparison is made with the prior chest x-ray of [**2195-5-25**]. The heart remains markedly enlarged and aortic valve replacement is present. Tortuosity of the aorta is again seen. No gross failure is seen. The costophrenic angles appear sharp. No infiltrates are present. . 2D-ECHOCARDIOGRAM performed on [**2195-1-12**] demonstrated: 1. The left atrium is dilated. 2. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. 3. There is severe global left ventricular hypokinesis. 4. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. A bileaflet aortic valve prosthesis is present. The aortic prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve. Trace aortic valve regugitation is seen. 7. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate to severe (3+) mitral regurgitation is seen. 8. Moderate [2+] tricuspid regurgitation is seen. 9. There is no pericardial effusion . MIBI [**12-1**] - 1. Moderate, fixed inferior and inferolateral wall perfusion defects. 2. Left ventricular enlargement with global hypokinesis and depressed ejection fraction of 34% . LABORATORY DATA: 138 102 57 ---|---|--< 97 AGap=10 4.5 26 3.3 estGFR: 18/22 CK: 45 MB: 4 Trop-T: 0.08 proBNP: [**Numeric Identifier **] Ca: 8.4 Mg: 2.9 P: 4.3 PT: 32.5 PTT: 45.1 INR: 3.5 5.1>------< 256 29.8 N:70.6 L:19.7 M:8.2 E:1.2 Bas:0.3 Brief Hospital Course: 79 year old male with severe cardiomyopathy (CHF, EF 20-25%), severe MR [**First Name (Titles) **] [**Last Name (Titles) **], s/p mechanical AVR in [**2182**], Afib on coumadin, CRI (baseline 2.2-2.6), cirrhosis/ascites from RH failure, h/o GI bleed (small bowel AVM), MRSA bacteremia p/w cough, dyspnea, found to have bradycardia down to 20s in setting of increased digoxin dose and acute on chronic renal failure. . 1)Dyspnea - this was likely multifactorial including poor mechanics from ascities, bradycardia, bronchitis, heart failure. He was also a former smoker but did not have a diagnosis of COPD. He did receive levofloxacin x1 but was without fever or infiltrate on admission to suggest pneumonia so antibiotics were stopped. His INR was 3.5 on admission therefore PE was unlikely. A lasix drip was started and metolazone and spironolactone were continued for diuresis. A dopamine drip was started for improved renal perfusion. The patient's urine output improved with these interventions and the lasix drip and dopamine drip were tapered off. He was started on PO lasix upon discharge. . 2) Bradycardia - The patient had bradycardia down to 20s on admission probably in setting of increased BB and increased digoxin dose and acute on chronic renal failure which may have decreased clearance. He was given atropine with moderate response. He is not a candidate for a pacemaker due to his multiple co-morbidities. His heart rate normalized during his stay. . 3) Afib - On coumadin at home. This was held for super-therapeutic INR. Once his INR was below 3, his coumadin was restarted (goal INR [**2-28**]). . 4) Acute on chronic renal failure - Likely secondary to low intravascular volume in combination with increased diuresis. However, we continued to diurese the pt. due to his respiratory distress and volume overload. His creatinine remained stable. . 5) UTI - E.coli (sensitive to ceftrioxone). Pt. was treated for his UTI with ceftriaxone. . 6) Anticoagulation - Mechanical valve and a fib. On coumadin on admission. INR of 3.5 on admission. When his INR trended down, coumadin was restarted as above. . 7) Anemia - Chronic GI blood loss on anticoagulation. He was transfused 1 unit of pRBC during his stay with appropriate increase in his Hematocrit. . 8)FEN - low salt, replete lytes [**Hospital1 **] initially. . 9) DNR/I . 10) Dispo - after discussion with the family, a decision was made for the patient to go home with hospice. Medications on Admission: Ascorbic Acid 500 mg DAILY Digoxin 125 mcg DAILY Fluticasone 110 mcg Two (2) Puff [**Hospital1 **] Furosemide 40 mg Tablet PO BID Polysaccharide Iron Complex 150 mg PO BID Metoprolol Succinate 25 mg PO DAILY Pantoprazole 40 mg Tablet q24H Coumadin 6 mg daily Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 10. Oxygen-Air Delivery Systems Device Sig: One (1) Device Miscellaneous continuous as needed for shortness of breath or wheezing. Disp:*1 Device* Refills:*0* 11. Home oxygen 2 liters per minute flow rate as needed for shortness of breath. Discharge Disposition: Home With Service Facility: Hospice Care Inc Discharge Diagnosis: 1. Congestive heart failure 2. Bradycardia 3. Acute renal failure 4. UTI 5. Atrial fibrillation 6. Anemia Discharge Condition: Afebrile. Stable. Tolerating PO. Discharge Instructions: You were admitted to the hospital and found to have a low heart rate. We have stopped your digoxin and metoprolol which are medications that were thought to contribute to your low heart rate. . You were also found to have low blood counts and were transfused a unit of blood. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L per day Followup Instructions: You should follow up with your cardiologist Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] in [**5-1**] weeks

[ "428.0", "571.5", "599.0", "585.9", "427.31", "V58.61", "V43.3", "397.0", "427.89", "584.9", "424.0", "789.5", "425.4", "280.0" ]

icd9cm

[ [ [] ] ]

[ "00.17" ]

icd9pcs

[ [ [] ] ]

9716, 9763

5635, 8091

322, 329

9913, 9949

3761, 5612

10408, 10550

2138, 2197

8401, 9693

9784, 9892

8117, 8378

9973, 10385

2212, 3742

275, 284

357, 1479

1501, 1932

1948, 2122

12,742

132,422

20962

Discharge summary

report

Admission Date: [**2113-6-27**] Discharge Date: [**2113-6-28**] Date of Birth: [**2089-5-3**] Sex: F Service: TRA HISTORY OF PRESENT ILLNESS: This is a 24-year-old female with no significant past medical history who slipped and sustained a fall down 13 steps while doing laundry, landing on her lower back and buttocks. The patient was ambulatory at the scene but had some leg weakness and presented to the Emergency Department an hour after the incident. She was able to ambulate into the yard, but on initial evaluation had a decreased strength in her lower extremities with some decreased sensation to heat and cold. She denied LOC or any associated head injury and denied any incontinence of bowel or bladder. However, she did note some hematuria when she was at home. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Cesarean section times 1. ALLERGIES: No known drug allergies. MEDICATIONS: None. SOCIAL HISTORY: No alcohol or IV drug use. Smokes half a pack a day, admitted to occasional marijuana use. INITIAL PHYSICAL EXAMINATION: Temperature was 98.6 degrees, heart rate was 93, blood pressure 127/56, respiratory rate 18, O2 saturation of 100 percent on room air. Head is normocephalic, atraumatic with poor dentition and GSC of 15. Trachea was in midline. There was C-collar in place, no cervical spine tenderness. Neck was otherwise, supple. Her chest had no crepitus or deformities, clear to auscultation bilaterally. Heart was regular rate and rhythm without murmurs, rubs or gallops. Abdomen was soft with some mild lower abdominal tenderness, but no rebound or guarding and pelvis was stable. Rectal was of normal tone, guaiac negative. She was tender in her lower lumbar spine with no step-off deformities. Extremities, upper extremity strength was 5 out of 5 in the upper extremities and 3 to 4 out of 5 in her lower extremities. Her white blood cell count was 62, hematocrit was 35.4, platelet count was 312,000, INR was 1.2, potassium was 3.6, BUN and creatinine were 22 and 0.6. Lactate was 2.9, her amylase was 61, her UA was negative. However, her urine toxins positive for benzodiazapine's and cocaine. Her serum Tox was negative. IMAGING STUDIES: Chest x-ray was negative. Pelvis negative for fracture. CT of her C-spine negative for fractures. CT of her TLS spine questioned possible fracture of the right pars interarticularis at L5. CT of the abdomen and pelvis no solid organ injury, no free fluid. Again noted with the possible spondylolysis of the L5 vertebra on the right. CT of the head, no intracranial hemorrhage. BRIEF HOSPITAL COURSE: She was seen and evaluated in the Emergency Department and given her peri-neurologic deficit, Solu-Medrol protocol was instituted. She was bolused and placed on a drip and a Emergency Neurosurgical consultation was held. The patient was found to be tender around the L1 area and the midline of the back and was weakest at the hip flexors on both sides with a 2 plus upper extremity reflexes and 1 to 2 plus lower extremity. Recommendations from me to continue with the Solu-Medrol drip with monitoring of her fingersticks and obtain an MRI of her thoracolumbar spine. This was obtained and it showed no evidence of fracture or spinal cord injury. However, there was a congenital anomaly of the L5 facet joint on the right with no associated herniated disc, no cauda equina syndrome either. The patient was seen by the neurosurgical attending who felt that she did not have any acute neurosurgical issues and the patient was cleared to be off log roll and out of bed. Her C-spine was clear clinically on hospital day number 1. She was switched to oral pain medication and on neurosurgery recommendations placed on Valium to relieve back spasm. She was afebrile and otherwise, hemodynamically stable and able to ambulate without assistance and was deemed stable for discharge to home. STATUS OF DISCHARGE: The patient is improved and will be discharged to home. DISCHARGE DIAGNOSES: Status post fall with lower back pain. DISCHARGE MEDICATIONS: 1. Percocet 1 to 2 p.o. q. 4 to 6 hours p.r.n. 2. Valium 5 mg p.o. q. 8 hours p.r.n. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern1) 13030**] MEDQUIST36 D: [**2113-6-28**] 17:07:06 T: [**2113-6-29**] 13:04:14 Job#: [**Job Number 55722**]

[ "599.7", "E880.9", "724.2", "305.60" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2636, 4007

4029, 4070

4093, 4452

854, 940

1081, 2210

164, 800

823, 830

957, 1058

2228, 2612

12,013

154,993

7468

Discharge summary

report

Admission Date: [**2186-1-11**] Discharge Date: [**2186-1-17**] Date of Birth: [**2135-6-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13256**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Upper gastrointestinal endoscopy (EGD) History of Present Illness: 50 yo M w/ h/o alcoholic cirrhosis c/b varices (grade I in [**2179**]) and encephelopathy who presents from nursing home with several hours of lethargy. Patient is s/p recent admission to [**Hospital1 18**] [**Location (un) 620**] from [**Date range (1) 27344**] where he was treated for alcoholic hepatitis and alcohol withdrawal. During that admission, labs were notable for INR 1.4, AST 114 --> 50, ALT 50-60s, TBili 4.42 --> 2.52. Given an elevated Madrey score he was started on prednisolone 20mg twice daily with a plan for four week course with 2 week taper. Per [**Hospital1 1501**] records he is currently on 10 mg prednisone [**Hospital1 **]. . In the ED, initial VS were: 101.2 88 106/58 16 99% 4L. Patient was initially arousable to voice, oriented, following commands and moving all extremities. During his stay in the ED, became obtunded, unarousable to sternal rub. He was intubated via RSI w/ etomidate and succinylcholine with a 7.5 ETT. In the ED, there was concern for meningitis/encephelitis given fevers & altered MS w/ relative HD stability so he received broad spectrum coverage with zosyn 4.5 g IV, vancomycin 1 g, CTX 2g, acetaminophen 1g PR. LP was not performed [**12-29**] to platelets of 50 and INR of 1.7. He was started on propofol after intubation. On repeat exam, neck was noted supple and he was felt to have subtle asterixis. VS on xfer: 99 110/74 18 100% on AC TV500 x RR18 O2 100% PEEP 5. . On arrival to the MICU, the patient is intubated and sedated and unresponsive to verbal stimuli and sternal rub. Past Medical History: Alcohol abuse Alcoholic Cirrhosis c/b varices, encephalopathy, alcoholic hepatitis Social History: Currently living in nursing facility. Patient is married with three children. He is currently unemployed but has a prior working history as an electrician. He denies any prior illicit drug use or blood transfusions. He does note a history of alcohol use at a maximum of roughly 2-3 bottles of wine per night. He denies any tobacco use. Family History: Father with CAD, had MI at age 55. Physical Exam: ADMISSION: General Appearance: Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm, Rash: Spider angiomas, cherry angiomas Neurologic: Intubated/sedated . Discharge: Vitals: 99.2 (Tm) 122/78 87 100%RA General: Obsese man smiling, in NAD. HEENT: MMM CV: RRR, normal S1 + S2, no excess sounds appreciated Lungs: Clear Abdomen: Distended but soft, non tender Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation. + asterixis Skin: Seborrheic dermatitis present over eyebrows, scalp. very large ecchymosis over left flank, hip. Non tender, not warm. Lines: Central line IJ, non-tender, site intact. Psych: Mental status very clear today, AAOx3, able to quickly name days of week backwards. Pertinent Results: CDiff Toxin negative x3 [**2186-1-11**] URINE CULTURE-No growth [**2186-1-11**] BLOOD CULTURE-PENDING [**2186-1-11**] BLOOD CULTURE-PENDING [**1-16**]: HSV 1 IgM, IFA <1:20 HSV 2 IgM, IFA <1:20 . Images: CXR: Low lung volumes, which accentuate the bronchovascular markings particularly at the lung bases. Given this, there may be mild right base atelectasis. No definite focal consolidation seen. Possible mild pulmonary vascular congestion. . CT Head: Moderate left maxillary sinus disease, but no acute intracranial process. MRI is more sensitive for acute ischemia. . CT Abd/Pelvis: ABDOMEN: The visualized lung bases are clear. Small pericardial effusion is present. The liver is shrunken and nodular compatible with cirrhosis. Small amount of perihepatic ascites is present. The gallbladder is distended with a mildly thickened wall (likely secondary to hepatic disease). Small amount of pericholecystic fluid is also seen. The spleen is enlarged measuring 14.8 cm in length. The portal vein appears patent. There is a dilated recanalized umbilical vein, a portion of which has herniated through a small umbilical hernia (2; 60). The pancreas appears normal. The adrenal glands appear normal. The kidneys enhance and excrete contrast symmetrically without hydronephrosis. The small and large bowel show no evidence of ileus or obstruction. There is no free air or lymphadenopathy. PELVIS: The bladder is decompressed around a Foley. The prostate and rectum appear unremarkable. There is no pelvic free fluid or lymphadenopathy. A small left buttock hematoma is present. BONES: There are no aggressive appearing lytic or sclerotic lesions. IMPRESSION: 1. Cirrhotic liver with a small amount of ascites. 2. Small pericardial effusion. 3. Umbilical hernia containing a loop of the dilated, recannalized umbilical vein. . RUQ ultrasound: Color Doppler and spectral waveform analysis was performed. The main portal vein is patent with hepatopetal flow. The left portal vein is patent, and there is a large patent umbilical vein. Hepatopetal flow is also seen within the right portal vein. The hepatic veins are patent, and appropriate arterial waveforms are seen in the main hepatic artery. IMPRESSION: 1. Patent portal veins with widely patent umbilical vein again noted. 2. No focal liver lesions, no biliary dilatation. 3. Splenomegaly. 4. Trace of ascites in the perihepatic space. . [**1-17**] EGD: Varices at the lower third of the esophagus No evidence of active bleeding or ulcers Polyps in the antrum (biopsy) Normal mucosa in the first part of the duodenum and second part of the duodenum Otherwise normal EGD to third part of the duodenum . Polyp biopsy: Antral mucosa with hyperplasia of gastric pits, mucin depletion, and focal acute inflammation consistent with foveolar hyperplastic polyp; no histologic evidence of H. pylori seen. . Discharge labs: [**2186-1-17**] 05:45AM BLOOD WBC-4.4 RBC-3.35* Hgb-11.8* Hct-33.8* MCV-101* MCH-35.1* MCHC-34.8 RDW-13.1 Plt Ct-44* [**2186-1-17**] 05:45AM BLOOD PT-17.1* PTT-33.2 INR(PT)-1.6* [**2186-1-17**] 05:45AM BLOOD Glucose-110* UreaN-7 Creat-0.7 Na-138 K-3.6 Cl-103 HCO3-31 AnGap-8 [**2186-1-17**] 05:45AM BLOOD ALT-43* AST-42* AlkPhos-57 TotBili-1.6* [**2186-1-17**] 05:45AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.3* Brief Hospital Course: Summary: This is a 50 year old male with PMH of alcohol abuse, cirrhosis c/b varices and encephalopathy, and recent alcoholic hepatitis who presented with lethargy and altered mental status requiring intubation for airway protection. . #. Toxic Metabolic Encephalopathy: The initial differential included hepatic encephalopathy, infection, meningitis, and toxin ingestion. There was no evidence of intracranial pathology on CT Head. In the ED, he was started on empiric treatment for meningitis with vancomycin/ctx/acyclovir. An LP was not pursued given his low platelets and elevated INR from his underlying liver disease. There was not enough ascites to tap on imaging. His regimen was initially tapered to acyclovir to cover HSV encephalitis and ceftriaxone to cover SBP. His mental status improved dramatically on lactulose and rifaximin alone and there was evidence in records from the [**Hospital1 1501**] that he was receiving lactulose only once daily. He was transferred from the MICU to the floor, where his mental status continued to improve off all antimicrobials and with lactulose/rifaximin. . # Respiratory failure: He was intubated in the setting of altered mental status in the emergency room. He was quickly extubated in the MICU without difficulty after lactulose loading, and was subsequently transferred to the floor. . # Cirrhosis: Complicated by varices, hepatic encephalopathy, and alcoholic hepatitis. He had AFP checked this admission which was on the higher end of normal (8). He also had an EGD performed which revealed 2 cords of Grade I varices. MVI/Folate/Thiamine were continued. Prednisone was stopped (had been started at OSH for alcoholic hepatitis, however discriminant function on that admission was not elevated to the point where this hospital would typically start steroid therapy). Omeprazole was continued. Lactulose and rifaximin were continued - this will be very important to take at the extended care facility to prevent confusion and a repeat of the events that led to this admission. . # Alcohol abuse: Patient has history of drinking several bottles of wine per night. The importance of abstinence from alcohol should continue to be stressed to the patient as he transitions from rehab to home. Continued vitamin supplementation as above. . # Hypokalemia: Patient was hypokalemic this admission. He was placed on standing 40mg daily potassium and magnesium oxide supplementation, with plans to check labs at least QOD for the first several days after discharge to make sure patient's electrolytes stay in a safe and acceptable range. . # [**Last Name (un) **]: Likely pre-renal in setting of hypovolemia from marked stool output and decreased PO, improved with gentle IVF to baseline Cr 0.6-0.8. . # Pancytopenia / Coagulopathy: Likely related to liver disease and history of alcohol abuse. Stable this admission. . # Depression: Patient reports he has not been taking sertraline, which had been listed on a medication list, so this medication was not given. . # Large flank ecchymosis: Pt noted to have large ecchymosis over left flank - he does not recall falling, and denies pain at the site. There was no tenderness, and no warmth. His CBC remained stable and there was low concern for ongoing bleeding into the hip . # Antral polyps: Two sessile non-bleeding polyps of benign appearance were found in the antrum of the stomach, biopsies were taken and showed antral mucosa with hyperplasia of gastric pits, mucin depletion, and focal acute inflammation consistent with foveolar hyperplastic polyp; no histologic evidence of H. pylori seen. . # Seborrheic Dermatitis: Patient had mild seb derm on admission, which improved with Ketoconazole cream . # Communication: Patient, Brother [**Name (NI) **] [**Name (NI) 27345**]; cell [**Telephone/Fax (1) 27346**]; home [**Telephone/Fax (1) 27347**] # Code: Full Code . ========== TRANSITIONAL ISSUES: -Vitally important to give rifaximin and lactulose to produce [**1-30**] BM per day -Patient discharged on standing potassium and magnesium supplementation, needs labs every other day for at least 2 sets to determine stability on this regimen -Continue to encourage abstinence from alcohol. Medications on Admission: Lactulose 30 mL TID Omeprazole 20 mg daily Prednisone 10 mg PO BID x 7 days (end [**1-11**]); 5 mg daily x 1 week (end [**1-17**]) Rifaximin 550 mg PO BID Folic acid 1 mg daily Magoxide 400 mg daily MVI w/ minerals Senna 17.2 mg PO qHS Thiamine 100 mg daily Vitamin D 1000 units daily Discharge Medications: 1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): Titrate to [**1-30**] bowel movements per day and/or clear mental status. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 6. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 9. potassium chloride 20 mEq Packet Sig: Two (2) PO once a day. 10. Outpatient Lab Work Full chemistry panel including Mg, LFTs including bilirubin, AST, ALT, Alk Phos, and CBC/diff weekly with results sent to [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]; Fax [**Telephone/Fax (1) 4400**] 11. Outpatient Lab Work Full chemistry panel with potassium and magnesium at least every other day starting [**2186-1-18**] until potassium and magnesium stabilize Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Hepatic encephalopathy Alcoholic cirrhosis Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You were admitted for confusion. This was most likely due to hepatic encephalopathy (this happens when your liver is not working well, and cannot remove all toxins from your blood). This improved with lactulose, which is a very important medication that helps remove toxins by increasing stool. Please make sure you continue taking this medication, and have at least [**1-30**] bowel movements per day. . We also did a procedure to look in your throat and stomach. This revealed a few dilated veins which can be seen in liver disease. You should continue to have this followed up with your outpatient team. . It will be important for you to follow-up with your doctors, as scheduled below. . Please note the following medication changes: . -STOP taking prednisone -START taking potassium chloride Followup Instructions: Department: LIVER CENTER When: FRIDAY [**2186-1-27**] at 10:20 AM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2186-1-18**]

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icd9cm

[ [ [] ] ]

[ "45.16", "38.97", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

12844, 12885

7082, 10984

327, 368

12972, 13087

3775, 4229

13971, 14341

2417, 2453

11632, 12821

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13888, 13948

266, 289

396, 1939

4238, 6636

13102, 13124

1961, 2045

2061, 2401

31,539

166,271

32822

Discharge summary

report

Admission Date: [**2124-12-30**] Discharge Date: [**2125-1-2**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: 88 yo F transfer from OSH with acute cholangitis. Patient initially presented to the outside hospital with a several hour history of confusion and nausea and vomiting. She became hypotensive at the OSH required resusicitation with pressors and also given Abx. She was transferred to [**Hospital1 18**] for definitive care Past Medical History: NIDDM, hypercholesterolemia, s/p cholectomy 20 years ago Social History: lives in [**Location (un) 3844**] with her daughters. does not drink or smoke. Family History: non-contributory Physical Exam: General - no acute distress, confused but may be directed HEENT - PERRL, EOMI, OPC CV - Regular rate and rhythm Pulm - Bibasilar crackles GI - Soft, nontender, nondistended EXT - No clubbing, cyanosis or edema Pertinent Results: Labs on Admission: [**2124-12-30**] 12:19AM PT-13.7* PTT-34.7 INR(PT)-1.2* [**2124-12-30**] 12:19AM WBC-25.4* RBC-2.39* HGB-7.9* HCT-22.8* MCV-95 MCH-33.1* MCHC-34.7 RDW-16.3* [**2124-12-30**] 12:19AM CRP-74.8* [**2124-12-30**] 12:19AM LIPASE-58 [**2124-12-30**] 12:19AM ALT(SGPT)-129* AST(SGOT)-222* CK(CPK)-133 AMYLASE-57 TOT BILI-2.0* [**2124-12-30**] 12:19AM GLUCOSE-200* UREA N-71* CREAT-2.6* SODIUM-139 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14 [**2124-12-30**] 12:30AM LACTATE-2.3* 12:19AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2124-12-30**] 12:19AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2124-12-30**] 06:04AM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-0.6* MAGNESIUM-1.0* [**2124-12-30**] 06:04AM CK-MB-27* MB INDX-13.7* cTropnT-0.69* [**2124-12-30**] 06:04AM ALT(SGPT)-112* AST(SGOT)-176* CK(CPK)-197* ALK PHOS-218* AMYLASE-45 TOT BILI-1.5 [**2124-12-30**] 04:14PM WBC-24.9* RBC-3.68*# HGB-11.6*# HCT-33.3*# MCV-91 MCH-31.5 MCHC-34.8 RDW-16.8* [**2124-12-30**] 04:14PM CK-MB-24* MB INDX-12.8* cTropnT-0.92* [**2125-1-2**] 05:40AM BLOOD WBC-10.1 RBC-3.91* Hgb-12.4 Hct-35.9* MCV-92 MCH-31.8 MCHC-34.7 RDW-16.3* Plt Ct-153 [**2125-1-2**] 05:40AM BLOOD Neuts-91.0* Lymphs-6.3* Monos-2.0 Eos-0.5 Baso-0.2 [**2125-1-2**] 05:40AM BLOOD Glucose-103 UreaN-42* Creat-2.0* Na-145 K-3.9 Cl-112* HCO3-20* AnGap-17 [**2125-1-2**] 05:40AM BLOOD ALT-39 AST-41* AlkPhos-155* Amylase-177* TotBili-0.4 [**2125-1-2**] 05:40AM BLOOD Lipase-644* [**2125-1-1**] 02:48AM BLOOD Lipase-230* [**2124-12-31**] 03:10AM BLOOD Lipase-42 [**2125-1-1**] 02:48AM BLOOD CK-MB-NotDone cTropnT-0.78* Pertinent Imaging: [**12-30**]: CT A/P - Bilobed 5.8 cm hyperdensity in the segment VII of the liver ?abscess v metastatic disease. 4.3 cm heterogeneous collection in duodenum ?diverticulum v fistula [**12-31**]: RUQ US - 3 hypoechoic lesions at the liver dome, which cannot be further characterized [**12-30**]: ERCP - Cholangiogram showed a single stricture that was 2cm long and was seen at the distal CBD. There was severe dilation of the proximal CBD. Successful placement of a 7 cm by 8.5 Fr Cotton [**Doctor Last Name **] biliary stent in the CBD using an Oasis stent introducer kit, with excellent drainage of bile Brief Hospital Course: Patient was admitted on [**2124-12-29**] from an OSH with sepsis, renal failure and suspected ascending cholangitis. Patient was transferred to [**Hospital1 18**] on Levophed with otherwise stable vital signs. Patient was found to have a WBC of 25.4 and elevated LFTs. Patient was given almost 10 liters of resuscitation fluid and was started on Unasyn. Given the septic picture acute cholangitis was suspected and the patient was transferred to the TICU and was taken for an ERCP which showed narrowing of the common bile duct with no stone present. A biliary stent was placed and the patient was transferred back to the TICU in stable condition. Cardiology was called regarding her elevated Troponin and they believed this was the result of demand ischemia and the patient would be suited with medical management. The patient did well post procedurally and was tranferred to the floor on PPD 2. During her hospital course the patient developed SVT and was seen by cardiology who felt as thought this was the result of heightened sympathetic activity in the setting of acute illness and [**Hospital 76427**] medical management with beta blocker. Her diet was advanced to regular without difficulty and antibiotics were continued. The family expressed that they would like to have her care continued at St. [**Hospital 13789**] Hospital in [**Location (un) 3844**] therefore the decision was made to transfer the patient there on [**2125-1-2**]. The patient will be admitted under the care of Dr. [**Last Name (STitle) 76428**]. Medications on Admission: Isordil SR 302 mg q24, metoprolol 25 mg qd, hctz 25 qd, cozaar 100 qd, synthroid 112 mcg qd, metformin 1000 [**Last Name (LF) **], [**First Name3 (LF) **] 81, lipitor 40 Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as directed per sliding scale Injection ASDIR (AS DIRECTED): please see attached sliding scale. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 10. Ampicillin-Sulbactam 3 gm IV Q8H 11. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift Discharge Disposition: Extended Care Facility: [**Doctor Last Name 1495**] josephs hospital Discharge Diagnosis: 1. acute cholangitis 2. sepsis 3. post-ERCP pancreatitis 4. renal failure Discharge Condition: stable for transfer to an outside hospital Discharge Instructions: You have been admitted to [**Hospital1 69**] with acute cholangitis. You have had an ERCP and a stent was placed. You have requested transfer to an outside hospital, which will continue your care. If there are any question regarding your care please call Dr. [**Name (NI) 56366**] office at [**Telephone/Fax (1) 600**] Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 52995**] in [**3-11**] weeks for a repeat ERCP to have the stent removed and the bile ducts reexamined. You may call his office to schedule a follow up appointment at ([**Telephone/Fax (1) 76429**]

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icd9cm

[ [ [] ] ]

[ "99.04", "51.87", "38.93" ]

icd9pcs

[ [ [] ] ]

6289, 6361

3437, 4967

270, 277

6479, 6524

1083, 1088

6893, 7142

820, 838

5188, 6266

6382, 6458

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6548, 6870

853, 1064

222, 232

305, 628

1102, 3414

650, 708

724, 804

44,491

185,763

6810

Discharge summary

report

Admission Date: [**2127-9-22**] Discharge Date: [**2127-9-26**] Date of Birth: [**2077-3-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6195**] Chief Complaint: hypertensive urgency/N/V Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 50y/o M with PMH of type 2 diabetes mellitus and ESRD s/p living related donor transplant in [**2118**] (now failing) admitted to the MICU with hypertensive urgency in the setting of nausea and vomiting leading to inability to take po medications. The patient reports that he has had nausea for the past several months. Two days prior to admission he began vomiting and began to have loose stools. He had 5 episodes of loose stools overnight. Denies abdominal pain. Denies hematochezia or hematemesis. Denies fever/chills. Denies recent travel or sick contacts. [**Name (NI) **] his diarrhea worsened after eating chinese "hot and sour" soup, but notes no other food exposures. . In the ED, the patient was given a GI cocktail, labetalol 20mg IV X1 and 40mg IV X1, ASA 325mg, and started on a nitro gtt. VS: T 98.3, HR 70, BP 229/110, RR 19, O2 100% RA. EKG unchanged from prior. . On arrival to the MICU the patient was c/o nausea and had emesis X1. Denies abdominal pain. BP 200/100 systolic on labetalol and nitro gtts. He denies changes in vision. Denies chest pain or dyspnea. Denies worsening edema or lesions of the skin. Past Medical History: - DM II, mild PNP, c/b b/l foot ulcers - HTN - ESRD s/p renal Tx in [**2118**] . - Debridement of L foot ulcer years ago - debridement of R foot ulcer Social History: No EtOH, cig, IVDU Unemployed x 2 years. He is divorced and living with his sister and her children. Family History: Mother, Father, Paternal GM, [**4-13**] siblings have DM. Parents and multiple siblings with HTN. Physical Exam: GEN: pleasant, NAD HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions NECK: supple, no JVD RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, 3/6 systolic murmur best heard at apex ABD: NT/ND +b/s, soft EXT: no clubbing or cyanosis, warm, good pulses, [**1-1**]+ ankle edema b/l, SKIN: no rashes/no jaundice NEURO: AAOx3. Moves all extremities, no asterixis Pertinent Results: 138 99 70 AGap=17 -------------< 107 4.2 26 6.6 Comments: K: Hemolysis Falsely Elevates K CK: 584 MB: 6 Trop-T: 0.20 Ca: 7.4 Mg: 1.5 P: 6.3 ALT: 12 AP: 65 Tbili: 0.6 Alb: AST: 33 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 27 8.3 6.0 >----< 139 25.5 N:76.3 L:15.8 M:6.3 E:1.3 Bas:0.3 . cxr - good inspiratory effort, cardiomegaly, no infiltrate or effusion . renal us - Tardus parvus waveforms in the renal arteries, concerning for proximal renal artery stenosis. This finding is new since prior study. Minimal elevation in the resistive indices. Brief Hospital Course: A/P: Pt is a 50 yo M with a PMH of type 2 DM, ESRD, s/p living donor transplant (now failing), admitted with N/V/D and hypertensive urgency. . 1) Hypertensive Urgency - On presentation, patient had BPs up to 220s systolically requiring labetalol and ntg gtt, in the setting of being unable to tolerate PO medications for several days. The drips were subsequently weaned off overnight in the ICU and by hospital day 2, he was tolerating pos without difficulty. He was then transferred to the medical floor where his home-HTN regimen was restarted. The patient had occasional elevations of his SBPs to the 180s, occasionally associated with headaches, which responded to po medications and an uptitration of his prior doxazosin dose from 1 mg to 2 mg qhs. Given his progressive renal disease, the decision was made to start HD during this admission (see below). If his BPs remain elevated as an outpatient, addition of an ACE-I for angiotensin pathway blockade should be considered given known proximal renal artery stenosis on a renal ultrasound on admission. . 2) N/V/D - Pt reports several months of nausea and poor appetite, likely due to uremia in the setting of rising creatinine. Onset of emesis and diarrhea over past 2 days may have been due to superimposed gastroenteritis. Symptoms rapidly resolved upon admission. . 3) ESRD s/p failing living related donor transplant - Renal team consulted for possible initiation of HD. Given graft failure, uremic symptoms, and HTN urgency, the decision was made to initiate HD during this admission. The patient underwent a tunneled HD line placement by IR on hospital day 1 without complication and HD was initiated on HD 2. He tolerated 3 sessions of HD without complication. Epogen and calcitriol were switched to be given at HD. Cellcept was discontinued at the recommendation of the renal team. He will continue on prednisone and tacrolimus as well as phoslo. A PPD was negative. He will continue to receive HD as an outpatient at [**Hospital1 18**] q Tues, Thurs, and Sat followed by placement at [**Location (un) **] dialysis on [**10-7**]. . 4) Anemia ?????? Likely due to ESRD, chronic disease, with possible contribution from immunosuppressive meds. Hematocrit stable during admission. Received epogen at HD. . 5) DM type 2 - Pt reports he has not been using long-acting insulin at home. Placed on ISS. He will need to f/u with his PCP in regards to diabetes care. Medications on Admission: CellCept [**Pager number **] mg twice a day prednisone four milligrams a day Prograf four milligrams twice a day insulin nifedipine 90 mg two tabs once a day metoprolol 300 mg daily doxazosin 1 mg daily Lasix 80 mg a day Aranesp injections PhosLo calcitriol 1mcg daily Discharge Medications: 1. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 6. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 8. Insulin Lispro 100 unit/mL Solution Sig: per enclosed sliding scale units Subcutaneous qachs. Disp:*5 bottles* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - Hypertensive urgency. - renal artery stenosis. . Secondary: - End stage renal failure. - Diabetes mellitus type II. Discharge Condition: stable. Discharge Instructions: You were admitted with elevated blood pressure, nausea, vomiting and diahrrea. You were first treated in the intensive care unit with blood pressure medications. Ultrasound of your pelvis showed narrowing of your kidney arteries, which may be a contributing factor for your elevated blood pressure. A tunneled catheter was placed in your right neck vein for Hemodialysis. You were transfered to the medicine floor where we continued your treatment with blood pressure medication and hemodialysis. . You are scheduled for dialysis Tuesday [**9-30**], Thursday [**10-2**] and saturday [**10-4**] at 7:30am here at [**Hospital1 18**] on [**Hospital Ward Name 121**] 7. You are scheduled to go to [**Hospital6 **] in [**Location (un) **] on Tuesdays, Thurdays and saturdays of the following weeks beginning on [**10-7**]. . For your elevated blood pressure, please continue to take your blood pressure medications. We have made the following changes to your medications: 1) We have increased your doxazosin dose to 2 mg daily. 2) Cellcept was discontinued. 3) Calcitriol and epogen are now given at dialysis and you will not have to take these yourself. 4) Lasix was discontinued. . For your diabetes, you were placed on an Insulin sliding scale. Please check your blood glucose and use your insulin as indicated by the sliding scale. . In the future please return to the emergency room if you experience abnormal headaches, blurry vision, change in your thinking, abnormal movements, abdominal pain, [**Last Name (un) 22761**] in your stool or blood in your urine. Followup Instructions: - Please follow up with your appointment for an ECHOCARDIOGRAM on [**2127-10-2**] at 2:00 - Phone:[**Telephone/Fax (1) 62**]. . - Please follow up with your appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2127-10-9**] at 11:20 - Phone:[**Telephone/Fax (1) 250**] . - Please follow up with your appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**] on [**2127-10-14**] at 9:30 - Phone:[**Telephone/Fax (1) 463**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**] Completed by:[**2127-9-26**]

[ "585.6", "440.1", "250.40", "584.9", "E849.8", "E878.0", "996.81", "285.21", "403.01", "583.81" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

6497, 6503

2956, 5381

340, 346

6674, 6684

2352, 2933

8297, 8952

1832, 1931

5701, 6474

6524, 6653

5407, 5678

6708, 7649

1946, 2333

7678, 8274

276, 302

374, 1522

1544, 1697

1713, 1816

32,433

111,453

32833

Discharge summary

report

Unit No: [**Numeric Identifier 76441**] Admission Date: [**2201-1-11**] Discharge Date: [**2201-1-26**] Date of Birth: [**2201-1-11**] Sex: M Service: NB PATIENT IDENTIFYING INFORMATION: The patient's discharge name is [**Name (NI) **] [**Name (NI) **]. His [**Hospital3 1810**] medical record number is [**Numeric Identifier 76442**]. HISTORY OF PRESENT ILLNESS: This is the former 585 gram product of a 26 week twin gestation pregnancy, born to a 43 year-old, G2, P1 woman. Prenatal screens: Blood type 0 positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta strep status unknown. This was a vaginal insemination pregnancy with donor sperm, resulting in monochorionic/diamniotic twins. Twin-to-twin transfusion syndrome was noted at 17 weeks. The mother underwent several amnioreductions for polyhydramnios on the recipient twin. Two days prior to delivery, 1.9 liters of fluid was removed. On the day of delivery, there was serious concern for the deteriorating status of the recipient twin. The mother was taken to elective Cesarean section under epidural and spinal anesthesia. This twin number 2 emerged from the breech position. He required bagged mask ventilation and was intubated for respiratory distress. Apgars were 5 at 1 minute and 8 at 5 minutes. He was transferred to the Neonatal Intensive Care Unit for treatment of prematurity. This was the identified donor twin in the twin-to-twin transfusion syndrome. Anthropometric measurements upon admission to the Neonatal Intensive Care Unit, weight was 585 grams; length 32 cm; head circumference 22 cm, all less than 10th percentile for less than 26 weeks gestation. PHYSICAL EXAMINATION AT DISCHARGE: Weight 753 grams. Head circumference 22.5 cm. Length 33 cm. General: Non dysmorphic, intubated, preterm male. Skin: Bronze in color. Warm and dry with flaking areas. Head, ears, eyes, nose and throat: Anterior fontanel open and flat. Sutures apposed. Eyes: Open with alert gaze. Orally intubated. Palate intact. Symmetrical facial features. Neck supple without masses. Chest: Breath sounds clear and equal, well aerated with ventilator breaths. Cardiovascular: Regular rate and rhythm. No murmur. Normal S1 and S2. Femoral pulses +2. Abdomen: Full, slightly tense, nontender to palpation. Faint bowel sounds. Cord remnant on and drying. Genitourinary: Preterm male. Mild swelling in inguinal canal with extension into the scrotum, noted to be air on x-ray. Anus patent. Extremities: Moves all, straight with normal digits. Neuro: Tone and reflexes consistent with gestational age. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: Respiratory: This infant received 3 doses of surfactant. He was initially managed on the conventional ventilator with initial settings of peak inspiratory pressure of 34 over positive end expiratory pressure of 6 and intermittent mandatory ventilatory rate of 38 and 40 to 60% oxygen. He was able to wean over the first 48 hours of life when he had worsening of his respiratory status and was transferred to the high frequency oscillating ventilator. He continued on the oscillator until [**2200-1-25**], day of life 14, when he was transitioned to the conventional ventilator. At the time of discharge, his ventilatory settings were peak inspiratory pressure of 21, positive end expiratory pressure of 26, intermittent mandatory ventilatory rate of 22 and oxygen requirement of 21 to 30%. His most recent capillary blood gas had a pH of 7.27, a Pc02 of 61. He has been noted to have old blood-tinged secretions from his endotracheal tube. Cardiovascular: This infant had profound hypotension noted at birth that persisted through the first week of life. He was treated with multiple volume boluses and started on Dopamine. His maximum Dopamine requirement was 25 mcg/kg/min. He received two, 3-dose courses of hydrocortisone for his intractable hypotension. A murmur had been noted on day of life 2 and the infant received a single dose of indomethacin. Repeat echocardiogram showed a patent ductus arteriosus with intermittent bidirectional flow. A repeat echo on [**2200-1-20**] showed a "huge" 3.5 mm patent ductus arteriosus with continuous left to right flow. He was taken for patent ductus arteriosus ligation on [**2201-1-21**]. He was able to wean off the Dopamine within 16 hours of surgery. At the time of transfer, his baseline heart rate is 140 to 160 beats per minute with a recent blood pressure of 69 over 38 mmHg. Mean arterial pressure of 50 mmHg. The rest of his cardiac echo showed a patent foramen ovale, no other structural heart disease noted and mild right ventricular hypertension. Fluids, electrolytes and nutrition: This infant was initially n.p.o. and maintained on IV fluids. He had umbilical arterial and venous catheters placed. The infant has remained n.p.o. through his entire Neonatal Intensive Care Unit. A percutaneously inserted central catheter was placed in the left saphenous vein with its tip in the inferior vena cava. At the time of discharge, he is receiving parenteral nutrition of 16% glucose with amino acids of 1.7%. Due to his cholestatic jaundice, his TPN was being cycled off for 4 hours per day. Serum triglycerides were stable on 2 grams per kg per day of intra-lipids which was being held for one day due to the concern of the cholestatic jaundice. Serum electrolytes were monitored closely during admission and most recently were sodium of 131, potassium of 4.1, chloride of 90, carbon dioxide of 24. Weight on the day of discharge is 753 grams. This infant had significant renal insufficiency with little to no urine output through the first 5 days of life. At the time of discharge, his urine output is 3 to 4 ml per kg per hour. His serum creatinine peaked at 3.6 and most recently checked was 2.9 on [**2200-1-26**]. A renal ultrasound was performed showing echogenic kidneys but otherwise normal collecting system. The etiology for the renal insufficiency was unclear. Infectious disease: This infant was evaluated for sepsis upon admission to the Neonatal Intensive Care Unit. A complete blood count was notable for a white blood cell count of 15,300 with 12% polymorphonuclear cells, 0% band neutrophils. A blood culture was obtained and the infant was started on IV ampicillin and gentamycin. With the onset of his gastrointestinal perforation on day of life one, his antibiotic coverage was switched to Zosyn. The Zosyn was adjusted for dosing for his renal insufficiency and he received 50 mg/kg per day. Blood cultures obtained on [**1-11**] and [**2200-1-12**] were no growth. Hematology: This infant is blood type 0 positive and direct antibody test negative. He has received numerous transfusions of all blood products including packed red blood cells, fresh frozen plasma, cryoprecipitate and platelets. He had a mild coagulopathy around the time of his gastrointestinal perforation. His coagulation studies improved after infusions of fresh frozen plasma. His most recent coagulation studies were on [**2200-1-24**] with a PT of 14.8, PTT of 49.1 and fibrinogen of 153. Of note, his most recent platelet count was 429,000 with a white blood cell count of 37,100 with 76 polymorphonuclear cells, 3% band neutrophils. His lowest white count occurred on day of life 4 at 4,600. Gastrointestinal: As previously noted, this infant suffered a gastrointestinal perforation which was temporarily related to a single dose of indomethacin, given for a symptomatic patent ductus arteriosus. The infant was evaluated by this general surgery consultation team from [**Hospital3 1810**] and 2 Penrose drains were placed. The perforation occurred on [**2200-1-12**]. The drains were removed on [**2200-1-22**]. Then 24 hours after the drains were removed, free air was once again noted on the abdominal x-rays. This was followed closely and on [**2200-1-26**], there appeared to be substantially more free air in the peritoneum with dissection down into the scrotum. The surgical team from [**Hospital3 1810**] was reconsulted and decision was made for the infant to be transferred to [**Hospital3 1810**] for an exploratory laparotomy. This infant also required treatment for unconjugated hyperbilirubinemia with phototherapy. The phototherapy was discontinued when the direct serum bilirubin began to rise. It was first noted to be 1.4 on day of life #8 and subsequently on day of life #5 was 2.2 mg/dl. On [**2200-1-24**], it was 2.6 mg/dl and most recently on [**2201-1-26**], it was 5.0 mg/dl. The etiology of the elevated direct bilirubin is unknown but is thought to be due to lack of feeding and prolonged PN and IntraLipids. An abdominal ultrasound was obtained on [**2200-1-23**] (his second) that showed echogenic kidneys without hydronephrosis, a distended gallbladder without stones or sludge, no gross biliary ductal dilatation. Free intrabdominal air and air within the liver was also noted. Neurology: This infant has had 4 head ultrasound with all results within normal limits, most recently on [**2201-1-19**]. He has maintained a totally normal neurologic examination since admission. He has been treated with Fentanyl intravenously for pain and sedation. At the time of discharge, he is receiving 1.2 mcg IV q. 2 to 3 hours. Sensory: Audiology: Hearing screening has not yet been performed but is recommended prior to discharge. Ophthalmology: This infant has not had his eyes examined for retinopathy of prematurity. His first examination will be due at 6 weeks of life. Psychosocial: [**Hospital1 69**] social worker has been involved with the family. Contact social worker is [**Name (NI) 46381**] [**Name (NI) 36527**] and she can be reached at [**Telephone/Fax (1) 56048**]. This parenting situation is 2 mothers. They have a 15 month old child at home. They have been very involved in [**Known lastname 43135**] care during admission. At one point, there was a "do not resuscitate" order entered at the height of his illness with his renal insufficiency and hypotension. The order was rescinded prior to his patent ductus arteriosus ligation. DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**], [**Location (un) 86**], for exploratory laparotomy surgery. The primary pediatrician is Dr. [**First Name4 (NamePattern1) 2270**] [**Last Name (NamePattern1) 59017**]. [**Hospital1 2921**] in [**Hospital1 3494**]. Telephone number [**Telephone/Fax (1) 76443**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. N.p.o./IV fluids at 140 ml/kg per day of peripheral nutrition: Solution 16% glucose, 1.7% amino acids with 5 meq of sodium and 2 meq of potassium for 100 ml. Reinitiate IntraLipds. 2. Medications: Zosyn 30 mg IV q. 24 hours. Vitamin A 5000 units IM q. Monday, Wednesday and Friday for a total of 12 doses. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u. (may be provided as a multi-vitamin preparation) daily until 12 months corrected age. 3. Car seat position screening is recommended prior to discharge. 4. State newborn screens were sent on [**2200-1-16**]. No notification of abnormal results to date. 5. Immunizations: No immunizations have been administered thus far. 4. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following four criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. This infant has not received the rotavirus vaccine. The Americ an Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. DISCHARGE DIAGNOSES: 1. Prematurity at 26 weeks gestation. 2. Small for gestational age. 3. Twin #2 of twin gestation. 4. Twin-to-twin transfusion syndrome. This is the donor twin. 5. Respiratory distress syndrome. 6. Hypotension, resolved. 7. Suspicion for sepsis. 8. Patent ductus arteriosus, status post ligation [**2201-1-21**]. 9. Indirect hyperbilirubinemia, resolved. 10. Gastrointestinal perforation with pneumoperitoneum, s/p Penrose drain placement. 11. Anemia of prematurity. 12. Disseminated intravascular coagulopathy, resolved. 13. Renal insufficiency, improving. 14. Cholestasis [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37201**] Dictated By:[**Name8 (MD) 75740**] MEDQUIST36 D: [**2201-1-27**] 01:32:58 T: [**2201-1-27**] 05:10:42 Job#: [**Job Number 76444**]

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Discharge summary

report

Admission Date: [**2174-1-18**] Discharge Date: [**2174-1-28**] Date of Birth: [**2096-7-19**] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Lisinopril Attending:[**First Name3 (LF) 5037**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Renal biopsy complicated by hemoperitoneum Right internal jugular central line placement History of Present Illness: 77 yo woman with CAD s/p stent and restented in [**2163**] and [**2170**], IDDM, HTN, HLD, h/o renal transplant who presents with DOE, SOB, tachypnea for today. States she has had no weight gain Otherwise ROS negative except for general fatigue. Denies dietary indiscretion and states she has been taking all of her medications as prescribed. . In the ED, initial vitals were P 57, 110/29, R 18, O2 100% on 2L. She was hypoxic 86% RA, improved with nebX3 to 90-92% RA. Lung exam was bilateral wet-sounding rales [**1-22**] way up. No significant lower extremity edema. Speaking in full sentenses. CXR looked like fluid overload. BNP was increased from prior, CK elevated but MBI and trop negative. K 5.9, received nebs, ASA 325, calcium gluconate 1G, 1 amp D50, 1amp bicarb, kayexalate 30G PO insulin 10U. Hct 29 (baseline). Renal function worse (Cr now 4.2), lasix 40mg IV X1.. . EKG slightly peaked T's. . Patient recently admited for CHF exacerbation. She was d/c'd on oxgen 1-2L which she has been using. She recently missed her appointment with Dr. [**Last Name (STitle) **] for PFTs and f/u of ground glass opacities and bronchial dilation. . VS on transfer to the floor, 52, 132/43, 17, 100% 3L. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes (poorly controlled on insulin (reports takes BS 3x per day, often high 100s to 200), +Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: PCI--[**2163**] stenting of the RCA, restented in [**2170**] -PACING/ICD: . Non-cardiac: -recent admission in early [**Month (only) 321**] for resp failure, CHF exacerbation complicated by NSTEMI and transplant pyelonephritis - ESRD [**2-22**] DM/HTN s/p deceased donor renal transplantation in [**3-26**]. (baseline Cr 2.0) -last bx [**12-27**]- high proportion of glomeruli sclerosed -hemodialysis for 1.5 yrs prior to txplant -Hypothyroidism Social History: Widow, no children, retired from [**Hospital1 18**], lives with sister and other family members, cares for [**Age over 90 **] year old mother at home. Able to exercise with 15-20 minutes walking daily. Smoking- quit smoking 15 years ago, prior had [**3-24**] cigs/day ETOH- None Illicits- None Family History: Brother died [**2-22**] cardiac arrest during a kidney transplant surgery; other siblings with DM and HTN Physical Exam: baseline wt 152 lbs per Dr[**Name (NI) 9388**] note from [**12-29**]; pt states she has been 150 at home. Is 156 here on our scale. VS: 97.7, 59, 124/52, 98%/4L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. pupils constricted, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MM. NECK: supple, no elevated JVP CARDIAC: RR, normal S1, S2. III/VI MR murmur. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB except crackles at bases b/l L>R. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No calf TTP. Pulses: 2+ DPs b/l Pertinent Results: at admission: 9.0>29<278 N 83.5, L10.5, M4.1, E1.5, B0.3 . 136 | 100 | 94 ----------------103 5.9 | 21 | 4.2 baseline Cr 1.5 -3, had been trending up since discharge . repeat: 135/4.9/96/27/90/4.4<pend . proBNP: 7531 . CK 900 down to 630 then 404 MB index 1.9-2.0, Trop <.01 X3 . Tac level [**1-19**] <2 ALT 18, AST 38, AlkPhos 34, TB 0.4 . UA neg for UTI . [**9-29**] Chol 167, LDL 100, HDL 29, TG 190 . EKG: SR @70, NL axis approx 0 degress, NL intervals, peaked T waves present previously but mildly increased in anterior leads . CXR [**1-18**]: Since examination of [**2173-11-29**], there has been interval improvement in moderate pulmonary interstitial edema, though mild interstitial pulmonary edema persists, as manifested by prominence of the interstitial markings and redistribution of the pulmonary vasculature. Trace left pleural effusion. . 2D-ECHOCARDIOGRAM: [**11-29**] The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). Tissue Doppler imaging suggests an increased left ventricular filling pressure PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2172-8-14**], no major change is evident. . CARDIAC CATH: [**6-26**] 1. Selective coronary angiography of this right dominant system demonstrated two vessel CAD. The LMCA was calcified but without significant disease. The LAD ahd diffuse disease, especially in teh mid segment up to 70%. The LCX had mild diffuse disease. The RCA had a 90% hazy lesion in the mid vessel which was diffusely diseased and calcified. The distal vessel had 50-60% ISR. 2. Limited hemodynamics demonstrated minimally elevated left sided filling pressures with LVEDP=13 mmHg. 3. Left ventriculography was deferred. 4. Successful placement of two overlapping Vision bare metal stents in proximal RCA with considerable difficulty and effort (3.0 x 12 mm distally and 3.0 x 8 mm proximally). Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). FINAL DIAGNOSIS: 1. Two vessel CAD. 2. Mild left ventricular diastolic dysfunction. 3. Successful placement of two bare metal stents in proximal RCA. TTE [**2174-1-19**] The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. At least mild to moderate ([**1-22**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2173-11-23**], mitral regurgitation is now more prominent, the right ventricle is now larger and estimated pulmonary artery systolic pressure is now higher. CXR [**2174-1-18**] FINDINGS: Since examination of [**2173-11-29**], there has been interval improvement in moderate pulmonary interstitial edema, though mild interstitial pulmonary edema persists, as manifested by prominence of the interstitial markings and redistribution of the pulmonary vasculature. Trace left pleural effusion. No evidence of pneumothorax. Stable appearance of cardiomediastinal silhouette demonstrates moderate cardiomegaly, atherosclerotic calcification and tortuosity of the thoracic aorta. Multilevel degenerative change of the thoracolumbar spine is noted with marginal osteophytic formation. IMPRESSION: Mild interstitial pulmonary edema, improved since [**2173-11-29**]. Renal U/S [**2174-1-20**] FINDINGS: The renal transplant is visualized in the right lower quadrant, and measures 11.4 cm longitudinally. The renal cortex is well preserved, with relatively good corticomedullary differentiation. Two nonobstructing calculi are again seen in the upper pole and interpolar region as before and are unchanged. There is no associated hydronephrosis. On color Doppler, there is adequate perfusion of the renal transplant. Again the resistive indices are increased, however, more so than on the previous ultrasound. The resistive indices vary from 0.87 to 0.92 within the kidneys. The peak systolic velocity in the main renal artery is 135 cm/sec. Again diastolic flow is almost absent as before. Views of the urinary bladder show a urinary catheter within the urinary bladder, which is empty. There are no perinephric collections. CONCLUSION: 1. Further increase in resistive indices, possibly due to rejection. 2. Two nonobstructing renal calculi as before. . Renal biopsy PATHOLOGY: 1. There is no evidence of acute cellular or humoral rejection in this sample. 2. The differential diagnosis includes obstruction, drug nephrotoxicity, and especially "acute tubular necrosis". 3. Cortical sample size is limited. Brief Hospital Course: 77 yo woman with CAD s/p stent and restent in [**2163**] and [**2170**], IDDM, HTN, HLD, h/o renal transplant who presents with DOE. . # Dyspnea/acute on chronic diastolic CHF: With mild elevation in weight here, no associated symptoms, and elevated BNP, as well as CXR findings, concerning for acute on chronic diastolic CHF exacerbation. In the setting of worsened forward flow this would account for both dyspnea and acute on chronic renal failure. Differential also includes infectious, however WBC not significantly increased and patient remained afebrile. With immunosuppression, and recent CT lung findings of ground glass, concerning for opportunistic infection or lymphoproliferative d/o causing a primary pulmonary process. UA was significant for no infection. CXR did not show a pneumonia. PE also on the differential, however patient would not currently tolerate a CTA given her renal failure and have other more likely reasons for dyspnea. Ischemia in the differential, however CEs not elevated and EKG unchanged and patient without CP. Patient did not respond appropriately to IV Lasix so a Lasix drip was started on [**1-20**]. A TTE showed worsened mitral regurgitation. Patient eventually diuresed sufficiently with the lasix drip and metolazone with a 5 kg weight loss, although she maintained a ~2L oxygen requirement (up from baseline of 1-2L oxygen at home. Patient also continued to have persistent bibasilar crackles, although gradually improved throughout her hospital course. Patient underwent renal biopsy that was complicated by hemoperitoneum. Although she became volume up as a result of her transfusions for the hemoperitoneum, she appeared to be autodiuresing during her MICU stay. Upon transfer to the floor, patient was diuresed with home PO Lasix 80mg with good effect. It was ultimately decided by the renal transplant team to continue patient on home Lasix upon discharge and Metolazone 2.5mg daily as needed (if weight gain exceeds 2 pounds daily when checked in the mornings post-void). These instructions were clearly conveyed to patient and family (sister/nephew) upon discharge. . # Anemia: Possibly due to renal failure. Iron, B12 and folate studies were significant for elevated ferritin, as likely acute phase reactant. All other values were within normal limits (iron, TIBC, B12, folate etc.) She required 1U of PRBC on [**1-20**]. LFTs normal. [**Month (only) 116**] consider outpatient EPO. Patient developed hemoperitoneum during renal biopsy, associated with hypotension and Hct drop from 33.6 to 27.7. Patient required 4 units of pRBCs, 2 units platelets, 2 units of cryoprecipitate. By [**2174-1-25**], patient's Hct had stabilized to her baseline anemia. Patient was started on ferrous sulfate. . # [**Last Name (un) **] sp renal transplant: Cr elevated to 4.4 from baseline 1.6, likely due to poor forward flow as FEurea inconclusive and no casts in urine sediment. Patient was followed by the renal transplant service. [**Last Name (un) **] was held, upon discharge as well. Renal transplant followed. MMF and prograf were continued; Tac level was low on day after admission but became therapeutic by the day of discharge. Daily tacrolimus levels never exceeded therapeutic level for any concerns of renal toxicity. Bactrim was continued for prophylaxis. Urine sediment did not have evidence of ATN. Transplant kidney ultrasound on [**1-20**] showed possible rejection so patient underwent a biopsy of her kidney graft on [**2173-1-24**] for evaluation of her acute on chronic renal failure that was complicated by hemoperitoneum, hypotension, and hct drop from 33.6 to 27.7. She was ultimately transfused 4 units of PRBCs, 2 units platelets, 2 units of cryoprecipitate. Her hematocrit eventually stabilized. Transplant surgery and nephrology followed her during this portion of her hospitalization. Patient's renal biopsy pathology ultimately was negative for acute cellular or humoral rejection. With gentle diuresis and discontinued [**Last Name (un) **], patient's creatinine trended down to 2.6. Patient did have some abdominal pain during the latter portion of her hospitalization, felt likely due to the hemoperitoneum. She was initially treated with IV Morphine, then Dilaudid PO and eventually Tylenol PRN with good effect. Her diet after the hemoperitoneum was started at clears and gradually advanced without complications. Patient was also briefly treated with cipro/vanc/flagyl while in the MICU and on the first day back on the floor for the hemoperitoneum. . #. AG metabolic acidosis: Most likely due to ARF and resolved quickly after admission. . #. Hyperkalemia: Resolved after ED intervention. [**Month (only) 116**] consider restarting [**Last Name (un) **] in future with close monitoring. Held [**Last Name (un) **] during this admission and upon discharge given patient's hyperkalemia and acute on chronic renal insufficiency. . # Elevated CK: Ddx includes myositis versus mild rhabdo, ACS but unlikely as MB index normal and no increase in troponin. Started to downtrend immediately at admission. Unclear etiology. . # HTN: Goal SBP 130. Patient had BPs more in the 100-120 range. Amlodipine was continued and Valsartan was held. After patient's hemoperitoneum, all blood pressure medications were held. Once her blood pressure (SBP150-160s) and hematocrit stabilized, patient was gradually resumed on her blood pressure medications, starting with Metoprolol and then Amlodipine. Valsartan was held upon discharge per above. . # DM: Placed on Insulin S/S during her hospitalization. Patient was encouraged to resume her home insulin sliding scale and fixed doses of glargine and NPH upon discharge. She is followed at the [**Last Name (un) **] Diabetes Center. . # Hypothyroidism: most recent TSH: 1.1 in [**11-29**] so continued Levothyroxine . # HLD: Continued Atorvastatin and Tricor as no sxs of rhabdomylysis. . # CODE: Full (documented from previous and confirmed with Filipino interpreter over the phone) . Patient was discharged with home oxygen and physical therapy # Contact: sister: [**Name (NI) 105179**] [**Name (NI) 105180**] [**Telephone/Fax (1) 105181**] Medications on Admission: per dc summary from [**2173-12-5**]- patient does not recall 1.Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2.Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3.Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4.Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6.Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7.Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 8.NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty (30) units Subcutaneous twice a day. 9.Insulin Lispro 100 unit/mL Solution Sig: Six (6) units Subcutaneous twice a day: to be taken with breakfast and dinner. 10.Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11.Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). Disp:*180 Capsule(s)* Refills:*2* 12.Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13.Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14.Oxygen 1L/min continuous flow portable oxygen to maintain O2 sat greater than 92%; Room air sat 84% during inpatient stay Diagnosis: diastolic heart failure 15.Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). . ALLERGIES: penicillin (denies), iodine, lisinopril Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO HS (at bedtime): take 1 pill after dinner for 2 weeks then increase to 1 pill twice a day. Disp:*30 Tablet(s)* Refills:*2* 2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for weight gain >2 pounds : ONLY TAKE AS NEEDED: When your daily weight, checked in the morning, is 2 pounds heavier than the day before(weigh yourself only after you have urinated in the morning). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 12. Insulin Please resume your home insulin sliding scale, glargine and NPH 13. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 14. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Home Oxygen 1L/min continuous flow portable oxygen to maintain O2 sat greater than 92% Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: - Acute on chronic diastolic CHF - Acute on chronic renal failure . Secondary: - Insulin dependent diabetes mellitus - Hyperlipidemia - Hypertension Discharge Condition: Mental Status: alert and oriented X3 Ambulating well without assistance Discharge Instructions: You were admitted to [**Hospital1 69**] because of shortness of breath. You had more fluid on your body than usual because of your heart failure. You were on a continuous dose of a medication called Lasix to help take off the fluid. Your weight at discharge was 147.6 pounds. . Your creatinine was also increased during this admission. You had an ultrasound of your kidney which was concerning for rejection of your transplant. Renal biopsy samples, however, showed NO acute rejection of your kidney transplant. Your kidney function gradually removed. Unfortunately, you bled internally after the biopsy procedure. You received blood transfusions and the bleeding eventually stopped. You were followed by your nephrologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] during this hospitalization. . CONTINUE to take these medications: Cellcept 1000mg twice a day Bactrim once a day Metoprolol SR 100mg once a day Aspirin 81 mg once a day Lasix 80mg once a day Tricor 145 mg once a day Levothyroxine 88mcg daily Prograf 3 capsules twice a day Atorvastatin 20mg daily Amlodipine 10mg daily . CHANGE this medication: INSTEAD OF Metolazone 2.5 mg daily, ONLY TAKE Metolazone 2.5mg daily AS NEEDED: When your daily weight, checked in the morning, is 2 pounds heavier than the day prior (weigh yourself only after you have urinated in the morning) . RESUME your home insulin sliding scale, glargine and NPH . STOP taking this medication: Valsartan . Also START taking this medication: Ferrous Sulfate 325 mg (iron) after dinner. Take one pill for 2 weeks. Then take 1 pill twice a day. Be sure to take Colace with this medication since it can cause constipation. Followup Instructions: You have the following appointments: Your primary care doctor, Dr. [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D. Date/Time:[**2174-2-3**] 11:40 . Your kidney doctor (nephrologist), Dr. [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2174-2-3**] 2:00 . Your eye doctor (opthalmologist), Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2174-3-9**] 9:30 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

[ "428.33", "244.9", "424.0", "414.00", "998.11", "V42.0", "272.4", "E879.8", "585.6", "568.81", "276.7", "V45.82", "V46.2", "584.8", "588.89", "458.29", "790.99", "428.0", "V58.67", "250.00", "403.91", "410.72", "V45.81", "285.1", "416.8", "V58.44", "285.21", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "38.93", "55.23" ]

icd9pcs

[ [ [] ] ]

18922, 18979

9621, 15793

333, 424

19181, 19181

3977, 6556

20998, 21650

3189, 3297

17362, 18899

19000, 19160

15820, 17339

6573, 9598

19279, 20975

3312, 3958

2366, 2860

274, 295

452, 2173

19196, 19255

2195, 2346

2876, 3173

3,851

107,139

30306+57691

Discharge summary

report+addendum

Admission Date: [**2193-12-23**] Discharge Date: [**2194-1-18**] Date of Birth: [**2130-5-22**] Sex: M Service: SURGERY Allergies: Ceftriaxone / Piperacillin Sodium/Tazobactam / Heparin Agents Attending:[**First Name3 (LF) 2597**] Chief Complaint: aortoenteric fistula Major Surgical or Invasive Procedure: [**12-27**] ex lap, NAIS (Neo-Aorto-Iliac Surgery, [**Last Name (un) 72148**] procedure), primay duodenal & pyloric exclusion, G & J tubes [**1-2**] ex lap, duodenostomy tube placement [**1-10**] percutaneous CT guided abdominal abscess drainage [**1-12**] ex lap, end duodenostomy, small bowel resection x2, G tube, J tube, repair of aortic tear multiple central line, arterial line and swan placements History of Present Illness: 63M s/p ruptured mycotic AAA repair with Dacron tube graft [**3-27**], now with infected AAA graft site by CT & MR. His symptoms include sharp epigastric and mid-back pain, low grade fevers and general failure to thrive. Past Medical History: PMH: htn, etoh abuse (recently stopped drinking 1 month ago), hyperlipidemia PSH: bilateral inguinal hernias, endo AAA repair x 2 ([**3-27**]) Social History: pos smoker / recently quit pos drinker Family History: n/c Physical Exam: ON PRESENTATION PE: v/s 98.9 87 124/76 20 95RA Gen: thin male in intermittant severe distress with movement, NAD when perfectly still, well-appearing HEENT: NC/AT, PERRLA bilat., slight L lateral strabismus, MMM, soft neck without LAD Cor: RRR without m/g/r, no bruits, no JVD Lungs: CTA bilat., no w/r/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: +BS, soft, NT, ND, no masses, 'swiss cheese' type incisional hernia at midline laparotomy incision Rectal: guaiac negative PVasc: warm feet, no edema Pulses: fem [**Doctor Last Name **] PT DP R palp palp palp palp L palp palp palp palp Ext: no tissue loss Neuro: grossly intact and non-focal Pertinent Results: review carevue Brief Hospital Course: review chart for specfics [**12-23**]: admitted to vascular. ID, neurosurg consulted [**12-27**]: operative repair of infected AAA. NAIS procedure performed. intraop surgical consult for duodenal involvement [**1-2**]: ex lap for duodenal leak - THAL patch performed [**1-10**]: EC fistula from duodenal repair & intraaabdominal abscess drained by CT [**1-12**]: aortic rupture. shock, UGIB, abddominal distension. taken to OR for ex alp, aortic repair & SB resection x 2 [**1-18**]: repear aortic rupture. shock, abddominal distension, blood from JP's, blown pupil. patient made CMO after discussion with family, who declined autopsy. ME & NEOB declined case. Medications on Admission: atorvastatin 20mg qd ASA 81mg qd mirtazapine 45mg qhs levofloxacin 500mg qd (prophylaxis) metoprolol 12.5mg [**Hospital1 **] methylprednisolone 4mg qd docusate 100mg [**Hospital1 **] lactobacillus ii [**Hospital1 **] fentanyl patch 12mg tp q72h Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: aortoenteric fistula ruptured AAA stroke hemodynamic collapse hemorrhagic shock septic shock respiratory failure postop atelectasis enterocutaneous fistula heparin induced thrombocytopenia blood loss anemia bacteremia line infection intraabdominal abscess Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2194-1-18**] Name: [**Known lastname 12065**],[**Known firstname 389**] Unit No: [**Numeric Identifier 12066**] Admission Date: [**2193-12-23**] Discharge Date: [**2194-1-18**] Date of Birth: [**2130-5-22**] Sex: M Service: SURGERY Allergies: Ceftriaxone / Piperacillin Sodium/Tazobactam / Heparin Agents Attending:[**First Name3 (LF) 1546**] Addendum: Discharge Addendum: In Progress Allergies Ceftriaxone / Piperacillin Sodium/Tazobactam / Heparin Agents Attending [**Last Name (LF) **],[**First Name3 (LF) **] B. Service SURGERY Brief Hospital Course Mr [**Known lastname 12067**] long hospital course will be summarized by organ system. Specific lab values can be obtained in OMR. NEURO: PCA, intermittent opiates used for postop pain control, chronic pain consulted for persistent pain. neurologically intact until operation on [**1-12**], after which he was medically sedated. after code on [**1-18**], R pupil found to be fixed and dilated. CV: initial complaint of mycotic abdominal aortic aneurysm was treated with NAIS/[**Last Name (un) 12068**] procedure on [**12-27**]. He subseuqnetly suffered two aortic ruptures, on [**1-12**] and [**1-18**], one of which was repaired. He was made CMO after the 2nd rupture. he intermittently required pressors to maintain blood pressure. his hemodynamics were monitored with arterial, central & swan lines. ASA, BB & statin used while he was able to tolerate. had PEA arrest on [**1-18**] AM, requiring compressions, epi & atropine. after being made CMO, he passed once pressors were stopped. RESP: intubated following surgeries. once extubated, treated with incentive spirometry. FEN: nutrition maintained with TPN. he was intermittently fed with tube feedings, but did not tolerate enteral feedings at goal for an extended period. he suffered from prerenal kidney failure, which was treated with IV hydration. he never required dialysis. GI: he suffered from several duodenal leaks, causing intra-abdominal abscesses and controlled enterocutaneous fistulae. these were treated with bowel rest, octreotide, and three surgical repairs ([**12-27**], [**1-2**] & [**1-12**]). he had feeding/drainage tubes in his stomach, duodenum & jejunum. HEME: he was prophylaxed against DVT's (especially in his right leg, from which his neoaortic graft was harvested, with SQ heparin & pneumatic boots. he was found to be HIT positive on [**1-16**], and all heparin was removed from his system. he still had p boots during his code on [**1-18**]. ID: infected AAA was treated with broad spectrum antibiotics throughout his hospital course. ID team followed throughout hospital stay. [**12-27**]: aortic graft culture grew out MRSA, VRE & yeast. [**1-7**] bacteremic with resistant enterobacter. [**1-10**] perc drain of intraabdominal abscess in CT. ENDO: received IV insulin gtt in CVICU & intermittent RISS while on floor. received stress dose steroids bc of his prior prednisone use (spinal stenosis) DISPO: deceased. no autopsy Brief Hospital Course: Mr [**Known lastname 12067**] long hospital course will be summarized by organ system. Specific lab values can be obtained in OMR. NEURO: PCA, intermittent opiates used for postop pain control, chronic pain consulted for persistent pain. neurologically intact until operation on [**1-12**], after which he was medically sedated. after code on [**1-18**], R pupil found to be fixed and dilated. CV: initial complaint of mycotic abdominal aortic aneurysm was treated with NAIS/[**Last Name (un) 12068**] procedure on [**12-27**]. He subseuqnetly suffered two aortic ruptures, on [**1-12**] and [**1-18**], one of which was repaired. He was made CMO after the 2nd rupture. he intermittently required pressors to maintain blood pressure. his hemodynamics were monitored with arterial, central & swan lines. ASA, BB & statin used while he was able to tolerate. had PEA arrest on [**1-18**] AM, requiring compressions, epi & atropine. after being made CMO, he passed once pressors were stopped. RESP: intubated following surgeries. once extubated, treated with incentive spirometry. FEN: nutrition maintained with TPN. he was intermittently fed with tube feedings, but did not tolerate enteral feedings at goal for an extended period. he suffered from prerenal kidney failure, which was treated with IV hydration. he never required dialysis. GI: he suffered from several duodenal leaks, causing intra-abdominal abscesses and controlled enterocutaneous fistulae. these were treated with bowel rest, octreotide, and three surgical repairs ([**12-27**], [**1-2**] & [**1-12**]). he had feeding/drainage tubes in his stomach, duodenum & jejunum. HEME: he was prophylaxed against DVT's (especially in his right leg, from which his neoaortic graft was harvested, with SQ heparin & pneumatic boots. he was found to be HIT positive on [**1-16**], and all heparin was removed from his system. he still had p boots during his code on [**1-18**]. ID: infected AAA was treated with broad spectrum antibiotics throughout his hospital course. ID team followed throughout hospital stay. [**12-27**]: aortic graft culture grew out MRSA, VRE & yeast. [**1-7**] bacteremic with resistant enterobacter. [**1-10**] perc drain of intraabdominal abscess in CT. ENDO: received IV insulin gtt in CVICU & intermittent RISS while on floor. received stress dose steroids bc of his prior prednisone use (spinal stenosis) DISPO: deceased. no autopsy Discharge Disposition: Expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**] Completed by:[**2194-1-20**]

[ "285.1", "998.59", "E934.2", "567.22", "518.5", "038.9", "997.3", "998.6", "998.11", "998.0", "578.9", "998.31", "995.92", "996.62", "998.2", "287.4", "785.52", "997.02", "997.4", "518.0" ]

icd9cm

[ [ [] ] ]

[ "45.91", "39.25", "99.15", "45.62", "39.49", "34.09", "46.79", "38.93", "46.41", "46.39", "96.6", "48.23", "45.13", "44.39", "43.19", "54.91" ]

icd9pcs

[ [ [] ] ]

8928, 9094

6454, 8905

343, 749

3317, 3327

1976, 1992

3379, 6431

1240, 1245

2981, 2986

3039, 3296

2711, 2958

3351, 3356

1260, 1957

283, 305

777, 1000

1022, 1167

1183, 1224

191

136,614

5073

Discharge summary

report

Admission Date: [**2196-4-9**] Discharge Date: [**2196-4-21**] Date of Birth: [**2123-2-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Fever & Chills Major Surgical or Invasive Procedure: Intubation/extubation Central line placement A-line placement Midline placement History of Present Illness: Mr. [**Known lastname 20904**] is a 73 year-old man with a history of recent TURP ([**3-28**]) who presents with respiratory failure and UTI. . Per family, the patient was generally feeling well until one day prior to admission when he "wasn't feeling that great" and felt as though he was "coming down with something". A slight fever (100) was noted along with chills. Took tylenol and Dayquil. Additionally noted a burning sensation and blood in urine. Additionally noted a cough since last week with sputum, no blood. . Regarding his breathing, the family felt that this was generally unchanged. He has had increasing DOE, worsening over the last few months. He gets SOB after one flight of stairs. He does not get chest pains. Family has also noted significant weight over last few months, mostly in abdomen. . EMS reports show an initial BP of 124/103 with a RR of 30 and O2 of 89% on room air. Their notes indicate that the patient was "sitting in bed shaking violently. States he can't breath." . In the ED, BP was initially 224/91, HR 120, RR 35, 99% on unclear amount of oxygen. Spiked to 104.8. Blood pressures trended down (200s to 80s systolic). When an EKG showed inferior ST-elevations, a code STEMI was called. Before taking the patient to the cath lab, it was noted that BPs were unequal so a CTA was obtained. This was negative for dissection and initially was thought to show a PE. Soon thereafter, the patient was intubated with a propofol gtt started. Was also given labetolol IV for hypertension. Soon after, blood pressure fell to 118/56, then to 80s systolic. A total of 5+ liters of normal saline were given, along with the following medications: - Aspirin 325mg - Zofran - Levaquin 750mg IV Past Medical History: 1. Diabetes 2. Dyslipidemia 3. Hypertension 4. Benign prostatic hypertrophy 5. Arthritis 6. Gout 7. Bladder stone Social History: Previous history of smoking, quit 10 years ago. Not currently drinking. Worked as a cook. Family History: Non-contributory. Physical Exam: Vitals - T 100.1, BP 138/48, HR 98, AC 600/16, PEEP 5, FiO2 100% GEN - Intubated. Does not respond to commands but is moving all extremities. HEENT - Surgical pupil on the right; 3mm -> 2mm on left. CV - Difficult to hear heart sounds. No obvious murmurs. PULM - No rales/wheeze. ABD - Soft. Non-tender. Guaiac + per ED. EXT - Warm. No edema. Pertinent Results: Admission labs Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative Serum ASA, EtOH, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative . UA: 1.017 / 6.5 Leuk Mod Bld Lg Nitr Pos Prot 500 Glu 250 Ket Neg . Lactate:4.3 . [**Doctor First Name **]: 56 Lip: Serum Acetmnphn 8.5 . Trop-T: <0.01 . PT: 13.7 PTT: 27.6 INR: 1.2 Fibrinogen: 869 . WBC: 9.6 PLT: 296 HCT: 41.7 . ECG: Sinus tachycardia with long PR interval. ST-elevations in II/II/F with Q-waves in same leads. Q-waves are old. . CXR ([**2196-4-9**]): Respiratory motion blurs the hemidiaphragms. Grossly, no consolidation or edema is evident. A tortuous atherosclerotic aorta is identified. The cardiac silhouette is within normal limits for size. No definite effusion or pneumothorax is seen. The osseous structures demonstrate a relatively short segment levoconcave curvature of the mid and lower thoracic spine with associated osteophyte changes. . CTA ([**2196-4-9**]): 1. No evidence of aortic dissection. 2. Equivocal filling defect in a right upper lobe subsegmental branch of the pulmonary artery. No evidence of pulmonary embolism. 3. Enlarged pulmonary artery may reflect an element of underlying pulmonary hypertension. 4. Mild upper lobe centrilobular emphysematous changes. 5. Markedly atrophic left kidney with associated dystrophic calcification and extensive cortical thinning and scar. Correlation with prior surgical history and medical history recommended. 6. Mild right renal hydronephrosis. 7. Fatty infiltration of the liver. 8. Air in the bladder is likely related to introduction of Foley balloon catheter, but clinical correlation is recommended. Brief Hospital Course: ASSESSEMENT/PLAN: 73 yo M s/p TURP procedure c/b UTI resistant to ciprofloxacin, developed urosepsis requiring intubation and ICU stay, also developed atrial flutter this admission. . # UROSEPSIS due to E. Coli: Urosepsis was felt to be secondary to recent procedure, which placed patient at high risk for UTI. He received Cipro post-procedure but on presentation had a markedly positive UA. Urine & blood cultures grew E.coli. Blood cultures with E.coli were sensitive to zosyn and ceftriaxone but resistant to cipro; ceftriaxone was given. Changed antibiotics to Ceftriaxone -> Cefazolin IV -> Keflex PO, currently started on Meropenem IV on day of discharge. Changed from Keflex to Meropenem due to possibility of AIN, rising creatinine as well as urine with eos. Will need to complete 2 week course of antibiotics with 5 additional days of Meropenem. . # Atrial flutter: The patient had developed atrial flutter with poor rate control, without prior history. Increased po metoprolol to 100 TID for rate control. The patient was started on heparin in the ICU, then bridging with lovenox to coumadin. . EP consulted about treatment, after discussion with family, family wanted to pursue option of anticoagulation prior to cardioversion. They did not want TEE and cardioversion during this hospitalization. INR 3.1 on day of discharge, decreased coumadin from 5 -> 4mg on day of discharge, holding tonight's dose. Pt will need frequent INR checks until stabilized. Pt will need to follow up with General cardiology 2weeks after discharge for managment of atrial flutter as well as CAD. . # CAD: Pt without prior history of CAD or MI, however ECG and echocardiogram revealed mild LVH with regional left ventricular systolic dysfunction consistent with CAD. Pt was initially started on low dose lisinopril, however holding due to worsening creatinine. Would restart once creatinine at baseline 1.2-1.5. Pt already on aspirin, simvastatin and metoprolol. He will need follow up with general cardiology for mangament of atrial flutter as well as CAD. . # Acute on chronic kidney disease: Baseline creatinine is variable, though 1.7 in ICU seemed somewhat elevated compared to [**10-18**] when SCr was 1.2. There are CT findings suggestive of mild hydro on the right though no stone was seen. Also has an atrophic left kidney. Increasing creatinine with +eos in urine, ?AIN from antibiotics, changed Keflex to Meropenem IV. Metformin also discontinued. Would check daily creatinine levels to monitor for improvement. . # Diabetes: Oral hypoglycemics were intially held given the patient's acute renal failure, also with dye load from CT imaging. However, restarted with improvement in renal function. Fingersticks well controlled on oral agents and sliding scale humalog. Discontinued Metformin due to worsening renal function. Would need to restart once creatinine improved. . # Hyperlipidemia: Continued on home regimen of simvastatin . # Hypoxia/resp failure (resolved): Extubated o/n [**Date range (1) 13864**]. Unclear etiology of hypoxic failure. Initially felt to be secondary to PE, though the second read is unclear. There is no infliltrate or failure on CXR. Given recent admission, DFA for influenza was performed and was negative. There were some changes consistent with emphysema on CT, though there are no wheeze noted at this time. Sputum culture was unremarkable. . Pt is being discharged to [**Hospital **] rehab facility. He is to follow up with cardiology for management of CAD as well as atrial flutter. Medications on Admission: 1. Amlodipine 5 mg daily 2. HCTZ 25mg daily? 3. Atenolol 50 mg daily 4. Metformin 500mg daily 5. Glyburide 5mg daily 6. Simvastatin 40 mg daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*54 Tablet(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 5 days: Start [**2196-4-21**] Stop [**2196-4-25**]. 9. Warfarin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please hold [**2196-4-21**] dose. 10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO at bedtime as needed for agitation. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 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: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Urosepsis Atrial flutter BPH s/p TURP Hypertension Discharge Condition: Hemodynamically stable, aferile Discharge Instructions: You were admitted with an infection of your bladder which was significant enough for you to be in the ICU. We are treating you with antibiotics. You developed an atypical rhythm of your heart called atrial flutter . Please continue Meropenem IV x 5 days for the infection. We have also started you on Coumadin because of the atrial flutter to decrease the risk of any clot formed to cause a stroke. . Please follow up with a cardiologist at 2 weeks to evaluate your heart rhythm. He will discuss if & what further procedures need to be done. . Please call your doctor or return to the emergency room if you have any of the following: Chestpain, shortness of breath, palpitations or any other worrisome rhythm. Followup Instructions: Urology: Please follow up with Dr. [**Last Name (STitle) 9125**] for post/op evaluation. s/p TURP on [**2196-4-28**] at 1115am. [**Telephone/Fax (1) 6445**] . You will need to follow up with cardiology for your atypical heart rhythm in 2 weeks. You or your family will be contact[**Name (NI) **] with an appointment. Please call [**Telephone/Fax (1) 62**], if you haven't been contact[**Name (NI) **] in 1 week. . PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 132**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**] Please follow up within [**1-13**] weeks of discharge.

[ "599.0", "591", "585.9", "785.52", "272.4", "995.91", "414.01", "584.9", "038.42", "403.90", "427.32", "518.81", "250.00", "998.59", "274.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

9547, 9618

4497, 8019

328, 410

9713, 9747

2816, 4474

10508, 11092

2418, 2437

8213, 9524

9639, 9692

8045, 8190

9771, 10485

2452, 2797

274, 290

438, 2156

2178, 2294

2310, 2402

7,304

134,533

12524+12525

Discharge summary

report+report

Admission Date: [**2157-3-22**] Discharge Date: [**2157-4-1**] Date of Birth: Sex: Service: DISCHARGE MEDICATIONS: Enteric coated Aspirin 81 mg po q day, Heparin 5000 units subcu [**Hospital1 **], Artane 2 mg po q day, Florinef .2 mg po q day, Prevacid 30 mg q day, Nystatin powder topical [**Hospital1 **] prn, Sinemet 10/100 one tablet tid, Ultracal with fiber at 55 cc per hour and Multivitamin one tablet q day. DISCHARGE DIAGNOSES: 1. Sepsis. 2. Pneumonia. 3. Advanced Parkinsons. 4. Bladder cancer, status post BCG. 5. Benign prostatic hypertrophy. 6. Hypertension. 7. PEG J tube placement. HISTORY OF PRESENT ILLNESS: The patient was admitted with a chief complaint of increasing lethargy. This 76-year-old man has a history of advanced Parkinsons, bladder cancer, hypertension, presented with increasing lethargy, decreased po intake and recent fall related to weakness. The patient's son, [**Name (NI) 449**] [**Name (NI) 10940**] #[**Telephone/Fax (1) 38825**], reports that the patient's Parkinson's disease had been worsening over the past week. He had difficulty walking and a subsequent fall four days prior to admission. Denies any head trauma or loss of consciousness. Then over the last 3-4 days prior to admission the patient had decreased po intake, increasing lethargy and some confusion. The patient's son denies any visible rigors or chills, denies any noted fevers, has not had recent cough, nausea, vomiting or diarrhea. Denies any recent complaints of pain. The patient became increasingly lethargic. EMS was called and the patient was brought to the [**Hospital1 69**] Emergency Room. In the Emergency Room he had junctional bradycardia to the low 40's and that EKG was fast by the cardiology fellow on call. By report from the ER resident, the rhythm was felt to be most likely metabolic in origin and patient was referred to the MICU for evaluation of his marginal blood pressure and overall tenuous status. PAST MEDICAL HISTORY: As mentioned, significant for advanced Parkinson's, bladder cancer, carcinoma in situ, status post BCG, enlarged prostate, question of prostate nodules and hypertension. MEDICATIONS: Outpatient medications were reported to be Atenolol 25 mg po q day, Artane, Sinemet, Aspirin 81 mg po q day and Seroquel. ALLERGIES: Codeine and Bactrim, unknown. SOCIAL HISTORY: He lives at home with his son, [**Name (NI) 449**] [**Name (NI) 10940**], [**Telephone/Fax (1) 38826**] who is the health care proxy. The patient is a former smoker. PHYSICAL EXAMINATION: On admission temperature was unmeasureable, heart rate 40, blood pressure 95/43 with a map of 63, sats 99% on room air. He is a generally ill appearing, frail elderly male who opened eyes to voice, with generalized stiffness. By the way, patient speaks Cantonese. Anicteric, dry mucus membranes, no oral lesions, no JVD, no lymphadenopathy. Lungs clear to auscultation. Distant heart sounds. Firm, nontender, non distended, no rebound or guarding, decreased bowel sounds. No clubbing or edema, poorly perfused distal extremities with dopplerable pulses in all four extremities. Neuro, generalized rigidity, no cogwheeling at the time, withdraws to pain in all extremities, no tremor. LABORATORY DATA: 8.2 white count, 43.8 hematocrit, 87 platelets. SMA 7, 154, 4.4, 110, 25, 95, 3.0, 69. Coags 11.5, INR 0.9, PTT 32.1. ALT 59, AST 61, alkaline phosphatase 78, total bilirubin 0.5, amylase 132, lipase 17, TSH was pending at the time. Albumin 3.2, calcium 9.3, phosphorus 7.4, magnesium 2.7, CK 470, CK MB 37 and the index 7.9. Patient's urinalysis showed 30 mg/dl of protein, [**7-18**] red blood cells, 0-2 white blood cells, rare bacteria, less than one squamous epithelial cell. Chest x-ray showed hazy bibasilar opacifications, also with peripheral right opacification, no cardiomegaly, no effusions, left subclavian line was placed in the SVC. CT of the head showed no acute intracranial processes. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and he developed a myocyte necrosis and developed acute renal failure on top of the known prior renal function. He was maintained on pressors and he was intubated. He was then extubated on [**3-24**] with increasing blood pressures after his sepsis from the pneumonia had been cleared. Echocardiogram done on the patient found him to have a decent cardiac function with a normal LV up to 55% with left ventricular wall thickness cavity and systolic function being normal. Regional left ventricular wall motion was also normal. Aortic valve leaflets were mildly thickened. There was mild 1+ aortic regurgitation seen and the mitral valve leaflets were mildly thickened. The patient, after being transferred to the floor on [**2157-3-25**], continued to have lethargy and increasing hypoxia on the floor and so he was readmitted back to the medical Intensive Care Unit on the 17th for an overnight stay. His initial ABG was 7.33, 44 and 56, went up to 7.36, 44 and 54 and chest x-ray done on the 17th showed new bilateral pleural effusions with mild volume overload CHF, persistent left lower lobe opacity and right lower lobe opacity. So the patient was admitted and observed overnight and then transferred back to the medical floor where he began to improve. While in the MICU the patient also received a nasogastric tube placed and confirmed by chest x-ray to be in appropriate position. While back on the floor the second time, several issues were addressed: 1. Cardiovascular: Coronary artery disease, the patient ruled in for myocardial infarction but the echo showed no wall motion abnormality, likely from metabolic stress, therefore no angiography was indicated. His enteric coated Aspirin was started and beta blocker will be restarted. The Atenolol he had once he demonstrates blood pressure stability. Electrophysiologically the patient had bradycardia which was thought to be due to metabolic process associated with the sepsis. The heart rate eventually moved to sinus rhythm and the patient was functioning normally. He was maintained on Florinef. Congestive heart failure, the patient had significant pleural effusions, likely believed to be secondary to diastolic dysfunction. That improved as the patient's heart rate improved over time. 2. Pulmonary: The patient had pneumonia which was treated with antibiotics. His oxygen saturation improved over time and the patient had a thoracentesis, diagnosed and therapeutic, on [**3-30**] where over a liter of the patient's thoracentesis fluid was removed and it was determined to be of a transudative nature consistent with the diastolic dysfunction believed from a cardiac analysis. 3. Renal: Patient's hypernatremia was corrected gradually with D5W. Sodium was checked and eventually the sodium was brought back to within normal limits. Magnesium and potassium were replaced as necessary to maintain within normal range limits. The patient's renal function corrected quite nicely so that by the time of discharge his BUN and creatinine were within the range of 19 and 1.3 respectively which was considerably improved from his admission levels of 95 and 3.0. The patient's urine output perked up as well. 4. Heme: The patient was maintained on DVT prophylaxis with subcu Heparin. The patient was restarted on his Artane and Sinemet. He had to be maintained on aspiration precautions because the patient was unable to pass his swallowing evaluation and so that is why on the [**5-30**] the patient had a PEG placed with a J tube extension so that the patient could receive his nutrition until his mental status improved to the point where he was able to protect his airway sufficiently to take in sufficient amount of food. The patient had a left subclavian placed on [**3-21**]. The patient was GI maintained with tube feeds for nutrition and NG tube was placed in the meantime and then removed as the patient's GJ tube was demonstrated to be functional. The patient remained full code. The patient lives at home with his son, [**Name (NI) 449**] [**Name (NI) 10940**], [**First Name3 (LF) **] the patient, before returning home had to be sent to rehab so that he could have assistance with his advanced Parkinson's disease to the point where he could actually walk around again and also be able to eat food. CONDITION ON DISCHARGE: Improved. DISCHARGE MEDICATIONS: In addition, there was also Atenolol 50 mg po q day which will be started once the patient's blood pressure reaches sufficient criteria of having a systolic blood pressure greater than 110, heart rate greater than 55 on a consistent basis. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern1) 3033**] MEDQUIST36 D: [**2157-4-1**] 16:44 T: [**2157-4-1**] 18:55 JOB#: [**Job Number **] Admission Date: [**2157-3-22**] Discharge Date: [**2157-4-5**] Date of Birth: [**2080-8-10**] Sex: M Service: [**Hospital1 3253**] INTERNAL MEDICINE ADDENDUM CODE STATUS: FULL CODE. HOSPITAL COURSE: The patient was not discharged on [**2157-3-11**]. This was due to the fact that after his PEG placement, his hematocrit dropped to 24 from 28. He received 2 U, and then his hematocrit went back down again to 26. He received two more units of blood, and his hematocrit went up to 33, then 34, and then remained stable at 34. Essentially the patient's discharge was delayed by what likely seemed to be a GIB. GI was consulted. An EGD was planned, but because his hct's stabilized and there was no further acute bleeding this was deferred. Outpatient EGD was recommended. Otherwise his condition remained stable. He is leaving with guaiac positive brown stool. DISCHARGE MEDICATIONS: Enteric coated Aspirin 81 mg p.o. q.d., Heparin 5000 U subcue b.i.d., Artane 2 mg p.o. q.d., Prevacid 30 mg PGT q.d., Nystatin topical powder b.i.d. p.r.n., Sinemet 10/100 one tab PGT t.i.d., ................... with fiber at 55 cc/hr tube feeds, Multivitamin 1 tab PGT q.d. in liquid form, Atenolol 50 mg p.o. q.d., hold for systolic blood pressure lower than 110, heart rate less than 55, Levofloxacin per gastric tube 500 mg p.o. q.d. x 2 more days, through [**4-7**], Flagyl 500 mg per gastric tube q.d. x 2 days, through [**4-7**], this is to complete his treatment for sepsis and pneumonia. DISCHARGE DIAGNOSIS: 1. Sepsis and pneumonia. 2. Advanced Parkinson's disease. 3. Bladder cancer status post VCG. 4. Benign prostatic hypertrophy. 5. Hypertension. 6. Status post PEG tube placement. 7. Acute renal failure which has resolved. He seems to be at his baseline BUN and creatinine of 19 and 1.4 which leaves him at a level of chronic renal insufficiency. The patient's creatinine on arrival was 3.0. DISCHARGE INSTRUCTIONS: The patient is to keep his central line and intravenous on discharge as he has a difficult time obtaining intravenous access. The rehabilitation facility, which is the [**Hospital6 310**], is free to pull his line after 24-48 hours if they determine that the central line is not needed. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern1) 3033**] MEDQUIST36 D: [**2157-4-5**] 11:04 T: [**2157-4-5**] 11:19 JOB#: [**Job Number 38827**]

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Discharge summary

report

Admission Date: [**2130-10-19**] Discharge Date: [**2130-11-3**] Date of Birth: [**2050-8-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7202**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization x2 History of Present Illness: HPI: 80yo M with CAD s/p CABG x5v in '[**14**] and multiple cardiac catheterizations, DM, Hypercholesterolemia, tob+, AF who presents with chest pain. Pt was last cathed on [**2130-9-28**] at [**Hospital1 18**] for tx of ISR of SVG to RCA (had cypher) and cypher to SVG to OM. At time of discharge, the pt continued to have angina pain and the original plan per Dr. [**Last Name (STitle) **] was that if patient continued to have pain, he would come back to lab for treatment of a 70% stenosis in the LIMA. The pt presented to OSH this AM with 10/10 chest pressure that began at 10:35 while the pt was at rest eating breakfast. The chest pressure was sudden onset without radiating. The pt denies any SOB, diaphoresis, nausea or vomiting. He took his own nitro SL with minor relief however the chest pressure persisted and therefore went to the ED. The pt was given 2 sl nitro which dropped SBP from 130/90. The pt was also given 12mg of morphine, IV nitro 50mcg/min, 4 baby aspirin. The pt has continued to have pain, currently a [**5-30**]. On exam at OSH, VS: 130-150/70, HR 50-60??????s AF, sats 99% on two liters. Afebile. LS: faint crackles. CXR no failure. CE neg x1, INR 5.0 , creatinine 2.6, K 5.5. Past Medical History: 1. CAD s/p CABG x5v in '[**14**] and multiple cardiac catheterizations since. Last cath at [**Hospital1 18**] in '[**24**] with 3VD and patent SVG to RCA, SVG to ramus -> posterior LV branch, patent LIMA to KAD but occluded SVG to 1st diag. 2. DM 3. Hypercholesterolemia 4. AF on coumadin 5. Stomach CA s/p partial resection Social History: Pt is a former marine who admits to smoking 2ppd x 3 years during the service and occasionally for the next 10 years,but quit smoking 25years ago. Pt also admits to occasional alcohol use 1-2 beers every couple of months. Pt denies any illicit drug use including cocaine. Married with eleven children. Family History: Mother: 1st MI at age 50 Father: no significant medical illness 11 kids: oldest son with DM Physical Exam: VS: 95.3 186/71 60 20 100% 4L GEN: Lying in bed with some distress/unresolved chest pressure, mentating well. HEENT: MMM, cracked lips with dried blood on lips and tongue surface EOMI RESP: CTA B/L, no crackles or wheezes CV: Irregularly Irregular, nml S1, S2, no murmur appreciated, No elevated JVP. ABD: Soft, ND/NT, +BS EXT: no C/C/E, 1+ DP pulse Pertinent Results: [**2130-10-19**] 07:07PM PT-29.5* PTT-50.2* INR(PT)-6.5 [**2130-10-19**] 07:07PM WBC-15.5*# RBC-3.95* HGB-12.8* HCT-37.4* MCV-95 MCH-32.5* MCHC-34.3 RDW-12.9 [**2130-10-19**] 07:07PM CK-MB-NotDone cTropnT-0.09* [**2130-10-19**] 07:07PM CK(CPK)-32* [**2130-10-19**] 07:07PM GLUCOSE-208* UREA N-42* CREAT-2.5* SODIUM-138 POTASSIUM-6.6* CHLORIDE-104 TOTAL CO2-22 ANION GAP-19 [**2130-10-19**] 08:43PM POTASSIUM-6.0* . LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2130-11-3**] 06:35AM 8.9 3.25* 10.0* 31.0* 95 30.7 32.2 14.2 338 [**2130-11-2**] 06:40AM 8.6 3.22* 10.4* 30.0* 93 32.3* 34.7 14.5 344 [**2130-11-1**] 06:05AM 9.3 3.37* 10.6* 31.4* 93 31.5 33.9 14.4 333 [**2130-10-31**] 06:55AM 11.0 3.57* 11.2* 33.1* 93 31.5 34.0 14.2 314 [**2130-10-30**] 06:30AM 10.5 3.59* 11.4* 33.4* 93 31.7 34.1 14.2 282 [**2130-10-29**] 06:40AM 9.9 3.47* 10.8* 31.9* 92 31.0 33.7 14.2 223 [**2130-10-28**] 06:45AM 12.1* 3.71* 11.9* 34.1* 92 32.0 34.8 14.3 194 [**2130-10-27**] 06:25AM 10.0 3.24* 10.2* 29.5* 91 31.4 34.6 14.3 164 [**2130-10-26**] 07:20AM 8.8 3.15* 9.8* 28.9* 92 31.0 33.8 14.4 155 [**2130-10-25**] 01:40PM 10.6 3.22* 10.0* 29.9* 93 31.2 33.5 14.8 147* [**2130-10-25**] 05:02AM 9.5 3.11* 9.8* 28.6* 92 31.5 34.3 14.8 141* [**2130-10-24**] 08:20PM 10.8 3.38* 10.7* 31.4* 93 31.6 34.1 14.8 133* [**2130-10-24**] 03:19AM 13.1* 2.76* 8.9* 26.2* 95 32.3* 34.1 13.3 153 [**2130-10-23**] 05:17AM 14.0* 3.11* 10.0* 29.0* 93 32.2* 34.5 13.0 182 [**2130-10-23**] 12:01AM 15.3* 3.29* 10.4* 30.9* 94 31.5 33.6 13.1 176 [**2130-10-22**] 06:45AM 13.7* 3.26* 10.2* 31.0* 95 31.3 32.9 13.2 213 [**2130-10-21**] 09:10PM 10.0 3.40* 10.8* 32.4* 95 31.8 33.4 12.9 223 [**2130-10-21**] 05:05PM 11.0 3.35* 10.3* 32.0* 95 30.8 32.3 13.2 255 [**2130-10-21**] 07:05AM 8.2 2.99* 9.7* 28.4* 95 32.4* 34.0 13.0 226 [**2130-10-20**] 04:33PM 30.1* 269 [**2130-10-20**] 07:05AM 12.1* 3.41* 10.6* 32.2* 94 31.1 33.0 13.1 303 [**2130-10-19**] 07:07PM 15.5*# 3.95* 12.8* 37.4* 95 32.5* 34.3 12.9 326 . Glucose UreaN Creat Na K Cl HCO3 AnGap [**2130-11-3**] 06:35AM 94 33* 2.6* 139 4.8 103 271 14 [**2130-11-2**] 06:40AM 82 32* 2.5* 138 4.6 102 271 14 [**2130-11-1**] 07:55PM 4.6 [**2130-11-1**] 06:05AM 80 33* 2.7* 138 4.5 102 261 15 [**2130-10-31**] 06:55AM 95 33* 2.7* 138 4.1 102 261 14 [**2130-10-30**] 04:00PM 35* 2.8* [**2130-10-30**] 06:30AM 146* 36* 2.9* 137 4.21 100 252 16 [**2130-10-29**] 06:40AM 146* 36* 2.6* 137 4.0 100 241 17 [**2130-10-28**] 06:45AM 167* 36* 2.6* 138 4.4 101 251 16 [**2130-10-27**] 06:25AM 214* 30* 2.1* 135 3.6 98 261 15 [**2130-10-26**] 07:20AM 156* 34* 2.2* 139 4.0 108 21*1 14 [**2130-10-25**] 05:02AM 118* 35* 2.2* 137 4.9 110* 19*1 13 [**2130-10-24**] 03:19AM 173* 33* 2.3* 137 4.2 108 18*1 15 [**2130-10-23**] 05:17AM 221* 29* 2.2* 137 4.21 104 20*2 17 [**2130-10-22**] 06:45AM 159* 28* 1.9* 141 4.0 109* 221 14 [**2130-10-21**] 07:05AM 123* 31* 2.0* 140 4.5 107 251 13 [**2130-10-20**] 07:05AM 164* 41* 2.4* 140 5.1 107 221 16 [**2130-10-20**] 01:10AM 5.9* [**2130-10-19**] 08:43PM 6.0* [**2130-10-19**] 07:07PM 208* 42* 2.5* 138 6.6*1 104 222 19 . CK-MB cTropnT [**2130-11-2**] 02:57AM 0.06 [**2130-10-31**] 07:50PM 0.07 [**2130-10-31**] 06:44PM <0.01 [**2130-10-31**] 06:55AM 0.08* [**2130-10-30**] 10:24PM 0.08* [**2130-10-30**] 07:35PM 0.09* [**2130-10-25**] 05:02AM 0.06* [**2130-10-24**] 03:19AM 0.07* [**2130-10-23**] 05:17AM 0.02* [**2130-10-23**] 12:01AM 0.05* [**2130-10-21**] 07:05AM 0.06* [**2130-10-20**] 04:33PM 0.08* [**2130-10-20**] 07:05AM 0.08* [**2130-10-20**] 01:10AM 0.06* [**2130-10-19**] 07:07PM 0.09 . ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBil [**2130-11-2**] 06:40AM 17*1 [**2130-11-2**] 02:57AM 17*1 [**2130-11-1**] 07:55PM 13*1 [**2130-10-31**] 07:50PM 17*1 [**2130-10-31**] 06:44PM 117 [**2130-10-31**] 06:55AM 17*1 [**2130-10-30**] 10:24PM 21* [**2130-10-30**] 07:35PM 25* [**2130-10-25**] 01:20PM 9 10 80 0.9 [**2130-10-25**] 05:02AM 53 [**2130-10-24**] 08:20PM 169 1.0 [**2130-10-24**] 03:19AM 25* [**2130-10-23**] 05:17AM 39 [**2130-10-23**] 12:01AM 25* [**2130-10-21**] 07:05AM 52 [**2130-10-20**] 04:33PM 42 [**2130-10-20**] 07:05AM 17* [**2130-10-20**] 01:10AM 16* [**2130-10-19**] 07:07PM 32* . Hapto Ferritn TRF [**2130-10-24**] 08:20PM 300* [**2130-10-23**] 05:17AM 222* 731 GREATER TH1 301 171* . . STUDIES: [**2130-10-19**] CXR: SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The patient is status post median sternotomy. There is mild cardiomegaly and a tortuous aorta. The lungs are clear. The pulmonary vasculature is unremarkable. The osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process . [**2130-10-19**] ECG: Atrial fibrillation with a moderate ventricular response. Compared to the previous tracing of [**2130-9-29**] there are continued ST-T wave abnormalities in leads I, aVL and V4-V6 without diagnostic interim change. TRACING #1 . [**2130-10-20**] ECHO: Conclusions: The left 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%). Resting regional wall motion abnormalities include basal to mid inferior akinesis/hypokinesis, basal to mid inferolateral hypokinesis and basal inferoseptal hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. 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 (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Compared with the prior study (tape reviewed) of [**2130-4-22**], lefte ventricular wall motion appears similar. . [**2130-10-23**] Portable CXR: IMPRESSION: AP chest compared to [**10-19**]: New peribronchial opacification has developed in the right infrahilar lung, which could be either an early stage of edema or pneumonia. Heart size remains top normal. The lungs are otherwise clear. There is no pleural abnormality. . [**2130-10-24**] Portable CXR: IMPRESSION: Persistent right perihilar hazy opacity, which may relate to asymmetric edema or developing pneumonia. . [**2130-10-25**] Portable CXR: The patient has prior CABG and median sternotomy. There is continued mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. Patchy atelectasis is seen at the lung bases. No evidence of pneumothorax is identified. . [**2130-10-26**] Cardiac Cath: COMMENTS: 1. Selective coronary angiography was deferred. 2. Selective graft venography revealed a 40% stenosis at the SVG to OM anastamosis with a patent proximal stent and a known occluded jump segment. The SVG to RCA had no angiographically apparent flow limiting lesions. The SV to Diagonal graft had a known occlusion. 3. Arterial conduit angiography revealed a probable old 60% origin stenosis of the LIMA to LAD. Despite attempts with a diagnostic catheter, guide, and angioplasty guidewires, we were unable to selectively engage the vessel. We had planned to perform FFR measurements by pressure wire. If anterior ischemia is demonstrated then suggest repeat attempt from left arm approach. 4. Limited resting hemodynamics demonstrated severely elevated systemic pressures. FINAL DIAGNOSIS: 1. Moderate stenosis of SVG to OM and patent SVG to RCA. 2. Moderate origin lesion of LIMA to LAD. 3. Severe systemic hypertension. . [**2130-10-27**] p-MIBI: IMPRESSION: 1. Stable mild/moderate, partially reversible defects in the inferior and inferolateral walls. 2. Moderate global hypokinesis with EF of 28%. 3. Right pleural effusion. . [**2130-10-29**] Abdominal MRI: IMPRESSION: Mild renal artery stenoses bilaterally, deemed unlikely to be of physiologic significance. Symmetric and normal-sized kidneys with good cortical thickness bilaterally. Findings suggestive of medical renal disease. Third spacing of fluid noted. Incidental finding of a moderate-high-grade stenosis at the right common iliac artery. . [**2130-11-1**] Cardiac Catheterization: COMMENTS: 1. Access was via the left radial artery with a 6 French sheath. 2. Selective angiography of the LIMA-LAD demonstrated an eccentric ostial 70% stenosis. 3. Successful PCI of the ostium of the LIMA-LAD with a 3.5 x 13 mm Cypher DES. FINAL DIAGNOSIS: 1. Successful PCI of the ostium of the LIMA-LAD. Brief Hospital Course: A/P: 80yo M with CAD s/p CABG and multiple PCA, DM, Hypercholesterolemia, tob+, AF who presents with chest pain/pressure transferred for further management and R/O NSTEMI. . #. CV: A. Coronaries: The pt has known CAD s/p CABG with mulitple cardiac catheterizations, with most recent PCI on [**2130-9-28**] with SVG-->RCA & SVG-->OM anastomosis. His EKG from OSH shows Irreg rhythm c/w Afib, some TWI in lateral leads I, III, aVL, no ST segment elvation or depression. Negative CE x 1 from OSH, cycled CE to r/o NSTEMI. EKG on admission showed no ischemic changes, Tn <.01 and cpk 18. Serial EKGs, on Tele to monitor for any dysrythmias, and for better rate control in setting of Afib and possible ACS. Started on Nitro gtt for chest pressure/pain [**5-30**] unrelieved and BP persistently elevated 170/80, HR in the 80s. He was started on [**Month/Year (2) **], BB, Statin, ACE-I. Hep gtt was held given his INR 5.3 Per cards fellow will gave vit K for INR at 6.1 and possible cath. on [**10-20**] pt developed CP and ST segment depressions in precordial leads, however INR 6.0, 6 U FFP given and 5mg Vit K PO given, am EKG showed improvement in ST segment depressions in precordial leads with better BP control and CP control with Nitro gtt, morphine and hydral IV given. Awaited INR to be <2 to take to cath. Pt however with difficult to control BP was transferred to MICU on [**10-22**] for management of BP and CP with increasing Nitro gtt, started on integrellin gtt. Pt was transferred back to [**Hospital Unit Name 196**] on [**2130-10-25**]. On [**10-25**]:with CP overnight [**5-30**], non radiating, constant for 45 min without associated symptoms. Pain is the same as he's been having since before and during time in CCU. No new EKG changes. Increased Nitro gtt to 200, 10mg Hydralazine IV X1, Morphine x2 given with relief of pain. Pt was taken to cath on [**2130-10-26**]. However, intervention not possible at the time, difficult to guide wire and pt was fatigued. Pt sent for P-MIBI on [**2130-10-27**] and found Stable mild/moderate, partially reversible defects in the inferior and inferolateral walls. 2. Moderate global hypokinesis with EF of 28% which was significantly depressed from prior EF noted on ECHO EF>55% on [**2130-10-20**]. Pt continued to have persistent CP and was maximally medically managed prior to sending to cath for second time. Pt was sent to cath for second time on [**2130-11-1**] with Successful PCI of the ostium of the LIMA-LAD via L radial A without complications. On day of discharge pt was CP free. . B. Pump: Pt does not appear to be volume overloaded. His JVP was not elevated, lungs were clear and no peripheral edema. However, in setting of possible ACS consider ECHO once pain relieved and cath for evaluation of any wall motion abnormalities. ECHO done [**2130-10-20**], normal EF >55%, Resting regional wall motion abnormalities include basal to mid inferior akinesis/hypokinesis, basal to mid inferolateral hypokinesis and basal inferoseptal hypokinesis. Right ventricular chamber size and free wall motion are normal. On [**10-27**] p-MIBI noted EF significantly depressed at 28%. pt was noted to c/o SOB, and was volume overloaded following post cath hydration and required IV lasix 20mg x2 . C. Rhythm: The pt has known Afib on coumadin. Will continue to monitor on Tele for any acute dysrythmias in setting of potential ACS, and hyperkalemia. Pt did not develop dysrhythmias in setting of AF and hyperkalemia. . #. ARF: His baseline runs from 2.1 to 3.5. Cr slightly elevated from previous admission. Held ACE-I initially in setting of increasing Cr, and recent dye load post cath. Continued to hydrate and holding diuretics. Was put on Hydral/Imdur instead of ACE-I. Pt received mucomyst and precath hydration x2 to protect renal function. His Cr remained stable and was 2.6 on day of discharge. . #. HTN: His BP was persistently elevated 180s/80s. He had an episode of nausea w/o emesis, diaphoresis and his HR dropped to 37, still mentating well. Nitro gtt was increased up to 160 to bring down BP. Morphine 1mg IV was also given to relieve his pain. Metoprolol 5mg IV pushed x1. Pt was also given 10mg IV Hydralazine. Pt was on 5 antihypertensive meds at home and difficult to control BP. Pt was on Imdur, Lopressor, Hydral, Nitro gtt titrated to SBP<130. On [**10-22**] pt with persistently elevated BP and difficult to control SBP 170-190S IV Labetolol up to 30mg, increased nitro gtt to max 200% On [**10-23**] pt was transferred to CCU for BP 208/79 and unrelieved CP. In setting of receiving-Lopressor 5mg IVX2, 5mg IV Hydralazine x2, 10mg IV Labetololx3, 2mg IV Morphine X5, 50mg PO hydralazine-->SBP remained 160s-190s. Recommended to increase nitro gtt and transfer to CCU. Course in CCU with better BP control on increased nitro gtt. The question of renal artery stenosis was raised, therefore Abdominal MRI obtained. No RAS noted on MRI but some mild RAS not likely physiological cause of HTN. Pt was better managed on BB, Hydral, ACE-I, Amlodipine. On last day of admission BP meds included: Amlodipine 5mg, Imdur 120mg, Lisinopril 5mg, Toprol XL 200mg [**Hospital1 **] . #. PAF: Pt w/chronic AF on coumadin, was supertherapeutic on presentation with INR 6. Pt was well controlled on BB, however continued to titrate BB for better BP and rate control. Anticoagulation reversed w/FFP and vitamin K for cath. His INR decreased to <2 in preparation for cath, following cath coumadin restarted. . #. Anemia: Initial hct 37 on admission, slowly trending down. low hct c/w Anemia of Chronic Disease, hct 28.4. On [**10-22**] was transfused 1UPRBC for hct 28.4. Pt had appropriate increase in hct to 31.0 post 1UPRBC. Hct remained stable throughout hospital course, guaiac neg and no signs of bleed, cath x2 without complications. . #. Leukocytosis-WBC 15.5. Sent UA and ordered CXR for possible PNA. Pt was initially afebrile, denied any cough. UA was + for UTI and started Cipro on [**2130-10-20**] for 3 day course. On [**10-22**] pt spiked temp to 101.1, blood culture x2 and urine clxr sent. He was continued on Cipro for persistent T 102.1 on [**10-24**]. Pt defervesed on [**10-25**], however was continued on the Cipro to complete a 7d course. Pt's WBC trended down and remained afebrile prior to d/c home. Blood cultures x3 came back with no growth and Urine culture was contaminated. . . #. Hyperkalemia: Initial K 6.6, was resent and came back at 6.0. Gave [**1-22**] Amp D50, 10 Units Insulin SQ, Kayexelate 30mg x1, and Calcium Gluconate. Pt on Tele did not develop any arrythmias in setting of hyperkalemia, repleted lytes carefully. . . #. Physical Therapy worked w/pt throughout hospital course once CP free and BP better managed. He was recommended outpatient cardiac rehab and ambulation program to help with conditioning following prolonged hospitalization. . . #. CODE: FULL, however no open heart surgery to be performed. Son is health care proxy. Medications on Admission: MEDICATIONS ON TRANSFER: -Nitro drip -Morphine -Zofran IVP MEDICATIONS AT HOME: 1. Aspirin 81 mg once a day. 2. Clopidogrel 75 mg Daily. 3. Atorvastatin 20 mg once a day. 4. Digoxin 125 mcg Daily. 5. Lisinopril 5 mg Daily. 6. Amlodipine 10 mg Daily. 7. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24HR Daily. 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Daily. 9. Hydrochlorothiazide 25 mg once a day. 10. Folic Acid 5 mg twice a day. 11. Warfarin 5 mg [**Month/Day (2) **] 12. Nitro-Dur 0.6 mg/hr Patch 24HR 13. Multiple Vitamin once a day Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO BID (2 times a day). Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2* 8. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual 1 every 5 minutes, repeat every 5 minutes for up to 3 times in 15 minutes as needed for chest pain. Disp:*30 tab* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Unstable angina and NSTEMI Discharge Condition: Stable. Discharge Instructions: Please take all your medications as indicated and follow up with all your appointments. . Extremely important that you continue to take Aspirin full dose 325mg and Plavix (Clopidogrel). . If you have chest pain take nitroglycerin under your tongue immediately. . If you experience chest pain, shortness of breath, nausea or vomiting please call your physician and go to the emergency room. . Please note the following changes in your medications: -Metoprolol was increased to 200mg two times per day for your blood pressure (Previously 50mg daily) -Aspirin dose was increased to 325mg daily (previously 81mg) -Your coumadin dose was changed to 4mg daily (previously 5mg) -You are no longer on Digoxin -You are no longer on Hydrochlorothiazide -You were started on Glipizide 2.5mg daily for your Diabetes . Please have your INR checked early next week. Followup Instructions: Please call your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1355**] at [**Telephone/Fax (1) 92377**] to make an appointment in the next 2 weeks. Completed by:[**2130-12-21**]

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icd9cm

[ [ [] ] ]

[ "00.45", "88.56", "99.20", "00.66", "99.04", "88.55", "37.22", "00.40", "99.07", "36.07" ]

icd9pcs

[ [ [] ] ]

20501, 20550

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327, 356

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42867

Discharge summary

report

Admission Date: [**2130-8-4**] Discharge Date: [**2130-8-11**] Date of Birth: [**2055-6-30**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 16115**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: Intubation Thoracentesis (Left) History of Present Illness: 74F with h/o recently dx pancreatic adenocarcinoma (cyberknife, gemcitabine most recently [**7-21**], attempted whipple but aborted when positive lymph node), DM2 who had outpatient scheduled CT scan complicated with code blue for hypoxemia. Patient presented for outpatient CT scan for oncology f/u. She received an IV contrast load. After CT scan she went for outpatient angio study to evaluate her port since there was no blood report. (Per patient report to IV team prior to event she had tPA in her port overnight last night.) On arrival to angio, patient was awake, conversant and denied any complaints but began to appear dyspneic and rapidly deteriorated. First aid was called and pt had pulmonary rales, desat to 70s. Suspected acute pulmonary edema, code blue was called and patient was intubated and transferred to ICU for further management. BP during event was 200s systolic, HR in 130s and appeared to be sinus on monitor. On arrival to ICU, pt is intubated and sedated. She was arousable to voice and tactile stimulation, and responded to commands. She was given 40mg IV lasix with urine ouput 500cc. Review of systems: (unable to obtain since intubated) Past Medical History: 1. History of hepatitis C virus cleared. 2. Hypertension. 3. GERD. 4. History of breast cancer status post left mastectomy in [**2094**]; no radiation or chemotherapy. 5. Status post left hip replacement in [**2124**]. 6. Status post cholecystectomy in [**2125**] after cholecystitis. 7. Type 2 diabetes mellitus. 8. L herniorrhaphy 9. S/p L hip replacement in [**2124**] 10. S/p CCY in [**2125**] after cholecystitis 11. Port-a-cath placed [**2-/2130**] 12. Pancreatic adenocarcinoma s/p gemcitabine, cyberknife Social History: Former smoker, 20 pack year hx quit in [**2088**]. Drinks EtOH socially, retired elementary school teacher. Single and lives alone. Her good friend is [**Name (NI) **] [**Name (NI) 29733**] [**Telephone/Fax (1) 92573**]. Her hCp is her sister but she will change it. She thinks it will be [**Doctor First Name **]. Family History: Father lived to be 94 and died of old age and dementia after breaking his hip. Father also with glaucoma. Sister at age 77 with AD in an ALF. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 98.6, HR 98, 124/75, CMV mode100% fio2, TV 500, PEEP 8, f 16, O2 sat 98% General: arousable to voice, intubated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, unable to assess JVP given body habitus, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: rales throughout lung fields bilatearlly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding. Scar below ribs bilaterally from prior abdominal incision and attempted whipple; chest with changes s/p L sided mastectomy GU: foley Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema to below the knees Neuro: PERRL, arousable to voice, follows commands intermittently when not sedated Discharge exam: VSS, 98% RA General: pleasant, no distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 7 cm CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: bibasilar rales, improved Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding. Scar below ribs bilaterally from prior abdominal incision and attempted whipple; chest with changes s/p L sided mastectomy Ext: Warm, well perfused, 2+ pulses, trace-1+ pitting edema to below the knees Pertinent Results: ADMISSION LABS [**2130-8-4**] 04:52PM WBC-7.1# RBC-3.77*# HGB-11.7*# HCT-36.1# MCV-96# MCH-31.1 MCHC-32.5 RDW-19.2* [**2130-8-4**] 04:52PM PLT COUNT-315# [**2130-8-4**] 04:52PM PT-11.3 PTT-37.9* INR(PT)-1.0 [**2130-8-4**] 04:52PM CALCIUM-8.3* PHOSPHATE-6.6*# MAGNESIUM-2.6 [**2130-8-4**] 04:52PM GLUCOSE-192* UREA N-38* CREAT-1.1 SODIUM-140 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-20* ANION GAP-15 [**2130-8-4**] 04:52PM CK-MB-3 cTropnT-0.12* proBNP-[**Numeric Identifier **]* [**2130-8-4**] 04:52PM CK(CPK)-59 Discharge labs: WBC 5.1 RBC 2.81 Hgb 8.6 Hct 26.1 MCV 93 Plt Ct 173 Glucose 167 UreaN 59 Creat 1.4 Na 143 K 4.2 Cl 111 HCO3 24 Mg 2.2 BNP [**Numeric Identifier **] Cholest 141 Triglyc 160 HDL 31 CHOL/HD 4.5 LDLcalc 78 Imaging: [**2130-8-4**] CT torso: IMPRESSION: .- New bilateral pleural effusions. .- New increase in diameter of the intrahepatic ducts at the right lobe with no apparent mass in the liver. Consider cholangitis. .- Enlarged pancreatic head but no distinct mass is seen. CXR [**2130-8-10**]: Final Report PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Recent acute diastolic heart failure, status post diuresis and left thoracentesis. Comparison is made with prior study, [**8-8**]. Moderate cardiomegaly is stable. Mild pulmonary edema is stable. Small bilateral pleural effusions, right greater than left, are stable. There is no pneumothorax or new lung abnormalities. Right Port-A-Cath is in unchanged standard position. TTE: The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mild depressed with inferolateral and basal inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. 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 (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The diastolic width of the pericardial effusion anterior to the right ventricular free wall is <0.5 cm. There is right atrial collapse and mild right ventricular diastolic indentation/collapse, consistent with impaired fillling/early tamponade physiology. Renal ultrasound: IMPRESSION: 1. Small angiomyolipoma in the left kidney. 2. Otherwise, normal examination. No evidence for renal artery stenosis. Pleural fluid: ATYPICAL. Rare atypical epithelioid cells in a background of reactive mesothelial cells and inflammatory cells. Note: A cell block is pending and will be reported separately. The patient's prior lymph node biopsy S12-7330 was also reviewed for morphologic comparison. Cell block: Pleural fluid, cell block: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells and inflammatory cells. Note: See also corresponding cytology report C12-[**Numeric Identifier 92574**]. Brief Hospital Course: 74F with h/o recently dx pancreatic adenocarcinoma, DM2, type 2 DM who had standard outpatient CT scan, complicated with code blue for hypoxia, likely secondary to acute pulmonary edema. # Pulmonary edema: Etiology of of acute pulmonary edema was not entirely clear but was most likely secondary to hypertension in the setting of SBP in the 200s during the event. She was intubated for protection of ventilation. Per her chart, she was not thought to have a h/o CHF however PCP is not in the [**Hospital1 18**] system and no echocardiogram in OMR. BNP was found to be elevated to 12,384. Increased osmotic load after receiving IV contrast was also considered, as was ACS although EKG was not suggestive of this and troponin trended down from 0.12 to 0.11. She received 40mg IV lasix on the day of admission and her respiratory status improved markedly after being only 800cc negative. She received further boluses of IV Lasix and eventually started Lasix drip on [**8-4**] with adequate UOP; this was discontinued on [**8-5**]. Due to a rise in the Cr to 1.3 and physical appearance of being dry, additional lasix was not given. Acute valve disease was additionally considered and she was ordered for a TTE. The echo revealed EF 55%, mild pulm HTN with PASP ~35, inferolateral and inferior basal hypokinesis. There was also a small pericardial effusion with right atrial collapse and mild right ventricular diastolic indentation/collapse, consistent with impaired fillling/early tamponade physiology. This fluid amount, however, was considered too small to tap. To evaluate for cardiac ischemia (trop leak, local wall motion abnl and unexplained pulmonary edema) and the pericardial effusion, cardiology was consulted. Their assessment was that the event was most consistent with diastolic dysfunction and recommended initiation of labetalol and lipitor - in addition to the ACEI and aspirin she already was on. Due to the Echo parameters of RA 0-5 mmHg, collapsable IVC and RA/RV collapse, rising Cr, additional diuresis was not considered necessary. Renal U/S was obtained to r/o renal artery stenosis as etiology of acute pulmonary edema (no stenosis identified). In addition, given the gemcytobine, non-cardiac pulmonary edema and PVOD were considered in the differential. Patient improved with diuresis, and was discharged on Lasix 80 mg [**Hospital1 **], labetalol, atorvastatin, and lisinopril with ASA. # Pleural effusion: Ms. [**Known lastname **] was able to wean down to RA but desaturatd with ambulation. A lateral decub CXR was obtained and revealed L>R pleural effusion. THoracentesis was performed and 600 cc withdrawn. Fluid studies - including cytology - as noted above were negative for malignancy. # Anemia- low haptoglobin suggesive of hemolysis. Hematology looked at smear, only saw one or two schistocytes, making microangiopathic hemolytic anemia unlikely. There was no evidence of GI bleed, and ferritin was 487, suggesting iron deficiency was not a likely etiology. She was given one unit of PRBCs with good response. Should monitor Hct as outpatient, and consider endoscopic evaluation if does not improve. # HTN: Patient was hypotensive periintubation likely due to propofol in combination with diuresis. Home meds were restarted, with close monitoring of renal function. #Renal insufficiency- Patient's creatinine increased to 1.3 and was stable throughout remainder of hospital course during aggressive diuresis. Creatinine 1.1 on admission, 1.4 at discharge, with close follow up of renal function and lytes as outpatient. # Access: Patient with port that was not having blood return during her outaptient CT prompting angio study. Angio study revealed no issues, and [**First Name4 (NamePattern1) 8817**] [**Last Name (NamePattern1) **] (IR access specialist) was closely involved. CHRONIC ISSUES # Pancreatic adenocarcinoma: s/p 6 cycles of gemcitabine (most recent [**7-21**]) and had cyberknife. She will f/u as an outpatient for further management with Dr. [**Last Name (STitle) 1852**]. # DM2: Home NPH insulin and ISS were continued. # GERD: She was given pantoprazole for stress ulcer ppx. # Full code Medications on Admission: FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 Tablet(s) by mouth daily INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100 unit/mL Cartridge - LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day LORAZEPAM - 0.5 mg Tablet - [**11-21**] Tablet(s) by mouth q4-6h as needed for nausea OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed for nausea PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed for nausea Medications - OTC CALCIUM CARBONATE [CALCIUM 500] - (Prescribed by Other Provider) - Dosage uncertain MV WITH MIN-LYCOPENE-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Dosage uncertain NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other Provider) - 100 unit/mL Suspension - 12 units in am , 3 units in pm Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. NPH 12 Units Breakfast NPH 3 Units Bedtime 4. Labetalol 400 mg PO BID RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 RX *labetalol 200 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*0 5. Lisinopril 20 mg PO DAILY RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Omeprazole 20 mg PO DAILY 7. Furosemide 80 mg PO BID RX *furosemide 80 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Outpatient Lab Work Please check BUN/creatinine, sodium, potassium, chloride, bicarbonate, and magnesium on [**2130-8-14**], and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18359**] at [**Telephone/Fax (1) 90646**]. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: - Acute pulmonary edema - Small pericardial effusion - Hypertension - Pancreatic Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the intensive care unit for shortness of breath and worsened oxygenation. Chest x-ray revealed fluids in the lung (pulmonary edema) and you were given intravenous diuretics to help eliminate the extra fluid. With this, your oxygenation improved significantly and you were able to be weaned off the oxygen. A number of studies were done to evaluate the cause of this acute event: an ultrasound of the kidneys revealed no abnormalities. Ultrasound of the heart revealed good pumping function, but small amounts of fluid around the heart and an area of reduced motion in a segment of the heart wall. Cardiology was consulted and made recommendations to your medications. These include, the addition of aspirin, labetolol, Lasix, and Lipitor. These should be continued with your lisinopril. HCTZ was discontinued. Lisinopril was continued at a higher dose. In addition, 600 cc of pleural (around the lung) on the left side. You did not need any oxygen therapy on the day of discharge. Followup Instructions: Primary Care AppointmentL **Please call for follow up appointment for this hospitalization with your PCP below to be seen 1 week from your discharge. Name:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD Address: [**Location (un) **] [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 70678**] Phone: [**Telephone/Fax (1) 18360**] Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2130-8-25**] at 1:15 PM With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2130-8-25**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Cardiology Appointment: [**2130-8-29**] 11:40a Dr. [**Last Name (STitle) 2194**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "34.91", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

13370, 13427

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283, 317

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138,859

6718

Discharge summary

report

Admission Date: [**2123-1-21**] Discharge Date: [**2123-3-16**] Date of Birth: [**2063-4-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal Pain Idopathic Pancreatitis Major Surgical or Invasive Procedure: ERCP Pancreatic Necrosectomy with Wide Drainage Small bowel resection G tube/J tube History of Present Illness: This is a 59 year old male with 5th episode of pancreatitis of unclear etiology, necrotizing, admitted to OSH [**2123-1-15**]. He presented to the OSH with pain, WBC to 16,000. A CT scan from the OSH revelaed necrotising pancreatitis, ileus, mechanical obstruction of descending colon. He was transferred to [**Hospital1 18**] after blood cultures from [**2123-1-20**] showed Gram negative rods, fever 104, and SMV partial thrombosis. Past Medical History: DM HTN dyslipidemia Social History: nonsmoker No EtOH Lives with wife Family History: N/C Physical Exam: VS: 99.4, 110, 144/70, 31, 98% 4L Gen: rigors, diaphoretic, some distress HEENT: EOMI, PERRLA Chest: CTA bilat CV: Reg tachycardia, S1, S2 Abd: Distended, mid epigastric tenderness Ext: WNL Pertinent Results: MRCP (MR ABD W&W/OC) [**2123-1-24**] 12:10 PM IMPRESSION: 1. Acute pancreatitis with necrosis of the head/body and proximal portion of the pancreatic tail with surrounding peripancreatic enhancing fluid collections. Superinfection of these collections cannot be excluded. 2. Non-occlusive SMV thrombosis. 3. Marked dilatation of the small bowel with collapse of the transverse and distal colon. Evolving small bowel obstruction cannot be excluded although these findings are most likely related to ileus in the setting of acute pancretitis. 4. No obstructing stone visualized within the intra- or extra-hepatic biliary tree. The distal portion of the CBD is not visualized and a mass in this region cannot be excluded. 5. The pancreatic duct is visualized along its entire course entering the duodenum, without obstruction in the pancreatic head. . CTA ABD W&W/O C & RECONS [**2123-1-26**] 12:34 AM IMPRESSION: 1. Acute pancreatitis with necrosis and replacement of the head and body with fluid, superinfection of this fluid collection cannot be excluded. 2. Small non-occlusive SMV thrombus and attenuation of the splenic vein at portal confluence. 3. No pseudoaneurysm is noted. 4. Marked dilation of a small bowel with collapse of the distal transverse colon and descending colon. This most likely represents functional collapse of distal transverse colon in the setting of acute pancreatitis. 5. Status post common bile duct stent placement. 6. Dilated pancreatic duct that is visualized along its course entering the duodenum. . CT ABDOMEN W/CONTRAST [**2123-1-30**] 4:11 PM IMPRESSION: 1. Acute pancreatitis with necrosis and replacement of the head and most of the body of the pancreas with unchanged multiloculated collection in the pancreatic bed. Again, superinfection of this collection cannot be excluded. 2. Nonvisualization of the previously seen SMV partially occlusive thrombus. Patent, however attenuated splenic vein at the portosplenic confluence. No evidence of pseudoaneurysm. 3. Unchanged marked dilatation of small bowel and right colon and transverse colon, this most likely represents ileus as contrast is seen within the colon. 4. Interval development of pneumobilia which can be seen in the presence of a common bile duct stent. 5. Right upper lobe air space disease suspicious for infection. . [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2123-2-2**] 2:50 PM IMPRESSION: Successful placement of post-pyloric feeding tube with termination in the third portion of the duodenum. . ERCP [**2123-1-25**] 1.The duodenum was distorted and oedomatous in keeping with acute pancreatitis. 2.The major papilla was located in the second part of the duodenum and was surrounded by oedomatous mucosa. 3.It was cannulated to access the CBD. 4.There distal CBD was v. narrowed due to extrinsic compression from surrounding pancreatitis. 5.The proximal CBD was of normal calibre. 6.There were no stones or other filling defects noted in the CBD. 7.The proximal PD visualised appeared normal. 8.A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. 9.A 7cm by 10Fr biliary stent was placed successfully in the in the CBD across the narrowed segment . PORTABLE ABDOMEN [**2123-1-31**] 12:28 AM FINDINGS: Comparison is made to the previous radiograph from [**2123-1-24**] and the CT scan from [**2123-1-30**]. There is again seen markedly distended loops of small bowel as well as loops of colon throughout the abdomen. Small bowel distension appears to have decreased slightly since the prior radiograph. Biliary stent and a nasogastric tube are seen. The hemidiaphragms are not included on the study nor is the right upper quadrant, which limits assessment for free air. However, no large amount of free air is seen. . CTA ABD W&W/O C & RECONS [**2123-2-4**] 9:07 PM IMPRESSION: 1. Interval appearance of nonocclusive extrahepatic portal vein thrombosis and narrowing of the proximal splenic vein. 2. Similar appearance of large enhancing necrotic pancreatic fluid collection, with intra-abdominal ascites. No evidence of splenic artery aneurysm. 3. Biliary catheter and Dobhoff tube in place. 4. Dense oral contrast in the colon, to the rectum. No evidence of obstruction. 5. Bilateral moderate-to-large pleural effusions with associated atelectasis. . CTA PANCREAS W/ CTCP [**2123-2-13**] 10:36 PM IMPRESSION: 1. Complications of acute pancreatitis, with a large pseudocyst and necrosis of the pancreatic body and head. Gas bubbles are seen, and infection cannot be excluded. 2. Nonocclusive portal vein thrombosis and obliteration of the splenic vein. The superior mesenteric vein is patent. Small pseudoaneurysm of a branch of the splenic artery. Nonocclusive thrombus is seen within the splenic artery as well. 3. Ascites. 4. Pneumobilia. . Cardiology Report ECG Study Date of [**2123-2-21**] 1:38:24 PM Intervals Axes Rate PR QRS QT/QTc P QRS T 78 122 92 396/429 42 23 39 . LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2123-2-20**] 11:24 AM IMPRESSION: Decreased ascites. No intra- or extrahepatic ductal dilatation. Limited evaluation for the pancreas. Previously noted clot in the portal vein was not demonstrated on this study. . CT ABDOMEN W/CONTRAST [**2123-3-10**] 12:49 PM IMPRESSION: 1. Status post debridement of infected pancreatic pseudocyst and pancreatic necrosis with residual air- and fluid-containing collections identified in the pancreatic bed which contain surgical drains. Probable small communicating perforation between smaller air-fluid collection in region of pancreatic tail and adjacent fourth portion of duodenum. 2. Improvement to intra-abdominal/pelvic ascites and fluid tracking along the paracolic gutters. New simple fluid collection noted posterior to the surgical staple line. 3. Reidentification of the splenic vein thrombosis with nonvisualization of previously noted nonocclusive portal vein thrombosis and pseudoaneurysm of portion of splenic artery due to the phase of contrast during current study image acquisition. 4. Multiple fluid-filled slightly dilated loops of bowel, imply underlying ileus. No evidence of bowel obstruction. . Brief Hospital Course: He was admitted on [**2123-1-21**] to the ICU. Neuro: He was A+O x 3 mostly, and he had periods of confusion, but was easily re-oriented and able to follow commands. GI/ABD: He was NPO with an NGT and IVF resuscitation. The NGT was putting out moderate amounts of bilious drainage. The NGt was removed on HD 3. A new NGT was placed on [**2123-1-25**] due to continued abdominal distention. CV: He was tachycardic and was being treated with Lopressor. He received 1 unit PRBC on [**2123-1-30**] for anemia. Hypertension: The patient was triggered on [**2-3**] for BP 186/90, HR 122, RR 36 and temp 102.4. Blood cultures were sent and CXR was negative. He received Hydralazine and Lopressor to control HR and BP. Cardiac enzymes were negative. GU: He had a Foley in place and had hypovolemia. He required several IV fluid boluses to treat the hypovolemia SMV thrombus: He was started on Heparin gtt for the thrombus. The Heparin gtt was stopped on [**1-31**] and he was switched to Heparin SC TID. FEN: He was started on TPN for nutritional support Hypernatremia: His sodium was elevated to 154 on [**1-22**] and [**1-23**]. He received free water to correct the hypernatremia and had q4h Na checks to monitor the decrease serum sodium. Endo: He was started on an Insulin gtt to control his hyperglycemia on HD 3. He had good blood glucose control. ID: [**2-14**] OR swab - gram+GNR, BCx - P; [**2-13**] UCx/BCx/tip P; [**2-12**] BCx - NG; 2/26,25 BCx - NG; [**2-6**] BCx - enterobacter, UCx - NG; [**2-3**] BCx - ([**12-15**]) Enterobacter He was on IV Meropenum for + blood cultures - gram negative rods. Meropenem started on [**1-21**], fluconazole [**1-30**], vanco [**1-30**]. [**2-1**] Bcx P, sputum contam., cath tip P [**1-30**] SpCx rare GNR [**1-29**] Bcx P x 3, ucx neg [**1-27**] BCx pend, cath tip negative [**1-23**] Bcx: coag neg Staph 1 of 4 bottles [**1-21**] BCx 3/4 bottles + for pansens. Ent aerogenes;UCx neg, cath tip neg MRCP on [**2123-1-24**] showed: 1. Acute pancreatitis with necrosis of the head/body and proximal portion of the pancreatic tail with surrounding peripancreatic enhancing fluid collections. Superinfection of these collections cannot be excluded. 2. Non-occlusive SMV thrombosis. 3. Marked dilatation of the small bowel with collapse of the transverse and distal colon. Evolving small bowel obstruction cannot be excluded although these findings are most likely related to ileus in the setting of acute pancreatitis. 4. No obstructing stone visualized within the intra- or extra-hepatic biliary tree. The distal portion of the CBD is not visualized and a mass in this region cannot be excluded. 5. The pancreatic duct is visualized along its entire course entering the duodenum, without obstruction in the pancreatic head. Resp: He was intubated prior to the ERCP due to high risk for aspiration. Following ERCP, he went for a CT and then was successfully extubated. ERCP on [**1-25**] showed: 1.The duodenum was distorted and edematous in keeping with acute pancreatitis. 2.The major papilla was located in the second part of the duodenum and was surrounded by edematous mucosa. 3.It was cannulated to access the CBD. 4.There distal CBD was v. narrowed due to extrinsic compression from surrounding pancreatitis. 5.The proximal CBD was of normal calibre. 6.There were no stones or other filling defects noted in the CBD. 7.The proximal PD visualized appeared normal. 8.A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. 9.A 7cm by 10Fr biliary stent was placed successfully in the in the CBD across the narrowed segment He was eventually transferred out to the floor and was doing well. He was cleared by Speech and Swallow and started on sips. However, on [**2123-2-13**], he had +BCx GNR, septicemia and now with G.I. bleed. On [**2123-2-13**] he requiring 8 units PRBC's most likely secondary to gastric varices. He went to the OR on [**2-14**] for S/p necrosectomy/small bowel resection/G tube/J tube. He was followed by GI for his GI bleed. He was on Heparin for his splenic vein thrombosis. He was having fresh rectal bleeding over the weekend [**Date range (1) 25583**]. He had a bleeding scan (tagged RBC) which was negative. He had a Colonoscopy on [**2-23**], which showed liquid stool & old blood were found in the whole colon. Impression: Stool in the whole colon, otherwise normal colonoscopy to transverse colon. There was no active bleeding. He remained in the ICU, and was transferred to the floor on [**2-24**]. GI: He complained of abdominal pain when his tubefeeding were advanced to goal. On [**2-25**], the tubefeedings were stopped and he was back on TPN. He continued on TPN ON the morning of [**2123-2-26**], he reported a bloody bowel movement. His HCT was stable, and he did not have any more melana. He was started back on a clear diet on [**2123-3-5**]. The patient was proceeding cautiously with his intake and was having daily bouts of nausea. He was started on J-tube feedings. It was again clear that he was unable to tolerate J-tube feedings and was switched back to TPN and can take clear fluids for comfort with the G-tube vented to a gravity bag. ID: He was on Fluc, Cipro, and Flagyl for the necrotizing pancreatitis and +BCx for ENTEROBACTER. All antibiotics D/C'd on [**2123-3-9**]. Abd: He had a midline abdominal incision with staples that was intact, with some spotty drainage. Staples were D/C'd [**2123-3-13**] and steri strips placed. He had a G-tube and J-tube in place and these were to gravity. He had JP drains in place. His TBili continued to decrease to 2.0 on [**2123-3-2**] from a peak of 8.5 on [**2123-2-18**]. His abdomen continued to heal. The JP x 3 were monitored for output and an amylase was sent from drain #3 and was [**Numeric Identifier **]. The drains will remain in place due to the pancreatic leak, but output is minimal from #2 and #4 drain. Leave all drains in place until his follow-up with Dr. [**Last Name (STitle) **]. He had a CT on [**2123-3-10**] and showed a probable small communicating perforation between smaller air-fluid collection in region of pancreatic tail and adjacent fourth portion of duodenum. Reidentification of the splenic vein thrombosis with nonvisualization of previously noted nonocclusive portal vein thrombosis and pseudoaneurysm of portion of splenic artery due to the phase of contrast during current study image acquisition. Multiple fluid-filled slightly dilated loops of bowel, imply underlying. Poral Vein Thrombus: On [**2123-2-26**] he went for an US to evaluate for a PV thrombus. This showed a patent portal vein. He was now on just Aspirin for anticoagulation due to the risk of rebleeing. Pain: He was not complaining of significant pain, mostly some abdominal distension. Pain was controlled with Oxycodone elixir which caused some nausea. Most recently he was taking Tylenol and Ativan. Activity: He was seen by PT and getting OOB with assistance and walking the halls. Medications on Admission: [**Last Name (un) 1724**]: metformin 500", lovastatin 20', lisinopril 5', prednisolone gtts Discharge Medications: 1. Octreotide Acetate 100 mcg/mL Solution [**Last Name (un) **]: One (1) Injection Q8H (every 8 hours). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 3. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 4. Prochlorperazine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 6. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 9. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) Injection Q4H (every 4 hours) as needed for agitation. 10. Metoclopramide 5 mg/mL Solution [**Last Name (STitle) **]: One (1) Injection Q6H (every 6 hours). 11. Dolasetron 12.5 mg/0.625 mL Solution [**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. 12. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily) as needed. 13. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Ten (10) Units Subcutaneous at bedtime. 14. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: Sliding Scale Injection four times a day: See sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Necrotizing Pancreatitis Ileus - Mechanical Obstruction SMV thrombus Sepsis GI Bleed Varices with Hemorrhage Acute Blood Loss Anemia Post-op Hyperglycemia Post-op Hypovolemia Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain . Please take all meds as ordered. . Continue to ambulate several times per day. . You may have clear liquids by mouth as tolerated. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment. Completed by:[**2123-3-16**]

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icd9cm

[ [ [] ] ]

[ "96.04", "99.15", "51.85", "96.6", "99.07", "38.91", "45.62", "45.13", "45.91", "46.39", "51.87", "43.11", "99.04", "96.07", "52.51", "45.23" ]

icd9pcs

[ [ [] ] ]

16211, 16283

7465, 14479

351, 437

16502, 16509

1241, 7442

16828, 16987

1011, 1016

14621, 16188

16304, 16481

14505, 14598

16533, 16805

1031, 1222

274, 313

465, 901

923, 944

960, 995

64,230

197,315

30077

Discharge summary

report

Admission Date: [**2120-10-9**] Discharge Date: [**2120-10-22**] Date of Birth: [**2049-3-15**] Sex: M Service: SURGERY Allergies: Unasyn Attending:[**First Name3 (LF) 4748**] Chief Complaint: Left lower extremity nonhealing ulcers Major Surgical or Invasive Procedure: Left lower extremity angiogram [**2120-10-15**] with Dr. [**Last Name (STitle) 1391**] [**Name (STitle) 2325**] femoral to femoral-posterior tibial graft bypass graft with PTFE and left fifth toe amputation [**2120-10-17**] with Dr. [**Last Name (STitle) 1391**] History of Present Illness: Mr. [**Known lastname 5721**] is a 71 year old male with an extensive past medical history s/p L SFA-PT [**Name (NI) **] who presented to clinic today from [**Hospital6 **] with complaints of worsening LLE ulcers and left 5th toe gangrene. His sister reports that he first developed LLE wounds approximately 2 months ago prior to his transfer to rehab, and that she feels they are related to dressings being too tight. She reports they have been growing continually worse over the past several weeks prompting Mr. [**Known lastname 71725**] clinic visit today. Past Medical History: PMH: DM, HTN, HLD, Carotid stenosis, PVD, severe AS, CRI, cataracts, OSA, neuropathy PSH: R CEA, L SFA-PT [**Name (NI) **] w NRSVG 09 and Dacron patch angioplasty 09, 10, EVAR, aortic balloon valvuloplasty 10, trach, PEG Social History: He has been living with his sister since [**2115**] with his medical disability. He does not currenly smoke but did smoke 3 packs per day for 20 years. He does not drink alcohol. Family History: There is a family history of diabetes and heart disease. There is no history of hypertension or strokes. His mother died at age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes and coronary artery disease. He has three healthy children. Physical Exam: PE on admission: Neuro/Psych: NAD, abnormal: Anxious, aphasic but oriented x3. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy. Skin: Abnormal: LLE wounds; sacral pressure wound. . Heart: Regular rate and rhythm, abnormal: Loud, high pitched systolic ejection murmur. Lungs: Clear, Normal respiratory effort. Gastrointestinal: No masses, No hernia, abnormal: Obese. Rectal: Not Examined. Extremities: No femoral bruit/thrill, abnormal: 2+ pitting edema of LE bilaterally. Chronic skin changes, L>R. LLE wounds x7. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE Femoral: P. DP: D. PT: D. LLE Femoral: P. DP: D. PT: D. DESCRIPTION OF WOUND: 1. Left dorsal foot: 4cm irregular wound with eschar, surrounding erythema and induration. 2. L 5th toe gangrenous, no evident purulence, dry 3. L lateral MTP wound 2x1cm with eschar, no drainage 4. L great toenail with onycomycosis, surrounding eschar, no purulence 5. L medial heel wound: 2x2cm with eschar, no surrounding erythema 6. L posterior heel wound: 3x3cm with eschar, depressed, no surrounding erythema or purulence. Tender to palpation. 7. L posterior calf: 1x-.5cm eschar, irregular, no surrounding erythema, no purulence. PE on discharge: Gen: AAOx4, conversant with expressive aphasia, NAD CVS: Regular, grade IV systolic murmur Pulm: clear bilaterally Abd: soft, nontender, nondistended Ext: left lower extremity wounds stable with eschars, adaptic dressings applied. Left leg incisions clean, dry and intact - no erythema, no drainage, no induration. Pulses: Fem: Palp b/l, DP/PT Dop b/l Neuro: CN II-XII grossly intact Brief Hospital Course: Mr. [**Known lastname 5721**] was admitted on [**10-9**] for evaluation of his left lower extremity vasculature, and he underwent non-invasive arterial studies on [**10-10**] which revealed occlusion of his left SFA-PT graft. On [**10-11**], he underwent upper extremity vein mapping in preparation for a possible bypass graft, which revealed patent upper extremity veins, R>L, and his right arm was subsequently protected from any needlesticks or IVs. His IV antibiotics were continued, and wound care with adaptic dressings was performed daily. On [**10-15**], he underwent left lower extremity angiography after being pre-medicated with IV bicarbonate. His left SFA to PT bypass was found to be patent, but the proximal left SFA was occluded on angiogram. He was thus offered a left femoral to graft bypass to circumvent the occluded SFA segment proximal to the patent graft. After discussion with the patient and his sister, [**Name2 (NI) 3548**], and discussion of the risks and benefits of surgery, Mr. [**Known lastname 5721**] agreed to undergo bypass on [**2120-10-17**]. After appropriate preparation and informed consent, Mr. [**Known lastname 5721**] [**Last Name (Titles) 8783**]t left femoral to existing (femoral-posterior tibial bypass) bypass graft with PTFE and left 5th toe amputation with primary closure. He tolerated the procedure well. After initial recovery in the PACU, Mr. [**Known lastname 5721**] was transferred to the vascular surgery floor for further monitoring and recovery. He was placed on the lower extremity bypass pathway, and his activity and diet were advanced accordingly, to full ambulation with physical therapy and regular diet by [**10-20**]. His pain was controlled with oral pain medication, and a heparin drip was maintained post-operatively until his usual coumadin dosing became therapeutic on [**10-22**]. His IV antibiotics were continued throughout his hospital stay, and transitioned to oral bactrim at the time of discharge. He remained hemodynamically stable, and received 3 units of pRBCs for falling hematocrit post-operatively in light of his critical aortic stenosis. His blood pressure remained within the target range throughout his post-operative course. On [**10-22**], Mr. [**Known lastname 5721**] was found to be ambulating with assistance (at his baseline), tolerating a regular diet, therapeutic on his coumadin, and reporting good pain control with oral pain medication. He was deemed stable for discharge back to [**Hospital **] with instruction to follow up with Dr. [**Last Name (STitle) 1391**] in clinic in 2 weeks for wound check and graft evaluation. He will continue his coumadin and a 10 day course of bactrim. He will need physical therapy and speech therapy, as well as wound care (adaptic and kerlex) for his left lower extremity wounds. Mr. [**Known lastname 5721**] understood and agreed with the plan and was transferred to [**Location (un) 25576**] on [**2120-10-22**]. Medications on Admission: coumadin 6' (held), Prilosec 20', Lovemir 42u SQ', Humalog ISS, minocin 100'', lasix 40', amiodarone 200', ASA 81', neurontin 800'', levemir 40u qHS, lidoderm 5% TD q12h, metoprolol 50'', MVI', serax 10''', pravastatin 40', senna' prn, colace 100'', lactulose 30 q6h prn, oxycodone 5 q4h prn, zinc sulfate 220' Discharge Medications: 1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for Pain for 5 days. Disp:*24 Tablet(s)* Refills:*0* 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. oxazepam 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. 13. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 14. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: *Please continue regular INR checks and adjust coumadin dosing accordingly for INR goal [**3-14**]*. 17. minocycline 50 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 18. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. 19. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 20. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous per sliding scale: Please see insulin sliding scale. 21. Insulin sliding scale Insulin SC Sliding Scale (Humalog) Breakfast Lunch Dinner Bedtime Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 3 Units 3 Units 3 Units 3 Units 201-250 mg/dL 6 Units 6 Units 6 Units 6 Units 251-300 mg/dL 9 Units 9 Units 9 Units 9 Units 301-350 mg/dL 12 Units 12 Units 12 Units 12 Units 351-400 mg/dL 15 Units 15 Units 15 Units 15 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Left lower extremity ulcers left 5th toe dry gangrene Occlusion of left superficial femoral artery to posterior tibial artery bypass graft Discharge Condition: Mental Status: Clear and coherent, severe expressive aphasia. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**3-14**] 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 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? 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: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over 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 over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Please call [**Telephone/Fax (1) 1393**] to schedule a follow up appointment with Dr. [**Last Name (STitle) 1391**] in clinic in 2 weeks. Please follow up with your PCP for INR checks and coumadin dose adjustments.

[ "250.00", "784.3", "401.9", "707.8", "440.24" ]

icd9cm

[ [ [] ] ]

[ "39.29", "88.48", "84.11" ]

icd9pcs

[ [ [] ] ]

9382, 9468

3650, 6625

306, 571

9651, 9651

12771, 12989

1623, 1891

6986, 9359

9489, 9630

6651, 6963

9861, 12338

12364, 12748

1906, 1909

3238, 3627

228, 268

599, 1163

1923, 3224

9666, 9837

1185, 1408

1424, 1607

58,955

120,352

51824

Discharge summary

report

Admission Date: [**2144-5-28**] Discharge Date: [**2144-6-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2972**] Chief Complaint: pneumonia Major Surgical or Invasive Procedure: NIPPV History of Present Illness: [**Age over 90 **]yo man with PMH of atrial fibrillation on coumadin, CRI, and possible CHF, who presents from his home with fever and SOB. His home health aides called EMS because they were concerned that he had been more SOB. He received 80mg IV lasix by EMS en route to the [**Hospital1 18**] ED. . In ED, VS were: 104.0 83 127/61 40 94% NRB. Was tachypneic, looked unconfortable. Exam showed diffuse coarse breath sounds. He was put on CPAP 8/5/40% with improvement in RR and good tidal volumes of 500-600cc. Labs revealed WBC count 10.0 with 82% polys, CRI at baseline 1.4, and lactate 2.2 CXR revealed slight central vascular congestion without overt edema or consolidation, with left base atelectasis and a small left pleural effusion, however the ED was concerned for LLL PNA. EKG showed atrial fibrillation without ischemic changes. U/A was clean. Urine outpt 1400cc in ED from lasix, but was given 1L IVF and tylenol for fever. Blood and urine cultures were drawn and the patient received CTX 1g and levofloxacin 750mg and was admitted to the ICU. Most recent VS: 104.6 93 129/66 26 99% CPAP. Access: PIV. . Currently, he appears comfortable and in NAD. He is follows basica commands and interacts appropriately but is not very communicative. Past Medical History: # Hypertension # Prostate CA # Afib # ? CHF # Depression Social History: lives at home alone, has 2 24 hour home health aides. At baseline does not ambulate at all. No EtOH/tobacco/drugs. Family History: NC Physical Exam: VS: T: 103 HR: 89 BP: 119/55 RR:23 Sat: 100% on [**2074-7-30**]% Gen: elderly caucasian male, NAD, comfortable, a&ox1 (self, [**2145**]) HEENT: NCAT, PERRL, sclera anicteric Neck: Supple, no LAD, JVP at 10-12 cm at 30 degrees CV: irregularly irregular, S1/S2, no m/r/g Resp: moderate air movement but not taking deep breaths volitionally, no appreciable crackles Abdomen: Soft, NTND, BS+ Ext: 1+ b/l LE pitting edema. DP pulses are 2+ bilaterally Neuro: A + O x 1, CN II-XII grossly intact, Motor [**4-29**] both upper and lower extremities Skin: Pink, warm, no rashes Pertinent Results: [**2144-5-28**] 09:25PM BLOOD WBC-10.0 RBC-4.51* Hgb-13.7* Hct-40.4 MCV-89 MCH-30.4 MCHC-34.1 RDW-14.2 Plt Ct-130* [**2144-5-28**] 09:25PM BLOOD Neuts-82.5* Lymphs-10.6* Monos-6.3 Eos-0.3 Baso-0.3 [**2144-5-28**] 09:25PM BLOOD Glucose-149* UreaN-22* Creat-1.4* Na-139 K-4.4 Cl-105 HCO3-24 AnGap-14 [**2144-5-28**] 09:25PM BLOOD PT-26.3* PTT-30.4 INR(PT)-2.6* [**2144-5-29**] 01:44AM BLOOD Type-ART pO2-107* pCO2-35 pH-7.50* calTCO2-28 Base XS-4 . [**5-28**] Blooc Cx: PNd [**5-28**] UCx: PND . [**5-28**] CXR: IMPRESSION: Slight central vascular congestion without overt edema or consolidation. Low lung volumes with left base atelectasis and a small left pleural effusion. Brief Hospital Course: Mr. [**Known lastname 107314**] is a 20yo man with PMH of ? CHF, afib on coumadin, who presents with fever and SOB, admitted for PNA. . # PNA - febrile to 104 in the ED, with LLL infiltrate on CXR. No HAP risk factors. Started on broad coverage, narrowed to levaquin on discharge. Started on NIPPV, rapidly transitioned to NC and room air by the time of discharged. Sent home after 3 nights, > 48 hours afebrile, to complete 7 days of antibiosis with chest PT and incentive spirometry for poor secretion clearance . # Hypoxemia - likely multifactorial from PNA + contribution from acute CHF exacerbation. Responded to brief NIPPV, O2 by NC, and aggressive pulm toilet. Discharged on room air . # acute CHF, ? diastolic - echo from [**2141**] showed preserved EF. Current presentation (CXR, vigorous repsonse to IV lasix and improvement on CPAP, LE edmea and mildly elevated JVP) do suggest some component of volume overload. # Chronic Renal Insufficiency: at baseline. -- renally dose medications . # Afib: restarted diltiazem. taught caretakers to no crush the XR formulation . # Dementia -- continue namenda . # H/o prostate CA: no active issues. . Medications on Admission: 1. Atorvastatin 5 mg daily 2. Aspirin 81 mg Tablet PO DAILY 3. Warfarin 2.5 mg daily 4. Diltiazem XT 120mg daily 5. Spectravite Senior 1 tab daily 6. Lasix 10mg po q M/W/F/S 7. Namenda 10mg [**Hospital1 **] Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H (every 48 hours): Take one [**2144-6-3**]. Disp:*3 Tablet(s)* Refills:*0* 2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day: do not crush this pill. If you cannot give a whole pill, then obtain prescription for immediate release diltiazem. 5. Lasix 20 mg Tablet Sig: 0.5 Tablet PO M/W/F/S. 6. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO once a day. 7. Spectravite Senior Tablet Sig: One (1) Tablet PO once a day: do not take with antibiotics. 8. Incentive Spirometer Use every waking hour for 7-10 days or until breathing difficulties resolve. Take a deep breath in and blow out into the device, holding your exhalation as long as possible. Do this 5 times every hour 9. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Hold and then restart on Wed, [**6-3**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Community Acquired Pneumonia Secondary: Dementia, Atrial Fibrillation Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). . Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Discharge Instructions: Mr. [**Known lastname 107314**], you were admitted with a pneumonia. You did well and were treated effectively with antibiotics. However, your lungs are weak and unable to clear your phlegm with ease. You were managed at first in the intensive care unit and later on the general floor where you continued to improve, needing oxygen supplementation at first and none by the time of your discharge. . NEW MEDICATION 1. Levofloxacin - continue until [**Month (only) **] the 10th, [**2143**] HOLD 1. Coumadin - the antibiotics keep your INR high. you will need to have your coumadin checked frequently. Restart on Wednesday [**2144-6-3**]. . You should have your INR checked on Wednesday [**2144-6-3**]. . We have also provided an Incentive Spirometer - use as directed every hour or so. Followup Instructions: Please follow up with [**Last Name (LF) **],[**First Name3 (LF) **] B. [**0-0-**] [**6-15**] at 3:30pm You can have the INR checked as per usual. Do so on Wednesday, Completed by:[**2144-6-10**]

[ "486", "428.31", "585.9", "V10.46", "427.31", "294.8", "311", "518.81", "428.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5576, 5634

3098, 4253

271, 278

5757, 5834

2399, 3075

6749, 6947

1790, 1794

4510, 5553

5655, 5736

4279, 4487

5941, 6726

1809, 2380

222, 233

306, 1561

5849, 5917

1583, 1642

1658, 1774

24,573

176,194

1122

Discharge summary

report

Admission Date: [**2130-7-18**] Discharge Date: [**2130-7-21**] Date of Birth: [**2070-7-15**] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[**First Name3 (LF) 613**] Chief Complaint: Bradycardia, chest pain Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Mr [**Known lastname 7203**] is a 60 year old spanish speaking man with Diabetes, hypertenion, hyperlipideamia, history of ESRD on HD (Tues, Thurs, Sat), presenting with chest pain radiating to the left arm. Patient reports his symptoms started yesterday, at rest while sitting. He describes the pain as localized over the left chest, dull pressure with radiation to the back mid scapular area. No palpitations, diaphoresis or nausea. Patient took nitroglycerin at home without improvement in symptoms. Patient has been taking all medications as prescribed and has not skipped any dialysis sessions. He does report difficulty breathing starting with above symptoms. EMS gave patient ASA, Atropine 1mg and Nitro Spray x 1. In the ED, vital signs Temp 97.1 BP 150/36 RR 24 O2 Sat: 99% RA Patient was found to be hyperkalemic, bradycardic (junctional rhythm per report). Patient underwent CTA chest/abdomen and pelvis without evidence of dissection or PE. Per ED report a "small amount of contrast extravasated" on the right hand. Right IJ line was attempted but not successful, left subclavian line was placed. Patient did not receive any aspirin, plavix or heparin. Renal, cardiology and EP teams were made consulted. Patient was given Morphine, Atropine (0.5mg x 2), 10 units of IV insulin with 1 amp of dextrose, Kayexalate and 2gm of calcium Gluconate. Past Medical History: 1. Coronary Artery Disease - s/p CABG [**2-28**] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1 - s/p PTCA and DES to proximal LAD with DES, POBA rescue of the D1 ([**2129-9-26**]) - s/p PTCA and DES sent to LM/LCx ([**2129-9-2**]) 2. DM 3. Dyslipidemia 4. Hypertension 5. Congestive heart failure (LVEF 60%, 1+ MR (eccentric), [**12-28**]+ TR, Mod PA HTN) 6. Peripheral [**Month/Day (2) 1106**] disease: s/p stent to bilateral CIAs (Genesis) and stent to [**Female First Name (un) 7195**], s/p POBA and atherectomy of L SFA [**2126-7-17**] bilateral iliac artery stenting and atherectomy of the left SFA in [**2125**] and [**2130-6-28**]. 7. End-stage renal disease: [**1-28**] Diabetic Nephropathy - on HD T/Th/Sat 8. COPD 9. Tracheomalacia 10. h/o c.diff colitis 11. h/o UGI bleed : EGD ([**2-2**]) showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, gastropathy, and gastritis 12. Pulmonary Fibrosis: PET scan [**2129-4-27**], no areas of abnormal FDG uptake. Cannot rule out broncheoalveolar carcinoma. 13. AV fistula in left arm 14. Retinopathy 15. Neuropathy Social History: Patient is originally from [**Location (un) 7225**], [**Country 7192**]. His wife and family are still there. Patient currently lives alone, but his brother is nearby. He is on disability. His sister-in law works @ [**Hospital1 18**] in housekeeping. Family History: # Mother, died 71: DM2 # Father, died 97: HTN Physical Exam: VS: T 95.9 HR:51 BP: 95/47 O2 Sat: 95% 2L NC GEN: Ill appearing man, uncomfortable but in good spirits. HEENT: PERRL, sclera anicteric, conjunctiva non injected. Dry Mucous membranes. CV: Regular rate, loud early peaking systolic crescend murmur at RUSB Lungs: Clear to auscultation bilaterally, no rales/rhonchi/wheezes Abdomen: Soft, non tender non distended, normoactive bowel sounds. No guarding, no hepato/splenomegaly Extremities: Cold, Right hand edematous, non pitting, with impaired finger flexion and cyanotic decoloration. Pulses present on doppler. Pertinent Results: ================== ADMISISON LABS ================== WBC-7.4 RBC-3.10* Hgb-10.1*# Hct-31.9* MCV-103* MCH-32.6* MCHC-31.7 RDW-15.0 Plt Ct-177 Neuts-70.1* Lymphs-20.0 Monos-6.0 Eos-3.0 Baso-0.9 PT-13.0 PTT-36.4* INR(PT)-1.1 Glucose-80 UreaN-60* Creat-8.3*# Na-140 K-6.3* Cl-113* HCO3-15* AnGap-18 cTropnT-0.04* CK-MB-4 Calcium-6.8* Phos-4.6* Mg-2.5 Glucose-122* Lactate-1.5 Na-136 K-9.0* Cl-103 calHCO3-22 ECG: ([**7-17**] @2200)Bradycardic at 44, likely junctional escape rhythm (narrow QRS, no P waves, regular without variation. Right bundleoid pattern, deep Q waves on lead III and Deep S wave on lead I, no T wave inversion on lead III. Peaked T waves with lateral T-wave flattening . ECG: (on arrival) Regular rate, likely sinus bradycardia although varying P wave morphology. Peaked T waves, prolonged QTc (478), Unchanged inferior Q wave in III and TWI in I. ECHO The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function Brief Hospital Course: 60 year old man with complicated medical history, relevant for diabetes, end stage renal disease on HD, PVD / CAD s/p CABG and repeated stenting, presenting with chest pain, hyperkalemia, bradycardia. #. Chest Pain: Acute onset of pain at rest was very concerning for unstable angina. Patient with TIMI risk score of 5 (Known stenosis, greater than 3 CAD risk factors, Aspirin use, recurring angina in 24 hrs and positive troponins). Nonetheless, it is possible that this event constituted demand ischemia from metabolic disturbance or new valvular disease (loud murmur) leading to increase in demand. Degree of known CAD however severely limits interventions as pt is s/p CABG and stenting. Patient was closely monitored and dialysis started at the bedside. With correction of hyperkalemia, heart rate improved spontaneously and sinus rhythm was again noted. Chest pain improved significantly and remaining pain was easily reproducible to light palpation. Echocardiogram was obtained to evaluate for new wall motion abnormalities or new valvular disease. Results revealed preserved global systolic function and no new valvular process. With availabe information, it appears symptoms at presentation were related to bradycardia and do not warrant further workup at this time. Patient no longer complaining of chest pain or shortness of breath on walking at discharge. #. Right Hand Contrast Infiltration: Per report this ocurred in ED at time of CTA chest/abdomen/pelvis. Hand was very edematous, tight and painful, concerning for compartment syndrome. Hand surgery team was [**Month/Year (2) 653**] and hand was elevated and splinted. Patient will need follow up with hand surgery clinic. #. Hyperkalemia: Unclear etiology, as pt has been complient with dietary restrictions and has not missed dialysis sessions. This quickly resolved with adequate dialysis, raising concerns for sub-optimal dialysis as an outpatient. Per renal team, no evidence of fistula disfunction at this time. Patient to resume dialysis per outpatient regimen. #. Bradycardia / Junctional escape rythm: Although well documented in medical record to correspond to hyperkalemia, we considered beta blocker toxicity in differential. After dialysis, rhythm spontaneouly returned to sinus and no more bradycardia was observed. There is no evidence of beta blocker toxicity. #. ESRD: Received dialysis, resume outpatient schedule of tues, Thurs, Sat. Medications on Admission: ATORVASTATIN [LIPITOR] - 80 mg Tablet B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule CLOPIDOGREL [PLAVIX] - 75 mg Tablet daily ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 20 mg daily LISINOPRIL - 2.5 mg Tablet daily METOPROLOL SUCCINATE [TOPROL XL] daily NITROGLYCERIN - 0.3 mg Tablet, Sublingual PRN OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet PRN PREGABALIN [LYRICA] - 25 mg Capsule - [**12-28**] Capsule(s) daily RANITIDINE HCL [ZANTAC] - 150 mg Tablet - daily [**Month/Day (2) **] HCL [RENAGEL] - 1 Tablet(s) by mouth three times a day ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) SENNA - 8.6 mg Capsule - 1 Capsule(s) by mouth [**Hospital1 **] prn Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet 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. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for Chest pain. 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. [**Hospital1 7222**] HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary 1. junctional bradycardia secondary to hyperkalemia 2. Contrast Extravasation in R. Hand Secondary 1. Coronary Artery Disease 2. chronic kidney disease, stage V, on HD 3. peripheral [**Hospital1 1106**] disease Discharge Condition: Ambulating without any shortness of breath, stable, no complaints, eating, drinking well, R. Arm strength 5/5 with good range of motion. Discharge Instructions: You were admitted for chest pain and during a scan, you had contrast extravasation which caused your hand/arm pain. You also had an incident where some of the chemicals in your blood increased to high levels (the potassium in your blood went up too high) -- as a result, we had to give you some medicatiosn to remove those chemicals along with your dialysis. You have several scheduled appointments listed below - please go to them all, and attend dialysis as scheduled. If you have any more chest pain, severe shortness of breath, severe back pain, please return back to the emergency room. Followup Instructions: 1. Provider: [**Name10 (NameIs) **] CLINIC Phone:[**Telephone/Fax (1) 3009**] Date/Time:[**2130-8-29**] 10:30 2. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2130-9-6**] 9:40 3. Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2130-8-25**] 9:00 4. Dr. [**Last Name (STitle) **] [**2133-9-20**]:30 AM [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2130-7-23**]

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icd9cm

[ [ [] ] ]

[ "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

9439, 9445

5422, 7850

292, 302

9709, 9848

3745, 5399

10491, 11095

3098, 3145

8571, 9416

9466, 9688

7876, 8548

9872, 10468

3160, 3726

229, 254

330, 1690

1712, 2813

2830, 3082

10,416

148,160

19067

Discharge summary

report

Admission Date: [**2117-7-16**] Discharge Date: [**2117-7-17**] Date of Birth: [**2063-9-29**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: transferred to ICU from endoscopy suite following episode of hypoxia and seizure Major Surgical or Invasive Procedure: ERCP with left intraheptic biliary stent placement. History of Present Illness: Patient is a 53 y/o M w/ metastatic colon CA (liver, porta hepatus), transferred from [**Hospital3 3583**] for ERCP [**1-13**] obstructive jaundice with goal of palliative stenting. During the procedure he became progressively hypoxic (O2 sats to 40's. Procedure was terminated but able to remove and replace old stent. Was given flumazenil 0.2mg X 2 for respiratory depression and subsequently had tonic-clonic seizure lasting approximately 5 minutes which terminated after 1mg Ativan IV. During episode of hypoxia HR decreased to 30s and SBP to 80s. HR increased spontaneously and BP increased to 110s w/ 500cc NS. Patient [**Name (NI) **] bagged and O2 sats improved to 90s. No prior h/o seizures. Patient had been admitted to OSH [**6-29**] with jaundice and abdominal pain. Was being treated for cholangitis with levoquin and flagyl. He had previously had a right biliary stent placed in early [**Month (only) 205**]. On transfer to [**Hospital Unit Name 153**] patient denied f/c, HA, SOB, CP, abd pain, n/v. Past Medical History: -Colon CA-dx [**2115**], s/p resection at [**Hospital1 2025**] w/ no adjuvant tx, liver mets confirmed w/ CT guided bx -vit K deficiency -DCM [**1-13**] ETOH w/ EF<20% in [**5-14**] -ankylosing spondylitis s/p fusion -h/o ETOH abuse but reports none since [**Month (only) 205**] -Afib Social History: lives in group home. no etoh since [**6-11**] ppd Family History: n/c Physical Exam: PE: 96.8 97 98/68 18 99NRB Gen: lethargic but answering questions appropriately, severe jaundice, ill-appearing HEENT: scleral icterus, poor dentition, trace blood on lip neck: supple, no JVd CVS: tachycardic, regular lungs: bibasilar crackles, no bronchial breath sounds or wheezes Abd: + BS, bulging flanks, significant distension, NT ext: 2+ pitting edema LE, wwp neuro: A&0 x 3, CNII=XII grossly intact, strength 5/5 throughout, no asterixis Pertinent Results: Labs: wbc 15.8 Hct 29.6 plt 251 INR 1.35 Na 136 K 3.4 Cl 100 HCO3 24 BUN 17 Cr 1.0 Glc 81 tbili 24.3 (23.3 direct) AST 46 ALT 81 AP 615 Alb 2.1 TP 5.7 Bcx: ([**7-4**], [**7-6**]) NGTD u/s ([**7-14**]): multiple echogenic masses c/w mets, mild intrahepatic duct dilation, dilated pancreatic duct MRCP ([**7-1**]) multiple mets, stricture of CBD, moderate dilation of intrahepatic and mild dilation extrahepatic ducts CXR ([**7-16**]): Right pleural effusion. An underlying infiltrate cannot be excluded, and followup PA and lateral views are recommended CT head ([**7-16**]): no intracranial bleed or mass effect Brief Hospital Course: 53 y/o M w/ metastatic colon CA c/b obstructive jaundice treated w/ palliative ERCP/stent. Procedure c/b hypoxia requiring flumazenil w/ subsequent seizure. Patient transferred to ICU for further monitoring and had an uneventful course. 1. Respiratory depression/hypoxia: - likely related to conscious sedation - CXR w/ right pleural effusion and possible infiltrate but unlikely primary source of hypoxia as readily reversed -no witnessed aspiration event 2. Seizure: -likely [**1-13**] hypoxia and flumazenil (although sz uncommon reaction) -head CT negative for bleed or mass effect but cannot r/o metastatic foci of sz activity (MRI would not affect tx) -prn Ativan but no need for empiric or further treatment 3. Hypotension: -likely related to narcotics as readily reversed w/ fluids and no evidence of sepsis -diuretics and lopressor were held o/n 4. Obstrucitve jaundice -s/p successful stenting of left intrahepatic duct; unsuccessful stenting of right intrahepatic duct -cover empirically levofloxacin and flagyl for 7 days. -no evidence encephalopathy or asterixis. continue prn lactulose 5. FEN: -was made NPO o/n with advancement of diet the next morning. 6. PPx: PPI, pneumboots 7. access: 2 PIV 8. code: DNR/DNI per d/c summary from [**Hospital3 3583**], confirmed w/ HCP (brother) 9. Communication: brother [**Name (NI) **] [**Telephone/Fax (1) 52054**] 10. Patient was tranferred back to [**Hospital3 3583**] (Accepted by Dr. [**Last Name (STitle) 25571**] [**Telephone/Fax (1) 52055**]). Medications on Admission: Meds on discharge from [**Hospital1 46**]: flagyl 500 IV q12 lasix 40 IV qd spironolactone 50 qam MSO4 8mg q2 prn oxycontin 80mg po BID EPO [**Numeric Identifier **] q week Lactulose prn lopressor 25mg po qd protonix 40 qam digoxin 0.125mg qam MVI, folate ?levofloxacin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 6 days: last day [**7-22**]. 5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 6 days: last day [**7-22**]. 6. Furosemide 10 mg/mL Syringe Sig: Forty (40) mg Injection qam. 7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO qAM. 8. OxyContin 80 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day. 9. Morphine 8 mg/mL Syringe Sig: One (1) mL Injection q2 hours as needed for pain. 10. Epogen 40,000 unit/mL Solution Sig: One (1) mL Injection once a week. 11. Lactulose 10 g/15 mL Solution Sig: One (1) dose PO once a day as needed for constipation. 12. Lopressor 50 mg Tablet Sig: 0.50 Tablet PO once a day. 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 14. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Obstructive jaundice Metastatic colon cancer Seizure Dilated cardiomyopathy Discharge Condition: stable, normotensive, mentating well Discharge Instructions: All medications as previously prescribed, should complete a 7 day course of levofloxacin and flagyl. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: as per [**Hospital3 3583**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "576.2", "E937.9", "799.0", "197.7", "427.31", "425.5", "458.29", "576.1", "780.39", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "97.05", "51.85" ]

icd9pcs

[ [ [] ] ]

6008, 6023

2992, 4510

370, 423

6143, 6181

2354, 2969

6432, 6599

1867, 1872

4831, 5985

6044, 6122

4536, 4808

6205, 6409

1887, 2335

249, 332

451, 1475

1497, 1784

1800, 1851

28,209

102,030

33846

Discharge summary

report

Admission Date: [**2146-7-7**] Discharge Date: [**2146-7-11**] Date of Birth: [**2108-1-31**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 30**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 38 yo man s/p assault multiple abrasions contusions, altered MS and seizures x2 at OSH intubated for decreased MS, and transfered for further management. He was found down on the boulders near ocean edge after a fall of ~25 feet. Per the EMS note, police stated that the residence where the patient was staying "had blood everywhere in it which suggested a possible fight." EMS took him to [**Hospital **] Hosp and received 1 dose of narcan with slight improvement in mental status. On arrival to the hospital he was awake but had no recollection of the mechanism of injury. His presenting GCS was 15. Tdap booster was given. While in the ED he had a 40 second seizure "full body involvement" that was treated with ativan 1mg IV x1. Following this he awoke and was asking for water and was agitated. He was then intubated with fentanyl, lidocaine, etomidate, succinyl choline. A CT head was unremarkable. He was then transfered to [**Hospital1 18**]. Prior to transport he was given vecuronium 10 mg x1. Initially going to trauma sicu, however there was concern for his recent seizure activity and he was transferred to MICU instead with trauma consulting. . In the ED, he remained intubated. Urine tox was positive for amphtetamines. He received valium 5 mg x1, fentanyl prn, versed prn, and started on propofol gtt. . In talking with his family and girlfriend he was discharged from EtOH detox in [**Hospital1 **] ~3 weeks ago. Following that he completed a 2 week addiction program at Addison-[**Doctor Last Name **]. He stated to them that he wanted to kill himself several times this week and per EMS note "took a blue pill" which per his brother was all of his doxepin. The family stated that for the past 3 days he has been on a drinking bender. His girlfriend spoke to him last night at ~11pm at which time he had slurred speech. Early this morning, his brother went to his home to check on him and found the front door open and blood all over the home. They met with the [**Location (un) 14663**] PD who found the patient down on the [**Male First Name (un) 3928**] beach. Per the family the injuries on his face were self-inflicted. . While in the ICU, he was successfully extubated shortly after his arrival. Social work was consulted as was psychiatry. He had no further seizure activity. Overnight, he received a total of 15mg PO valium per CIWA scale. . ROS: Denies HA/changes in vision. No fevers/chills. No numbness/tingling/weakness. No CP/SOB, no cough. No abdominal pain at rest (however endorses mild epigastric/RUQ discomfort on exam). No blood in stool/dark/tarry stool. No dysuria/hematuria. Past Medical History: Heroin & ETOH abuse DTs Recent suicide attempt Depression Social History: ~20 years of EtOH, active, last drink he reports was aprox. 1 week ago. h/o IVDU, none currently. No intranasal drugs. Currently self-employed working as handyman and painter. Current girlfriend is [**Name (NI) 6129**] [**Name (NI) 78229**]. Family History: mom - deceased. Former heroin user. dad - deceased. EtOH abuse and cirrhosis. Physical Exam: VS: 98.9 130/80 87 20 96%RA wt. 71.2kg GEN: lying in bed, NAD HEENT: multiple straight lacerations to face including bilateral eyelids. PERRLA, oculocephalic reflex intact, no conjuctival injection, anicteric, OP bloody with multiple missing teeth, MMM, Neck: supple with full ROM, no LAD, no carotid bruits, NTTP of spinal column and no bony deformities appreciated. CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout CHEST: Multiple abrasion and ecchymoses b/l flanks. Most tender to palpation left chest wall/ribs but with clear bony step offs ABD: multiple abrasions on chest and lower abd. soft, ND, + BS, no HSM (however pt lying towards his right side and refuses to turn onto back currently). Milldy TTP epigastic and RUQ. No rebound/guarding. EXT: bilateral abrasions to knees. warm, dry, +2 distal pulses BL, no femoral bruits NEURO: AAOx3, strength 5/5 triceps, biceps, wrist extensors, hip flexor, dorsi/plantar flexion. Sensation intact to soft touch throughout. Pertinent Results: CT C-spine: Superior endplate depression and irregularity of the C5 and C6 vertebral bodies which likely represents degenerative changes. However, in the setting of acute trauma, compression fractures and ligamentous injury cannot be excluded. MRI is recommended for further evaluation as clinically necessary. CT head: IMPRESSION: No fracture or hemorrhage. Rib X-ray Brief Hospital Course: # EtoH abuse/withdrawal: Long history of etoh use now with likely tonic-clonic withdrawal seizure without current evidence of DTs (autonomic instability). Remained seizure free in MICU and received total of 15 mg valium for CIWA the night of admission. Once transferred to the floor, he had no CIWA requirement and per psychiatry recommendations, CIWA was discontinued. Continued on thiamine, folate and MVI. . # Trauma: Superficial lacerations prominent over entire body. Has exquisitely tender area on left flank with bruising causing the most symptoms which was not evaluated in his initial work up. Getting Xray of flank that showed a left 10th posterolateral rib. C-spine CT on admission that showed superior endplate depression and irregularity of the C5 and C6 vertebral bodies which likely represented degenerative changes. His neck was clear by trauma team. MRI was performed from cervical, thoracic and lumbar spine. No acute lesions. Urine tox screen positive for amphetamines. . # Pain: from left flank lesion/fall and superficial wounds. Standing tylenol (has mildly abnormal LFTs--see below), standing naprosyn, prn oxycodone . # Abnormal LFTs: mildly elevated transaminases at admission and patient with significant nausea and vomiting at floor transfer. Hepatitis serologies sent that were positivive for Hep B, Hep C. His LFT's trended down. . # Anemia: iron deficiency, started on iron supplementation. . # Suicidal ideation: Patient expressed on multiple occassions suicidal ideation to family and friends. Family has much concern for his safety if he were to leave hospital Psychiatry team followed through hospitalization. Maintained on 1:1 sitter. Held wellbutrin. PRN Haldol ordered for agitation. After medicance clearance, patient was d/c to [**Hospital1 **] 4 for further psych care. . # Leukocytosis: WBC was initially elevated to 18.9 on presentation but has since normalized on this am's labs. No clear source of infection based on labs, ROS, exam to suggest infectious etiology. Does have new onset nausea however suspect this is in setting of withdrawal. Seems most likely reactive to seizure activity and also element of hemoconcentration as all cell lines down a bit today after IVFs. Trended down to normal. . # Nausea/vomiting: Has been taking PO, but reports onset of N/V since this afternoon. Although denies abdominal pain, does have epigastric discomfort on exam. [**Month (only) 116**] have low grade pancreatitis in setting of recent EtOH binge or may just be in setting of withdrawal. His symptoms improved while in house. . # Tobacco use: - Continue Nicotine TD patch. . # Respiratory failure: Initially intubated at OSH secondary to altered mental status. Extubated successfully in less than 24h. . # Dispo: discharged to Psychiatric inpatient unit Medications on Admission: Wellbutrin 300 mg? Doxepin Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 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. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 [**Hospital1 18**] Discharge Diagnosis: Suicidal attempt. Alcohol withdrawal seizures s/p trauma Hepatitis B Hepatitis C Substance abuse Discharge Condition: Good Discharge Instructions: d/c to [**Hospital1 **] 4 for Psychiatric care Followup Instructions: PCP Completed by:[**2146-7-11**]

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icd9cm

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icd9pcs

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33912

Discharge summary

report

Admission Date: [**2138-7-4**] Discharge Date: [**2138-7-10**] Date of Birth: [**2069-5-8**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Intracerebral hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 69M h/o strokes in [**2129**] on coumadin, htn, dm and h/o fall 1 wk ago transferred from OSH after waking up w/confusion this am, found to have 2 x 2.7 cm left temporo-parietal IPH. Family reports, 1 wk ago, pt fell backwards hitting his head while walking up deck stairs outside in the rain (~10 steps), unwitnessed. Wife found him on the ground, unclear how long he had been there and needed help to get up. He apparently didn't have any speech problems and had been back to his baseline afterwards. This past Wed, patient was very tired and slept until 2pm. He was speaking fine but was slightly disoriented and asked his wife "what day is it today". Then this morning, patient woke up and went to the kitchen, then turned and went back to bed, which is unusual for him. His wife went in the bedroom to ask him what was the matter. He said that he had a headache but everything else came out gibberish. He was subsequently taken to an OSH where a NCHCT showed 2.5 cm hematoma in the left periventricular white matter between the temporal and parietal lobes with extension into the lateral ventricle. Effacement of adjacent sulci but no shift of midline and no uncal herniation. At OSH ED, VS 98.2 195/92 82 18. Pt as given vitamin K 10mg IV. WBC 9.7, Hct 42.8, Plt 204, TropI 0.03, Na 134, K 4.4, Cl 97, CO2 29, Gluc 346, BUN 23, Cr 1.93, Ca 9.1, TB 1.3, LFTs unremarkable, CPK 122, Serum tox neg. EKG NSR 79BPM, no acute ischemic changes, ?prolonged QT. ROS: Lately, pt had not been taking Byetta, the new diabetes meds and as a result his sugars had been running somewhat high. Past Medical History: - H/o strokes [**1-/2129**], 2 in [**2129**] for which pt was started on coumadin in [**2128**], family denies h/o carotid stenosis or atrial fibrillation however. Pt reportedly had unsteadiness on his feet but no language deficits or obvious unilateral weakness per their report. Unclear severity of deficits from these strokes but family reports that he is not as steady on his feet. -malignant renal tumor which was resected in [**2137-8-11**], patient is supposedly cancer free now. He is followed every three months. His wife is not sure which kidney had the resection. patient has not had chemo or radiation. - HTN - DM - CRI (baseline creatinine is unclear) - [**Name2 (NI) **]mia Social History: SH: Lives in [**Location 3320**], MA with wife [**Name (NI) 1743**] [**Name (NI) 1274**], daughter [**Name (NI) **] (cell) [**Telephone/Fax (1) 78354**]. Family History: NC Physical Exam: T- 100.1 BP- 177/71 HR- 86 RR- 22 96 O2Sat 3L Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: MS: Alert and awake. Able to follow some simple commands but mainly mimicking. Fluent aphasia with mainly nonsensical speech. Unable to repeat. CN: I: not tested II,III: Decr'd blink on the right, PERRL 4mm to 2mm III,IV,V: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**6-16**] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk and tone; no tremor, asterixis or myoclonus. Right parietal drift w/some pronation. Delt [**Hospital1 **] Tri WE FE Grip C5 C6 C7 C6 C7 C8/T1 L 5 5 5 5 5 5 R 5 5 5- 5 5- 5 IP Quad Hamst DF [**Last Name (un) 938**] PF L2 L3 L4-S1 L4 L5 S1/S2 L 5 5 5 5 5 5 R 5 5 5 5 5 5 Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 2 2 Flexor R 2 2 2 2 2 Flexor Sensation: Says "ouch!" with noxious stim on the left, less so on the right. Coordination: unable to understand commands Gait/Romberg: deferred Pertinent Results: [**2138-7-10**] 06:50AM BLOOD WBC-9.1 RBC-4.07* Hgb-12.5* Hct-36.6* MCV-90 MCH-30.7 MCHC-34.2 RDW-14.3 Plt Ct-217 [**2138-7-10**] 06:50AM BLOOD Plt Ct-217 [**2138-7-10**] 06:50AM BLOOD Glucose-180* UreaN-41* Creat-2.1* Na-135 K-4.0 Cl-99 HCO3-24 AnGap-16 [**2138-7-8**] 06:40AM BLOOD ALT-15 AST-18 LD(LDH)-193 AlkPhos-67 Amylase-44 TotBili-0.9 [**2138-7-8**] 06:40AM BLOOD Lipase-60 [**2138-7-4**] 03:25PM BLOOD CK-MB-4 cTropnT-<0.01 [**2138-7-8**] 06:40AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.9 Mg-2.0 [**2138-7-5**] 12:00AM BLOOD %HbA1c-11.3* [**2138-7-5**] 12:00AM BLOOD Triglyc-186* HDL-44 CHOL/HD-4.3 LDLcalc-110 [**2138-7-4**] 03:25PM BLOOD TSH-0.92 [**2138-7-4**] 03:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CXR [**7-4**]: Cardiomediastinal and hilar contours are normal. There are linear opacities at the left lung base, likely reflecting left basilar atelectasis. No focal consolidation is identified. There is no pleural effusion or pneumothorax. Osseous structures are unremarkable. IMPRESSION: Left basilar atelectasis. No focal consolidation. Repeat CXR [**7-8**] (fever): In comparison with the study of [**7-4**], the patient has taken a much better inspiration. The opacification at the left base, consistent with atelectasis, has substantially cleared. No evidence of acute pneumonia. CT head [**7-4**]: There is a left intraparenchymal hemorrhage, largest centered in the temporal lobe, with extension up to the parietal lobe. This hemorrhage measures approximately 2.8 cm x 2.2 cm, with surrounding area of vasogenic edema. There is intraventricular extension of the hemorrhage, with hemorrhage seen within the left lateral ventricle. There is asymmetry of the temporal horns, with the left temporal [**Doctor Last Name 534**] dilated, suggesting an element of hydrocephalus. No shift of normally midline structures is identified. No other foci of hemorrhage identified. There is no acute major vascular territorial infarction. Periventricular white matter low attenuation likely reflects chronic small-vessel ischemic disease. Visualized paranasal sinuses and mastoid air cells are clear. Osseous structures reveal no evidence of a fracture. IMPRESSION: 1. Left temporal and parietal intraparenchymal hemorrhage, with intraventricular extension into left lateral ventricle. 2. Dilated left temporal [**Doctor Last Name 534**], suggesting an element of hydrocephalus. [**7-5**] CT head: NO CHANGE - There is relatively no interval change in the size of the left parietotemporal intraparenchymal hemorrhage which now measures 2.5 x 2.1 cm. The surrounding vasogenic edema is also unchanged. The intraparenchymal hemorrhage extends into the left lateral ventricle with no interval change in the size of left ventriculomegaly. No shift of midline structures noted. The diffuse periventricular white matter hypodensities are suggestive of small vessel disease. No other focus of intraparenchymal hemorrhage is noted. The mild mucosal thickening of both ethmoid sinuses is unchanged. The rest of the paranasal sinuses and mastoid air cells are clear. Incidental note is also made of calcification of intracavernosal portion of both carotid arteries. IMPRESSION: Unchanged left temporoparietal intraparenchymal hemorrhage with intraventricular extension. No interval changes noted within the dilated left temporal [**Doctor Last Name 534**] suggesting stable hydrocephalus. Brief Hospital Course: NEURO - Remarkable clinical recovery, normal exam at time of discharge. Serial scans did not reveal worsening. MRI to rule out latent metastasis from RCC as well as amyloid angiopathy (microbleeds on GRE*) postponed in order to avoid the necessity of 2 MRI's with contrast since the fresh blood will obscure now. Two times contrast would be worse for CRI and increase the risk of fibrosis. INR remained stably low with a max of 1.4. MRI has been arranged on an outpatient basis. Aspirin was started the day prior to discharge - he is to remain off warfarin until further specific order from his stroke neurologist. CARDIOVASC - High bloodpressure, switched to metoprolol as it is easier to titrate. ENDO - Elevated bloodsugars up to 300's, on RISS. Home medications 1st continued, later switch to Glipizide, since Glyburide is renally cleared. RENAL - CRI, with max of Cr 2.2, coming down with better hydration just prior to discharge. Encouraged to take plentiful oral intake since at risk for dehydration (glucose elevated) and worsening renal function (prerenal). ID - He has spikes a fever up to 101.3, and was on empiric Ciprofloxacine for a day and then off, and then was put on Zosyn for one dose during another call. His infectious workup was negative throughout, including multiple blood, urine and sputumcultures, no white count, not ill-appearing, no source found clinically. So he was kept off all antiobiotics for 2 - 3 days and he defervesced - it was likely a central fever. HEME - Received 4 vials of prophyline in the ED, INR stabilized. The PCP was [**Name (NI) 653**] and will see him directly after the weekend, so three days post-discharge. Medications on Admission: HCTZ 12.5mg QD Lipitor 20mg QD Warfarin 2.5mg Atenolol 50mg QD Glyburide 5mg QID(?) Actos 30mg QD Metformin 850mg TID Diovan 320mg QD Byetta 10mg [**Hospital1 **] ALL: NKDA Discharge Medications: 1. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Bayada Nurses Inc Discharge Diagnosis: Left temporal-parietal hemorrhage Discharge Condition: Improved - for details please see discharge summary under [**Hospital **] hospital course' Discharge Instructions: You have been admitted with a small bleed. We are still in the process of determining the cause, that is why you will have an MRI as an outpatient when the blood has cleared, to take another close look at the area that has bled. Note that you've had very high bloodsugars as well as poor renal function. It is of importance that you follow-up closely and ASAP after discharge with your PCP. [**Name10 (NameIs) **] have [**Name (NI) 653**] your PCP, [**Name10 (NameIs) **] you are expected to visit soon. Make sure you have plenty of fluid intake to ensure good function of your kidneys. Please take all your medications excactly as directed and please attend all your follow-up appointments. Please report to the nearest ER or call 911 or your PCP immediately when you experience recurrence of weakness, numbness, tingling, problems with vision, speech, language, walking, thinking, headache, or difficulties arousing, or any other signs or symptoms of concern. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2138-8-26**] 2:30 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2138-7-11**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10391, 10439

7897, 9567

340, 347

10517, 10610

4440, 6881

11624, 11933

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275, 302

375, 1978

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25,338

125,902

10804

Discharge summary

report

Admission Date: [**2169-8-13**] Discharge Date: [**2169-8-18**] Date of Birth: [**2097-8-30**] Sex: M Service: Vascular NOTE: Initially admitted under Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], vascular surgery, discharged under Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**], [**First Name3 (LF) **] surgery/hepatobiliary pancreatic surgery. HISTORY OF PRESENT ILLNESS: Briefly, the patient is a 71-year-old man with a history of coronary artery disease, diabetes, chronic renal insufficiency, chronic obstructive pulmonary disease, peripheral vascular disease, spontaneous aortobifemoral on [**2169-8-2**] who had a relatively uneventful course during his prior admission and was discharged to rehabilitation on [**2169-8-8**]. He noted nausea and vomiting ............. eating at rehabilitation that had been worsening over the past two days and unable to keep anything down. He had normal bowel movements and was passing gas with no signs of obstruction. He came in with an increased white count of 24 with admission hematocrit of 1.8. His admission date is [**2169-8-13**]. PAST MEDICAL HISTORY: As above. 1. Coronary artery disease 2. Myocardial infarction x3. Last echocardiogram showed ejection fraction of 75%, carotid stenosis right side 40%, left side 69% 3. Type II diabetes 4. Retinopathy 5. Neuropathy 6. History of chronic obstructive pulmonary disease 7. Lung nodules 8. Right kidney atrophy with baseline creatinine ranging from 1.8 to 2.0, though has been as low as 1.5 as well. 9. He had an aortobifemoral on [**2169-8-2**]. 10. Vocal cord polypectomy in [**2167**]. 11. Laser surgery of his eyes of some sort in '[**65**]. ALLERGIES: He had no known drug allergies. MEDICATIONS: 1. Regular insulin sliding scale on admission 2. Lopressor 75 mg po bid 3. Percocet prn 4. Imdur 60 mg [**Hospital1 **] 5. Minoxidil 2.5 mg [**Hospital1 **] 6. Lipitor 40 mg qd 7. Diltiazem extended release 120 mg once a day 8. Niacin sustained release 1 gm once a day 9. Aspirin 325 mg once a day PHYSICAL EXAM: VITAL SIGNS: The patient on admission had a temperature of 100.1??????, pulse 78, 146/50 blood pressure, 20 and 97% saturation 2 liters. ABDOMEN: Minimal right upper quadrant tenderness without a physical exam [**Doctor Last Name 515**] sign. EXTREMITIES: Warm, some slight left greater than right edema for which he had an ultrasound which showed no deep venous thromboses. RECTAL: Normal tone, guaiac negative. LABS: His white count was stated previously. The rest of his labs were a chemistry of 136, 3.7, 101, 27, 20, 1.8, calcium of 7.9 at [**Hospital1 1474**]. On admission the [**Hospital6 1760**], his CBC was 20.0, 30.6 and 295 with a chemistry of 136, 3.7, 99, 26, 20, 1.7, 137. Coagulation profile was within normal limits. His liver function tests at [**Hospital6 256**] were an ALT of 28, AST 22, alkaline phosphatase 91, amylase 17, total bilirubin 1.2, lipase of 31. RADIOLOGY: KUB showed mildly dilated small bowel with good air and contrast without evidence of obstruction, no free air. Ultrasound at outside hospital showed sludge in the gallbladder wall duct scan. Post fluid CT at the outside hospital showed stranding around the gallbladder, mild dilated loops, scanned fluid around the previously right aortic limb and of the aortobifemoral. HOSPITAL COURSE: The picture was that the patient was likely to have cholecystitis and we were consulted. Our evaluation was that the patient did indeed have cholecystitis and he was taken to the Operating Room on [**2169-8-14**]. His white count at this point had gone up to 21.3 from 20. The patient had an attempted laparoscopic cholecystectomy which had to be converted to open and postoperatively the patient had a nasogastric tube and a Foley and was receiving perioperative antibiotics which had also been started preoperatively on admission. He did not tolerate the postoperative period well. The patient was kept in the PACU and had to be extubated by anesthesia after he had desaturations. The patient had an A-line immediately placed and was put on ventilation. He had his epidural line fixed. He was hemodynamically stable. His hematocrit was stable too at this point. Invasive monitoring was performed and the patient was kept in the Recovery Room overnight. The determination was made that the patient could later be extubated and ............. was transferred to the floor in the Vascular Intensive Care Unit setting for additional monitoring. The rest of his hospital course is as follows: Neurologically, the patient originally had an epidural. After his diet was advanced and he was tolerating po's, he was switched over to po pain medication without difficulty and his pain was well controlled. He had never had signs of a stroke. He never had any neurological deficits. Cardiac: The patient was on intravenous Lopressor and his po medications were on hold after the operation given his NPO status. His po medications were then slowly added back, as he began to tolerate a diet and his blood pressure was well controlled. The patient upon discharge was tolerating a regular diabetic diet. Respiratory: Patient outlined as above wound up being intubated in the Recovery Room for an overnight stay and was then transferred to the Vascular Intensive Care Unit past being extubated. The rest of the stay was significant for aggressive chest PT and pulmonary toilet along with nebulizers and supplemental oxygen which he had preoperatively. Abdomen: The patient's old aortic bifemoral wound has had staples discontinued as did the groin wound from his previous aortobifemoral. His gallbladder cholecystectomy incision looked red on postoperative day #3 and Kefzol was started, renally dosed in order to prevent infection. The wound was carefully monitored and with Kefzol the patient's wound improved. He is going to be discharged on Keflex with regards to that. Otherwise, there are no acute issues. His abdominal pain from the cholecystitis was resolved. Gastrointestinal: The patient is tolerating a diabetic diet well, getting Colace. Renal: Patient has elevated creatinine which is consistent with his chronic renal insufficiency. The patient had some swelling for which he was given Lasix twice during the course of his admission and his electrolytes were appropriately repleted. The patient is not in congestive heart failure upon discharge. Infectious disease: The patient will receive seven days of Keflex as an outpatient, has received Kefzol in house after signs of the wound having a slight amount of erythema and cellulitis. Heme: The patient's heme as stated was stable and the patient received deep venous thrombosis prophylaxis including Venodynes and subcutaneous heparin. He had a vascular duplex prior to discharge, on the day of discharge on [**2169-8-18**], which was again negative for deep venous thrombosis. The patient is being discharged to rehabilitation today in good condition. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po qd 2. Regular insulin sliding scale 101 to 150 2 units, 151 to 200 3 units, 201 to 250 4 units, 251 to 300 5 units, 300 plus [**Name8 (MD) 138**] M.D. 3. NPH 8 units subcutaneous a.m., 16 units p.m., qid fingersticks 4. Lopressor 75 mg po bid held for a heart rate of 65 or less, systolic blood pressure less than 110. 5. Percocet 1 to 2 tablets po q4h prn pain 6. Colace 100 mg po bid 7. Keflex 500 mg po qid x7 days 8. Aspirin 325 mg po qd 9. Niacin 1 gm po qd 10. Albuterol nebulizers prn 11. Heparin subcutaneous 5000 units [**Hospital1 **] until ambulating well 12. Lipitor 40 mg po qd 13. Minoxidil 2.5 mg po bid, hold for systolic blood pressure less than 110. 14. Imdur 60 mg [**Hospital1 **], hold for systolic blood pressure less than 110. 15. Diltiazem extended release 125 mg po qd, hold for a systolic blood pressure less than 110 and heart rate less than 70. 16. Aspirin 325 mg qd 17. Niacin 1 gm qd The patient is going home on a diabetic low sodium heart healthy diet. Will follow up with Dr. [**Last Name (STitle) 468**] with regards to his cholecystectomy in a period of one week. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2169-8-18**] 11:30 T: [**2169-8-18**] 11:37 JOB#: [**Job Number 35263**]

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icd9cm

[ [ [] ] ]

[ "51.22" ]

icd9pcs

[ [ [] ] ]

7072, 8474

3404, 7049

2108, 3386

438, 1151

1174, 2093

25,988

177,534

17117

Discharge summary

report

Admission Date: [**2152-7-22**] Discharge Date: [**2152-7-28**] Date of Birth: [**2116-3-15**] Sex: F Service: [**Hospital **] MEDICAL HISTORY OF THE PRESENT ILLNESS: The patient is a 36-year-old female with a history of hepatitis C and hepatitis A who was found unresponsive in her home when EMS arrived to respond to a call for a "nosebleed". Per reports, she was sitting in a chair, looking cyanotic and unresponsive. The initial vital signs revealed a heart rate of 30, blood pressure 80/palpable, 50% 02 saturation, respiratory rate 60. Endotracheal tube intubation was attempted in the field without success but a nasopharyngeal airway was placed. The 02 saturations came up to 96% and the patient was taken to [**Hospital3 3583**]. The patient was given 0.4 mg Narcan times two in the ambulance and did not become more responsive. The patient also received lidocaine 100 mg IV, Etomidate 20 mg IV, succinylcholine 160 mg IV, Norcuron 10 mg, and Ativan 4 mg IV in the [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]. The patient's blood pressure and heart rate were better at [**Hospital1 46**] apparently without pressors. The head CT was reportedly normal. The patient was transferred to [**Hospital6 256**] for further care. The patient received 50 grams of charcoal in transit. Significant laboratories included a white blood count of 27,000, 12% bands, hematocrit 41.3, tox screen positive for cocaine and opioids. The patient was initially normotensive on arrival but then became hypertensive with a systolic blood pressure in the 70s. The patient received IV fluids and dopamine drip. The patient was given ceftriaxone and vancomycin in the Emergency Department and successfully intubated in the ED. The patient's EKG showed sinus rhythm at 98 beats per minute with ST depressions and wide QRS and alternate beats. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Hepatitis A. SOCIAL HISTORY: The patient has two children, Spanish-speaking only. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 94, pulse 98, blood pressure 96/55. General: The patient was an obese woman, intubated, eyes closed, opens eyes to voice at 5:00 p.m. At 9:00 p.m., she opens eyes to voice and was able to follow simple commands. HEENT: The pupils were 2 mm, minimally reactive to light. Anicteric sclerae. The nares were full of bloody nasal discharge. Lungs: Coarse breath sounds bilaterally. Cardiovascular: Regular rate and rhythm. Good heart sounds. No murmurs, rubs, or gallops. Abdomen: Obese, soft, nontender, nondistended, minimal bowel sounds. Extremities: No pedal edema, bilateral DP pulse present. Neurologic: Opens eyes to voice, moving all four extremities spontaneously. Follows simple commands in Spanish. LABORATORY/RADIOLOGIC DATA: Sodium 143, potassium 4.0, chloride 111, bicarbonate 20, BUN 20, creatinine 1.0, glucose 246. CK 1,024, MB 46.5, MBI 4.5, troponin 24. Calcium 7.9, magnesium 2, phosphate 3.8, ALT 59, alkaline phosphatase 101, total bilirubin 0.7. AST 141, amylase 214, lipase 39. Serum was negative for aspirin, ethanol, acetaminophen, benzos, barbiturates, and tricyclics. Positive for opiates and cocaine. The urine was negative for benzos, barbiturates, amphetamines, and methadone. White count 19.6, hemoglobin 11.8, platelets 343,000, hematocrit 36.7, 91.7 neutrophils, 0 bands, 4.2 lymphs. PT 13.8, PTT 30.4, INR 1.3. ABGs 7.21, 53, 92, lactate 2.1. Chest x-ray revealed no infiltrates, no cardiomegaly. Endotracheal tube 2.5 cm from the carina. HOSPITAL COURSE: 1. UNRESPONSIVENESS: The etiology most likely was secondary to cocaine plus/minus opioid overdose. The patient's mental status quickly improved, following commands, and was able to be extubated the following day on [**2152-7-23**]. The patient tolerated extubation well and was maintained on 02 nasal cannula. 2. COCAINE-INDUCED MYOCARDIAL INFARCTION: Regarding increased CK MB and troponin, Cardiology was consulted. Cardiology recommended 48 hours of heparin drip, aspirin, and an echocardiogram. Cocaine-induced coronary spasm was suspected cause for MI. Troponins steadily declined. The patient remained chest pain-free. Echocardiogram showed normal left ventricular ejection fraction. On [**2152-7-26**], the patient experienced chest pain times three overnight relieved by sublingual nitrogen. The pain was positional and related to cough and deep inspiration. The pain was thought likely pulmonary in nature. Cardiology was reconsulted. Cardiology recommended workup by cardiac catheterization. The cardiac catheterization showed a LVEF of 55% with no mitral regurgitation, right dominant coronary arteries with normal vasculature. At the time of discharge, the patient was chest pain-free. 3. ASPIRATION PNEUMONIA: The patient was with a fever and leukocytosis. Sputum culture was performed with grew Staphylococcus aureus. The patient was treated with Levaquin and metronidazole for a total course of ten days. The patient remained afebrile for 72 hours prior to discharge. The patient was discharged to complete final three days of a ten day course of antibiotics. 4. DEPRESSION: Psychiatry was consulted and felt that the patient was not a suicide risk, did not need one-to-one monitoring. The patient was restarted on her Paxil and Seroquel in the evening and Psychiatry recommended consult of addiction services. 5. DRUG ADDICTION: [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**] was consulted regarding drug addiction. The patient reported willing to undergo inpatient treatment for dual-diagnosis therapy. At the time of dictation, the patient was to be evaluated for transfer to Dual Diagnosis Center. 6. RHABDOMYOLYSIS: The patient was with elevated CKs and deceased calcium, again thought induced by cocaine. The patient was placed on IV fluids. The CKs rapidly trended downward with no renal sequelae. CONDITION ON DISCHARGE: Good. DISCHARGE INSTRUCTIONS: The patient was instructed to seek medical care for recurrent chest pain or shortness of breath. The patient was instructed to finish the final three days of ten day antibiotic course and to follow-up for treatment with Psychiatry and for drug addiction. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg one tablet q.d. for three days. 2. Metronidazole 500 mg one tablet three times a day for three days. 3. Paxil 20 mg one tablet q.d. 4. Seroquel 50 mg at bedtime for insomnia, may repeat once as necessary. FINAL DIAGNOSIS: 1. Respiratory failure secondary to drug overdose. 2. Cocaine-induced myocardial infarction. 3. Aspiration pneumonia. 4. Depression. 5. Drug addiction. ADDENDUM: The patient was noted to have high blood glucose levels throughout the hospital stay. The patient was instructed to follow-up with primary care physician regarding diabetes screen. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Name8 (MD) 13747**] MEDQUIST36 D: [**2152-7-28**] 06:05 T: [**2152-7-28**] 18:54 JOB#: [**Job Number 48084**]

[ "276.4", "304.01", "304.21", "507.0", "416.8", "728.89", "482.41", "410.71", "518.81" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "96.71", "88.53", "96.04" ]

icd9pcs

[ [ [] ] ]

6309, 6542

3590, 5974

6559, 7181

6030, 6286

2046, 3572

1904, 1939

1956, 2031

5999, 6006

58,005

196,023

39214

Discharge summary

report

Admission Date: [**2171-2-15**] Discharge Date: [**2171-2-19**] Date of Birth: [**2102-2-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2763**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 69M with [**First Name3 (LF) 2091**], DM, history of PE, laryngeal and bladder cancers, initially admitted to [**Hospital 1562**] hospital on [**2171-2-2**] with shortness of breath, now transferred to [**Hospital1 18**] after complicated ICU course. . He was admitted [**2-2**] with shortness of breath with exertion for one day with orthopnea. No chest pain or fevers. Mild cough. His family describes ongoing anasarca for at least one year, worse lately, requiring large doses of lasix as an outpatient. In addition, over the last three months he has had a more rapid decline since a syncopal episode thought related to overdiuresis led to hospitalization. He has since been in and out of the hospital and rehab; total of 4 hospitalizations. During these courses diagnosed with PE, HAP, mucous plugging. Family describes him as having intermittent worsening dyspnea on exertion and generalized weakness. His left leg (where DVT was present) was noted to be weaker than right). Also seemed to have slow cognitive decline as well - slower speech and responses, though prior to admission was still living at home, managing finances, cooking at times. Family admits he has seem depressed, but very certain that he would not take any ingestions in attempt to harm himself. . With current hospital course he was found to have bilateral pleural effusions, transudative on [**Female First Name (un) 576**], and anasarca. On the floor he was diuresed. Per notes was also C.diff positive on [**2-4**]. He was transferred to the ICU on [**2-12**] for hypothermia, confusion, and lethargy. The following issues were noted in his ICU course: - Hyperammonemia: Ammonia 222 upon ICU transfer. CT abdomen notable for fatty liver. No major LFT abnls otherwise. Per notes, negative viral hep panel, [**Doctor First Name **], AMA; no known EtOH. Tried on lactulose. Discussed possible hemodialysis at OSH. - Hypotension/septic shock. Thought ?line sepsis. Negative cultures. On dopamine and levophed and IV albumin, now weaned off pressors. Antibiotics - IV and PO vanc, IV flagyl, IV cefepime, IV fluconazole. - Respiratory failure. Intubated due to encephalopathy. Bilateral pulmonary infiltrates that were thought to be aspiration. Also with bilateral effusions s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**] x 2. - C.diff colitis. Positive on [**2-4**]. On PO vanco and IV flagyl. - Anasarca. Given natrecor and edecrin during course. Resulted in rising creatinine without much gains in edema. - [**Month/Year (2) 2091**] - baseline increase from 2.8 to 3.4. - Maintained on anticoagulation (most recently heparin gtt) for history of PE. - Difficulty tolerating enteral feedings (?ileus). Getting TPN. - Anemia. unclear etiology. Received 2 units PRBCs. - Leukocytosis. - Dropping platelet count (66K today, down from 115 three days ago). PF4 antibody negative. - PICC placed [**2-11**]. - TTE [**2171-2-4**]: EF 65% normal wall motion, mild diastolic dysfunction, normal RV, small pericardial effusion. - Rash: per nursing report, progressive over the last 3 days. . On the floor, patient intubated and encephalopathic; unable to provide further history. Past Medical History: - [**Name (NI) 2091**], unclear etiology. ?due to underlying DM. No proteinuria per notes. Baseline creatinine 2.5. - DVT/PE in [**2170-11-25**]. - syncope/fall [**2170-10-25**] thought due to overdiuresis; fractured left wrist vs. left rib (inconsistently documented) - paroxysmal Afib. - HTN - Laryngeal cancer s/p resection. - Bladder cancer - RUL pneumonia (HAP) [**2170-12-25**]. Also had associated pleural effusion that was "grossly bloody" on thoracentesis. Treated with vanco/zosyn. - R lung nodule on CT scan [**2170-12-25**]; PET negative. - Diabetes type II. - Calcified pancreas on CT scan since [**2165**] of unclear significance. - s/p TURP - Recent perirectal abscess Social History: - Tobacco: Quit smoking 7 years ago. - Alcohol: Rare - Illicits: None. Retired from work in the supermarket deli. Recently living in nursing home/rehabs (since recent hospitalizations), prior was living with wife. Daughter is a nurse. Family History: Sister died of CAD. Brother died of DM and CAD. No kidney disease. Mother had [**Name2 (NI) 3484**] disease. Physical Exam: Admission: General: Intubated. Blinks eyes spontanously, but no other spontaneous movement. HEENT: Sclera anicteric, PERRL 3->2, periorbital and scleral edema, tongue and lips appear swollen/enlarged but without obvious mucosal ulcerations. Neck: supple, JVD difficult to appreciate, no LAD, RIJ in place. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, distant heart sounds, no murmurs, rubs, gallops appreciated. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, liver edge palpable 2-3 cm below costal margin. No evidence of ascites. Ext/Skin: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Marked diffuse anasarca of UEs, LEs, torso. Skin of arms with diffuse ecchymoses with few skin tears. Legs (particularly R leg) and to lesser degree UEs with scattered large flaccid bullae; R leg with large area of erythema adjacent to fully denuded areas of skin - epidermis appears to be sloughing off at parts. Neuro: Minimal spontaneous movement (blinking occasionally) No movement of UEs or LEs to painful stimuli. Pertinent Results: [**2171-2-19**] 01:38AM BLOOD WBC-13.8* RBC-3.41* Hgb-10.0* Hct-30.3* MCV-89 MCH-29.4 MCHC-33.1 RDW-19.6* Plt Ct-62* [**2171-2-16**] 03:48AM BLOOD Neuts-89.7* Lymphs-8.1* Monos-1.8* Eos-0.2 Baso-0.2 [**2171-2-19**] 11:58AM BLOOD Glucose-120* UreaN-27* Creat-3.1* Na-146* K-4.9 Cl-114* HCO3-15* AnGap-22* [**2171-2-15**] 04:23PM BLOOD Fibrino-133* [**2171-2-19**] 01:38AM BLOOD ALT-20 AST-35 LD(LDH)-217 AlkPhos-212* TotBili-1.5 [**2171-2-17**] 03:22AM BLOOD Ammonia-204* [**2171-2-17**] 04:53PM BLOOD calTIBC-39* Ferritn-855* TRF-30* [**2171-2-16**] 05:52PM BLOOD TSH-3.1 [**2171-2-16**] 05:52PM BLOOD T4-2.0* T3-38* calcTBG-0.80 TUptake-1.25 T4Index-2.5* [**2171-2-15**] 04:23PM BLOOD Free T4-0.78* [**2171-2-19**] 01:52AM BLOOD Glucose-70 Lactate-1.4 Na-143 CT HEAD W/O CONTRAST Study Date of [**2171-2-17**] 10:25 AM IMPRESSION: 1. Subcortical white matter hypodensities in the frontal lobes and posteroparietal lobe could reflect chronic small vessel ischemic disease, findings are not typical for anoxic or hypotensive event. MRI is recommended for further assessment. 2. Mucosal thickening and fluid in the paranasal sinuses, likely related to intubation. 3. Opacification of mastoid air cells bilaterally. ABDOMEN U.S. (COMPLETE STUDY) PORT Study Date of [**2171-2-15**] 6:42 PM IMPRESSION: 1. Echogenic liver indicative of hepatic steatosis. Note that coexistent forms of hepatic disease such as cirrhosis or fibrosis are not excluded. 2. Patent portal vein with normal hepatopetal flow. 3. Small ascites and left pleural effusion. 4. Apparently dilated pancreatic duct without etiology. This finding merits further investigation with CT or MRCP. Brief Hospital Course: Mr. [**Known lastname **] is a 69 year-old man with sub-acute decline in mental status, anasarca that presented to [**Hospital 1562**] Hospital with shortness of breath on [**2170-2-2**]. At that time his ammonia level was 223 and he was slurring speech and somewhat somnolent. He spent 10 days on the floor. During the admission he was transferred to the ICU, intubated and started on pressors. It appears that hypotension was an issue at that time. He became unresponsive at this time, we think, although this is not well documented. He was transferred to [**Hospital1 18**] with desquamative skin and comatose. He was made CMO after discussion with family on [**2171-2-19**], and expired shortly after extubation. # Altered mental status Numerous contribitors to his AMS, but the overall picture was that of vastly decreased cortical function, consistent with anoxic brain injury. His elevated ammonia, hypernatremia and low ceruloplasmin may have contributed to his AMS. # Adventitious head movements Several muscle groups involved in these movements during [**2171-2-19**] ?????? therefore cortical in nature. Suggestive of seizure activity and treated with Dilantin prophylaxis. Likely was secondary to anoxic injury with some sparing of motor neurons versus edema and mass effect. # Desquamating skin reaction Unclear etiology, and thought related with profound skin hypoperfusion. Unifying diagnosis unclear. Not likely [**Last Name (LF) **], [**First Name3 (LF) **] Dermatology, who thought that it was most likely secondary to previously dramatic anasarca and then microtrauma of being in bed. Treated with fluid replenishment as if burn patient. # Respiratory Failure Agonal brainstem breathing, +/- liver breathing. Brainstem also appeared to be affected based on reflexes/exam, thus likely neurologic. Also contributions by expansion acidosis. # Goals of Care Patient made CMO on [**2171-2-19**] and expired shortly after extubation. # Hypotension Clear loss of spinal reflexes and pupils small suggesting sympathetic output likely lower at brainstem or spinal level. # Hyperammonemia Unclear etiology. Too late to present with metabolic disorder, although not impossible. No valproic acid recently. Has liver failure and pancreatic calcification of unknown etiology. Family claim little to no alcohol use. # Hypothyroidism Likely sick euthyroid. # Hypernatremia Corrected quite quickly ?????? concerning. 5 mEq over nine hours maximal rate from labs. Unlikely problem in itself, but may be edema from anoxic brain injury and the two together may become significant. # Anasarca Liver failure, low albumin and renal failure, now with large fluid shift and protein losses through skin. Will likely worsen. # Renal failure # Liver failure # PE/DVT prophylaxis Medications on Admission: Medications at home: - Humibid LA 600 mg [**Hospital1 **] - Calcitriol 0.25 mg daily - Pravastatin 40 mg daily - Lopressor 12.5 mg [**Hospital1 **] - Omeprazole 20 mg daily - Coumadin 0.5 mg daily - Humalog sliding scale - Tylenol prn pain. . Medications on transfer: - Vancomycin 500 mg IV TID - Vancomycin 125 mg NGT QID - Cefepime 2 grams IV Q24H - Metronidazole 500 mg Q8H - Fluconazole 400 mg IV once today - Albumin 50 grams IV BID - Calcitriol 0.25 mcg daily - Pantoprazole 40 mg IV daily - Thiamine 100 mg IV daily - Humalog sliding scale - Reglan 5 mg IV Q8H - Colace 100 mg TID - Nystatin powder TID - Artificial tears - Lactobacillus [**Hospital1 **] Past medications: omeprazole, guiafenesin, coumadin, zofran, metoprolol, pravastatin, ethacrynic acid, dopamine, norepinephrine, bisacodyl, midazolam, morphine, heparin gtt, nesiritide, lactulose. Discharge Medications: Expired; Discharge Disposition: Expired Discharge Diagnosis: Expired; Discharge Condition: Expired; Discharge Instructions: Expired; Followup Instructions: Expired; [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2171-2-19**]

[ "789.59", "518.81", "348.30", "V10.21", "V10.51", "287.5", "V12.51", "270.6", "276.2", "584.5", "286.6", "785.52", "276.0", "995.92", "571.5", "695.89", "244.9", "585.9", "V66.7", "008.45", "782.3", "250.00", "038.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

11228, 11237

7501, 10286

334, 340

11289, 11299

5818, 7478

11356, 11487

4544, 4657

11195, 11205

11258, 11268

10312, 10312

11323, 11333

10333, 10555

4672, 5799

275, 296

368, 3562

10580, 11172

3584, 4273

4289, 4528

20,400

105,707

23823+57378

Discharge summary

report+addendum

Admission Date: [**2162-4-2**] Discharge Date: [**2162-4-9**] Service: MEDICINE Allergies: Heparinoids Attending:[**First Name3 (LF) 398**] Chief Complaint: transfer for biliary obstruction Major Surgical or Invasive Procedure: ERCP History of Present Illness: 85 year old male with CAD s/p CABG X 3, post-op AF, HTN, ESRD on HD initially admitted [**2162-4-2**] to SICU from [**Hospital1 **] with hyperbilirubinemia, fever, and left pleural effusion. His CABG c/b mediastinal hemorrhage requiring re-exploration [**2162-3-6**], prolonged vent wean requiring trach ([**2162-3-15**]) and PEG ([**2162-3-24**]), acute on chronic renal failure requiring dialysis, and persistent post-op atrial fibrillation. He was transferred to [**Hospital **] rehab [**2162-3-30**] shortly after which he was noted to be febrile (102.8 [**2162-4-1**]) with bili 7.5 and jaundice -> [**Hospital1 18**] SICU. Following admit, he was pan-cx (sputum, blood) started empirically on vanco/levo for ?cholangitis. An Abd U/S [**4-3**] showed stones/sludge in gallbladder and the pt underwent ERCP [**2162-4-5**] which showed diffuse dilation of CBD up to 10 mm without filling defects (although gallstones noted in GB), and dilation of pancreatic duct to 6 mm. A stent was placed in the common bile duct with recommendation to repeat ERCP in 3 mos to evaluate for change. CXR w/ left pleural effusion, the size of which decreased following hemodialysis. On [**4-5**] the patient was started on Bactrim for Stenotrophomonas growing from sputum. The patient was transferred to the MICU for further management. The patient can only answer yes or no questions. He denies chest pain, abdominal pain, nausea, vomiting, fevers, chills, or diarrhea. Past Medical History: 1) CAD - cath [**2162-3-1**] 30% LM, 90% LAD, 70% RCA, 60% OM - CABG X 3 [**2162-3-5**] 2) Right carotid stenosis: 80-99% by U/S 3) ESRD on HD - RIJ tunneled HD catheter [**2162-3-29**] 4) AF: developed post-CABG 5) DJD 6) HTN 7) PVD 8) prostate CA s/p XRT 9) Rirght renal artery stenosis; left kidney renal artery occlusion 10) bilateral THR 11) s/p appy 13) bilateral inguinal hernia repeair 14) ?HIT Ab 15) hypothyroidism Social History: no tobacco, no ethanol Family History: non-contributory Physical Exam: PE: Tc 98.8, Tm 100.5 ( 4 p.m. [**4-5**]; afebrile X >12h), pc 78, pr 70s-80s, bpc 114/51, bpr 110-120s/40s-70s, resp 20 98% PS 12, PEEP 5, FiP2 40%, TV 450 Gen: elderly, alert, answering yes/no questions and obeying simple commands, NAD HEENT: Pupils equal, non-reactive to light, EOMI, OMMM, OP clear, trach in place with moderate yellow secretions. Cardiac: irregularly irregular, no m/r/g. Well-healing sternal scar Pulmonary: coarse BS throughout with occasional ronchi, decreased breath sounds at bases bilaterally L>R Abd: hypoactive BS, NT/ND, no masses, no HSM Ext: No cyanosis or edema. Bilateral heel ulcers, clean-based. Pneumoboots in place Neuro: Face symmetrical, EOMI, moves all 4 extremities, 2+ DTR [**Name (NI) **] bilaterally, 1+ DTR LE bilaterally, withdraws all 4 extremities in response to pain Access: Right tunnelled SC dialysis cath C/D/I, Left SC TLC C/D/I. Pertinent Results: [**2162-4-6**] 03:21AM BLOOD WBC-12.4* RBC-3.29* Hgb-10.0* Hct-30.3* MCV-92 MCH-30.5 MCHC-33.1 RDW-20.9* Plt Ct-276 [**2162-4-5**] 12:30AM BLOOD WBC-12.2* RBC-3.33* Hgb-10.2* Hct-29.9* MCV-90 MCH-30.6 MCHC-34.1 RDW-19.8* Plt Ct-303 [**2162-4-4**] 03:00AM BLOOD WBC-9.6 RBC-3.04* Hgb-9.1* Hct-26.9* MCV-89 MCH-30.0 MCHC-33.9 RDW-19.5* Plt Ct-310 [**2162-4-6**] 03:21AM BLOOD Plt Ct-276 [**2162-4-6**] 03:21AM BLOOD PT-13.9* PTT-29.2 INR(PT)-1.2 [**2162-4-5**] 12:30AM BLOOD Plt Ct-303 [**2162-4-5**] 12:30AM BLOOD PT-13.6 PTT-28.0 INR(PT)-1.2 [**2162-4-6**] 03:21AM BLOOD Glucose-128* UreaN-49* Creat-4.0* Na-142 K-4.0 Cl-101 HCO3-27 AnGap-18 [**2162-4-5**] 03:28PM BLOOD Glucose-123* UreaN-38* Creat-3.3*# Na-144 K-3.6 Cl-100 HCO3-28 AnGap-20 [**2162-4-5**] 12:30AM BLOOD Glucose-133* UreaN-89* Creat-6.0*# Na-139 K-4.9 Cl-96 HCO3-25 AnGap-23 [**2162-4-6**] 03:21AM BLOOD ALT-48* AST-134* LD(LDH)-479* AlkPhos-351* Amylase-1015* TotBili-6.3* DirBili-4.9* IndBili-1.4 [**2162-4-5**] 12:30AM BLOOD ALT-25 AST-57* AlkPhos-286* Amylase-40 TotBili-5.5* DirBili-4.2* IndBili-1.3 [**2162-4-6**] 03:21AM BLOOD Lipase-2804* [**2162-4-5**] 12:30AM BLOOD Lipase-27 [**2162-4-6**] 03:21AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-2.5 Iron-PND [**2162-4-5**] 03:28PM BLOOD Calcium-8.9 Phos-4.0 Mg-1.8 [**2162-4-6**] 03:21AM BLOOD TSH-9.5* [**2162-4-5**] 03:28PM BLOOD Vanco-18.5* [**2162-4-5**] 03:10AM BLOOD HEPARIN DEPENDENT ANTIBODIES-PND Micro [**4-5**] MRSA screen pending [**4-5**] VRE screen pending [**4-3**] O&P (-) [**4-2**] O&P, fecal cx (-), C. diff (-) [**4-3**] right PICC tip cx (-) [**4-2**] spcx moderate stenothrophomonas maltophilia (bactrim [**Last Name (un) 36**]) [**4-2**] bcx pending Radiology [**4-6**] renal U/S: Right kidney without stones/hydronephrosis/masses. No left kidney viualized. (+) gallstones/sludge, (+) left pleural effusion [**4-6**] bilateral LENI: (-) DVT [**4-4**] left wrist plain films: osteoarthritis [**4-3**] Abd U/S: stones/sludge in GB, no GB distension/thickening/edema, CBD upper limits of nl. No IHD dilitation [**4-3**] AP CXR: lg lucency at right lung base (bullous vs loculated PTX), moderate left pleural effusion Brief Hospital Course: A: 85 yoM w/ CAD s/p recent CABG, HTN, AF admitted with hyperbilirubinemia and fevers, now s/p ERCP. P: 1) Hyperbilirubinemia: likely secondary to biliary obstruction [**2-24**] sludge, although ischemic injury is also possible 2) Fevers: Most likely secondary to biliary obstruction, possible cholangitis. DDx includes nosocomial pneumonia (sputum from [**4-2**] growing Stenotrophomonas, although this may represent colonization), empyema (although pleural effusion appears chronic), line infection (had S. aureus line infection of temp HD catheter in Fla.). Pt afebrile ~48 hrs since ERCP.NO thoracentesis was done as pt has no tappable amount of fluid. Fluid effusion likely fluid related. He will have bactrim for 7 more days and ampicillin/levofloxacin/flagyl for 7 more days for presumed cholangitis. 3) Post-ERCP pancreatitis: He was clinically improving and decreasing pancreatic enzyme as of [**4-7**] and [**4-8**]. He is to restart on tube feed on [**4-8**] 4) Pleural effusion:THis was chronic and resolved with hemodialysis yesterday on [**4-7**]. No plan to tap as minimal amount on CXR. 5) Respiratory failure: c/b long respiratory wean. Was tolerating trach collar at rehab prior to transfer. 6) Atrial fibrillation: Started post-CABG. Pacing wires placed in Fla. were removed on admission.He was cntinued on admiodarone and metoprol. He is to restart on coumadin on [**4-8**] w/ 2mg initially and carefully titrate up w/ him on amiodarone 7) HTN: Stable. He is continued on metoprolol and hydralazine as of [**4-8**]. 8) Anemia: Likely [**2-24**] ESRD (had been on epogen). Lab panel consistent with anemia of chronic inflammation.Hct is stable as of [**4-8**]. 9) HIT?: Intially there was a concern of HIT, but his HIT antibody was negative as of [**4-8**] 10) CAD s/p CABG: His statin is held for LFT abnormalitis. He is continued on aspirin and low dose b-blocker 11) F/E/N: NPO for now given post-ERCP pancreatitis. - He is to restart on tube feed today on [**4-8**]. 12) ESRD: CRF likely due to HTN and renovascular dz; renal U/S [**4-6**] shows R kidney without hydronephrosis, stones, or masses. No left kidney viualized. HD started post-CABG. - He is continued on MWF dialysis 13) Access: R tunnelled SC dialysis cath, L SC TLC 14) Ppx: pneumoboots (no DVT on LENIs [**4-6**]), PPI 15) Code: Full Code Medications on Admission: Meds (on transfer) 1) Bactrim DS 3 tabs given following dialysis 2) Vancomycin 1 g IV prn vanco <15 3) levofloxacin 250 mg IV q48h 4) NTP q6h for sbp >150 5) RISS 6) acyclovir5% 6X/day 7) Lansoprazole 30 mg NG daily 8) morphine 2 mg IV q4h prn 9) Nephrocaps 1 cap PO daily 10) Albuterol neb q4h prn 11) Atrovent neb q6h prn 12) Levothyroxine 25 mg PO/NG daily 13) Amiodarone 200 mg NG daily Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D (6 times a day). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Three (3) Tablet PO QHD (each hemodialysis) for 7 days. 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please check INR every day for [**Date range (1) 32718**] and every 3 days for 1 week, then every week afterward. 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 7 days. 12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 7 days. 13. Ampicillin 2 gm IV Q12H 14. Hydralazine HCl 20 mg IV Q6H hold for SBP<120 15. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): please give 2 unit for FS 150-200; 4 unit for FS 201-250; 6 unit for FS251-300; 8 unit for FS 301-350; 10 unit for FS 351-400; please give 10 units for FS>401 and call house officer. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: cholethiasis Discharge Condition: stable Discharge Instructions: please call your doctor if you experience chest pain, shortness of breath or abdominal pain. Please take your medication Followup Instructions: need repeat ERCP in 3months (please have your primary care provide call for appointment with GI at [**Hospital1 18**]) Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 41197**] Name: [**Known lastname **],[**Known firstname **] G Unit No: [**Numeric Identifier 11079**] Admission Date: [**2162-4-2**] Discharge Date: [**2162-4-9**] Date of Birth: [**2077-6-12**] Sex: M Service: MEDICINE Allergies: Heparinoids Attending:[**First Name3 (LF) 6727**] Addendum: Pt's discharge to a rehab facility was held [**2-24**] to an episode of hypotension after ultrafiltration. His blood pressure responded to a 750cc fluid bolus. Brief Hospital Course: 1. Post-ERCP pancreatitis/cholangitis: He will be treated with Levaquin, Ampicillin, Flagyl for a total of 7 days. Levaquin's last day is [**4-9**] and last day of Ampicillin, Flagyl is [**4-12**]. . 2. Hypotension: Pt became hypotensive one day prior to discharge secondary to too much fluid taken off during ultrafiltration in combination with hydralazine. He was given a 750cc fluid bolus, hydralazine was discontinued and metoprolol was decreased to 12.5mg tid. The goal should be to run pt even during dialysis as his blood pressure is very responsive to fluid shifts. He will be continued on 12.5mg of metoprolol and it can be titrated up to 25mg if needed to control blood pressure Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D (6 times a day). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Three (3) Tablet PO QHD (each hemodialysis) for 7 days. 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please check INR every day for [**Date range (1) 11080**] and every 3 days for 1 week, then every week afterward. 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 7 days. 12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 7 days. 13. Ampicillin 2 gm IV Q12H 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): please give 2 unit for FS 150-200; 4 unit for FS 201-250; 6 unit for FS251-300; 8 unit for FS 301-350; 10 unit for FS 351-400; please give 10 units for FS>401 and call house officer. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6728**] MD [**MD Number(1) 3662**] Completed by:[**2162-4-9**]

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icd9cm

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icd9pcs

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8958

Discharge summary

report

Admission Date: [**2123-9-8**] Discharge Date: [**2123-9-24**] Date of Birth: [**2057-10-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1711**] Chief Complaint: Status post cardiac arrest with intracardiac defibrilator shock x9 Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: Patient is a 65 year old woman with hx of mixed cardiomyopathy with EF 20-25% s/p AICD placement, CAD s/p PCI to RCA, diabetes, hypertension and afib on warfarin. She presented from nursing home s/p fall out of bed after which she hit her head. She reportedly vomited shortly thereafter. Nursing home staff put her back into bed, and she was later noted to be unresponsive. Nursing home staff felt she had no pulses and initiated chest compressions; however, when EMS arrived, patient was noted to have pulses. EMS intubated patient at the scene and sent her to outside hospital, where she had Head CT negative for bleed. She was transfered to [**Hospital1 18**] ED for further management. . [**8-26**]-admitted for N/V and RLQ pain at OSH, found to have E.coli sepsis [**3-17**] UTI, treated with Augmentin and d/c'ed amiodarone during that admission. Of note, CT head w/o contrast was neg. . In the ED, initial vitals were as follows: 60 109/65 17 100% vent: TV 500, rate 12, PEEP 5, FiO2 100%. Exam notable for being combative, roving horizontal eye movements but not following commands(on sedation). Labs notable for Hct 35.6, WBC 14, troponin of 0.16, creatinine of 0.16 and BNP of [**Numeric Identifier 31100**]. Blood gas as follows: 7.52/41/391/35 on CMV(FiO2 100%, Vt 450cc, RR 14, PEEP 5). EKG was significant for prolong QT. . She was noted to be hypotensive to 70 in the ED with wide complex polymorphic tachycardia at 200 beats/min which subsequently degenerated into ventricular fibrillation terminated by ICD shock x 2. She again went into wide complex tachycardia with no pulse requiring one round of CPR. She underwent another similar episode requiring CPR and external shock at 200 [**Doctor First Name **] with ROSC. She was started initially given amiodarone bolus but was switched to lidocaine bolus + gtt with concern for torsades from prolong QT vs ischemic polymorphic wide complex tachycardia. She was given 2 grams of magnesium, 40 meq of potassium and transferred to CCU. Cardiac arrest/Cooling team was not called per ED team as her cardiac arrest were brief at OSH and here. . On the floor, she is intubated. Past Medical History: CAD, s/p MI post op to CCY with RCA stent in [**2112**], Cath from [**2117**] with no e/o significant CAD Sepsis with E-coli bacteremia Ischemic Cardiomyopathy with EF 10% s/p AICD biventricular placement, complicated by coronary sinus perforation, followed by Dr. [**Last Name (STitle) 31101**] History of ventricular tachycardia s/p AICD placement hx of high degree AV block hx of intracardiac thrombus ? CAD s/p PCI to RCA Diabetes Hypertension Atrial fibrillation s/p cardioversion on warfarin Diabetes diet controlled Hypertension Chronic kidney disease stage 3 Social History: - Tobacco: 40 pky hx, quit 10 years ago - Alcohol: denies heavy alcohol use - Illicits: Family History: Mother - died at 47 from heart attack Father - died from emphysema Sister - died at 50 from heart attack one brother - CAD s/p CABG Physical Exam: Admission Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Exam: GENERAL: 65yo F in no acute distress HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP at clavicle CHEST: CTAB post. Has dressing over ICD site, minor skin tear over breast area. No sig ecchymosis or hematoma. CV: RRR, grade [**3-21**] holosystolic murmur radiating to axilla, no rubs/gallops ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp. Right and left arms mildly swollen with diffuse non-tender redness, improving daily. No LE edema, 2+ pulses b/l NEURO: CNs II-XII intact. Oriented x3. SKIN: no open areas PSYCH: A/O, telling jokes, looking forward to d/c. Pertinent Results: Admission Labs: [**2123-9-8**] 04:00AM WBC-14.0* RBC-4.23 HGB-11.6* HCT-35.6* MCV-84 MCH-27.3 MCHC-32.5 RDW-19.8* [**2123-9-8**] 04:00AM NEUTS-92.6* LYMPHS-3.8* MONOS-2.8 EOS-0.2 BASOS-0.6 [**2123-9-8**] 04:00AM PLT COUNT-423 [**2123-9-8**] 04:00AM GLUCOSE-174* UREA N-10 CREAT-1.6* SODIUM-137 POTASSIUM-3.5 CHLORIDE-90* TOTAL CO2-34* ANION GAP-17 [**2123-9-8**] 04:00AM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.9 [**2123-9-8**] 04:00AM PT-23.4* PTT-32.7 INR(PT)-2.2* [**2123-9-8**] 04:00AM ALT(SGPT)-119* AST(SGOT)-216* ALK PHOS-118* TOT BILI-1.0 [**2123-9-8**] 04:00AM LIPASE-29 [**2123-9-8**] 04:00AM proBNP-[**Numeric Identifier 31100**]* [**2123-9-8**] 04:00AM DIGOXIN-2.0 [**2123-9-8**] 04:00AM cTropnT-0.16* [**2123-9-8**] 04:01AM TYPE-ART RATES-16/0 TIDAL VOL-500 O2-100 PO2-202* PCO2-25* PH-7.65* TOTAL CO2-28 BASE XS-8 AADO2-496 REQ O2-82 -ASSIST/CON INTUBATED-INTUBATED [**2123-9-8**] 01:39PM TSH-8.2* [**2123-9-8**] 01:39PM T4-7.5 Pertinent Labs: Studies Admission EKG [**2123-9-8**]: A-V sequential pacemaker. It is likely the pacemaker is set with a long P-R interval. Compared to the previous tracing of [**2112-7-4**] the rhythm appears to be atrio-ventricular paced on the current tracing. TTE [**2123-9-8**]: The left atrium is moderately dilated. The coronary sinus is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is akinesis of the septal and inferior walls and global hypokinesis of the remaining walls. The basal inferolateral wall is relatively preserved. No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severely dilated left ventricle with severe regional and global biventricular systolic dysfunction. Moderate to severe mitral regurgitation. Small to moderate circumferential pericardial effusion. Borderline pulmonary hypertension. Compared with the prior report (images unable to be reviewed) of [**2112-7-4**], the severity of mitral regurgitation has increased. The pericardial effusion is larger. . CT Head w/o Contrast [**2123-9-8**]: There is no evidence of hemorrhage, edema, mass effect, or infarction. Ventricles and sulci are normal in size and in configuration. The mastoid air cells and paranasal sinuses are clear. IMPRESSION: No acute intracranial abnormality. . CXR AP [**2123-9-8**]: An endotracheal tube ends at the level of the clavicular heads, 5.3 cm above the carina. A nasogastric tube ends with the tip just distal to the gastroesophageal junction. This tube could be advanced by 5-10 cm. Note is made of a dual-lead pacer/AICD device. A left neck IV catheter is noted, with the tip not positioned within any identifiable large vessel. The cardiac silhouette is enlarged, and note is made of a dense left lower lobe opacity. Note is also made of mild pulmonary vascular congestion. . CXR AP [**2123-9-15**]: Left transvenous pacemaker leads terminate in the standard position in the right atrium and right ventricle. Severe cardiomegaly is stable. There is no evident pneumothorax. Right PICC remains in place. Small right pleural effusion has increased. Small left pleural effusion and bibasilar atelectasis, left greater than right, have increased on the right. Pulmonary edema has improved. . Echo [**2123-9-24**]: The left atrium is dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. 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. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2123-9-8**], the mitral regurgitation is reduced. The left ventricular ejection fraction is similar. . Labs at discharge: [**2123-9-24**] 05:10AM BLOOD WBC-7.5 RBC-3.21* Hgb-9.3* Hct-28.1* MCV-88 MCH-28.9 MCHC-33.0 RDW-22.5* Plt Ct-301 [**2123-9-24**] 05:10AM BLOOD Glucose-80 UreaN-17 Creat-1.6* Na-133 K-3.7 Cl-90* HCO3-36* AnGap-11 [**2123-9-23**] 05:52AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9 Brief Hospital Course: 65 yo F with PMH of mixed cardiomyopathy with EF 20-25% s/p AICD placement, CAD s/p PCI to RCA, diabetes, hypertension and afib on warfarin presenting with ventricular fibrillation s/p shock. . #MONOMORPHIC VENTRICULAR FIBRILLATION ARREST The cause of VT is likely secondary to a degrading rhythm centered around a scar from her previous RCA myocardial infarction in [**2112**] versus toxicity with digoxin as level returned at 2. Other possibilities include inherited prolonged QT. Cardiac troponins peaked at .21. Patient was initially on levofed and a lidocaine drip. Both these medications were discontinued after the first day without incident and patient was briefly treated with amiodarone. Patient did endorse some chest pain during admission, but this was centered around her ribs and is likely due to compressions. The pain resolved with lidocaine patches and occasional vicodin. With regards to the AICD, the device was reprogrammed with pAVI 120msec, [**Last Name (un) **] 100msec, HR=80 to improve the patient's diastolic heart failure. Additionally, the reprogrammed VT therapy to VT detection ON at 150bpm with ATP x3 followed by 3 shocks at 25J, 36J, 36J. She was successfully transferred to the floor on hospital day 6. Given the patient's severe MR, and low EF was likely exacerbated by the dyssynchronous rhythm, therefore it was determined the patient would likely benefit from placement of an epicardial lead versus another attempt at placement via a coronary sinus approach (prior attempt resulted in unroofing of left coronary sinus). EP felt that the patient was a candidate for endovascular placement of a left ventricular lead. Therefore she had a biventricular pacemaker upgrade on [**2123-9-23**] and tolerated the procedure well. Repeat echocardiogram showed similar ejection fraction and improvement in her mitral regurgitation. . #Acute on Chronic Systolic Congestive Heart Failure Patient with history of cardiomyopathy with EF of 15-20% from [**2123-9-8**]. Patient was edematous upon admission and started on a Lasix drip at 10mg/hr. She was diuresed initially with lasix then with torsemide and metolazone with improvement in her respiratory status and edema. However diuretics were discontinued due to rising creatinine. With improvement in her renal function she was discharged on home torsemide. Patient's oxygen requirement was at her baseline at the time of discharge. . #UROSEPSIS Patient was recently admitted for E.coli sepsis at an outside hospital and discharged on oral amoxicillin. When patient represented to this hospital, she was hypotensive, likely due to decreased volume, but there was concern for ongoing sepsis. Patient was initially treated with vanc/ zosyn/ flagyl and initially narrowed to cefepime, with final dose given [**2123-9-12**] for a total of 2 weeks antibiotic therapy following diagnosis of the urosepsis. Blood cultures from admission showed no growth and WBC ranged from 6.5 to 14 and patient was afebrile throughout admission. ID was consulted who felt there were no signs or symptoms concerning for infection. . # Elevated creatinine: Over the course of admission patients creatinine trended upward. This was felt to be due to a combination of diuresis in addition due to her poor ejection fraction. This is expected to improve now that she had undergone BiV upgrade. At the time of discharge her creatinine was trending down. . # Hx atrial fibrillation: Patients home coumadin was held for her lead placement. This was restarted prior to discharge. At the time of discharge her INR was 1.3. Her home coreg was changed to metoprolol due to hypotension. Additionally she was restarted on PO amiodarone. . # Depression- The patient was noted to have low mood throughout her hospital stay. She was seen by social work who offered her support in terms of dealing with her illness. Additionally her home celexa was increased from 20 to 30 mg. . #CONDYLOMA ACCUMINATTA Bilateral and extending 6 inches along perianal region. Monitored throughout admission with consideration of involving dermatology/ surgery in the future. . # Hypertension: Pt was hypotensive during hospitalization so antihypertensives were initially held. At the time of discharge her home anti-hypertensives were restarted with the exception of coreg which was changed to metoprolol. #TRANSITIONAL ISSUES - Patient maintained full code status throughout hospitalization - Patient will have follow up with Dr. [**Last Name (STitle) **] of cardiology on [**10-1**]. - Transfer management of coumadin to the rehab facility Medications on Admission: Medications (Discharge Medications from [**2123-9-2**]) coumadin 2 mg / 1 mg qod titrated to 3 mg qd Aspirin 81 mg qd Coreg 3.125 mg [**Hospital1 **] Digoxin 0.125 mg po qdaily Colace 100 mg po BID Lasix 80 mg po qdaily Levothyroxine 0.1 mg po qdaily Lisinopril 2.5 mg po qdaily Miconazole 2% antifungal cream topically [**Hospital1 **] Prilosec 20 mg po qdaily Senakot one table qhs celexa 20 mg qd augmentum 875 mg [**Hospital1 **] for 10 days ([**9-12**] AM last dose) Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO once a day: Hold SBP < 90. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for nausea. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day): please d/c after pt is ambulating regularly. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. potassium chloride 20 mEq Packet Sig: One (1) packet PO once a day. 12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 15. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 6 days. 16. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Ventricular tachycardia arrest Acute on Chronic systolic congestive heart failure Atrial fibrillation on warfarin Diabetes Mellitus Type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You fell out of bed and hit your head. You were found to be in a dangerous rhythm called ventricular tachycardia and needed to be shocked out of this rhythm. You were brought to [**Hospital **] Hospital, then to [**Hospital1 18**]. You were admitted to the CCU and needed to be on a breathing machine and your body temperature cooled. You also had an acute exacerbation of your congestive heart failure and needed lasix intravenously to take off the extra fluid. Your ICD settings were adjusted. As your heart function is so weak, it will be helpful to change your pacemaker function to a biventricular mode. This will require the addition of another pacemaker lead and we hope to do this on Thursday [**9-23**]. You will need to weigh yourself every day and call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 31102**] if your weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. Your weight as discharge is 144 pounds. . We made the following changes to your medicines: 1. WE changed your carvedilol to metoprolol succinate to lower your heart rate 2. We changed your furosemide to torsemide to better prevent fluid overload. 3. Discontinue digoxin 4. Increase celexa to 30 mg to better treat your depression 5. Start amiodarone again to treat your ventricular tachycardia 6. Start cephalexin for 6 days to prevent an infection at your ICD site. Followup Instructions: Primary Cardiology: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: THE MEDICAL GROUP Address: [**Last Name (un) 15488**] [**Apartment Address(1) 31103**], [**Hospital1 420**],[**Numeric Identifier 26668**] Phone: [**Telephone/Fax (1) 10508**] Fax: [**Telephone/Fax (1) 31104**] Date/Time: [**10-1**] at 9:40am with [**First Name4 (NamePattern1) **] [**Name (NI) 31102**], NP, pt's regular provider . Department: CARDIAC SERVICES When: MONDAY [**2123-10-4**] at 9:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2123-11-3**] at 1:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "414.8", "V15.82", "427.1", "311", "428.0", "V45.82", "V45.02", "412", "403.90", "789.03", "785.50", "425.4", "585.3", "273.8", "276.3", "427.31", "414.01", "428.23", "V58.61", "584.9", "078.11", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.97", "00.51", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

16750, 16850

10223, 14825

371, 396

17033, 17033

4588, 4588

18613, 19686

3279, 3413

15348, 16727

16871, 17012

14851, 15325

17211, 18590

3428, 3938

3954, 4569

265, 333

9928, 10200

424, 2564

4604, 5558

17048, 17187

5575, 9908

2586, 3155

3171, 3263

21,510

138,332

53731+59547

Discharge summary

report+addendum

Admission Date: [**2190-4-29**] Discharge Date: [**2190-5-2**] Date of Birth: [**2128-5-7**] Sex: F Service: [**Hospital Unit Name 153**] This is a discharge summary up until [**2190-5-2**]. HISTORY OF THE PRESENT ILLNESS: The patient is a 61-year-old female with a long history of interstitial lung disease on chronic prednisone, COPD, and bronchiectasis on home CPAP and 02 who presents with increasing somnolence and possible increased sputum production. The patient gives an unclear history as to the reason she called 9-1-1 but notes that over the past two to three days she has not been feeling well and has been somewhat sleepier than usual. She was seen approximately two days prior in the clinic for complaints of dysphagia which felt like swallowing razor blades, at which time her proton pump inhibitor was increased. She notes modest sputum production and cough but more importantly increased lethargy. In the ED, there was concern for C02 narcosis given her long-standing lung disease. An ABG was performed showing C02 of 58 which is within her baseline. Her 02 saturations were 89% on room air. She was also given Narcan with minimal improvement. She was given one dose of prednisone 60 and sent to the [**Hospital Unit Name 153**] for further evaluation. PAST MEDICAL HISTORY: 1. COPD/interstitial lung disease/IPF/bronchiectasis. History of pan-resistant Pseudomonas colonization sensitive only to Tobramycin. 2. CHF with diastolic dysfunction, EF 50%. 3. Obstructive sleep apnea, on home BIPAP. 4. History of ductal breast CA, status post resection. 5. Osteoporosis. 6. History of lumbar fracture. 7. History of DVT. 8. Hyperlipidemia. 9. Type 2 diabetes mellitus. 10. History of syncope, possibly medication related. 11. Recent history of hip fracture in [**Month (only) 958**] of this year with open reduction and internal fixation. She is currently on Coumadin for DVT prophylaxis with a goal INR of 1.5 to 2. She is suppose to receive six weeks of therapy and has currently received five weeks of treatment. ALLERGIES: She has a history of acute renal failure after a long course of Tobramycin. SOCIAL HISTORY: The patient quit tobacco many years ago. She does not drink alcohol or use IV drugs. She is cared for by her two sons at home. DISCHARGE MEDICATIONS: The patient has an extensive medical regimen which was somewhat unclear. [**Name2 (NI) **] the ED records, the patient is taking the following medications. 1. Glyburide 2.5 mg p.o. q.d. 2. Celecoxib 200 mg p.o. q.d. 3. Venlafaxine XR 37.5 mg b.i.d. 4. Gabapentin 600 mg q.i.d. 5. Nortriptyline 50 mg q.h.s. 6. Lasix 40 mg p.o. q.d. 7. Lipitor 20 mg p.o. q.d. 8. Lisinopril 2.5 mg p.o. q.d. 9. Bactrim SS q.d. 10. Coumadin 4 mg Thursday, Friday, and Sunday, 2 mg Monday, Tuesday, Wednesday, and Saturday. 11. Protonix 40 mg b.i.d. 12. Mexiletine 150 mg t.i.d. 13. Anastrozole 1 mg q.i.d. 14. Albuterol nebulizer p.r.n. 15. Alendronate 70 mg q. Saturday. 16. Calcium 500 mg two tablets b.i.d. 17. Klonopin 0.5 mg t.i.d. 18. Ipratropium/Albuterol MDIs three puffs q.i.d. 19. Fluticasone 220 two to three puffs t.i.d. 20. Morphine CR 30 mg b.i.d. 21. Multivitamin b.i.d. 22. Prednisone 10 mg q.d. 23. Vitamin D 0.5 micrograms q.d. PHYSICAL EXAMINATION ON ADMISSION TO THE [**Hospital Unit Name 153**]: Vital signs: Temperature 100.1, blood pressure 98/49, heart rate 101, respirations 23, saturating 96% on 1.5 liters 02 nasal cannula. General appearance: The patient was somnolent but arousable, intermittently falls asleep during the examination. Head and neck examination: No JVD noted. Neck supple. The oropharynx was slightly dry. Cardiovascular: Regular rate and rhythm. Lungs: Diffuse inspiratory rales and squeaks. Abdomen: Soft, nontender, nondistended, obese. Extremities: No clubbing, cyanosis or edema. Neurologic: The patient was with notable asterixis on examination. Otherwise, nonfocal. LABORATORY/RADIOLOGIC DATA: On admission, the white count was 13.2, hematocrit 30.2, platelets 457,000. The initial INR was 3.6. Chem-7 revealed a sodium of 135, K 4.4, chloride 96, bicarbonate 31, BUN and creatinine 21 and 1.8, glucose 53. ABGs 7.36/55/69/32. Chest x-ray showed interstitial opacities consistent with interstitial lung disease with no focal consolidation or CHF. EKG was without acute ST changes. Previous echocardiogram in [**12-24**] showed an EF of 40-45%. HOSPITAL COURSE: 1. SOMNOLENCE/ASTERIXIS: After withholding the patient's medications overnight, she was increasingly alert in the morning. She had no evidence of uremia, liver failure, or other etiology of her asterixis and as her asterixis significantly improved the following day it was felt that her mental status was likely related to excessive use of sedating medications. This was felt to be the reason for her admission. It was not thought that she had any increased C02 retention. Her medications were slowly restarted but her MS Contin was held. She was urged to keep careful track of her medications as she is on numerous psychiatric and pain medications which may be sedating. 2. RESISTANT PSEUDOMONAS COLONIZATION: The patient was not felt to have a new pneumonia and chest x-ray was similar to her baseline; however, she is thought to have resistant Pseudomonas colonization related to her bronchiectasis. For treatment of this, she was begun on a regimen of inhaled Tobramycin for 28 days which will alternate with an inhaled dose of [**Doctor Last Name **] for 28 days indefinitely. This will be followed-up by her pulmonologist, Dr. [**Last Name (STitle) 575**], as an outpatient. 3. CHRONIC LUNG DISEASE: She will continue on home CPAP, home 02, home nebulizers including Albuterol, Ipratropium, and Mucomyst as well as outpatient chest PT. Her initial prednisone dose will be tapered. 4. ARTHRITIS/PAIN CONTROL: Her oxycodone was restarted as well as her Cox2 inhibitor, Tylenol, calcium. Her MS Contin was held because of concern for somnolence. 5. CONGESTIVE HEART FAILURE: She had no evidence of heart failure during her admission. She was restarted on her ACE inhibitor after her creatinine improved and was restarted on her home Lasix dose. 6. ELEVATED INR: The patient is status post hip fracture five weeks ago and was ambulating with a walker. Her INR was as high as 4.7. She is currently five weeks into a six week course of Coumadin therapy for DVT prophylaxis with a goal INR of 1.5 to 2. Her Coumadin dose was held during her hospital course. She will follow-up with an INR check as an outpatient. She may not need to receive additional Coumadin doses as her INR is elevated during the fifth week of her anticoagulation course. She is currently ambulating with a walker. 7. RENAL: Her creatinine was initially elevated, thought to be related to hypovolemia and decreased p.o. intake. After IV fluid hydration, her creatinine improved to baseline. 8. DIABETES MELLITUS: Her Glyburide was initially held as she was not tolerating p.o. She was placed on an insulin sliding scale. Her Glyburide may be restarted at the time of discharge. 9. PSYCHIATRIC MEDICATIONS: Her psychiatric medications that were thought to be sedating such as tricyclics were held initially. They may be restarted one by one as tolerated. 10. GASTROINTESTINAL: The patient had a history of dysphagia two days prior to admission. This was thought to be unrelated to her current admission. Her PPI was continued. She was given Nystatin swish and swallow for possible thrush as a cause of her dysphagia, although no thrush was noted on examination. She was urged to have outpatient follow-up for possible EGD if these symptoms continue. Her hematocrit remained stable during her stay. She was told that she may need outpatient colonoscopy which had been discussed during her previous outpatient visits. DISPOSITION: Physical Therapy was consulted and the patient was felt to be safe for discharge to home with PT as she previously completed a course of rehabilitation after hip surgery. She was transferred to the medical floor on [**2190-5-2**]. A discharge summary addendum will follow this dictation for her hospital course after [**2190-5-2**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 6289**] MEDQUIST36 D: [**2190-5-5**] 02:48 T: [**2190-5-7**] 08:54 JOB#: [**Job Number 110300**] Name: [**Known lastname 18072**], [**Known firstname 540**] Unit No: [**Numeric Identifier 18073**] Admission Date: [**2190-4-29**] Discharge Date: [**2190-5-3**] Date of Birth: [**2128-5-7**] Sex: F Service: ACOVE ADDENDUM: This is an addendum to previously dictated discharge summary of [**2190-5-2**] from Dr. [**Last Name (STitle) 212**]. As per the previous discharge summary, the patient was transferred from the ICU to the General Medicine floor. She was discharged to home the next day. She was discharged to home with services. CONDITION ON DISCHARGE: Ambulating with walker on 2 liters oxygen which is her home dose, afebrile, INR 2.2, tolerating p.o. diet, and creatinine 1.1. She was alert and oriented times three. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease exacerbation. 2. Acute renal failure. 3. Altered mental status. 4. Supratherapeutic INR. 5. Bronchiectasis. 6. Pulmonary colonization with multidrug resistant Pseudomonas. 7. Interstitial pulmonary fibrosis. 8. Chronic anemia. 9. Bronchitis. 10. Diastolic congestive heart failure. 11. Osteoporosis. 12. Recurrent sinusitis. 13. History of deep venous thrombosis. 14. Recent hip fracture. 15. History of syncope. DISCHARGE MEDICATIONS: 1. Tobramycin 300 mg inhalation b.i.d. 2. Bactrim 400/80 mg p.o. q.d. 3. Atorvastatin 20 mg p.o. q.d. 4. Albuterol nebulizer treatment q. two hours p.r.n. 5. Ipratropium bromide nebulizer treatment q. six hours p.r.n. 6. Multivitamins. 7. Vitamin D 400 mg p.o. q.d. 8. Mexiletine 100 2 mg p.o. q. eight hours. 9. Glyburide 2.5 mg p.o. q.d. 10. Senna 8.6 mg p.o. b.i.d. 11. Colace 100 mg p.o. b.i.d. 12. Mucomyst one nebulizer q. four to six hours p.r.n. 13. Lasix 40 mg p.o. q.d. 14. Nortriptyline 50 mg p.o. q.h.s. 15. Clonazepam 0.5 mg p.o. q.h.s. 16. Prednisone taper 10 mg tablets starting at 30 mg a day (this started at 60 mg and will go down to her maintenance dose of 10). 17. Oxycodone 5-10 mg p.o. q. four to six hours p.r.n. 18. Gabapentin 300 mg p.o. b.i.d. 19. Nystatin p.r.n. 20. Anastrozole 1 mg p.o. q.d. 21. Acetaminophen 325 p.r.n. 22. Calcium 500 mg p.o. t.i.d. 23. Pantoprazole 40 mg p.o. b.i.d. 24. Celebrex 200 mg p.o. q.d. 25. Effexor XR 37.5 mg p.o. b.i.d. 26. The patient was given a Pari LC + nebulizer (this is what is needed for her to take Tobramycin inhalation). FOLLOW-UP: The patient is to follow-up with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on [**2190-5-7**]. In addition, she will follow-up with Dr. [**Last Name (STitle) 1614**] from Pulmonary. I spoke with Dr. [**Last Name (STitle) 1614**] and he is planning on placing the patient on Colistin on alternating months with inhaled Tobramycin. There was a confusion with pharmacy about the correct dosing and, therefore, when she follows up with Dr. [**Last Name (STitle) 1614**] she will be given a prescription for this medication at that time. She will follow-up with the [**Hospital 1209**] Clinic on Wednesday to follow her INR. When her INR is less than 2.0, her Coumadin will be restarted. Of note, on discharge, her sensitivities for the Pseudomonas found in her sputum are pending. These sensitivities were requested by Dr. [**Last Name (STitle) 1614**] and will be followed-up by him. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16917**], M.D. [**MD Number(1) 16918**] Dictated By:[**Last Name (NamePattern1) 2823**] MEDQUIST36 D: [**2190-5-3**] 04:12 T: [**2190-5-5**] 16:46 JOB#: [**Job Number 18074**]

[ "515", "780.57", "276.5", "494.0", "491.21", "584.9", "733.00", "428.32", "285.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9825, 12132

9338, 9802

4456, 9123

1320, 2157

2174, 2303

9148, 9317

20,320

165,333

19312

Discharge summary

report

Admission Date: [**2185-4-23**] Discharge Date: [**2185-5-3**] Date of Birth: [**2132-10-19**] Sex: M Service: Liver Transplant Surgery Service CHIEF COMPLAINT: End stage liver disease. HISTORY OF PRESENT ILLNESS: 52 year-old male with hepatitis C cirrhosis and hepatocellular carcinoma. He presented to [**Hospital1 69**] for orthotopic liver transplantation. The patient underwent a recent RFA of hepatocellular carcinoma in [**2184-12-7**] and [**2185-2-6**]. The patient had end stage liver disease. The patient also has a history of esophageal varices, status post endoscopy that showed grade I varices in [**2183-6-7**]. The patient had history of alcohol use as well. REVIEW OF SYSTEMS: No chest pain, no shortness of breath, no fevers, chills, no dysuria. PAST MEDICAL HISTORY: Hepatitis C cirrhosis, esophageal varices, hepatocellular carcinoma, status post RFA. IV drug use, ethanol abuse. History of perforated duodenal ulcer. Hiatal hernia. PAST SURGICAL HISTORY: RFA x2. Surgical repair of the cheek bone. Surgical diskectomy in [**2180**]. Status post AESCULAP, gram patch and primary closure of perforated duodenal ulcer in [**2184-7-7**]. MEDICATIONS AT HOME: Lasix 20 mg p.o. b.i.d., Protonix 40 mg p.o. daily, Colace 100 mg p.o. daily, Lactulose, Spironolactone, Metamucil, Methadone 26 q. a.m. and 26 q. p.m. ALLERGIES: Penicillin. SOCIAL HISTORY: 40 pack year smoking, 1 pack per day. Ethanol use. IV drug use. The patient is divorced and has 2 daughters. The patient's sister is the health care proxy. PHYSICAL EXAMINATION: Temperature is 98.8; heart rate of 66; blood pressure 112/62; respiratory rate of 16, saturating 98% on room air. The patient had a number of teeth that were missing. The patient was anicteric. The patient had regular rate and rhythm, clear to auscultation bilaterally on exam of the lungs. Abdomen was soft, nondistended, tender to palpation over the right upper quadrant, well-healed midline scar. Extremities: 1+ edema. LABORATORY: White count was 3.1; hematocrit was 36.8; platelets were 56. PT was 22; PTT was 38. INR was 2.2. Fibrinogen was 106. Sodium was 137; potassium 4.6; BUN 6; creatinine 0.7. ALT 13, AST 23. Alkaline phosphatase was 143. INR was 3.0. Chest x-ray showed no acute coronary or pulmonary process. EKG showed prolonged QT interval. Echo showed a left ventricular ejection fraction of greater than 55% with mild left ventricular dilatation and stress test showed no ischemic changes. The patient had PFT's that showed mild obstructive defect. HOSPITAL COURSE: The patient was consented for liver transplantation and underwent liver transplant on [**2185-4-23**]. Patient had an orthotopic donor after cardiac death liver transplantation with portal vein to portal vein anastomosis and iliac artery conduit from repaired celiac artery and common bile duct to common bile duct anastomosis and repair of a small bowel enterotomy and repair of duodenal enterotomy. Please see the dictated operative note for the details of the operation. Postoperatively, the patient was taken to the ICU for continued support. On postoperative day number 1, the patient was sedated. The patient was put on pressor support with fluid resuscitation for low blood pressure. The patient was continued on ventilator after the operation. Patient had liver ultrasound that showed patent vessels. Patient had adequate urinary output and patient was on broad spectrum antibiotics for perioperative purposes. On postoperative day number 2, the patient continued to have high LFTs with abnormal coags. Patient was on pressor support and was intubated, was kept n.p.o. The patient's abdomen was not closed because of the size of the abdomen. The patient went into renal failure. The patient was initially on CVVHD. The patient was continued on broad spectrum antibiotics and received Solu-Medrol and MMF. Despite full support, the patient's liver never functioned and the patient was diagnosed with primary non function of the liver. The patient was placed back on the transplant list. Patient was continued to be supported. Despite support, we had difficulty ventilating the patient. The patient had a bedside AESCULAP to wash out the abdominal cavity and do a liver biopsy. The liver biopsy showed a 70% cellular necrosis, consistent with rejection. The patient also underwent another wash-out the next day to help improve the oxygenation. On postoperative day number 4, the patient's renal function and pulmonary function continued to decompensate. The patient underwent plasmapheresis for a period of time, for a potential ABO mismatch liver. However, the donation was cancelled and plasmapheresis was stopped. On postoperative day number 3 from the initial operation, the patient underwent another liver transplantation. The patient received liver from a donor. The patient underwent piggyback transplantation, portal vein to portal vein, bile duct to bile duct and aortic conduit to celiac patch anastomosis. Please see details of the operative note for details of the operation. Postoperative, the patient was continued to be intubated and was on pressor support and was on CVVHD. Postoperatively, the patient's liver function improved with correction of the INR and improvement in the LFTs. On postoperative day number 5 and 2, patient was slowly weaned from the vasopressor and the Levophed. The patient's vent was slowly weaned. Patient was started on TPN and was continued on CVVHD. The patient had continued improvement in overall function. On postoperative day number 6 and 3, the patient continued to do well. The patient was fully supported. On postoperative day number 8 and 4, however, the patient had worsening respiratory distress with inability to ventilate the patient. The patient's vent settings were increased to improve ventilation. The patient was also weaned off the Levophed and Vasopressin was weaned slowly. The patient was also continued CVVHD. The patient did develop a significant neutropenia of 1.3. The patient was started on Neupogen and the ascending medications were stopped. On postoperative day number 9 and 5, the patient had significant worsening ventilatory effort. The patient had increasing heart rate and became profoundly neutropenic. The patient remained afebrile but tachycardiac, requiring increasing amounts of Levophed and Vasopressin. The patient was on maximal ventilatory support. The patient was continued on CVVHD. The patient's white count was 0.1. LFTs were slightly improved; however, total bilirubin remained stable and coags were improved. The chest x-ray showed patchy infiltrates. The patient was also placed on broad spectrum antibiotics that included Daptomycin, Zosyn and Caspofungin per infectious disease recommendations. However, during the course of the day, the patient had worsening cardiac physiology consistent with septic physiology. The patient required increasing amount of pressors, increasing amounts of fluids and despite both full pressor support and fluids, the patient was difficult to maintain patient's pressures. With addition of fluid, the patient was unable to ventilate and oxygenate and had difficulty maintaining his respiratory status. During the course, a discussion was had with the family, the patient's sister, [**Name (NI) 501**] [**Name (NI) 15785**], who wanted a DNR order in the case that the patient's heart went into an odd rhythm and stopped. This was also discussed with Dr. [**Last Name (STitle) **] and that decision was made. At 3:27 a.m. on [**2185-5-3**], the patient went into SVT to 250s and then dropped his pressure and then became bradycardiac. The patient subsequently expired at that time. Discussion was made with the attending surgeon, Dr. [**Last Name (STitle) **] as well as the patient's sister. The decision was made to undergo an autopsy. DISPOSITION: Death. DISCHARGE DIAGNOSES: 1. Hepatitis C cirrhosis, status post liver transplantation x2. 2. Esophageal varices. 3. Hepatitis C cirrhosis, status post RFA. 4. Intravenous drug use. 5. Ethanol abuse. 6. History of perforated duodenal ulcer. 7. Hiatal hernia. 8. Radiofrequency ablation x2. 9. Surgical repair of the left cheek bone. 10. Cervical diskectomy. 11. Gram patch and primary closure of perforated duodenal ulcer. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **] Dictated By:[**Doctor Last Name 6052**] MEDQUIST36 D: [**2185-5-3**] 05:22:21 T: [**2185-5-3**] 06:00:12 Job#: [**Job Number 52590**]

[ "995.92", "518.5", "571.5", "288.0", "305.1", "996.82", "997.5", "584.9", "038.9", "070.54", "V11.3", "155.0", "286.9" ]

icd9cm

[ [ [] ] ]

[ "99.07", "00.93", "99.15", "99.06", "50.59", "00.14", "99.05", "99.04", "39.95", "50.11", "38.95", "38.93", "54.25", "99.71" ]

icd9pcs

[ [ [] ] ]

7947, 8626

2592, 7926

1214, 1393

1010, 1192

1592, 2574

722, 793

183, 209

238, 702

816, 986

1410, 1569

23,885

165,607

4168+4169

Discharge summary

report+report

Admission Date: [**2195-11-2**] Discharge Date: Date of Birth: [**2145-8-22**] Sex: M Service: Surgery HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old male with a history of hepatitis B, hepatitis C, and intravenous drug abuse with recurrent aspiration pneumonia, schizoaffective disorder, and history of left greater than right peripheral neuropathy, admitted for acute dysarthria and chest pain at rest. PAST MEDICAL HISTORY: (Significant for) 1. Chronic obstructive pulmonary disease. 2. Hypertension. 3. Hepatitis B. 4. Hepatitis C. MEDICATIONS ON ADMISSION: Home medications included albuterol 2 puffs p.r.n., Aristocort 0.5% p.r.n., doxepin hydrochloride 25 mg p.o. q.h.s., Flovent 110 mcg 2 puffs q.d., Neurontin 300 mg p.o. t.i.d., Prilosec 20 mg p.o. b.i.d., tramadol hydrochloride 50 mg p.o. b.i.d. p.r.n., Zestril 5 mg p.o. q.d., Prozac 80 mg p.o. q.d., Clozaril 225 mg p.o. b.i.d. HOSPITAL COURSE: The patient was initially admitted to the Medicine Service. The attending was Dr. [**First Name (STitle) **] [**Doctor Last Name **] on the Medicine Service. The patient had an abdominal CT scan on hospital day four which showed portal vein air, and the patient was taken by Dr. [**Last Name (STitle) 468**] to the operating room emergently on [**11-16**]. During the exploratory laparotomy the patient was found to have a total toxic megacolon, and the patient underwent total colectomy and ileostomy at the mucous fistula. Postoperatively, the patient did well, was afebrile, vital signs were stable until postoperative day five when the patient began to experience a copious amount of output from his ostomy bag, reaching 4 liters to 5 liters per day. The patient became progressively dehydrated, and his creatinine bumped to 3.5, and aggressive hydration was instituted. The patient's creatinine came down to 1 over the course of two days. Clostridium difficile culture from the ostomy output was sent off. Otherwise, the patient's recovery was otherwise unremarkable. On postoperative day 11 the patient began to tolerate some p.o. diet. CT scan on postoperative day 9 showed contrast flowing through the small intestine and into the ostomy bag without any problem. [**Name (NI) **] fluid collection and no abscess, were seen; it was a negative CT scan. The patient's renal function recovered and was back to his baseline. DR,[**Doctor Last Name **],MARK 02-365 Dictated By:[**Name8 (MD) 186**] MEDQUIST36 D: [**2195-11-17**] 12:09 T: [**2195-11-17**] 13:25 JOB#: [**Job Number 18158**] Admission Date: [**2195-11-2**] Discharge Date: [**2195-11-21**] Date of Birth: [**2145-8-22**] Sex: M Service: HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 50 year old male with a history of schizophrenia, multiple pneumonia, chronic obstructive pulmonary disease, who presented to the medical service on [**2195-11-2**], with chest pain and slurred speech. Although the history is somewhat unclear, the patient was thought to be encephalopathic by the medical teams. He was also diagnosed with a presumed pneumonia. Neurological consultation was obtained in the Emergency Department and they thought his dysarthria was secondary to a toxic metabolic state. The patient was admitted for encephalopathy workup. PAST MEDICAL HISTORY: 1. Schizophrenia. 2. Gastroesophageal reflux disease. 3. PPD positive. 4. Hypertension. 5. Hepatitis B and hepatitis C. 6. History of recurrent aspiration pneumonia. 7. Status post cholecystectomy. 8. Alcohol abuse. 9. Cocaine abuse. 10. Heroin abuse. MEDICATIONS ON ADMISSION: 1. Albuterol nebulizer. 2. Azmacort nebulizer. 3. Flovent inhaler. 4. Neurontin 300 mg b.i.d. 5. Prilosec. 6. Tramadol. 7. Zestril. HOSPITAL COURSE: The patient was admitted to the Medical Service where he underwent an evaluation. Surgery became involved in this patient on [**2195-11-5**], when we were asked to see this man for distended, nontender abdomen. The patient on 12./20./01, underwent abdominal ultrasound which showed no ascites. It was noted that his abdominal distention was increasing as was his white count and he underwent an abdominal CT which revealed air in the portal system. His examination at this time showed temperature 100.6 and vital signs were otherwise stable. He seemed somewhat lethargic. He had decreased breath sounds at the bilateral bases. His abdomen was significantly distended, tense, diffusely tender and tympanitic. He had voluntary guarding. His rectal was stool guaiac positive. Abdominal CT revealed air in the portal system including bisuperior mesenteric vein branches. The left and transverse colon were dilated with a question of pneumatosis. The patient was taken to the operating room for an emergent exploratory laparotomy by Dr. [**Last Name (STitle) 468**]. Please see operative note for details of the procedure. Briefly, the patient underwent a total colectomy and end ileostomy with a mucous fistula. The patient tolerated the procedure and was stable, intubated to the Surgical Intensive Care Unit. His course in the Intensive Care Unit was [**Male First Name (un) 3928**]. He was covered with broad spectrum antibiotics of Ceftriaxone and Flagyl with spiking fevers with a significant requirement of ventilatory support. On [**2195-11-10**], the patient continued to spike fevers. His ventilatory support was weaned and the patient was extubated. He remains on Ceftriaxone and Flagyl. Over the ensuing days, the patient did extremely well. His bowel function slowly returned and on [**2195-11-12**], he was started on clear diet by mouth. His diet was slowly advanced. He received parenteral nutritional support. The patient continued to have a significant intravenous fluid requirement which kept him in the hospital. On [**2195-11-21**], the patient was postoperative day sixteen and he was comfortable. Temperature maximum was 98.6 and heart rate was 76 with a blood pressure of 106/70. He was breathing comfortably at 22 times per minute and saturating 97% in room air. He took in 2270 p.o., 600 intravenous fluids, liter out in urine and 30 liters out from the ileostomy. The chest was clear to auscultation. Cardiovascular was regular rate and rhythm. The abdomen was soft, nontender, nondistended. The extremities were warm and well perfused. The patient was deemed doing extremely well and was discharged to rehabilitation with the contingency that he would be able to maintain hydration. MEDICATIONS ON DISCHARGE: 1. Thiamine 100 mg p.o. q.d. 2. Multivitamin one p.o. q.d. 3. Zestril 5 mg p.o. q.d. 4. Albuterol MDI two puffs q4hours p.r.n. 5. Atrovent MDI two puffs q6hours p.r.n. 6. Nicotine patch 7 mg per day. Psychotropic medications prehospital arrival were Clozaril 225 mg p.o. b.i.d., Prozac 80 mg p.o. q.d and Neurontin 300 mg p.o. t.i.d. These medications were held prior to his discharge secondary to a psychiatric nurses recommendations. The patient is to follow-up with Dr. [**Last Name (STitle) 468**] in approximately one week for wound check. CONDITION ON DISCHARGE: Stable. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern1) 13197**] MEDQUIST36 D: [**2195-11-21**] 10:50 T: [**2195-11-21**] 10:57 JOB#: [**Job Number **]

[ "070.51", "997.4", "584.9", "496", "560.1", "276.5", "293.0", "997.5", "557.0" ]

icd9cm

[ [ [] ] ]

[ "03.31", "45.93", "96.72", "45.72", "99.15", "38.93", "45.75", "46.21" ]

icd9pcs

[ [ [] ] ]

6584, 7139

3661, 3801

3819, 6558

2775, 3351

3373, 3635

7164, 7433

56,864

100,952

40226

Discharge summary

report

Admission Date: [**2186-3-16**] Discharge Date: [**2186-3-22**] Date of Birth: [**2118-6-9**] Sex: F Service: MEDICINE Allergies: Dilantin Kapseal / Calcipotriene / Lorazepam Attending:[**First Name3 (LF) 5141**] Chief Complaint: syncope and pleuritic chest pain upon waking Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 67 year old female with epilepsy, hypertension, and pancreatic cancer s/p Whipple with positive margin who is currently undergoing chemotherapy and radiation. She had a syncopal episode after returning home from a radiotherapy session today and was initially seen at an OSH where she was diagnosed with bilateral PEs. She was transferred to [**Hospital1 18**] and admitted to the ICU for further management. . After returning home from her radiotherapy session today, she had a syncopal episode as she was entering her home. Her husband was next to her and managed to lower her to the ground as she fell. She did not strike her head or sustain any other injuries. She reports losing consciousness and waking up several minutes later. She reports that it was very different than prior seizures and there was no evidence of seizure activity. After waking, she felt SOB with new bilateral chest and back pain on inspiration. She felt somewhat better after resting, but once again felt SOB, weak, and dizzy later in the day when getting up to the bathroom. EMS was called and she was brought to the [**Hospital3 417**] ED. While there, she was tachy to the 140s with BP in the 80s-90s, and CTA showed bilateral PEs and evidence of right heart strain. She was started on a Heparin drip and received several liters of IV fluids. She was given Zofran 4 mg IV and Ativan 1 mg PO for nausea. She was transferred to [**Hospital1 18**] per patient request. . In the [**Hospital1 18**] ED, her initial vitals were T 98.3, HR 116, BP 103/67, RR 18, SpO2 98% on 3L. She was on a Heparin drip at 1000 units/hr. She complained of continued pleuritic chest pain and back pain worse with inspiration. EKG showed sinus tachycardia at 113 bpm and slight ST depressions in the lateral leads, as well as a mild S1Q3T3 pattern. She was given Acetaminophen 1000 mg, which she reports helped the pain significantly. Her Heparin drip was titrated and she was admitted to the ICU for further management. . Once in the ICU, she reported feeling much better than earlier, but with some continued pleuritic chest pain. She reports having a long history of varicose veins, but noted a recent palpable vessel on her medial right thigh near the knee which worsened and then improved a few days ago. She has chronic LE edema and venous stasis changes. She has lost about 50 lbs since her diagnosis with pancreatic cancer. She has chronic nausea, vomiting, and diarrhea related to her chemotherapy and radiation. She has had difficulty staying hydrated, requiring periodic IV fluids in [**Hospital **] clinic. Past Medical History: # Pancreatic Cancer -- as below # Epilepsy -- (Neurologist Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**Hospital1 1474**] MA) -- No seizure in about 5 years # Psoriasis # Basal cell carcinoma of the skin, status post excision # Hypertension -- now resolved # Tonsillectomy History . ONCOLOGIC HISTORY: # Pancreatic Cancer -- stage IIB (pT3, pN1, M0) -- Summer [**2184**] developed epigastric discomfort -- Few months later obstructive jaundice -- [**2185-11-21**]: CT scan at [**Hospital1 18**] showed mass in the pancreatic uncinate process -- [**2185-12-8**]: Whipple procedure with Dr. [**Last Name (STitle) 468**] -- Pathology showed a 2.4-cm moderately differentiated ductal adenocarcinoma in the head of the pancreas. One of the 11 lymph nodes examined was positive, although it was noticed that the single lymph node that contained carcinoma appeared to be involved by direct contiguous tumor growth. The primary tumor was extending beyond the pancreas, but without involvement of the celiac axis or superior mesenteric artery. The uncinate process margin was positive for carcinoma. There was no vascular or lymphatic invasion but there was extensive perineural invasion. -- [**2186-1-12**]: Started cycle 1 of chemotherapy with Gemzar. -- [**2186-2-2**]: Cyberknife therapy to positive margin. -- [**2186-2-9**]: External beam radiation and concomitant XELODA. -- [**2186-2-22**]: Xeloda held due to GI toxicity. Social History: # Tobacco: Never smoked, but husband is a heavy smoker. # Alcohol: Rare alcohol 1-2 drinks/month # Drugs: None Married with 5 children and 5 grandchildren. Denies tobacco, drinks beer occasionally. Family History: The patient is an only child. She reports that the son and grandson of her mother's sister died from pancreatic cancer, but no more immediate family members. She has five children. # Mother -- Died at age 89 of leukemia and had a history of CHF. # Father -- Died at age 63 of MI. Physical Exam: VS: T 97.6, BP 95/67, HR 116, RR 21, SpO2 95-97% on 3L NC Gen: Elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign. Neck: Supple, full ROM. JVP to jaw at 30 degree angle. No cervical lymphadenopathy. CV: Tachycardia, regular with normal S1, S2. No M/R/G. Chest: Respiration unlabored, no accessory muscle use. CTAB except for a few scattered crackles L>R. No wheezes or rhonchi. Abd: Active bowel sounds. Soft, NT, ND. No organomegaly or masses. Well healed transverse surgical incision across upper abdomen. Ext: WWP. Digital cap refill <2 sec. Distal pulses intact radial 2+, DP 1+. LE edema 1+ bilaterally. Palpable cord right medial thigh proximal to knee. No calf tenderness. Neuro: CN II-XII grossly intact. Moving all four limbs. Normal speech. Pertinent Results: ADMISSION LABS: [**2186-3-16**] 02:35AM BLOOD WBC-8.1# RBC-3.36* Hgb-11.7* Hct-34.5* MCV-103* MCH-34.8* MCHC-33.8 RDW-17.2* Plt Ct-136* [**2186-3-16**] 02:35AM BLOOD Neuts-89.6* Lymphs-5.0* Monos-4.6 Eos-0.6 Baso-0.3 [**2186-3-16**] 02:35AM BLOOD PT-17.3* PTT-150* INR(PT)-1.6* [**2186-3-16**] 02:35AM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-136 K-5.2* Cl-103 HCO3-21* AnGap-17 [**2186-3-16**] 02:35AM BLOOD ALT-38 AST-82* AlkPhos-169* TotBili-0.6 [**2186-3-16**] 02:35AM BLOOD cTropnT-0.32* proBNP-2404* [**2186-3-16**] 02:35AM BLOOD Albumin-2.9* IMAGING: ECHO [**2186-3-16**]: Conclusions The left atrium is normal in size. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). 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) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate 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 very small pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. CONCLUSIONS: Small underfilled hyperdynamic left ventricle. Right ventricular systolic dysfunction with relative preservation of the right ventricular apex consistent with acute RV strain in the setting of her known PE. Likely severe pulmonary artery systolic pressure. BILATERAL LENIs [**2186-3-16**]: IMPRESSION: 1. DVT involving the right peroneal vein. Superficial thrombophlebitis of the right great saphenous vein. 2. No DVT in the left lower extremity. ABDOMINAL U/S [**2186-3-16**]: FINDINGS: The liver is normal in echotexture, without focal lesions. There is no intra- or extra-hepatic biliary dilatation. The patient is status post Whipple's procedure. The common hepatic duct is normal, measuring 3 mm. Main, right, and left portal veins demonstrate normal directional flow and waveforms. The right, middle,left hepatic veins and IVC demonstrate normal venous waveforms. The main hepatic artery is patent. The spleen is not visualized due to extensive bowel gas. There is no intra-abdominal free fluid. IMPRESSION: Normal liver, with patent hepatic vasculature. No evidence for portal vein thrombosis. CXR [**2186-3-19**]: One portable view. Comparison with [**2186-3-15**]. The lungs remain clear. The left hemidiaphragm is indistinct. The cardiac silhouette is prominent but may be exaggerated by AP technique. The aorta is mildly tortuous. Mediastinal structures appear stable. The bony thorax is grossly intact. IMPRESSION: No active pulmonary disease. The retrocardiac area is suboptimally evaluated and a lateral view is recommended if further evaluation is clinically indicated. Brief Hospital Course: The patient is a 67 year old female with epilepsy, hypertension, and pancreatic cancer s/p Whipple with positive margin who is currently undergoing chemotherapy and radiation. She presented to OSH with syncope from bilateral PEs and was transferred to [**Hospital1 18**] for further management. # Pulmonary Embolism: She presented with syncope and then had classic signs of PE including rapid onset SOB, pleurisy, and tachycardia. She was at high risk given her pancreatic cancer and ongoing treatments. - Found to have bilateral PEs on CTA at the OSH and was started on a Heparin drip. - Thrombolysis was considered given her initial low BP (80-90??????s), low UOP (10-20cc/hr), and echo showing right heart strain. - She and her family initially opted for thrombolysis, but her rectal guaiac was positive and she was unable to receive it. - No IVC filter will be placed as the benefit does not outweigh the risk. - Her LE dopplers showed DVT involving the right peroneal vein and superficial thrombophlebitis of the right great saphenous vein. - Her hepatic vessels were normal on RUQ US. - She was transitioned to Enoxaparin on [**2186-3-18**] and her Heparin drip was stopped. - She will be continued on enoxaparin 70mg SQ Q12H. - Once the patient was transferred to the floor on [**3-19**], she was foudn to be hemodynamically stable with no episodes of oxygen desaturation, pleurisy, or tachycardia . # Atrial Fibrillation: She had an episode of AFib with HR in the 140s overnight [**Date range (1) 88312**], but was asymptomatic and her BP remained fairly stable. - She was given Metoprolol 2.5 mg IV once, and converted back to sinus rhythm shortly thereafter. - She again went back into AFib the morning of [**3-19**], and was given 15mg total of IV lopressor, and then 1 hour after her last lopressor dose, she went back to NSR. - We started her on 12.5mg metoprolol tartrate TID with good achievement of rate control . # Anemia: Her Hct on admission was 34.5, which was at her recent baseline, but then was dropping after admission to 26.6 on [**3-19**]. - Her MCV is elevated in the 100s with an increased RDW. - Her B12 and folate levels on [**2186-3-7**] were normal at 1081 and 9.5 respectively. Her Hct has fallen from 34.5 to 26.0 in the setting of receiving some IVF, but not enough to account for the observed fall in Hct. - Her stools were guaiac positive and a mild GI bleed was suspected given her treatment with Heparin - She did not show any evidence of upper or lower GI bleeding once transferred to the floor, and her hematocrit rose back up to 30.5 on DOD - Her hematocrit will be followed closely on her anticoagulation treatment and any potential cessation of treatment or intervention will be avoided while she is still in the subacute phase of PE treatment # Epilepsy: She has a history of epilepsy treated with Carbamazepine and Levetiracetam, so we continued Carbamazepine 200 mg PO TID and Levetiracetam 500 mg PO Q6H per her home dosing regimen. . # Pancreatic Cancer: She has pancreatic adenocarcinoma stage IIB and is s/p Whipple procedure with positive margins on [**2185-12-6**]. She is currently being treated with radiation and chemotherapy. She was started on Dexamethasone [**2186-2-22**] for nausea relief and improved appetite. She has had chronic nausea and diarrhea after her surgery and with her ongoing treatments. She is also on pancreatic enzyme supplements. She was briefly placed on stress dose steroids due to concern that it may have been contributing to her hypotension, however she was quickly changed back to her home dexamethasone 2mg PO daily. We continued pancreatic enzyme supplements with meals, and continued lorazepam 0.5mg PO Q6H PRN anxiety or nausea. Medications on Admission: Carbamazepine 200 mg PO TID Levetiracetam 500 mg PO Q6H Dexamethasone 2 mg PO daily Lipase-protease-amylase [Zenpep] (20,000-68,000-109,000 units) -- Take 3 capsules PO with meals and 2 capsules PO with snacks Pantoprazole 40 mg PO daily Potassium chloride 10 mEq PO BID Lorazepam 0.5 mg PO Q6H PRN anxiety or nausea Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous twice a day. Disp:*60 syringes* Refills:*2* 2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety or nausea. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Zenpep 20,000-68,000 -109,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO 3 caps with meals and 2 with snacks as needed for pancreas enzyme. 7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary: Pulmonary Emboli Paroxysmal atrial fibrillation Secondary: Pancreatic Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dr. [**Last Name (STitle) **] [**Known lastname 1458**], You were admitted to the [**Hospital1 18**] for evaluation and treatment of blood clots that were found in your lungs. You were intially managed in the ICU, but recovered well and were able to be transferred to the floor. There you regained good functional status, finished your radiation treatments, and continued lovenox therapy for your blood clots. Because of your blood clots, you had evidence of strain on your heart. This also likely caused your heart to go into an irregular rhythm called atrial fibrillation. You will need to start taking a medication called metoprolol for your heart rhythm. Also please start taking lisinopril for heart protective effects and for blood pressure. The following changes have been made with your medications: 1. START using lovenox shots twice a day 2. START metoprolol succinate 1.5 tablets once a day (for your new irregular heart rhythm) 3. START lisinopril for blood pressure control and for protective effects on your heart Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2186-3-29**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2186-3-29**] at 11:30 AM With: [**Name6 (MD) 5145**] [**Name8 (MD) 5146**], MD, PHD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PSYCHIATRY When: TUESDAY [**2186-4-4**] at 10:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23908**], MD [**Telephone/Fax (1) 1387**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**] Campus: EAST Best Parking: Main Garage

[ "276.2", "345.90", "415.19", "157.0", "427.31", "453.42", "401.9", "451.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14289, 14352

9156, 12890

349, 355

14483, 14483

5864, 5864

15691, 16684

4715, 4999

13258, 14266

14373, 14462

12916, 13235

14634, 15668

5014, 5845

265, 311

383, 3000

5881, 9133

14498, 14610

3022, 4482

4498, 4699

24,893

176,751

29452

Discharge summary

report

Admission Date: [**2148-12-1**] Discharge Date: [**2148-12-8**] Date of Birth: [**2103-11-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**12-1**] replacement of aortic valve and ascending aorta with [**Street Address(2) 70723**]. [**Male First Name (un) 923**] mechanical aortic valved composite graft History of Present Illness: 45 yo M with acute onset chest pain, to ER at OSH where he was initially treated as ACS, subsequent CTA showed Type A dissection. Past Medical History: lyme disease hemorrhoids T&A Social History: no tob 2 beers/day 2 marijuana cigarrettes daily Family History: NC Physical Exam: 98.3 90 21 98% on 2l 123/70 NC/AT, EOMI, PERRL Lungs CTAB RRR Abd benign Extrem 2+ pulses Pertinent Results: [**2148-12-8**] 05:10AM BLOOD WBC-15.6* RBC-4.56* Hgb-12.7* Hct-37.1* MCV-81* MCH-27.9 MCHC-34.4 RDW-13.5 Plt Ct-333# [**2148-12-5**] 05:55AM BLOOD WBC-10.9 RBC-3.88* Hgb-10.9* Hct-32.0* MCV-82 MCH-28.0 MCHC-34.0 RDW-14.1 Plt Ct-200 [**2148-12-8**] 05:10AM BLOOD Plt Ct-333# [**2148-12-8**] 05:10AM BLOOD PT-22.2* PTT-48.7* INR(PT)-2.2* [**2148-12-7**] 05:00AM BLOOD PT-20.2* PTT-35.9* INR(PT)-1.9* [**2148-12-6**] 04:05PM BLOOD PT-17.3* PTT-29.6 INR(PT)-1.6* [**2148-12-8**] 05:10AM BLOOD Glucose-99 UreaN-17 Creat-0.8 Na-136 K-3.9 Cl-100 HCO3-22 AnGap-18 Brief Hospital Course: Mr. [**Known lastname 70724**] was taken emergently to the operating room late in the evening on [**12-1**] where he underwent a Bentall precedure with #29 St. [**Male First Name (un) 923**] Mechanical Aortic Valve for aortic dissection and bicuspid AV. He was extubated on POD #1. He was transfused with 2 units for an HCT of 24. He was weaned from his nitroglycerin and transferred to the floor on POD #2. He was started on coumadin and heparin drip for his mechanical valve. He was ready for discharge home on [**12-8**]. Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 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). Disp:*30 Capsule(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Outpatient Lab Work check protime and INR Monday [**2148-12-9**] and Wed [**2148-12-11**]. Call results to Dr. [**Last Name (STitle) **]. Bagdasian's office 9. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc Discharge Diagnosis: 1. Ascending aortic dissection 2. Placement of mechanical aortic valve and aortic graft Discharge Condition: Good Discharge Instructions: no heavy lifting >10lbs no driving for 8 weeks. Followup Instructions: Follow up appointment with with Dr. [**Last Name (STitle) 914**]. Office will call to arrage this. Follow up appointment with Dr. [**Last Name (STitle) **]. Bagdasian. Completed by:[**2148-12-9**]

[ "E878.2", "441.01", "998.11", "746.4" ]

icd9cm

[ [ [] ] ]

[ "39.61", "99.07", "36.99", "88.72", "35.22", "99.05", "99.04", "38.45" ]

icd9pcs

[ [ [] ] ]

3152, 3260

1504, 2030

332, 501

3392, 3399

923, 1481

3495, 3694

794, 798

2053, 3129

3281, 3371

3423, 3472

813, 904

282, 294

529, 660

682, 712

728, 778

50,651

157,619

27777

Discharge summary

report

Admission Date: [**2192-7-31**] Discharge Date: [**2192-8-4**] Date of Birth: [**2138-7-23**] Sex: F Service: MEDICINE Allergies: Iodine / Shellfish Derived Attending:[**First Name3 (LF) 6021**] Chief Complaint: blood tinged emesis Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 54 yoF w/ a h/o metastatic breast cancer (to hips spine, skull- on taxol weekly) who was initially admitted for pain control of her hip metastasis on [**2192-7-31**] (increasing L groin pain and difficulty with ambulation). She was treated with IV morphine on the floor and her pain is well controlled. After eating dinner on [**2192-8-1**] (chicken pot pie and apple pie) she developed nausea and vomiting x 1. Her nausea was relieved after her vomiting. She had 400cc of vomit (food) and [**11-25**] teaspoon of blood. No clot. No further vomiting. No retching prior. No blood in stool or melena. She was hemodynamically stable. She is thrombocytopenic. She currently feels well and has no complaints at all. . Vital signs prior to transfer were 98.0, BP 112/62, HR 98, RR 18 and 100% on RA. Past Medical History: Oncologic History: Patient presented in [**2188**] with back pain, and underwent an MRI which showed spinal mets with cord compression. Physical exam then revealed a previously undetected breast mass. Pt was then diagnosed with Stage IV breast cancer (ER+ PR+ Her2/neu- ductal invasive carcinoma) s/p XRT and spinal fusion T9-L4 on [**2189-5-9**] and treated with Arimedex and lupron. Shortly after the patient was diagnosed with a PE. In [**9-29**], Arimdex was switched to Tamulosin/Lupron until [**6-30**] when the patient was found to progressive disease in her spine and her regimen was switched to Xeloda/Zometa. At that time the patient also recieved additional treatments with XRT, and the patient then underwent a posterior laminectomy and fusion T1-T9 in [**8-30**]. While on Zometa, the patient continued to have progressive disease, and due to this, she began currently recieving adriamycin/cytoxan. Currently getting weekly taxol. . Other Past Medical History: 1. tubal ligation and uterine fibroid removal 2. severed right 5th digit 3. tonsilectomy 4. HTN 5. paroxysmal AFib 6. PE/DVT - on lovenox in past 7. Portal Vein Thrombosis Social History: The pt any tobacco, EtOH, or IVDU. She lives with her husband and does not work, she has 2 children (in college). Family History: Denies family history of breast CA or other malignancy Physical Exam: Vitals: T: 99.2 BP: 128/74 P: 97 R: 18 O2: 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 8cm 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, moderate distension, +shifting dullness, BS+, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pitting pedal edema, R>L Pertinent Results: [**2192-7-31**] WBC-1.2*# RBC-2.47* Hgb-8.5* Hct-26.2* MCV-106* MCH-34.5* MCHC-32.5 RDW-18.6* Plt Ct-66*# [**2192-8-1**] WBC-0.5*# RBC-1.74*# Hgb-6.0*# Hct-19.1*# MCV-110* MCH-34.6* MCHC-31.6 RDW-19.0* Plt Ct-47* Neuts-68 Bands-2 Lymphs-28 Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* PT-11.9 PTT-28.3 INR(PT)-1.0 Gran Ct-1050* Glucose-110* UreaN-16 Creat-0.7 Na-139 K-3.6 Cl-103 HCO3-26 AnGap-14 ALT-39 AST-102* LD(LDH)-248 AlkPhos-215* TotBili-1.4 Albumin-3.1* Calcium-8.6 Phos-2.8 Calcium-8.2* Phos-2.6* Mg-1.6 Lactate-2.3* . Blood culture pending. H. Pylori serology pending. . [**7-31**]: Hip xrays IMPRESSION: No acute fracture or dislocation . [**7-31**]: CXR: IMPRESSION: No acute cardiopulmonary abnormality. . [**8-1**]: Right upper quadrant biopsy: 1. Moderate ascites. 2. No evidence of portal venous thrombosis. Hepatic veins and portal veins demonstrate proper flow with no evidence of thrombosis. 3. Numerous hypoechoic lesions scattered throughout the liver consistent with history of metastatic disease. 4. Splenomegaly . [**8-1**]: Lower extremity dopplers: IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity. Brief Hospital Course: Assessment and Plan: 54 yoF w/ a h/o metastatic breast cancer, admitted for pain control and possible L hip irradiation is transferred to [**Hospital Unit Name 153**] after small amount of hematemesis. . # Hematemesis: small amount of hematemesis (1 tbsp of blood in 400 ccs of emesis) and 5 point hct drop was transferred to the MICU for monitoring. In the MICU pt was transfused 2 units PRBCs, remained hemodynamically stable, and felt better. No more hematemesis throughout the remainder of the admission. Possibilities include PUD, gastritis, esophagitis. She has never had an EGD, she does not have GERD or dyspepsia symptoms. She had no prior retching [**First Name8 (NamePattern2) **] [**Doctor First Name 329**] [**Doctor Last Name **] tear is less likely. GI was consulted. Given her low plts and neutropenia will hold off on NGT. Continued [**Hospital1 **] ppi to cover PUD, esophagitis and gastritis x 6 week course. GI recommended that no urgent scope was necessary and NG lavage deferred due to thrombocytopenia. Coags were normal, will keep plts > 50. 2 units PRBCs transfused overnight and pt with no further episodes of hematemsis and denied any further symptoms. Pt remained hemodynamically stable with SBP > 100. After call out from the MICU, the patient felt much better and remained stable upon discharge. # L groin pain: likely related to femoral head lesion. This resolved with morphine and tylenol PRN. # Neutropenia: counts improved on Filgrastim 300 mcg SC Q24H. # Metastatic breast CA: No active issues, did not continue taxol as an inpatient # h/o afib: currently sinus. Continued home metoprolol. # ascites: initially thought to be related to history of portal vein thrombosis. No PVD on abd ultrasound. She has liver mets on this ultrasound. The ascites could be due to metastatic disease. Pt not interested in paracentesis. Medications on Admission: Medications: (home) calcium 500mg po bid metoprolol 50mg po tid multivitamin zofran q8hrs prn ativan 1mg po qhs compazine . (transfer) Filgrastim 300 mcg SC Q24H Nystatin Oral Suspension 5 mL PO QID:PRN Docusate Sodium 100 mg PO BID:PRN constipation Ondansetron 4 mg IV Q8H:PRN nausea [**7-31**] @ 2318 View Prochlorperazine 10 mg PO/IV Q6H:PRN nausea Acetaminophen 500 mg PO Q6H:PRN pain or fever > 101 Acetaminophen 500 mg PO Q6H Morphine Sulfate 2-4 mg IV Q4H:PRN severe pain Lorazepam 1 mg PO/IV HS:PRN insomnia Metoprolol Tartrate 25 mg PO TID Hold for SBP < 100 or HR < 60 [**7-31**] @ 2318 View Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea: do not drive while taking lorazepam . 4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. 5. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 6. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for pain. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: Inadequate pain control Secondary: GI bleed Discharge Condition: Stable, afebrile, pain free. Discharge Instructions: You were admitted for inadequate pain control. During your hospitalization you developed an anemia, possibly due to hemorrhage. We observed you in the ICU for 24 hours and gave you 2 units of blood. GI offered an endoscopic evaluation of your upper gastrointestinal tract which you were not interested in pursuing. Your blood counts remained stable throughout the admission and your pain was very well controlled with minimal use of your pain regimen. We have made one change to your medications: START taking Pantoprazole 40mg by mouth daily Continue using your oxycodone for as needed for pain. Please return to the emergency department if you experience chest pain, shortness of breath, fevers, or any other symptoms that are concerning to you. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2192-8-8**] 12:00 Please set up a follow up appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 1-2 weeks ([**Telephone/Fax (1) 14328**]). Completed by:[**2192-9-10**]

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icd9cm

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44130

Discharge summary

report

Admission Date: [**2201-1-12**] Discharge Date: [**2201-1-19**] Date of Birth: [**2129-6-2**] Sex: M Service: MEDICINE Allergies: Keflex Attending:[**First Name3 (LF) 898**] Chief Complaint: mental status change Major Surgical or Invasive Procedure: Central line placement History of Present Illness: 71 year-old man with baseline dementia presented on [**1-11**] at 9:20pm with fever to 103.9, lethargy, and mental status changes per NH staff. Of note, the patient was recently treated for a PNA with Z-pack x4 days at his nursing home. In the ED, CXR showed ?RLL infiltrate and he received levo/flagyl/vanco. He subsequently became hypotensive (80's/40's), lactate 2.9. Multiple Urgent Sepsis Treatment (MUST) protocol was initiated, and he received 4 u FFP (INR 3.5), Central line placement, and 3L NS before transfer to MICU for further mgmt. LP was attempted X 3 without success. While in the MICU, he was covered empirically with Bactrim for presumed meningitis, vanco/levo for possible pneumonia. Sbp stabilized at 110-120 following hydration. He was subsequently transferred to the general medical floor for further management. At time of transfer to the general medical floor, he was intermittently answering simple questions and denied shortness of breath, chest pain, abdominal pain, nausea, vomiting, or headache. Past Medical History: - Dementia with delusions - OA - PVD - R hip avascular necrosis - Seizure disorder - h/o DVT - ?bone cancer: diagnosis is unclear Social History: Lives in [**Location **]. Is dependent with feeding and all ADLs and is bedbound. Family History: Noncontributory Physical Exam: Vitals: Tc 100.4, Tm 100.6, pc 77, pr 73-82, bpc 124/58, bpr 90s-120s 30s-50s, resp 30, resp 20-40, O2 sat 97% 3L NC I/O 10 hrs: 1340/550 General: Elderly, chronically-ill appearing male, alert, oriented to person and "hospital," tachypnic HEENT: PERRL, anicteric, dry mucus membranes. Stiff neck, although unclear how much of this is volitional/contractures. No LAD, no JVD. Pulm: Scaterred wheezes L>R, occasional ronchi, decreased LS at bases bilaterally Cardiac: RRR, soft S1/S2, no M/R/G appreciated Abdomen: Moderately distended, soft, NT, no masses, NABS Extremities: LE edema, L (2+) >R (1+) to mid calf, warm with palpable DP pulses bilaterally. Upper extremities contracted bilaterally. Neuro: Able to squeeze hands and wiggle toes bilaterally. 1+ DTR upper extremities and lower extremities bilaterally. Pertinent Results: Labs on admission: [**2201-1-12**] URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR URINE RBC->50 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0-2 ABG PO2-86 PCO2-39 PH-7.40 TOTAL CO2-25 BASE XS-0 GLUCOSE-97 UREA N-17 CREAT-0.5 SODIUM-141 POTASSIUM-3.1* CHLORIDE-108 TOTAL CO2-26 PHENOBARB-17.1 PHENYTOIN-12.2 WBC-11.3* RBC-3.40* HGB-10.5* HCT-30.8* MCV-90 MCH-31.0 MCHC-34.3 RDW-12.8 NEUTS-84.6* LYMPHS-10.4* MONOS-4.3 EOS-0.5 BASOS-0.2 PLT COUNT-334 Radiology: [**1-13**] CXR: low lung volumes, no congestive heart failure, no new infiltrates [**1-12**] Head CT: no ICH; previous seen abnormality represented artifact [**1-11**] KUB: No free air, stool/gas in rectum. Chronic deformities of the right hip joint and left acetabulum. Osteopenia. [**1-11**] CXR: Low lung volumes, multiple healing left rib fractures . EKG: NSR @ 88, nl axis, TWI in III, no ST changes. Brief Hospital Course: Assessment and Plan: 71 year-old man with baseline dementia, seizure disorder, presents from nursing home with fever to 103.9, lethargy, and change in mental status. 1) Hypoxia: The etiology of the patient's hypoxia is unclea,r as there is no clear evidence of pneumonia/CHF on CXR, although he is a clear aspiration risk. ABG [**1-14**] 7.46/33/65 on 4L NC, consistent with a respiratory alkalosis (possibly central) and non-AG metabolic acidosis (in the setting of recent NS volume resuscitation). The patient was continued on albuterol/atrovent nebs and flovent. He will be treated with a 14 day course of levofloxacin/metronidazole for presumed aspiration pneumonia. 2) Leukocytosis/fever: On admission, the patient had a fever and leukocytosis. The source of infection was unclear, given no clear infiltrate on CXR (although certainly an aspiration risk), negative influenza DFA, negative urine cultures, and blood cultures with NGTD. Given fever, mental status change, there was concern for meningitis. Given that an LP could not be obtained in the emergency department on admission, he was treated with an empiric 7 day course of Bactrim/Vancomycin for possible meningitis (to cover typical organisms and Listeria). The patient developed an erythematous rash over his upper extremities and neck on [**1-14**], which was believed to possibly be secondary to Bactrim. However, given his allergy to cephalosporins and limited meningitis treatment options, he was treated with H2 blockers and topical steroids, and was able to complete the Bactrim course without further complications. As mentioned above, he will complete a 14 day course of metronidazole/levofloxacin for presumed aspiration pneumonia. 4) Change in mental status: Initial change in MS likely in the setting of infection (see above). There was no evidence of seizure activity, and he was continued on his home dose of dilantin/phenytoin. TSH and vitamin B12 levels were normal. At time of discharge, the patient was at his baseline mental status. 5) Nutrition/Goals of Care: Mr. [**Known lastname 284**] failed multiple speech and swallow evaluations during the course of his hospital stay. Initially, a nasogastric tube was placed for tube feeding. Following discussion with the patient's guardian [**Name (NI) 4233**] [**Name (NI) 5930**], it was decided that the patient would not have a PEG tube placed, given his poor long-term prognosis, poor baseline functional status, and desire to keep him as comfortable as possible. He will be given assistance with eating what he wants, and his guardian accepts the risk of aspiration/clinical deterioration. He will complete his 14 day course of antibiotics, but the remainder of his meds will be limited to those needed for his comfort. He is being discharged to his nursing home with plan to transition to hospice care. Medications on Admission: coumadin 3.5 mg PO QOD Furosemide 40 mg PO daily Dilantin 200 mg PO daily Phenobarbitol 90 mg PO daily Actinel 35 mg PO qweek Seroquel 12.5 mg PO BID, 25 mg PO qhs Colace/Dulcolax/Enemas prn Azithromycin (started [**1-5**]) Tylenol 500 mg PO BId vitamin c 500 mg PO BID Oscal 500 + D TID Vicodin prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 4. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO DAILY (Daily). 5. Phenobarbital 30 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Primary: systemic inflammatory response syndrome Secondary: aspiration pneumonia, seizure disorder, dementia, peripheral vascular disease, history of deep vein thrombosis, osteopenia Discharge Condition: Patient is currently stable. Discharge Instructions: Comfort-oriented care Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 53939**] ([**Telephone/Fax (1) 64415**]) as needed. Completed by:[**2201-1-19**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled " Care Protocol". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks.

[ "425.1", "999.2", "403.01", "451.84", "585.6", "710.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11817, 11823

5701, 9733

312, 318

11912, 11945

4666, 5678

12902, 12986

3861, 3986

10188, 11794

11844, 11891

9759, 10165

11969, 12879

4001, 4647

241, 274

346, 1762

1784, 3633

3649, 3845

9,906

175,051

7465

Discharge summary

report

Admission Date: [**2103-2-7**] Discharge Date: [**2103-2-21**] Date of Birth: [**2035-9-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: transfer from OSH for evaluation and treatment of new lung mass Major Surgical or Invasive Procedure: none History of Present Illness: Pt has h/o NSCLC diagnosed [**2096**] s/p L pneumonectomy and 3 vessel CABG in [**2101**], presented to Bay State Hospital on [**2103-2-5**] with 20# weight loss over 1 month, malaise, RLQ abdominal pain. Pain was dull, continuous, and radiates to his R flank and back at times. C/o nausea/vomiting. Admitted to Bay State Hospital, where cause of abdominal pain not found; however, imaging showed new RUL lung mass. Pt was transferred here for further care on [**2103-2-7**] as had been treated here for previous lung Ca. Past Medical History: Oncologic History: Locally advanced non-small cell lung CA diagnosed in [**2096-6-5**], s/p chemotherapy, radiation, and L pneumonectomy. Course complicated by osteomyelitis of the sternum, with a long course of antibiotics. There had been no evidence of recurrence on followup as recently as fall of [**2102**]. 3 vessel CABG in [**10-10**] DVT in [**2094**] History of depression Type II DM GERD hyperlipidemia s/p bilateral inguinal hernia repair s/p lipoma resection Social History: He lives with his son. Retired postmaster. He quit smoking 20 years ago, has a 30 pack year history. He drinks alcohol very occasionally. Family History: Significant for mother with cancer (uncertain type) and DM, brother with [**Name2 (NI) 27339**] cancer, another brother with CAD and DM. Physical Exam: AF, 104, 145/68, 98%%5L Gen: laying in bed, non-toxic appearing HEENT NCAT, MM slightly dry Neck supple, JVP 6 cm Chest scattered rales in RUL, R lung base, otherwise clear CVS tachy without murmur Abd benign Extrem Tr edema Neuro A & O x 3 Pertinent Results: OSH Studies: . [**2103-2-5**] Chest CT: 1. RUL mass extending from the hilum to the chest wall, most likely malignancy, malignant LAD with poss postobstructive PNA 2. Peripheral ill-defined nodules likely due to metastatic disease, but could potentially be granulomatous/infecious. 3. Mediastinal lymphadenopathy. 4. Prior L pneumonectomy. Loculated L pleural effusion. Left sided calcific pleural thickening. 5. Hypodense lesion in the liver maybe due to metastatic disease. Small intra-abdominal paraaortic nodule of indeterminate signifance. . [**2-5**] CT abd/pelvis: No urolithiasis or obstructive uropathy. L renal cyst. . Admission Labs: [**2103-2-7**] 05:00PM BLOOD WBC-7.3 RBC-3.56* Hgb-9.8* Hct-28.9* MCV-81* MCH-27.5 MCHC-33.9 RDW-13.6 Plt Ct-286 [**2103-2-7**] 05:00PM BLOOD PT-14.6* PTT-27.7 INR(PT)-1.3* [**2103-2-7**] 05:00PM BLOOD Plt Ct-286 [**2103-2-7**] 05:00PM BLOOD Glucose-57* UreaN-20 Creat-0.7 Na-134 K-4.1 Cl-94* HCO3-29 AnGap-15 [**2103-2-7**] 05:00PM BLOOD ALT-16 AST-25 AlkPhos-206* TotBili-0.3 [**2103-2-7**] 05:00PM BLOOD Albumin-3.1* Calcium-10.7* Phos-3.9 Mg-1.3* . [**2103-2-8**] Bone Scan: Findings concerning for diffuse osseous metastases. . [**2103-2-8**] MR [**Name13 (STitle) 430**]: No sign of an enhancing intracranial mass to indicate the presence of a parechymal metastatic disease. . [**2103-2-9**] Biopsy Pathology: Combined invasive carcinoma with a squamous component and an undifferentiated component with marked cell size variation. Immunohistochemical studies have been performed. The tumor cells are positive for cytokeratin cocktail (squamous component greater than undifferentiated component) and synaptophysin (undifferentiated component) and negative for LCA and chromogranin. TTF-1 is equivocal. The synaptophysin positivity suggests the presence of neuroendocrine differentiation within the tumor. In the appropriate clinical setting, the tumor is compatible with a lung primary. . [**2103-2-17**] CXR: New right upper lobe opacity which likely represents pneumonia. A followup after clinical resolution is recommended as this could be post-obstructive in nature. . [**2103-2-17**] Head CT: No intracranial hemorrhage or mass effect. No significant change allowing for differences in technique. . Discharge Labs: [**2103-2-21**] 06:25AM BLOOD WBC-5.8 RBC-3.88* Hgb-10.9* Hct-31.2* MCV-81* MCH-28.0 MCHC-34.8 RDW-14.3 Plt Ct-245 [**2103-2-21**] 06:25AM BLOOD Plt Ct-245 [**2103-2-21**] 06:25AM BLOOD Glucose-116* UreaN-21* Creat-0.7 Na-134 K-4.3 Cl-94* HCO3-30 AnGap-14 [**2103-2-21**] 06:25AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.6 Brief Hospital Course: 67y/o M with h/o NSCLC s/p L pneumonectomy, admitted for workup and treatment of a fnew right lung mass. . # Lung cancer - The patient was found to have a new right lung mass, which was revealed to have small cell and non small cell features on pathology. The patient underwent a bronchoscopy by interventional pulmonology to obtain the tissue diagnosis. A bone scan revealed diffuse osseous mets. MRI was negative for brain mets. Chemotherapy (etoposide and carboplatin) was initiated during this hospital course. Neupogen was started 24h after chemotherapy. Further treatment is to be determined by the patient's oncologist, Dr. [**Last Name (STitle) 3274**], on followup as an outpatient. . # mental status changes/hypotension - The patient had an episode of acute mental status changes, unresponsiveness, and hypotension which was likely multifactorial in etiology. It was likely partly due to medications (narcotic pain medications among them) as well as a possible contribution of infection (pneumonia as described below). There was no intracranial hemorrhage by CT scan, no brain mets by recent MRI. Electrolytes were within normal limits. The patient was found to be hypercarbic, though it was difficult to say whether this is a cause or result of MS changes. He was alert and oriented shortly after arrival in the ICU. Some of his pain medications were then discontinued, and narcotics were used with caution for his pain. His antihypertensives were initally held, then restarted once his blood pressure recovered. . # Hypercarbic resp failure: The patient had an elevated CO2 on blood gas in association with the altered mental status and hypotension described above. This was likely secondary to medication effect, with the respiratory failure being secondary to sedation. This improved as the patient became more awake. . # Pneumonia - The patient had a new RUL infiltrate on chest xray, likely a postobstructive vs. aspiration pneumonia. As he was also hypotensive at the time (see above) vancomycin, levofloxacin, and flagyl were all started. Vanco was then discontinued, and treatment with levo/flagyl was continued, with a planned course of 10 days. . # abdominal pain - The patient presented with abdominal pain of unclear etiology, and had a negative CT abd/pelvis at an outside hospital. Possible etiologies included metastatic disease, hypercalcemia, constipation, or a combination of these. He was given bowel regimen for constipation, treatment for hypercalcemia as below, and pain medications. He ultimately had good control of his pain, as well as resolution of his constipation. . # hypercalcemia - Calcium was 11.2 on admission, likely related to the patient's malignancy. This improved somewhat with hydration and lasix, but remained above normal. The patient received a dose of pamidronate on [**2103-2-9**], after which the calcium level remained normal. . # Anemia: Hematocrit drifted downward slowly, and reached a nadir of [**2109-3-1**] (this in the setting of IV hydration). Iron studies were consistent with anemia of chronic disease (ferritin >[**2097**]). Stools were guaiac negative. Some of the decrease in hematocrit may also have been related to chemotherapy. The patient received a total of 3 units of PRBC during the hospital course, after which his hct remained stable. . # DM: We continued metformin per home regimen, but discontinued glipizide when blood glucose levels became too low. We checked QID fingersticks and covered with insulin sliding scale. The patient was on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet. . # Hyponatremia: Na was 131 on [**2-20**]. This was likely hypervolemic hyponatremia, in the setting of IVF and blood products. Sodium returned to [**Location 213**] after a small dose of lasix. . # h/o CAD: Currently asymptomatic. Cardiac enzymes were negative when checked in the ICU in the setting of hypotension and mental status changes as above. We continued his home regimen of beta blocker, ACE inhibitor, aspirin, and statin. . # h/o depression: Paxil had been discontinued in [**Month (only) **], but then was restarted at the outside hospital, and was continued here. Medications on Admission: lisinopril 5 daily glipizide 10 [**Hospital1 **] coreg 6.25 [**Hospital1 **] paroxetine 20 daily skelaxin 800mg TID prn back spasms metformin 1000mg [**Hospital1 **] lipitor 40 daily oxycodone-APAP 7.5-325 q4h prn pain aspirin 81mg daily Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed for wheezing, shortness of breath. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Filgrastim 300 mcg/mL Solution Sig: Three Hundred (300) mcg Injection Q24H (every 24 hours). 12. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 13. Outpatient Lab Work Please check a CBC on Monday [**2103-2-26**] and on Monday [**2103-3-5**]. Please fax the results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3274**] at [**Telephone/Fax (1) 22294**]. 14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 27340**] Discharge Diagnosis: Primary Diagnoses: lung cancer metastatic to bone hypercalcemia right upper lobe pneumonia, likely post-obstructive anemia of chronic disease Secondary diagnoses: hypertension type II diabetes depression coronary artery disease Discharge Condition: stable Discharge Instructions: If you experience fever, chills, worsening abdominal pain, nausea, vomiting, shortness of breath, or any other new or concerning symptoms, please call your doctor or return to the emergency room for evaluation. . Please take all medications as prescribed. - We have been holding your glipizide because your sugars have been too low. Please continue taking your metformin. . Please attend all followup appointments. Followup Instructions: Please call Dr.[**Name (NI) 3279**] office as soon as possible to make an appointment for followup after discharge. Please call [**Telephone/Fax (1) 15512**]. . You have the following appointments already scheduled: Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2103-4-23**] 2:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2103-5-3**] 11:00 Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Date/Time:[**2103-5-3**] 2:00 [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

[ "428.0", "250.00", "780.09", "162.3", "486", "276.51", "458.29", "276.1", "564.00", "275.42", "401.9", "198.5", "285.22" ]

icd9cm

[ [ [] ] ]

[ "33.27", "99.25", "99.04" ]

icd9pcs

[ [ [] ] ]

10541, 10613

4636, 8826

378, 385

10885, 10894

2024, 2653

11358, 12086

1605, 1745

9115, 10518

10634, 10776

8852, 9092

10918, 11335

4297, 4613

1760, 2005

10797, 10864

275, 340

413, 936

4175, 4281

2669, 4166

958, 1433

1449, 1589